This article was originally published June 9, 2020 on the Health Affairs Blog.
As confirmed COVID-19 cases top 1.8 million in the United States and the pandemic batters our nation’s health care system and economy, data are starting to retell an all-too-familiar story: Black Americans are disproportionately affected. Simply put, black Americans’ COVID-19 hospitalization and death rates are too high considering that we only make up about 13 percent of the US population. As health researchers, government officials, and philanthropists sound the alarm and mount a response, they admit that COVID-19 racial health disparities were to be expected.
Several factors help to explain COVID-19 racial disparities. Prevalence rates of chronic conditions are higher among black Americans than among whites, which puts many black Americans at higher risk for COVID-19 illness. Compared with whites, a higher proportion of black Americans work in the service industry, which can increase their exposure to COVID-19. In general, racial and ethnic minorities are more likely to live in densely populated areas, and this can pose challenges for implementing social distancing measures to prevent the spread of COVID-19. The COVID-19 pandemic is spotlighting the many different pathways through which social determinants of health (SDOH), or the “conditions in the places where people live, learn, work, and play,” affect health risks and outcomes over a person’s life and across generations.
That SDOH, which include discrimination and racism, are part of the COVID-19 discourse signals progress in terms of mainstream acknowledgement that social, economic, and environmental factors are key contributors to population health. As we study and work to address longstanding racial health disparities in the US, and current disparities in COVID-19 outcomes, however, we need to shun lip service and do genuine work, which includes:
- confronting the hard truth that injustice and the devaluing of black Americans’ lives is woven into our society—it is part of our nation’s origins and design;
- honoring the diversity of the black American population; and
- meaningfully engaging black experts and citizens in defining the problems, developing solutions, and assessing progress toward health equity.
Confronting Hard Truths
How we comprehend problems matters because it informs how we depict and study them, which determines how we think about solutions. When we talk about black-white health disparities in the United States, our country’s legacy of oppression—the very intentional oppression of black Americans from slavery to racial terrorism and on to segregation laws and mass incarceration—must be a part of the conversation. We also have to confront the hard truth that oppression persists in policies, systems, and structures that thwart black Americans’ well-being, such as residential segregation, discrimination in health care, and voter suppression. Thoughtful reflection, and really digging deep on SDOH within the context of this hard truth, leads to more-comprehensive analyses and depictions of racial health disparities, which calls researchers, policy makers, and funders to more-impactful solutions. Existing depictions and solutions often fall short; for example, some well-meant and creative visual aids designed to advance the dialogue on equity actually reiterate some common shortcomings in the conceptualization of inequities. Depicting inequity as an arbitrary barrier due to people’s physical attributes (such as height … or skin color) can convey that some people are “less than” others. This perspective draws attention to propping up individuals with support services to address only their immediate needs. Addressing individuals’ health-related social needs is a critical, but insufficient, strategy for redressing racial health disparities. Black-white disparities in health is a deeply rooted, complex problem, and it requires a comprehensive response that involves providing individual-level support, tearing down structural and systemic barriers through policy change, and promoting the equal value of all human lives. We absolutely need immediate action to help address COVID-19 racial disparities, such as increasing testing among black Americans through affordable, convenient, and quality care from trusted providers to help curb the spread of COVID-19 and facilitate earlier treatment. But it is just as critical to grapple with how black Americans have come to bear a disproportionate burden of conditions that increase risk for COVID-19 and COVID-19 complications. From this vantage point, the necessity of policy solutions becomes clearer. Combatting racial health disparities, including those in COVID-19 testing, treatment, hospitalizations, and deaths, requires policies that help ensure economic stability and access to quality health care, education, and housing for all.
In addition to confronting the hard truths of systemic racism and discrimination, honoring the diversity of the black American population helps us avoid the pitfall of short-sighted solutions. Data are essential for capturing racial health disparities and informing efforts to address them. However, it is important to consider how well-meaning calls to action on black Americans’ higher imprisonment rates, lower rates of college success, and higher poverty rates compared to whites, for example, can feed into the racist narrative that black Americans are a homogenous group stuck in a hopeless state.
Absolutely, black Americans at all levels of socioeconomic status are burdened by systemic injustice. It is also true that black Americans are a diverse group with different lived experiences. As we talk about the complex interplay of racial health disparities and SDOH, we need to examine data with an eye to similarities and differences across education and income levels, geographic locations, generations, and family structure.
Our messaging on COVID-19 and all racial health disparities and intervention strategies should reflect an appreciation for the diversity of the black American population. For example, to help address disparities among black Americans with low socioeconomic status, we need to pursue policy interventions for the millions of working poor pressured to work while sick and to work jobs that can increase their exposure to COVID-19. We must also be attuned and respond to the disproportionate impact of COVID-19 on the physical and mental health of black doctors, nurses, and other health care workers in the US. This includes considering how the COVID-19 toll on black health care workers can lead to decreased racial diversity in the health care workforce, which can weaken health care equity efforts for a long time to come.
Committing To Meaningful Engagement
Addressing racial health disparities requires confronting our nation’s systemic racism and discrimination, and understanding how these systemic ills manifest in black Americans’ lived experiences and affect health. When it comes to understanding the lived experiences of black Americans, black Americans are the experts. Researchers and government officials need to partner with the experts on defining the problems, developing solutions, and assessing progress toward health equity. This level of meaningful engagement of black citizens and communities is essential for understanding and redressing health disparities. Additionally, research and evaluation teams should include experts with a genuine connection to the issues being studied and to the people whose health we endeavor to improve.
Of course, these are not new notions. From community-based participatory research and health impact assessments to culturally responsive evaluation and equitable evaluation, meaningful engagement is a well-established principle. But this principle bears repeating as we respond to COVID-19. Yes, meaningful engagement involves relationship building and requires time, so it can seem a tall order during emergency response. When urgently responding to a pandemic, there may not be time or bandwidth to develop new forums and procedures to support meaningful engagement. Fortunately, there are established community coalitions and community-led initiatives, university-community partnerships, hospital-community partnerships, and other collaborations and networks across the country that can be leveraged to rapidly activate engagement strategies. Likewise, black health care providers, researchers, public health practitioners, community leaders, and other relevant experts serving on existing national, state, and local government health advisory groups can be recruited to advise on pandemic response.
We cannot ever afford to shelve meaningful engagement, no matter how urgent the public health problem—that is a slippery slope to well-meant but uninformed interventions. Meaningfully engaging black Americans in the response to COVID-19 and other racial health disparities can help us anticipate, and strategize to mitigate, planned interventions’ potential risks and harms (such as the danger of racial profiling or increased anxiety black men may experience when wearing a homemade face covering to help prevent the spread of COVID-19). Meaningful engagement can also support judicious use of response resources by warding against disparities interventions that miss the mark on acceptability and appropriateness: “For example,” the president and CEO of Meharry Medical College James Hildreth said in recent testimony, “with the best intentions—the State of Tennessee sent the National Guard into public housing to test residents. Not surprisingly, the people living there were apprehensive, and stayed behind closed doors.”
Toward A Better Story
A genuine approach to addressing black-white health disparities that includes confronting hard truths about systemic ills and injustice; honoring black Americans as a diverse group of people; and meaningfully engaging black citizens, communities, and experts will help deepen our understanding of this complex problem and lead us to better solutions. Failing to do the genuine work required to understand and address racial health disparities in the midst of this pandemic can widen the racial gap in COVID-19 illness, hospitalizations, deaths, and recovery and almost ensures that this all-too-familiar and reprehensible story will be retold in future pandemics.