Capstone Project Topic Selection and Approval

In collaboration with the approved course preceptor, students will identify a specific evidence-based topic for the capstone project change proposal. Students should consider the clinical environment in which they are currently employed or have recently worked. The capstone project topic can be a clinical practice problem, an organizational issue, a leadership or quality improvement initiative, or an unmet educational need specific to a patient population or community. The student may also choose to work with an interprofessional collaborative team.

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Students should select a topic that aligns to their area of interest as well as the clinical practice setting in which practice hours are completed.

Write a 500-750 word description of your proposed capstone project topic. Include the following:

The problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project that will be the focus of the change proposal.
The setting or context in which the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project can be observed.
A description (providing a high level of detail) regarding the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project.
Effect of the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project.
Significance of the topic and its implications for nursing practice.
A proposed solution to the identified project topic with an explanation of how it will affect nursing practice.

You are required to cite to a minimum of eight peer-reviewed sources to complete this assignment. Sources must be published within the last 5 years, appropriate for the assignment criteria, and relevant to nursing practice. Plan your time accordingly to complete this assignment.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Prepare this assignment according to the guidelines found in the APA Style Guide. An abstract is not required.

www.diverseeducation.com16 Diverse | February 4, 2021

A few hours a� er receiv-ing the second dose of the COVID-19 vaccine,
Dr. Valerie Montgomery Rice,
president of Morehouse School
of Medicine (MSM), says she was
“feeling great.” Rice, who says she
has “a history of participating in
clinical trials,” received her fi rst
dose of the vaccine on Decem-
ber 18 with CNN anchor Sanjay
Gupta to raise awareness and
public trust in the vaccine.
Rice and MSM are part of a group of

higher ed professionals, doctors and public
health experts known as the Black Coalition
Against COVID, which is working to
address community concerns and dispel
misconceptions about the disease and the
vaccine and to inspire trust in the medical

community around these
issues to hopefully save
Black lives.
� is is no small feat.
“Black folks’ mistrust in

the medical system really
stems from enslavement,”
s ay s D r. Ve r o n i c a
Newton, an assistant
professor of sociology at
Georgia State University.
She is working with a
research team studying
C OVID-1 9 res e arch
participation in the
Black community.
From the gynecological

experiments conducted
on enslaved African
A m e r i c a n w o m e n
without anesthesia, to
the forced sterilization
of Black women after
emancipation as a form
of social control, to the
Tuskegee experiments

Dr. Veronica Newton

A Cultural
Conundrum

Physicians are fighting against historic distrust and

misinformation in their quest to save African American

patients, who are dying from COVID-19 at disproportionally

high numbers.

By Autumn A. Arnett

www.diverseeducation.com February 4, 2021 | Diverse 17

that withheld treatment for Syphilis from infected
Black men, to even more recently not believing
Black women and putting their lives at risk during
childbirth, there has been systemic institutional
violence against Black bodies by the medical
community, Newton says.
“I think it’s really important that we remember

that it’s institutional racism and sexism that has
led Blacks to mistrust medical professionals, not
just, ‘Oh, Black people don’t have a trust of medical
professionals,’” she says. “It’s more than Blacks all
having a bad experience with a specifi c type of
doctor. It’s across all facets and specifi cities within
the medical fi eld.”
� ese disparities don’t only aff ect poor Black

people. Dr. Geden Franck, an assistant professor in
the school of medicine at Texas A&M University,
pointed out how a lack of cultural responsiveness has
impacted patient care.
“Yes, there are errors

within the system,
there are misdiagnoses
within the system, but
we tend to see there
is a higher percentage
of these when dealing
with cultures or races
that physicians are
unfamiliar with —
like what happened
with Serena Williams
during her pregnancy,”
Franck says. “That
showed us that even
when the African
American patient is
very affl uent, they still
face these disparities
in treatment. It’s not a class issue or a disenfranchisement
issue, it’s a system issue.”
Franck says other cultural customs come into play as well,

such as historic disenfranchisement and a lack of access to
healthcare.
“Many Black people across the diaspora, especially Afro-

Caribbeans and Afro-Latinos, have always relied on their
elders and homeopathic remedies before seeking any type of
Western medicine,” Franck says. But since most doctors are
trained primarily in fi rst-line techniques, it becomes harder
to treat patients who come for treatment later when it comes
to the progression of disease.
And then there’s a proliferation of misinformation on the

internet, he says, which doesn’t only aff ect Black people, but
exacerbates the fact that this population is already dying at
higher rates than others.
“We’ve entered the world in which misinformation is very

prevalent,” Franck says. “Any mistrust in any system, whether
it be medical or in the democratic system, is further amplifi ed
with the spread of misinformation when you politicize things
that shouldn’t be politicized, like saving lives.”

Dr. Wayne A.I. Frederick, president of Howard University,
says getting information to the Black community is a
constant challenge. Howard is also a member of the Black
Coalition Against COVID, which has worked to broadcast
webinars and virtual town halls featuring public fi gures —
such as Dr. Anthony Fauci, director of the National Institute
of Allergy and Infectious Diseases, and National Urban
League President Marc Morial — in an eff ort to push out
accurate information about the coronavirus pandemic and its
impact on the Black community.
A January report from the APM Research Lab found over

55,000 Black people — or more than one in every 750 — had
died from COVID through January 5, a higher mortality
rate than every other demographic group, except Indigenous
Americans.
Frederick pointed out the eff ort is literally a matter of life

and death, but it is diffi cult to win the trust of the community.
“You remember very, very early on in the pandemic, there

was some conversation that maybe it doesn’t aff ect Black
people. So there’s a lot of disinformation as well that you have
to deal with and overcome,” he says. “But Black people are
more likely to have comorbidities, more likely to be frontline
and essential workers, less likely to be able to isolate. All of
the social determinants of health are working against our
community.”
“What we’re trying to do is educate people about why they

should take a vaccine and then have them make the right
decision,” Frederick says.
He is most worried about the way the positive rates and

death rates are trending, and what that could mean for the
Black community overall. “� ere is a scenario where in the
early spring, in April or May, we could have a circumstance
where lots of people have been vaccinated. And despite that
happening, we may not have a lot of African Americans
vaccinated,” Frederick says. “So we could actually have a really
bad outcome in which (the Black community gets) hurt
disproportionately on top of what has already happened, and
that worries me.”
Understanding the vaccine
“� ere are a lot of people who talk about Tuskegee syphilis

experiment, the Mississippi appendectomy experiment, they
talk about Henrietta Lacks. … And one of the things that I tell
them that’s diff erent from then and now is that we have Black

Dr. Geden Franck

Dr. Wayne A.I. Frederick, president of Howard University, receives a COVID-19 vaccine.

www.diverseeducation.com18 Diverse | February 4, 2021

scientists at every stage of the development of this vaccine,”
says Rice. “Whether it was the early stage work, looking at
the history of whether the messenger RNA could be used in
the vaccine, whether it was the launching of the early trials,
starting with animals and moving onto people, … even down
to the marketing, there have been Black and Latinx scientists
at every stage of that development, so we have been in the
rooms where decisions have been
happening.”
Franck pointed out that in the

Tuskegee study, which is the most
widely-cited example of egregious
mistreatment, the treatment for a
very curable disease was withheld
from Black people. They were not
injected with syphilis to study its
impact, he points out, they were
refused treatment.
“In this case, we’re trying to offer

Black people a vaccine that could
combat the disease — which, by the
way, is disproportionately killing us
— not keep it from them,” he says.
There has also been a lot of

discussion of how fast the vaccine
was developed. Many do not
understand how the vaccine can
possibly be safe for wide use in only
a few months.
“People are minimizing the

effect that the coronavirus has
had globally,” Franck says. “The
global impact has created a huge financial interest for the
development of this vaccine, which has led to it being
developed so quickly and the recruitment of a number of
people into initial trials. Those are usually the two biggest
barriers in the development of any vaccine: funding and
participation. In this case, it quickly passed all the normal
steps that any other vaccine would normally have to pass
in order to be approved, because of the compelling global
interest to get it done.”
Another misconception is that the vaccine is intended to

prevent people from contracting the disease, Franck says.
“In contrast to other vaccines, which have either dead or

live virus in it, [an MRNA, or Messenger RNA, vaccine] has
none of that,” Franck says. “It takes it two steps down the
road and takes what the body would normally have to build
immunity and puts more of that into itself and gives the body
instructions to build its own antibodies for immunity. This
doesn’t mean you can’t get the disease, but it’s giving your
body information to defeat it quickly.”

Changing the narrative
Franck is a member of a group of roughly 20 young, Black

doctors who are working the social media angle to reach the
community under the hashtag #RMRN — Real Medicine,
Right Now.
“Fortunately or unfortunately, a majority of people are

consuming their news on social media these days,” says

Franck. “So we’re leveraging it to gain the exposure of
providing the right information, providing the access to
people, as far as testing and vaccines, but also, quietly, one
of the biggest things is the exposure that we get as a group
to motivate the younger population to pursue careers in the
field of medicine.
“When they see doctors who look like them, and who

they can also see having regular
lives with regular interests —
representation matters.”
Newton agrees.
“We need Black doctors that

have the same list of demands
and c onc e r ns and l ive d
experiences — knowing Black
folks. Actually knowing what
Black life is like, and having that
rapport and those relationships
with your patients. We need
people who can actually relate to
Black folks. Not talking at people,
but talking with and centering
those voices,” she says.
Frederick pointed out that, in

the 1800s, there were eight Black
medical schools dedicated to
the production of Black doctors
in the U.S. Now, there are four:
Howard, Morehouse School of
Medicine, Meharr y Medical
School and the Charles R. Drew
School of Science and Medicine.

“We’re not trying to absolve other medical schools across the
country from educating more students of color to be doctors,
but we’re going to do more,” says Rice, whose institution
recently entered a partnership with CommonSpirit Health,
one of the nation’s largest healthcare providers, to train more
Black physicians. “We need more physicians who are Black
and Latinx, who come from rural communities, who have
more cultural competency with the communities they serve.”
Newton says it is important to acknowledge the systemic

failures that have brought us to this point. In addition to
needing more Black and Latinx doctors, she says, White
doctors and doctors of other races should still be held
accountable for being able to relate to their patients. Newton
is a proponent of all medical students being required to take a
sociology course to help them better understand the cultural
nuances that impact their patients.
“If we can’t use the words to describe the institutional

racism, sexism in the medical field, we’re never going to be
able to get there,” Newton says. “We’re just going to think it’s
individual biases from doctors and not a structural problem.”
“These groups really need to learn the language so that

they know how to communicate with folks who don’t look
like them,” she says. “Not looking at Black folks as just Black
bodies, but as actual human beings who do want folks in
these positions to help us, but these systems haven’t shown us
anything different.” D

“There are multiple ways to build confidence in people who are
trying to ever have a better understanding of why they should
be confident in something,” said Dr. Valerie Montgomery Rice,
president of Morehouse School of Medicine. “Sometimes
people have to see you actually participate.”

Copyright of Diverse: Issues in Higher Education is the property of Cox Matthews &
Associates Inc and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder’s express written permission. However, users may print,
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1 Department of Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD, USA

2 Office of Public Health Practice and Training, Department of Health Policy
and Management, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD, USA

3 Department of Health Behavior and Society, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD, USA

4 Center for Teaching and Learning, Department of Epidemiology, Johns
Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

5 Department of Epidemiology, Johns Hopkins Bloomberg School of Public
Health, Baltimore, MD, USA

Corresponding Author:
Beth A. Resnick, DrPH, Johns Hopkins Bloomberg School of Public Health,
Department of Health Policy and Management, 624 N Broadway #457,
Baltimore, MD 21205, USA.
Email: bresnick@ jhu. edu

Commentary

Public Health Reports
2021, Vol. 136(1) 23-26

sagepub. com/ journals- permissions
DOI: 10. 1177/ 0033 3549 20966024

journals. sagepub. com/ home/ phr

The COVID-19 Pandemic: An
Opportunity to Transform Higher
Education in Public Health

Beth A. Resnick, DrPH1 ; Paulani C. Mui, MPH2; Janice Bowie, PhD, MPH3;
Sukon Kanchanaraksa, PhD, MHS4; Elizabeth Golub, PhD, MEd5;
and Joshua M. Sharfstein, MD1

The coronavirus disease 2019 (COVID-19) pandemic has
revealed deficiencies in our public health infrastructure and led to
calls for long- overdue investment, an improved focus on equity,
and new approaches to crisis readiness and response. Higher
education in public health faces a similar moment of reckoning.
The immediacy of the pandemic forced schools and programs of
public health to shift to remote learning and to support response
efforts. The pandemic provides an opportunity to consider funda-
mental changes to improve our approaches to, effectiveness in,
and impact on public health education.

Immediate Educational Changes
Undertaken

Schools and programs of public health were forced to move
quickly in response to COVID-19 to keep teaching students, sup-
porting the training needs of public health agencies, engaging the
public, assisting communities, working across sectors, and con-
ducting research.

The immediate shift from onsite to remote learning forced
rapid adaptations to teach and engage with students at a distance,
including the use of online formats for classroom teaching, webi-
nars, discussion groups, mentoring, and applied learning.
Sheltering in place also elevated the need for student engagement
in research and practice activities to assist communities in their
COVID-19 response in myriad ways. For example, public health
students across the country assisted with performing contact trac-
ing, monitoring statistics on cases, staffing COVID-19 testing
sites and help lines, creating COVID-19 educational materials in
multiple languages, collecting data on personal protective equip-
ment needs, working with senior centers to obtain contact infor-
mation, and assisting with food distribution.1

In response to urgent needs in the field, schools and programs
of public health quickly developed specialized training in contact
tracing, surveillance measures, data analysis, and risk communi-
cation. Examples of this specialized training include the Johns
Hopkins University’s online contact- tracing course that was
required training for contact tracers in multiple states; more than
200 000 people enrolled in the course during its first 2 weeks.2 In

addition, the Rutgers School of Public Health New Jersey
Community Contact Tracing Corps Program launched in May
2020 in collaboration with the New Jersey Department of Public
Health to train at least 1000 contract tracers to work in New
Jersey.3

Academic experts have been highly sought after as public
health communicators in the demand for COVID-19 informa-
tion. Faculty from public health institutions across the country
have provided continual updates through television, radio inter-
views, podcasts, social media posts, and popular as well as peer-
reviewed publications and academic presentations.

Research collaborations were quickly forged among schools
and programs of public health, health care providers, and scien-
tific and technology experts to study the epidemiology, patho-
genesis, and therapeutics of severe acute respiratory syndrome
coronavirus 2.

Schools and programs of public health have engaged in cross-
sector collaborations to aid the COVID-19 response. In addition
to traditional partnerships with health departments and hospitals,
relationships with transportation systems, housing authorities,
schools, and business communities, among others, facilitated a
wide range of response activities. These activities included acti-
vation of incident command and emergency response measures,

mailto:bresnick@jhu.edu

https://journals.sagepub.com/home/phr

https://orcid.org/0000-0001-6214-9378

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Public Health Reports 136(1)24

implementation and evaluation of prevention measures, and pro-
vision of food, medicines, and other necessities to populations in
need.

Long-term Educational Investments
and Innovations

During the past few years, changes have been made in public
health education curriculum and approaches, including expan-
sion of online degree offerings, increased opportunities for
applied learning, and shifts to competency- based accreditation
requirements. However, the COVID-19 pandemic has brought
attention to educational gaps, creating an opportunity to reassess
and make substantial changes for the long term. Such changes
should include the following: (1) increased investment in educa-
tional infrastructure; (2) expanded practice- based educational
approaches; (3) demonstrated commitment to educational diver-
sity, equity, and inclusion; (4) increased access to education in
public health; (5) deepened cross- sector collaborations; and (6)
formalized training in public health advocacy.

Increased Investment in Educational Infrastructure
The need for a strong educational infrastructure was apparent in
the immediate shift in March 2020 to remote learning as a result
of the COVID-19 pandemic. However, even in the absence of a
global pandemic, a strong educational infrastructure is critical to
supporting high- quality teaching and learning and ensuring read-
iness for schools and programs to adapt in response to future
emergencies or ongoing public health challenges. Educational
infrastructure is fundamental to schools and programs of public
health and to ensure adequate response to public health threats.
Thus, sustaining a strong educational infrastructure and commit-
ting to protect and promote the health of the public are critical to
the core missions of schools and programs of public health.

Sustained investment in education from educational institu-
tions and governmental, philanthropic, and the private sectors
can support excellence in teaching and learning in public health.
These investments may include formally supporting excellence
in teaching with instructional designers or other educational tech-
nologists to provide training in pedagogy for faculty and teaching
assistants for both in- person and online instruction. Investment in
educational infrastructure should also extend to designing class-
rooms and providing equipment that is suitable for both active
learning and full participation by remote learners through various
technologies. Funding for research on educational methods,
expanded training options for new faculty, and continuing educa-
tion is also needed to keep staff up- to- date on new technologies
and approaches to learning.

Underlying this sustained investment from educational insti-
tutions, industry, and government should be a commitment to
improving the quality of learning for all students through the
application of universal design for learning (UDL) principles.4
UDL principles facilitate improved learning outcomes by

making learning environments (face- to- face, online, and hybrid)
inclusive to learners of varied backgrounds, geographic loca-
tions, and talents and abilities by ensuring multiple means of
engagement, delivery of information, and opportunities for learn-
ers to set goals and build fluency via applied learning activities.

Expanded Practice-Based Educational Approaches
The pandemic has emphasized the importance of transdisci-
plinary practice- based approaches to education in public health.
Schools and programs of public health quickly engaged in a wide
range of practice and translation initiatives to guide pandemic
response. Examples include developing COVID-19 data dash-
boards, communicating research findings to advance prevention
and treatment efforts, and making evidence- based recommenda-
tions to inform the safe reopening of businesses, schools, and
other community activities.

Curriculum changes in response to the pandemic fostered
cross- disciplinary teaching and practice- based learning. For
example, more than 450 students participated in a COVID-19
course at the Johns Hopkins Bloomberg School of Public Health
in spring 2020. The course included experts from across disci-
plines explaining the epidemiology of COVID-19, treatment
strategies, and policy options to prevent disease transmission.
The applied learning component engaged students in data collec-
tion in real time on testing rates and stay- at- home orders in
numerous countries that informed ongoing COVID-19 response
efforts. Both the teaching faculty and students were eager to par-
ticipate in the course.5

Demonstrated Commitment to Educational Diversity,
Equity, and Inclusion
The pandemic has amplified inequities and disparities that have
long existed; these disparities underscore the need for trusted
public health experts to provide interventions that are structurally
acceptable and train future public health practitioners to provide
interventions. In this light, it is urgent not only for schools and
programs of public health to assess and adapt their own curricu-
lum and performance metrics to emphasize health equity, but
also for schools and programs to be more representative of the
populations they serve. In 2016, 11% of graduates of Association
of Schools and Programs of Public Health (ASPPH)–member
schools and programs of public health were Black and 13% were
Hispanic,6 which falls short of racial/ethnic diversity of the US
population (13% Black, 18% Hispanic).7 Although schools and
programs of public health have made progress in diversifying the
student population during the last several decades, more work
needs to be done. At the faculty level, the diversity problem is
more acute. In 2017, 6% of ASPPH- member faculty were Black
and 6% were Hispanic; of these faculty, 3% of full professors
were Black and 5% were Hispanic.6 Diversity and inclusion
efforts need to be broadened to consider and collect data on
senior staff positions and to consider other priority population
groups in teaching and learning, such as people with disabilities.

Resnick et al 25

Access to affordable, structurally competent education in
public health aligned with UDL principles is a fundamental need
that requires meaningful changes in our educational approaches
and practices. For real change to occur, it will require creative
thinking and new funding models for higher education. In addi-
tion, sustainable investment in educational infrastructure to sup-
port UDL modalities and expansion of scholarship programs is
needed. The Gates Millennium Scholarship Program8 and the
Robert Wood Johnson Foundation’s Health Policy Research
Scholars program9 are examples of support for racial/ethnic
minority scholars that could be expanded and adapted on a larger
scale to give underrepresented students (eg, low- income racial/
ethnic minority groups) access to public health programs in
higher education from undergraduate through doctoral levels at
institutions nationwide.

Increased Access to Education in Public Health
Options beyond traditional degree programs for education in
public health are needed, including alternative and accessible
educational opportunities and modes of delivery that are lower in
cost than traditional degree programs and available to the current
public health workforce and diverse audiences worldwide.
Findings from the 2017 Public Health Workforce Interests and
Needs Survey indicated that fewer than 15% of the current public
health workforce had received formal public health training,10
and even public health employees with formal training require
skills to adapt to emerging challenges such as COVID-19, new
technologies, and other innovations. Public health roles and
responsibilities have been amplified in the wake of COVID-19
and have taken on a new urgency in areas of disease prevention
and health protection, particularly for vulnerable populations,
and emphasized the need for flexible curriculums and more
practice- based public health training accessible to diverse audi-
ences. Training courses aimed at public health practitioners in
areas such as contact tracing and public health surveillance have
been developed by schools and programs of public health.11

However, outside of a pandemic, schools and programs of
public health have a mandate to prepare future workers and
maintain capacity of the current public health workforce. The
Health Resources & Services Administration funds 10 regional
public health training centers housed in schools and programs of
public health12; however, the training centers are limited in scope,
and funding for the centers has decreased since the late 2000s.13
In addition, many schools and programs of public health offer
part- time online public health degree programs for working pro-
fessionals; however, these programs tend to be costly and often
include prerequisites for admission that preclude enrollment for
many.

The nontraditional educational arena has had an expansion of
curriculum in public health and offering of credentials that have
fewer requirements and are less expensive than a traditional
bachelor’s or master’s degree (eg, certificates, specializations)
through massive open online courses on online platforms such as
Coursera ( coursera. com), edX ( edX. com), and FutureLearn

( FutureLearn. com). These advances have enabled learners to
expand their public health knowledge and skills at a lower cost
and with easier access than traditional degree programs.
However, the scope of these programs needs to be more far-
reaching, affordable, and convenient to working populations and
incorporate UDL principles to attract and serve people from
communities with the greatest needs (eg, tribal communities).
Furthermore, many existing curricula are limited in language
availability and require members of online learning communities
to commit to a specific educational institution or platform.

In times of public health crisis and to address pervasive health
disparities, it is vital to innovate to get the expertise of faculty
across institutions to the communities that need it most in the
most efficient and affordable way possible. An example of such
innovation is the development of an online curriculum that brings
together contributions across multiple schools and programs of
public health with a range of perspectives and expertise. The pan-
demic spurred innovation in this realm, as 3 public health train-
ing centers in different academic institutions worked together in
2020 to produce the “Thriving in an Online Work Environment”
course to help public health professionals stay productive and
connected in the remote work environment.14 Such collaborative
efforts can serve as a model for future innovations to increase
access to education in public health to communities that need it
most, leverage resources, and expand offerings.

Deepened Cross-sector Collaborations
The pandemic has underscored the need for a broad view of pub-
lic health that requires collaborative approaches with multiple
stakeholders. In response to immediate needs during the pan-
demic, public health faculty and students have worked with pri-
vate industry (eg, hospitals, personal protective equipment
producers, drugstores, pharmaceutical companies, and the tech-
nology industry) to advance preventive measures. Partnerships
among public health, schools, food banks, restaurants, farmers,
and fisheries were forged to provide people with food.
Collaborations with public transportation, housing, criminal jus-
tice, advocacy organizations, group homes, and senior facilities
have focused on protecting vulnerable residents and priority
populations.15

Schools and programs of public health now have an opportu-
nity to build on these partnerships forged in the immediacy of the
pandemic response to advance health equity. Cross- sector part-
nerships can provide opportunities for applied learning in various
ways, including collaborative projects and communications, ser-
vice learning, and co- teaching, that emphasize a broad perspec-
tive on public health and the social determinants of health. In
addition, schools and programs can emphasize career trajectories
and mentorship across sectors (eg, housing, transportation, pub-
lic safety, economic development) to advance public health
knowledge and foster long- term collaborations. With a new and
broad set of partners, schools and programs of public health
should play major roles in collective efforts to advance health
equity and improve health outcomes.

Public Health Reports 136(1)26

Formalized Training in Public Health Advocacy
The COVID-19 pandemic laid bare shortcomings in our public
health infrastructure and pervasive health and social inequities.
Solving these challenges will require advocacy. Implicit in the
educational mission of schools and programs of public health is
training students both in the classroom and in the field to advo-
cate for improved public health. Schools and programs of public
health must work to address the social influences and inadequate
policies that drive the inequities so often seen in the communities
in which these institutions reside, as well as conduct research and
seek to serve. Engaging students in advocacy efforts as part of
their public health educational experience through a range of
opportunities, including advocacy centers, internships, and grass-
roots efforts, should not be an elective option but a core compo-
nent of a public health education.

Conclusion

Schools and programs of public health have been actively
engaged in the response to the COVID-19 pandemic. Institutions,
government agencies, and industry should capitalize on the
opportunity of this moment to invest in and institutionalize
improvements in teaching, learning, and practice in education in
public health to improve our educational effectiveness and lead
the charge in shaping future public health leaders to better protect
and promote the health of all populations.

Acknowledgments

The authors thank Laura Morlock, PhD, executive vice dean for
academic affairs at the John Hopkins Bloomberg School of Public
Health, for her educational leadership and input on this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research,
authorship, and/or publication of this article.

ORCID iD

Beth A. Resnick, DrPH https:// orcid. org/ 0000- 0001- 6214- 9378

References

1. Association of Schools and Programs of Public Health. ASPPH
fellows on the frontlines of COVID-19. June 11, 2020. Accessed
September 8, 2020. https://www. aspph. org/ aspph- fellows- on-
the- frontlines- of- covid- 19

2. Johns Hopkins University. COVID-19 contract tracing: about this
course. Accessed June 5, 2020. https://www. coursera. org/ learn/
covid- 19- contact- tracing? edocomorp= covid- 19- contact- tracing

3. Rutgers School of Public Health. New Jersey COVID-19
Community Contact Tracing Corps Program: information about
student contact tracers. May 14, 2020. Accessed September 7,
2020. https:// sph. rutgers. edu/ covid19/ index. html

4. CAST. About universal design for learning. Accessed
September 7, 2020. http://www. cast. org/ our- work/ about- udl.
html#. X1eebB17mL4

5. Pearce K. With “lightning speed,” Johns Hopkins develops
a course focused on COVID-19. March 27, 2020. Accessed
September 7, 2020. https:// hub. jhu. edu/ 2020/ 03/ 27/ covid- 19-
public- health- course

6. Goodman MS, Plepys CM, Bather JR, Kelliher RM,
Healton CG. Racial/ethnic diversity in academic public health:
20- year update. Public Health Rep. 2020;135(1):74-81. doi: 10.
1177/ 0033 3549 19887747

7. US Census Bureau. American Community Survey demographic
and housing estimates 2016. Accessed June 5, 2020. https:// data.
census. gov/ cedsci/ all? tid= ACSDP1Y2016. DP05& hidePreview=
false

8. United Negro College Fund. Gates Millennium Scholars
Program. Accessed June 8, 2020. https:// gmsp. org

9. Robert Wood Johnson Foundation. Health Policy Research
Scholars. Accessed June 8, 2020. https:// healthpolicyresearch-
scholars. org/

10. De Beaumont Foundation. Public Health Workforce Interests
and Needs Survey: 2017 national findings. 2018. Accessed June
5, 2020. https://www. debeaumont. org/ phwins- signup/ ph- wins-
explore- the- data/ ph- wins- 2017- national- findings/

11. Public Health Foundation. Coronavirus disease 2019
(COVID-19) training. Accessed September 7, 2020. http://
www. phf. org/ resourcestools/ Pages/ Coronavirus_ Disease_
2019_ COVID_ 19_ Training. aspx

12. Health Resources & Services Administration. Regional Public
Health Training Centers. Updated April 2020. Accessed
June 8, 2020. https:// bhw. hrsa. gov/ grants/ publichealth/
regionalcenters

13. US Department of Health and Human Services. HHS FY 2020
budget in brief. Accessed June 8, 2020. https://www. hhs. gov/
about/ budget/ fy2020/ index. html

14. Rocky Mountain Public Health Training Center. Thriving in
an online work environment. Accessed August 2, 2020. https://
rmphtc. org/ thriving- in- an- online- work- environment/ index.
html#

15. Piramal S. How future partnerships, collaborations will roll out
in a COVID world. Business Today. August 10, 2020. Accessed
September 7, 2020. https://www. businesstoday. in/ opinion/
columns/ how- future- partnerships- collaborations- will- roll- out-
in- a- post- covid- world/ story/ 412511. html

https://orcid.org/0000-0001-6214-9378

https://www.aspph.org/aspph-fellows-on-the-frontlines-of-covid-19

https://www.coursera.org/learn/covid-19-contact-tracing?edocomorp=covid-19-contact-tracing

https://sph.rutgers.edu/covid19/index.html

http://www.cast.org/our-work/about-udl.html#.X1eebB17mL4

https://hub.jhu.edu/2020/03/27/covid-19-public-health-course

https://data.census.gov/cedsci/all?tid=ACSDP1Y2016.DP05&hidePreview=false

https://gmsp.org

https://healthpolicyresearch-scholars.org/

https://www.debeaumont.org/phwins-signup/ph-wins-explore-the-data/ph-wins-2017-national-findings/

http://www.phf.org/resourcestools/Pages/Coronavirus_Disease_2019_COVID_19_Training.aspx

https://bhw.hrsa.gov/grants/publichealth/regionalcenters

https://www.hhs.gov/about/budget/fy2020/index.html

https://rmphtc.org/thriving-in-an-online-work-environment/index.html#

https://www.businesstoday.in/opinion/columns/how-future-partnerships-collaborations-will-roll-out-in-a-post-covid-world/story/412511.html

The COVID-19 Pandemic: An Opportunity to Transform Higher Education in Public Health

Immediate Educational Changes Undertaken
Long-term Educational Investments
and Innovations
Increased Investment in Educational Infrastructure
Expanded Practice-Based Educational Approaches
Demonstrated Commitment to Educational Diversity, Equity, and Inclusion
Increased Access to Education in Public Health
Deepened Cross-sector Collaborations
Formalized Training in Public Health Advocacy
Conclusion
Acknowledgments
Declaration of Conflicting Interests
Funding
ORCID iD
References

COVID-19 Among African Americans: An
Action Plan for Mitigating Disparities
Monica E. Peek, MD, MPH, MS, Russell A. Simons, BS, William F. Parker, MD, MS, David A. Ansell, MD, MPH, Selwyn O. Rogers, MD,
MPH, and Brownsyne Tucker Edmonds, MD, MPH, MS

As the COVID-19 pandemic has unfolded across the United States, troubling disparities in mortality have

emerged between different racial groups, particularly African Americans and Whites. Media reports, a

growing body of COVID-19-related literature, and long-standing knowledge of structural racism and its

myriad effects on the African American community provide important lenses for understanding and

addressing these disparities.

However, troubling gaps in knowledge remain, as does a need to act. Using the best available evidence,

we present risk- and place-based recommendations for how to effectively address these disparities in the

areas of data collection, COVID-19 exposure and testing, health systems collaboration, human capital

repurposing, and scarce resource allocation.

Our recommendations are supported by an analysis of relevant bioethical principles and public health

practices. Additionally, we provide information on the efforts of Chicago, Illinois’ mayoral Racial Equity Rapid

Response Team to reduce these disparities in a major urban US setting. (Am J Public Health. 2021;111:

286–292. https://doi.org/10.2105/AJPH.2020.305990)

Since April 2020, striking disparities inCOVID-19 mortality between African
Americans and Whites have been re-

ported in US cities and states. For ex-

ample, 51% of deaths in South Carolina

have been among African Americans

despite their representing only 30% of

the population.1 In Chicago, Illinois, Af-

rican Americans constituted 70% of

early COVID-19 deaths despite com-

posing only 30% of the population, and

deaths continue to cluster in neighbor-

hoods where more than 90% of the

residents are African American.2

A national analysis of county-level data

confirmed what many scholars pre-

dicted: that place matters in COVID-19

racial disparities. Counties with higher

proportions of African Americans have

higher numbers of COVID-19 cases and

deaths; these counties have more

crowded living conditions and lower

social distancing scores, higher unem-

ployment, lower rates of health

insurance, and higher burdens of

chronic disease.3 Structural racism and

residential segregation have forced a

disproportionate number of African

Americans into low-income neighbor-

hoods that are more physically crowded

and have fewer resources.4 As a result,

social isolation practices can be more

challenging to implement; people must

travel farther for necessary supplies,

often utilizing public transportation, and

return to homes with less personal

space because of multigenerational

living.

Individual risk also matters. Although

not all African Americans live in racially

segregated neighborhoods, all African

Americans, to varying degrees, are af-

fected by economic and sociopolitical

burdens of racism that may increase

their risk for COVID-19 morbidity and

mortality. Structural racism has led to

inequities in education, employment,

income, policing and incarceration,

health care access, chronic stress, and

multiple other factors that affect

health.5,6 For example, African Ameri-

cans are more likely to be employed as

low-wage essential workers, in areas

such as mass transit and airport facili-

ties, food production, and pharmacies.7–9

In New York City, African Americans

constitute 30% of the essential

workforce—more than any other racial

group.10 Those workers, who have kept

critical services operating, have too often

been left without adequate personal

protective equipment.11

Consequently, addressing racial dis-

parities in COVID-19 must use both

place-based and individual risk-based

strategies grounded in public health

practices that utilize data, boost public

health infrastructure, leverage cross-

sector collaboration, and mobilize

community partnerships.

We can draw upon the bioethical

principles of fairness, distributive justice,

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RESEARCH AND ANALYSIS

https://doi.org/10.2105/AJPH.2020.305990

and reciprocity to provide guidance for

understanding resource allocation and

the sharing of burdens and benefits

across society. Fairness is essential to

building public trust in pandemic-

related processes. Although it is often

thought of as “to each person an equal

share,” it can also be defined as “to each

person according to need.”12 Distribu-

tive justice, as defined by John Rawls,

offers an additional health equity lens by

proposing that institutions, processes,

and structures should be allocated in a

manner that seeks to improve the well-

being of the least advantaged in society,

whose social positions exist because of

limitations placed on their opportuni-

ties.13 Finally, the principle of reciprocity

argues that it is our collective respon-

sibility to ensure that those being placed

in harm’s way are prioritized and

protected.14

Thus, it is the ethical obligation and

civic duty of our governments, hospitals,

and public health agencies to address

COVID-19 racial disparities that our so-

ciety has helped to create. With these

principles in mind, we make the follow-

ing recommendations for policy and

practice. We highlight examples from

the Chicago Racial Equity Rapid Re-

sponse Team formed to address the

city’s COVID-19 disparities (see the

boxes on pages 288 and 289).15 This

discussion is of critical import, not only

for the current crisis but also as we re-

open, rebuild, and reinvest in commu-

nities moving forward.

RECOMMENDATIONS

The following recommendations for re-

ducing COVID-19 disparities among Af-

rican Americans are based in public

health and bioethical principles

designed to promote the health of the

most marginalized populations.

Recommendation #1: Require collection

of race/ethnicity data with COVID-19

reporting. Such data are fundamental

and essential to operationalize dis-

tributive justice. In spite of recom-

mendations set forth by the National

Standards for Culturally and Linguis-

tically Appropriate Services for uni-

versal collection of sociodemographic

data, state-level data on COVID-19

cases, deaths, and testing are missing

for 3, 5, and 46 states, respectively.

For those that have reported, an es-

timated 50% of patients were missing

race/ethnicity data in May 2020.16,17

On May 1, the Centers for Disease

Control and Prevention updated the

COVID-19 reporting form, but race/

ethnicity data are still not required.

Such standards will allow better

tracking of disease burden in different

communities across the United States

and inform just allocation of critical

resources (e.g., remdesivir, ventila-

tors) and infrastructure (e.g., field

hospitals).

Recommendation #2: Utilize risk- and

place-based strategies to decrease

COVID-19 exposure. Reciprocity

demands that essential workers be

outfitted with personal protective

equipment and physical barriers

(e.g., plexiglass partitions) because

of the increased assumed risks as-

sociated with their work. Partner-

ships with community-based

organizations to disseminate re-

sources, such as COVID-19 pre-

vention kits (e.g., soap, gloves, facial

masks, educational materials)

within high-risk communities will be

important. Community policing

practices must not counter these

public health efforts, as evidence

has emerged of racial profiling

among African American men

wearing facial masks.18 Persons

living and working in congregant,

densely populated settings (e.g.,

prisons, skilled nursing facilities)

should have facial masks or cover-

ings. In addition, we recommend

that prison systems identify and

safely release low-risk, nonviolent

offenders, as has been done suc-

cessfully in numerous countries and

US states, to reduce unnecessary

overcrowding that puts the entire

population at risk for COVID-19 in-

fection.19,20

Recommendation #3: Utilize risk- and

place-based strategies to increase

COVID-19 testing. Racial/ethnic mi-

norities have had disparate access

to COVID-19 testing. Recent survey

data suggest that 23% of federally

qualified health centers and similar

community-level care settings, where

African Americans are more likely to

receive care, do not currently offer

drive-through or walk-up testing.21,22

Although many academic medical

centers have developed in-house

tests to increase capacity and de-

crease the wait time for results, Afri-

can Americans have reduced access

to such centers in some areas.23 This

violates the fairness principle. We

must implement universal screening

in high-prevalence areas, based on

epidemiological modeling and hot

spot analyses, with subsequent con-

tact tracing. Drive-through centers

and pop-up clinics in trusted com-

munity spaces (e.g., churches) within

high-risk neighborhoods will be criti-

cal, but insufficient.24 In the short

term, there needs to be a coordinated

investment in and involvement of

public health nurses, community

health workers, and trained civilians to

successfully identify, reach, and test

populations that have been margin-

alized from health care institutions for

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generations.25–28 In the long term,

there needs to be an expansion of the

proportion of underrepresented-in-

medicine minority physicians, who

help create trusted spaces for racial/

ethnic minority patients and dispro-

portionately work to address histori-

cal injustices that have caused many

African Americans to distrust health

care systems. Larger medical centers

will need to share testing resources

with smaller, community-based clinics

and hospitals.

Recommendation #4: Repurpose am-

bulatory staff and infrastructure for

COVID-19 prevention, support, and

monitoring. Chronic diseases such as

diabetes and hypertension, which

disproportionately burden African

Americans, are associated with severe

forms of COVID-19.29–31 Reduced in-

person ambulatory volume creates

opportunities to reorganize human

capital and infrastructure to provide

high-risk patients with enhanced tel-

ehealth monitoring, education, social

risks screening, and supplies to help

manage chronic disease and mitigate

coronavirus risk. Oak Street Health, a

network of outpatient clinics serving

primarily low-income, elderly, minority

patients, has redirected their front

desk and outreach staff to call pa-

tients to screen for social risks (e.g.,

food insecurity) and behavioral health

issues when their offices are virtual

during the pandemic. Their social

work team assesses those who screen

positive, and patient transport vans

are used to deliver food, thermome-

ters, pulse oximeters, medicine, and

other supplies.32

Recommendation #5: Safely isolate and

support COVID-19 patients from high-

risk living conditions. This would in-

volve collaboration between health

care organizations; housing agencies,

hotels, and other housing facilities;

food banks and food distribution

services; mental and behavioral

health services; and other social ser-

vice agencies to facilitate safe social

isolation and support services for

COVID-19–positive, low-income per-

sons living in overcrowded living

conditions. These efforts must be led

by public health campaigns that are

socio-culturally and linguistically ap-

propriate for the intended population,

utilize multimedia dissemination

strategies, and include accurate and

understandable information about

COVID-19 risks, prevention, testing,

contact tracing, treatment, and

recovery.

Recommendation #6: Implement city-

and statewide plans to share re-

sources and patients across hospital

systems. African Americans are more

likely to live in health care deserts

(with no nearby hospital) and more

likely to receive medical care at

resource-limited health care sys-

tems.22,33,34 A landmark study of

Medicare recipients found that 80% of

African Americans received their

health care from 22% of US physi-

cians, and these providers were less

likely to have access to subspecialists

and diagnostic tests.35 Community

hospitals have smaller intensive care

units with fewer ventilators and

trained personnel. Thus, efficient and

Recommendations Illustrative Examples

#1: Require the collection of race/ethnicity data with
COVID-19 reporting.

Race/ethnicity data regarding COVID-19 mortality
is released daily through city maps showing the
neighborhood density of COVID-19 burden.

#2: Utilize risk- and place-based strategies to
decrease COVID-19 exposure.

Partner hospitals and health departments work
with community-based organizations for
distribution of personal protective equipment and
food and to conduct contact tracing.

#3: Utilize risk- and place-based strategies to
increase COVID-19 testing.

Clients and staff in congregate settings (e.g.,
homeless shelters, nursing homes, senior
buildings) are targeted in high-risk Black and
Brown neighborhoods via aggressive testing and
contract tracing (30%–40% of Chicago’s COVID-19
mortality is from these settings).

#4: Repurpose ambulatory staff and infrastructure
for COVID-19 prevention, support, and monitoring.

Systematic outreach is being conducted to high-
risk patients for prevention, social needs, and
chronic disease management (with in-home
monitoring and medicine delivery) starting with
African American and Latinx patients from the
highest-risk zip codes.

#5: Use multisector collaboration to facilitate the
safe isolation and support of COVID-19 patients
from high-risk living conditions.

The city has established a partnership with the
Greater Chicago Food Depository to provide
additional support for food insecure persons from
high-risk zip codes.

#6: Implement city- and statewide plans to share
resources and patients across hospital systems.

Regionalization of the treatment of the sickest
COVID-19 patients is being accomplished by
transfer policies (such as the regionalization of
trauma) that allow safety net hospitals to transfer
their sickest patients to higher resourced hospitals,
often academic medical centers.

#7: Allocate scarce medical resources to reduce
racial inequities.

Allocation of remdesivir is based on current and
projected hospital caseloads of COVID-19 patients,
directing effective medications to hospitals serving
the hardest-hit African American and Latinx
communities.

Summary Recommendations and Illustrative Examples From
the Racial Equity Rapid Response Team of Chicago, Illinois

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data-driven resource sharing not only

advances distributive justice, but can

save lives. Some have suggested

protocols that use zip codes to assign

ventilators and other scarce re-

sources to ensure fair distribution

across communities based on need.36

Having statewide crisis care standards

reduces interhospital variability and

can facilitate dissemination of best-

practice updates from centers of ex-

cellence. Academic medical centers

and large hospital networks have the

ethical obligation to share testing,

personal protective equipment, and

other critical resources with smaller,

less-resourced hospitals to help

maximize patient and employee

safety and health. Finally, all hospitals

should commit to the comprehensive

care of coronavirus patients regard-

less of their ability to pay, and to

transferring patients across health

systems to align patient volume and

acuity with hospital capacity.

Recommendation #7: Allocate scarce

medical resources to reduce racial

inequities. Early in the pandemic, the

possibility that the health care system

would be overwhelmed was very real.

Although the United States has gen-

erally avoided widespread shortages

of critical care resources such as

ventilators, we will soon be faced with

allocation challenges concerning

novel therapies and vaccines.37,38 The

national conversation on the alloca-

tion of scarce health care resources

has focused on developing objective

priority scores, but there are growing

concerns that these algorithms would

be unfair to racial/ethnic minorities,

exacerbate mortality disparities, and

further undermine the African Amer-

ican community’s trust of physi-

cians.39,40 Priority scores that use

chronic diseases as part of their cal-

culations result in the disproportion-

ate assignment of lower scores to

African Americans in 2 distinct ways.

First, these scores may inaccurately

predict mortality risk for African

Americans (because there is variability

in life span associated with different

chronic diseases). Second, systemic

inequities have unfairly disadvantaged

African Americans by increasing their

chronic disease burden, which then

makes them less eligible for life-saving

resources. To date, these points have

been largely underrepresented in the

national conversation. Most plans

published thus far suggest ignoring

race and ethnicity,41,42 but these

proposals clearly will not address the

problem, as severity of illness and

chronic diseases are strongly corre-

lated with race. Although there may

be no single best answer, we must

consider potential options. With fair-

ness, distributive justice, and reci-

procity in mind, we suggest that (1)

predictive models used in scarce re-

source allocation systems be vali-

dated in minority populations (Miller

et al., unpublished data) and (2) ad-

ditional priority be given to persons

from marginalized populations. One

approach has been developed in

Pennsylvania, where individuals from

areas with high area deprivation

The majority of COVID-19–related deaths in Chicago are people of color. Though racial disparity in health care is a historic and ongoing problem in Chicago, the
intensity and immediate life-and-death impact of disparity during the COVID-19 crisis calls for an urgent and forceful response from the city. To help save the lives
of those most vulnerable and to mitigate effects from the crisis caused by racial disparities, the city mounted the Racial Equity Rapid Response—a data-driven,
community-based and community-driven mitigation of COVID-19 illness and death in African American and Latinx Chicago communities.

The goals of this endeavor are to

· Flatten the COVID-19 mortality curve in African American and Latinx communities in Chicago.
·Build a groundwork for future work to address long-standing and systemic inequities in African American and Latinx communities (health, economic, and social).
To meet these goals we will need to

· Develop a citywide community mitigation operation that works hyperlocally in partnership with African American and Latinx community organizers and
leadership to mitigate COVID-19 illness and death.

· Listen and respond to community-identified needs within the context of partnership that is mutual and centered around benefiting, not burdening, African
American and Latinx communities.

· Marshal data, screening tools, testing, and human resources needed to respond to community-identified barriers and needs.
The response is organized into 4 categories

· Education: Provide communication and updates that are relevant for residents and speak to realities of their lives.
· Prevention: Work to ensure residents have the resources and information needed to protect themselves and their families.
· Testing and treatment: Work alongside our health department to ensure the expansion of testing and treatment goes to areas in greatest need and lowers, or
eliminates, barriers to access.

· Support services and resources: Work to ensure people have access to supportive services and resources that sustain their livelihoods.

The Racial Equity Rapid Response of the City of Chicago, Illinois

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indices receive additional priority.43,44

This strategy seeks to address the

increased COVID-19 risk (and subse-

quent mortality) created as a primary

consequence of structural racism:

residential segregation and racialized

poverty.45 By considering economic

disadvantage rather than race in

general, this strategy allows a closer

alignment between identifying sub-

groups of high-risk populations

(among racial/minorities) for mitiga-

tion efforts.

SUMMARY AND
CONCLUSIONS

Our recommendations for reducing

COVID-19 disparities among African

Americans are based in public health

and bioethical principles designed to

promote the health of the most mar-

ginalized populations. It is our moral

obligation to right these wrongs.

Grounded in bioethical principles of

fairness, distributive justice, and reci-

procity, these recommendations include

required reporting of COVID-19 race/

ethnicity data; strategies to decrease

COVID-19 risk and increase COVID-19

testing; opportunities for health care

systems to repurpose infrastructure to

enhance COVID-19 prevention, support,

and monitoring; strategies for health

care systems to collaborate with other

health care systems, public health

agencies, and community-based orga-

nizations to share data, resources, and

patients; and suggestions to bring racial

equity to scarce resource allocation

protocols.

Our recommendations can reduce

racial disparities in COVID-19 outcomes

and also rebuild trust between African

Americans and the systems designated

to care for them. Sustained and

reciprocal community partnerships,

through community-engaged programs

and community-based participatory re-

search, will be a critical part of this re-

building, especially as we continue

implementing treatments (e.g., remde-

sivir, monoclonal antibodies) and make

plans for population-based COVID-19

vaccination.

It is important to note that this article

has explicitly focused on direct action

recommendations for health care delivery

and public health sectors. For example,

we do not address health insurance and

the need for millions of persons in the

United States to access insurance ex-

changes through the Affordable Care

Act. Nor do we address the disparate

impact that the growing economic

crisis is having on the African American

community and COVID-19 outcomes.

In addition, it is important to recognize

that we focused our attention on Af-

rican Americans, the group for which

the most data currently exist and

whose disparities have been most

highlighted in national discourse. Yet

other marginalized populations—the

Latinx community, low-income per-

sons, immigrants, and others—are also

suffering from COVID-19 disparities

because of structural inequities. Many

of our recommendations may apply to

those populations and communities as

well.

These recommendations require

leadership at the local, state, and federal

levels, and a willingness to engage

in difficult conversations about both

data and race. Indeed, the legacy

of racism remains our nation’s alba-

tross, posing some of the most fun-

damental challenges that we face

as a country. Our response determines

the health and hope not only for our

most vulnerable, but for us all. Ulti-

mately, we will rise or fall as a nation

based on how we empower and take

care of the most marginalized among

us. Chicago and other cities have be-

gun to answer this call. In less than

2 months, the proportion of African

American COVID-19 deaths in Chicago

decreased from 72% to 47% of the

total COVID-19 deaths.46 We can do

this. The choice is ours.

ABOUT THE AUTHORS

Monica E. Peek, Russell A. Simons, William F. Parker,
and Selwyn O. Rogers are with the University
of Chicago, Chicago, IL. David A. Ansell is with
the Department of Medicine, Rush University
Medical Center, Chicago. Brownsyne Tucker
Edmonds is with the Department of Obstetrics
and Gynecology, Indiana University School of
Medicine, Indianapolis.

CORRESPONDENCE

Correspondence should be sent to Monica E. Peek,
MD, MPH, MS, Section of General Internal Medicine,
The University of Chicago, 5841 S. Maryland Ave, MC
2007, Chicago, IL 60637 (e-mail: mpeek@medi-
cine.bsd.uchicago). Reprints can be ordered at
http://www.ajph.org by clicking the “Reprints”
link.

PUBLICATION INFORMATION

Full Citation: Peek ME, Simons RA, Parker WF, Ansell
DA, Rogers SO, Edmonds BT. COVID-19 among
African Americans: an action plan for mitigating
disparities. Am J Public Health. 2021;111(2):286–292.

Acceptance Date: September 20, 2020.

DOI: https://doi.org/10.2105/AJPH.2020.305990

CONTRIBUTORS

M. E. Peek and B. Tucker Edmonds performed ar-
ticle design, preparation, and editing. R. A. Simons
and W. F. Parker performed article preparation and
editing. D. A. Ansell and S. O. Rogers performed
article editing. All authors made significant intel-
lectual contributions.

ACKNOWLEDGMENTS

M. E. P. is supported by the National Institute of
Diabetes and Digestive and Kidney Diseases’ Chi-
cago Center for Diabetes Translation Research and
the Merck Foundation. M. E. P. and B. T. E. have re-
ceived grants from the Greenwall Foundation.
We thank Bernard Lo, MD, for his thoughtful

review of the article and helpful, constructive
feedback.

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mailto:mpeek@medicine.bsd.uchicago

http://www.ajph.org

https://doi.org/10.2105/AJPH.2020.305990

CONFLICTS OF INTEREST

The authors have no conflicts of interest to report.

HUMAN PARTICIPANT PROTECTION

This article was exempt from protocol approval
because it did not involve human participants or
primary data.

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COVID-19 Among African Americans: An Action Plan for Mitigating Disparities

RECOMMENDATIONS
SUMMARY AND CONCLUSIONS
ABOUT THE AUTHORS
CORRESPONDENCE
PUBLICATION INFORMATION
CONTRIBUTORS
ACKNOWLEDGMENTS
CONFLICTS OF INTEREST
HUMAN PARTICIPANT PROTECTION
REFERENCES

PREVENTING CHRONIC DISEASE
P U B L I C H E A L T H R E S E A R C H , P R A C T I C E , A N D P O L I C Y

V o l u m e 1 7 , E 8 3 A U G U S T 2 0 2 0

COMMENTARY

Community Engagement of African
Americans in the Era of COVID-19:

Considerations, Challenges, Implications, and
Recommendations for Public Health

Tabia Henry Akintobi, PhD, MPH1; Theresa Jacobs, MD2,3; Darrell Sabbs3,4; Kisha Holden, PhD, MSCR5;
Ronald Braithwaite, PhD1; L. Neicey Johnson, JD, RN, BSN3,6; Daniel Dawes, JD5; LaShawn Hoffman7,8

Accessible Version: www.cdc.gov/pcd/issues/2020/20_0255.htm

Suggested citation for this article: Henry Akintobi T, Jacobs T,
S a b b s D , H o l d e n K , B r a i t h w a i t e R , J o h n s o n L N , e t a l .
Community Engagement of African Americans in the Era of
COVID-19: Considerations, Challenges, Implications, and
Recommendations for Public Health. Prev Chronic Dis 2020;
17:200255. DOI: https://doi.org/10.5888/pcd17.2002

55.

PEER REVIEWED

Summary

What is already known on this topic?

African Americans are more likely to contract coronavirus disease 2019
(COVID-19), be hospitalized for it, and die of the disease when compared
with other racial/ethnic groups. Psychosocial, sociocultural, and environ-
mental vulnerabilities, compounded by preexisting health conditions, ex-
acerbate this health disparity.

What is added by this report?

This report adds to an understanding of the interconnected historical,
policy, clinical, and community factors associated with pandemic risk,
which underpin community-based participatory research approaches to ad-
vance the art and science of community engagement among African Amer-
icans in the COVID-19 era.

What are the implications for public health practice?

When considered together, the factors detailed in this commentary create
opportunities for new approaches to intentionally engage socially vulner-
able African Americans. The proposed response strategies will proactively
prepare public health leaders for the next pandemic and advance com-
munity leadership toward health equity.

Abstract
African Americans, compared with all other racial/ethnic groups,
are more likely to contract coronavirus disease 2019 (COVID-19),
be hospitalized for it, and die of the disease. Psychosocial, so-

ciocultural, and environmental vulnerabilities, compounded by
preexisting health conditions, exacerbate this health disparity. In-
terconnected historical, policy, clinical, and community factors ex-
plain and underpin community-based participatory research ap-
proaches to advance the art and science of community engage-
ment among African Americans in the COVID-19 era. In this
commentary, we detail the pandemic response strategies of the
Morehouse School of Medicine Prevention Research Center. We
discuss the implications of these complex factors and propose re-
commendations for addressing them that, adopted together, will
result in community and data-informed mitigation strategies.
These approaches will proactively prepare for the next pandemic
and advance community leadership toward health equity.

Introduction
Racial/ethnic minority populations have historically borne a dis-
proportionate burden of illness, hospitalization, and death during
public health emergencies, including the 2009 H1N1 influenza
pandemic and the Zika virus epidemic (1–4). This disproportion-
ate burden is due to a higher level of social vulnerability — “indi-
vidual and community characteristics that affect capacities to anti-
cipate, confront, repair, and recover from the effects of a disaster”
— among racial/ethnic minority populations than among non-
Hispanic White populations (5). These characteristics include, but
are not limited to, low socioeconomic status and power, predispos-
ing racial/ethnic minority populations in general and African
Americans in particular to less-than-optimal living conditions.
Some racial/ethnic minority populations are more likely than non-
Hispanic White populations to live in densely populated areas,
overcrowded housing, and/or multigenerational homes; lack ad-
equate plumbing and access to clean water; and/or have jobs that
do not offer paid leave or the opportunity to work from home
(6,7). These factors contribute to a person’s ability to comply with

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health
and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

This publication is in the public domain and is therefore without copyright. All text from this work may be reprinted freely. Use of these materials should be properly cited.

www.cdc.gov/pcd/issues/2020/20_0255.htm • Centers for Disease Control and Prevention 1

the mitigation mandates of the coronavirus disease 2019 (COVID-
19) pandemic established to reduce risk for infection, such as
physical distancing and sheltering in place (8).

The COVID-19 pandemic presents new challenges for public
health evaluators, policy makers, and practitioners, yet it mirrors
historical trends in health disparities and poor health outcomes
among African Americans. African Americans are more likely to
contract, be hospitalized, and die of COVID-19–related complica-
tions (9–12). Social vulnerability is often compounded by preex-
isting health conditions, exacerbated during times of crisis
(13–17).

Public health leaders are now at a critical juncture to advance
health equity among vulnerable African Americans. To advance
this health equity, we must first have a comprehensive understand-
ing of the factors that create health disparities and the factors that
can contribute to an effective, multilevel response. With this un-
derstanding, we can then deploy effective mitigation strategies
based on a community-based participatory research framework
that fosters and sustains community leadership in the assessment
and implementation of culturally appropriate and evidence-based
interventions that enhance translation of research findings for
community and policy change (18,19). The objective of this com-
mentary is to 1) detail the interconnected historical, policy, clinic-
al, community, and research challenges and considerations central
to comprehensively advancing the art and science of community
engagement among African Americans in the COVID-19 era; 2)
describe The Morehouse School of Medicine Prevention Research
Center (MSM PRC) pandemic response strategies, driven by
community-based participatory research (CBPR); and 3) discuss
community-centered implications and next steps for public health
action.

Challenges and Considerations
Historical context

Racial/ethnic health disparities have always existed in the United
States. Differential health outcomes between African Americans
and non-Hispanic White Americans have been part of the Americ-
an landscape for more than 400 years (20). Many measures of
health status have been used to assess differences among racial/
ethnic groups; more recently, health researchers have advanced
concepts and constructs of health equity and social determinants of
health (21). Reaching back to the mid-20th century, the US gov-
ernment documented that African Americans were far more likely
than non-Hispanic White Americans to have a wide range of po-
tentially fatal illnesses, including noncommunicable diseases such
as type 2 diabetes, asthma, end-stage renal disease, and cardiovas-
cular disease (21). In 1985, the US Department of Health and Hu-

man Services published the landmark Report of the Secretary’s
Task Force on Black and Minority Health, better known as the
Heckler report (21). The report documented an annual excess
60,000 deaths among African American and other racial/ethnic
minority populations. These underlying determinants can only res-
ult in disproportionately adverse health outcomes for racial/ethnic
minority populations during the COVID-19 pandemic.

The COVID-19 pandemic is intensified by the long-standing in-
come inequality between non-Hispanic White people and racial/
ethnic minority populations. Economists use the Gini coefficient
to measure income inequality. Values for this measure range from
0 to 1, with higher values representing greater income inequality.
From 1990 to 2018, the Gini coefficient in the United States rose
from 0.43 to 0.49 — an increase in income inequality. When in-
come disparities exist along with other disparities (eg, health in-
surance, employment, education, social justice, access to quality
health care), public health pandemics marginalize racial/ethnic
minority groups, and this marginalization requires a strong and
strategic response (22).

Policy landscape

Racial/ethnic minority populations are disproportionately affected
by COVID-19 (23), as they are by many diseases. In the United
States, African Americans, Hispanics/Latinos, Native Americans,
Native Hawaiians, and Pacific Islanders are more likely than other
racial/ethnic groups to die of COVID-19 (24). The pandemic has
not affected all populations equally for several reasons, including
social, behavioral, and environmental determinants of health. In
addition, economic and social policies have not benefitted all pop-
ulations equally. Obesity, asthma, depression, diabetes, heart dis-
ease, cancer, HIV/AIDS, and many other disorders that put vulner-
able populations at greater risk of dying of COVID-19 can often
be linked to a policy determinant (25). Air pollution; climate
change; toxic waste sites; unclean water; lack of fresh fruits and
vegetables; unsafe, unsecure, and unstable housing; poor-quality
education; inaccessible transportation; lack of parks and other re-
creational areas; and other factors play a large role in overall
health and well-being (26). These factors increase a person’s stress
and limit opportunities for optimal health (27). Too often, public
health researchers and practitioners stop at the social determinants
of inequities. These social determinants do, indeed, play an out-
sized role in these human-made inequities, but underlying each
one is a policy determinant that should be addressed to improve
health equity.

Consider, for example, the problem of asthma among many racial/
ethnic minority populations. One community, in East Harlem, one
of Manhattan’s poorest neighborhoods, found that a bus depot
caused the high rates of asthma among children who lived near it

PREVENTING CHRONIC DISEASE VOLUME 17, E83
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2020/20_0255.htm

(28). Six of 7 bus depots in Manhattan are located in East Harlem,
and East Harlem has the highest rate of asthma hospitalizations in
the country (29–31). In another community, the exhaust and dust
from the vehicles traveling a major highway that cut through the
middle of the community was found to contribute to the high rates
of asthma among residents who lived near it (32). In both of these
examples, an underlying policy determined the placement of the
bus depots and the highway, which led to the eventual health in-
equities.

Examples of how legislative and policy change can immediately
affect the social determinants of health are demonstrated in gov-
ernment and public responses during the first 3 months of the
COVID-19 pandemic in the United States. Federal, state, and loc-
al policies were implemented to stimulate local economies and in-
fuse communities with free food and direct revenue, including in-
creases in SNAP (Supplemental Nutrition Assistance Program) be-
nefits and expanded unemployment benefits. These initiatives
have helped communities and individuals during the crisis. Des-
pite these programs, however, some marginalized African Americ-
an communities have not benefitted. As the nation adjusts to the
“new normal,” it is imperative that the social, economic, and
health gaps in these communities also conform to a “new normal”
that is driven by new or expanded and sustained policies.

Clinical mechanisms, chronic conditions, and
increased risk of COVID-19

African Americans are twice as likely as non-Hispanic White
Americans to die of heart disease and 50% more likely to have hy-
pertension and/or diabetes (33,34). This elevated risk increases the
likelihood of other complications and death from COVID-19
(35,36). Let us consider, for example, people living with diabetes.
Their immune system is depressed overall, because their blood
glucose is not well controlled (hyperglycemia) (37). It is hypothes-
ized that hyperglycemia causes an increase in the number of a par-
ticular receptor in the lungs, pancreas, liver, and kidneys; this in-
crease impairs the function of white blood cells, which are de-
signed to fight off infections (37). This impairment predisposes
the person living with diabetes to an increased risk of bacterial and
viral infections. When severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) enters the lungs by way of this par-
ticular receptor, it overwhelms the alveoli (air sacs) in the lungs
and disables the exchange of oxygen and carbon dioxide (38). As
a result, some people with diabetes may need supplemental oxy-
gen, intubation, and/or admission to an intensive care unit (37).
Hyperglycemia in combination with a disease such as COVID-19
makes recovery difficult (37). People with diabetes who are in
good mental health, know the names and dosages of their medica-
tions, and know their blood pressure, blood glucose, and other
laboratory values, such as hemoglobin A1c, tend to have better

control of their disease and have lower levels of illness and death
(16,37). Emphasizing the importance of good blood glucose con-
trol to prevent diabetes complications and associated COVID-19
risk is more important now than ever (36–38). Mental health plays
a major role in a person’s ability to maintain good physical health
and optimally manage their chronic conditions, and mental ill-
nesses may affect the ability to participate in health-promoting be-
haviors (39).

Mental and behavioral health

The constellation of stressors triggered by the COVID-19 pandem-
ic undermines the nation’s mental health (40–42). Various disrup-
tions in daily life, coupled with the threat of contracting the deadly
virus, is leading some people to experience anxiety and depres-
sion, sometimes to the extreme. Reports of family violence and
use of suicide prevention hotlines have increased (43,44). Physic-
al distancing, shelter-in-place orders, business and school closures,
and widespread unemployment have radically changed ways of
life and contributed to a sense of hopelessness, isolation, loneli-
ness, helplessness, and loss (45,46). Pandemic-related factors, in-
cluding quarantine, have led to posttraumatic stress disorder, con-
fusion, and anger (47). One study indicated that a constant con-
sumption of media reports had detrimental psychological effects
on some people (48). If interrelated mental, behavioral, and emo-
tional issues are not adequately addressed, disorders among racial/
ethnic minority populations and other vulnerable populations (eg,
the medically underserved, homeless, and disabled; inmates in the
criminal justice system) will surge and exacerbate disparities (49).

Interrelated COVID-19–related stressors include childcare and
safety, elder care, food insecurity, and interpersonal relationships
(50). These stressors may trigger aspects of unresolved trauma.
Poor coping mechanisms (eg, use of illicit drugs, excessive alco-
hol consumption, overeating, inadequate sleep) may develop or
worsen. In addition to facing chronic stressors, communities of ra-
cial/ethnic minority populations often deal with the stigma associ-
ated with seeking mental and behavioral health care. A Surgeon
General’s report, Mental Health: Culture, Race, and Ethnicity,
concluded that racial/ethnic minority populations, compared with
the non-Hispanic White population, have less access to mental
health care, are less likely to receive treatment, and when treated,
often receive poorer quality of care (51). As a result, racial/ethnic
minority populations often have a greater burden of behavioral
disorder–related disability (51). Addressing the multifaceted men-
tal and behavioral health needs of racial/ethnic minority popula-
tions in the United States is a complex issue that warrants atten-
tion from clinicians, researchers, scientists, public health profes-
sionals, and policy makers. It is imperative to recognize the signi-

PREVENTING CHRONIC DISEASE VOLUME 17, E83
PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY AUGUST 2020
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

www.cdc.gov/pcd/issues/2020/20_0255.htm • Centers for Disease Control and Prevention 3

ficant role of community leaders in exploring solutions to COVID-
19–related mental and behavioral health problems among racial/
ethnic minority communities. Their lived experiences are central
to the co-creation of pandemic response strategies for these popu-
lations.

Perspectives of community leaders

The realities of research, evaluation, and clinically focused com-
munity engagement after the COVID-19 pandemic may change
for the foreseeable future. Efforts to initiate and sustain culturally
competent engagement of racial/ethnic minority groups previ-
ously relied on face-to-face interactions in homes, churches, and
other community settings. Social or physical distancing has nearly
stopped communities and their collaborators from real-time gath-
ering. These changes challenge the human need for connection and
in-person exchange. Although the adjustment has been difficult,
the pandemic has resulted in new modes of engagement. Webinar
and digital technology are now accessible for most people at low
or no cost. Many community residents have newfound capacities
to use technology for social and professional interactions as part of
daily life.

Current health communication and messaging require community-
informed improvements. The use of terms like sheltering in place,
social distancing, and flattening the curve do not naturally reson-
ate with many people. For some, these terms foster anxiety and
distrust of systems perceived to separate communities rather than
promote COVID-19 mitigation strategies. Community leaders, as
well as business and faith leaders, have found themselves in a
space of terminology and descriptions that are understood mostly
by public health practitioners. Therefore, health literacy and the
interpretation of current health conditions are vital.

The pandemic has intensified the economic strains among low-
income and moderate-income people and families (52). Low-wage
workers, many on the frontlines of the pandemic since it began,
have had little to no increase in income (53). African American
families who struggled to make ends meet before COVID-19 are
now facing dire economic circumstances in making the best de-
cisions for their families. Stressors include, but are not limited to,
deciding how to pay rent or a mortgage, paying for food, assisting
children with virtual learning, and protecting themselves with min-
imal or no health care benefits. The mental and behavioral health
implications of these problems, along with the economic and prac-
tical challenges, have made a fragile ecosystem even more un-
stable. Low-wage workers in hospitality, food service, and retail
industries cannot work from home. Workers who depend on
employer-provided health insurance now have the additional bur-
den of how to maintain health insurance coverage (54). Ulti-

mately, lack of adequate access to health care, along with the com-
plex realities of the COVID-19 pandemic, will increase health dis-
parities for socially vulnerable African American employees and
their families.

Local examples of COVID-19 response strategies
driven by community-based participatory research

The MSM PRC relies on a deeply rooted, community partnership
model that responds to the health priorities of vulnerable African
American residents before, during, and after public health emer-
gencies such as the COVID-19 pandemic. For more than 20 years,
the MSM PRC has applied dynamic CBPR approaches that focus
on prevention, establish partnerships between communities and re-
search entities, and are culturally tailored (6,55–57).

The MSM PRC capitalizes on community wisdom through a com-
munity coalition board (CCB) that has governed the center since
its inception. The CCB is composed of 3 types of members: neigh-
borhood residents (always in the majority), academic institutions,
and social service providers (58). Neighborhood residents hold the
preponderance of power, and all leadership seats and are at the
forefront of all implemented approaches. Neighborhood resident
members are intentionally recruited from census tracts with a high
incidence and prevalence of chronic and infectious diseases. The
communities served by the MSM PRC are majority (87%) Afric-
an American, have an average household income of $23,616, and
rank lowest among other local communities in other socioeconom-
ic conditions and community neighborhood health factors (55).

The MSM PRC has strategically partnered with the CCB and the
community to facilitate health research and related interventions
based on a comprehensive understanding of historical, political,
clinical, and community considerations. The community gov-
ernance model was developed to address CBPR challenges that
exist when academics are not guided by neighborhood leaders in
understanding a community’s ecology, when community mem-
bers do not lead discussions about their health priorities, and when
academics and neighborhood leaders do not work together as a
single body with established rules to guide roles and operations
(59,60).

The MSM PRC conducts a recurring (every 4 years) community
health needs and assets assessment (CHNA2) process through the
CCB, empowering community members to take on roles as cit-
izen scientists who develop locally relevant research questions and
identify priority health strategies (60). The recently completed
CHNA2 (February 2018) was co-led by neighborhood residents to
advance a community health agenda. Survey development, data
analyses, and response strategies are reviewed, monitored, and
evaluated by the CCB and its Data Monitoring and Evaluation

4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2020/20_0255.htm

Committee (55). This 7-member committee, established in 2011,
is designed to extend the CBPR engagement of CCB members in
the work of the MSM PRC. It exists through academic–com-
munity co-leadership (a CCB neighborhood resident member and
the MSM PRC assistant director of evaluation) of a group of CCB
members tasked with leading assessments. For CHNA2, members
met bimonthly (every other month, when the CCB did not meet) to
discuss and inform evaluation and data collection activities and
prepare for reporting of evaluation findings and interim results to
the broader CCB to determine corresponding respond strategies.
CHNA2 primary data included surveys administered to 607 com-
munity residents. The most frequently cited community health
concerns were diabetes, nutrition, high blood pressure, over-
weight/obesity, and mental health. County-level, top-ranking
causes of illness and death, including cardiovascular disease, dia-
betes, and mental health disorders, align with these community
perspectives (61).

CHNA2 is relevant, despite being administered before the out-
break of COVID-19. The chronic conditions and health problems
identified are those exacerbated by COVID-19 (diabetes, cardi-
ovascular disease, and mental health), thereby making their focus
even more relevant to the community.

The mental and behavioral health components of CHNA2 were
amplified to address the stress and anxiety caused by the pandem-
ic. First, during National Mental Health Awareness Month (May
2020), the MSM PRC convened a virtual forum, Our Mental and
Behavioral Health Matters. It was strategically designed to ad-
dress the culturally bound mental health stigma in racial/ethnic
minority communities that is due, in part, to the schism between
religion and therapy. The forum also addressed challenges related
to social isolation. Concerns centered on how to navigate a virtual
mental health checkup and support for parents seeking to help
their children process the realities of the pandemic and minimize
childhood trauma. Featuring psychologists, researchers, and
community- and faith-based pioneers, the forum engaged more
than 230 local and national participants. Second, a CCB member
representing Fulton County’s Department of Behavioral Health
and Developmental Disabilities helped the MSM PRC to develop
and disseminate an infographic on mental and behavioral health
services for insured and uninsured residents. Third, the MSM PRC
will offer annual Mental Health First Aid (62) trainings to com-
munity residents and professionals over the next 4 years.

The MSM PRC leads the Georgia Clinical and Translational Sci-
ence Alliance’s Community Engagement Program, which is de-
signed to advance community-engaged clinical and translational
research (63,64). The Program is led by a community steering
board adapted from the CCB model and includes co-leaders (fac-
ulty and staff, including a community health worker) from Emory

University, the Georgia Institute of Technology, and the Uni-
versity of Georgia. The program conducted a webinar, Community
Engagement in the Era of COVID — Opportunities, Challenges
and Lessons Being Learned, in May 2020. The webinar addressed
the challenges and opportunities associated with initiating or sus-
taining community-engaged research during physical-distancing
and shelter-in-place mandates. Clinicians, scientists, and com-
munity leaders from Atlanta, Athens, and Albany, Georgia, dis-
cussed uniquely nuanced issues for urban and rural community en-
gagement and the basic need for social connectedness through vir-
tual navigation of community engagement strategies (eg, via
Zoom) and newly expanded access to telehealth medical visits
(65). The webinar emphasized the importance of being a credible
source of COVID-19 information and linkage across social and
economic services, given heightened community anxiety and
preexisting mistrust of medical research.

The MSM PRC is a central collaborator in a national initiative led
by the National Center for Primary Care at Morehouse School of
Medicine and the Satcher Health Leadership Institute, also at
Morehouse School of Medicine. The National COVID-19 Resili-
ency Network is designed to mitigate COVID-19 in racial/ethnic
minority, rural, and socially vulnerable communities. The initiat-
ive will work with community organizations to deliver education
and information on resources to help fight the pandemic. The in-
formation network will strengthen efforts to link communities to
COVID-19 testing, health care services, and social services
through the institution’s leadership in policy, community engage-
ment, and primary care. The MSM PRC’s CCB model will be
scaled to collaborate with community organizations in highly af-
fected geographic areas to assess and inventory community assets
for COVID-19 testing, vaccination, and other health care and so-
cial services through a national community coalition board. The
MSM PRC CHNA2 model will also be scaled to inform mitiga-
tion approaches implemented by community-based organizations
through establishment of a centralized inventory of culturally ap-
propriate COVID-19 response strategies, by geography and popu-
lation vulnerability. Approaches will engage community health
workers, who are mission-critical stakeholders, nationally galvan-
ized, and locally deployed.

These MSM PRC activities are founded on long-standing,
community-partnered, and informed relationships in response to
preexisting health priorities that are simply heightened by the
COVID-19 pandemic. Ideally, this CBPR framework is estab-
lished before a public health crisis. This framework and the prac-
tice of identifying community needs and mobilizing strengths are
now poised, adapted, and scaled up in response to the COVID-19
pandemic. The continued evolution of the pandemic means that

www.cdc.gov/pcd/issues/2020/20_0255.htm • Centers for Disease Control and Prevention 5

these approaches and solutions must be flexible in response to
changing needs and new data.

Implications for Public Health
Public health practitioners, evaluators, policy makers, researchers,
and clinicians with a community-engaged mindset have long un-
derstood, grappled with, and proclaimed the complexities of health
disparities in the context of historic and current social determin-
ants (66). When considered together, the challenges and realities
detailed in this commentary create opportunities for new ap-
proaches to intentionally engage socially vulnerable African
Americans. The response strategies proposed below reflect the
complex web of historical and current policy and clinical, mental
and behavioral, and community factors. Use of a CBPR frame-
work undergirds all response strategies proposed.

Promote local community leadership to proactively inform
mitigation strategies. The importance of CBPR and related needs
assessments and response strategies are heightened during the
COVID-19 era. Health promotion for chronic conditions such as
diabetes, obesity, and cardiovascular diseases may have previ-
ously been structured to result in poor health or premature death
for racial/ethnic minority populations through reduced or nonexist-
ent access to health care; these conditions now require more im-
mediate attention because they increase vulnerabilities and risks
that can lead to poor health outcomes or death. Community know-
ledge, perceptions, and approaches to culturally responsive mitiga-
tion strategies must be prioritized. Carefully constructed local
community governance boards that include multidisciplinary lead-
ership (clinical, policy and social service, and research, among
others), should be formed to lead assessments toward community
and data-informed COVID-19 mitigation strategies for vulnerable
populations in highly affected geographic areas.

Strategically engage public health and community-attuned policy
leaders and prioritize community stimulus strategies. The political
landscape calls for public health leadership by mitigation re-
sponse teams (25). These teams are key informants from the be-
ginning of public health initiatives designed to mitigate the pan-
demic, and their engagement is essential. They will provide anoth-
er lens through which to examine the structures and processes that
enable inequities to systematically develop and flourish or be erad-
icated through community co-created responses.

The essential areas of policy for optimal community health are in
prioritized economic development, food security, and access to
health care protection for vulnerable African American communit-
ies. Collectively, these areas present opportunities for intervention
in response to chronic disease self-management (clinical), eco-
nomic strains (community), and health care protections (policy)

associated with the COVID-19 vulnerabilities of many African
American communities. These essential policy areas represent a
proposed foundation that rests on 4 “Es” hypothesized to narrow
disparity gaps and offer opportunities for self-sufficiency and
community resiliency.

Employ trained/certified, compensated community health workers, coaches,
and ambassadors who are charged with cultural messaging and education,
contact tracing, and surveillance toward increased adherence to policies on
physical distancing and sheltering in place.

•

Expand SNAP programs with vouchers to include the purchase of household
and personal care items rather than encouraging recipients to barter for ba-
sic care products.

•

Enhance school lunch programs so that all children receive high-quality, bal-
anced meals throughout the year, regardless of the ability to pay.

•

Ensure universal broadband internet access to reduce education, health
care, and information barriers.

•

Cultivate community-informed public health disaster health
literacy. Health literacy concepts, modes, and education must be
reframed. The media have newly exposed the lay public to the
realities of unequal treatment and unequal pandemic risk. The pub-
lic is, thereby, witnessing the more rapid connection between who
they are, where they live, and who is more likely to suffer from
and die of COVID-19. Marketing frameworks for community-
based prevention can be used to position community leaders to in-
form and lead health communication strategies. These marketing
frameworks will ensure that messages resonate, engage, and foster
action with objectivity and community/cultural sensitivity.

Foster culturally tailored behavioral and mental health dialogue
and response. Multidimensional prevention education strategies
that encourage resilience (positive adaptation to adversity) must be
promoted in African American communities. This promotion
should involve advocating for proactive self-care, reducing stigma,
and encouraging integrated health care. These strategies should be
promoted and proactively integrated as cross-cutting components
of any research and health initiative.

Prioritize patient-centered medical homes and neighborhood
models. Patient-centered medical home infrastructures that in-
clude models of integrated care (mental and behavioral health care
services in primary health care settings) can help overcome barri-
ers to comprehensive health care and overall wellness. This model
engages comprehensive resources to care for a patient, regardless
of race/ethnicity, sex/gender, sexual orientation, language, so-
cioeconomic status, or health insurance coverage. Primary care
providers are encouraged to incorporate this model into their prac-
tices to decrease illness and death among African Americans at
heightened risk of COVID-19 (67,68).

6 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2020/20_0255.htm

Redefine essential workers. Although the accomplishments of first
responders — physicians, nurses, scientists, and other people
fighting to preserve life — are laudable and undeniable, many
African American nonclinical frontline workers, such as mainten-
ance, janitorial, or food processing workers, are excluded from the
definition of essential workers. The social vulnerability of nonclin-
ical frontline workers, who often have chronic health conditions
that place them at particular risk for contracting COVID-19,
should be acknowledged and considered in planning.

Community and public health leaders in health care, behavioral
health, and policy must consider the implications of health inequit-
ies among racial/ethnic minority populations, seriously tackle their
root causes, and develop culturally responsive COVID-19
strategies for socially vulnerable African Americans. CBPR-
driven approaches that elevate marginalized communities as seni-
or partners in planning, implementing, and evaluating strategies
will promote community leadership and increase adherence to
health communication messages as the COVID-19 pandemic
evolves. Efforts should be characterized by strong data (research
or evaluation), contextually relevant community engagement
strategies, and action (policy, systems, and environmental change
approaches). The COVID-19 pandemic has presented an optimal
opportunity to reprioritize and sustain approaches toward advan-
cing community engagement of vulnerable African Americans.
These new approaches will prepare us for the next pandemic.
More importantly, they will foster CBPR leadership in advancing
health equity.

Acknowledgments
The project described in this commentary was completed through
the Morehouse School of Medicine Prevention Research Center,
Atlanta, Georgia. This project was supported through funding
from the Centers for Disease Control and Prevention (grant no.
1U58DP005945-01) and the National Center for Advancing
Translational Sciences of the National Institutes of Health (grant
no. UL1TR002378). We thank the Morehouse School of Medi-
cine Prevention Research Center and the leadership, faculty, staff,
and students at the Georgia Clinical & Translational Science Alli-
ance for assistance. We also acknowledge the Morehouse School
of Medicine Prevention Research Center Community Coalition
board members and residents for their leadership and invaluable
contributions to the CHNA2 process and elevation of its com-
munity governance model. No copyrighted materials were used in
the preparation of this article.

Author Information
Corresponding Author: Tabia Henry Akintobi, PhD, MPH,
Professor, Department of Community Health and Preventive
Medicine. Morehouse School of Medicine, 720 Westview Dr,
A t l a n t a , G A 3 0 3 1 0 . T e l e p h o n e : 4 0 4 – 7 5 2 – 1 1 4 4 . E m a i l :
takintobi@msm.edu.

Author Affiliations: 1Prevention Research Center, Morehouse
School of Medicine, Atlanta, Georgia. 2Georgia Primary Care
Association, Decatur, Georgia. 3Georgia Clinical and Translational
Science Alliance Community Steering Board, Atlanta, Georgia.
4Phoebe Putney Memorial Hospital, Albany, Georgia. 5Satcher
Health Leadership Institute, Morehouse School of Medicine,
Atlanta, Georgia. 6Visions, Incorporated, Atlanta, Georgia.
7Hoffman & Associates, Atlanta, Georgia. 8Morehouse School of
Medicine Prevention Research Center Community Coalition
Board, Atlanta, Georgia.

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Social and Psychological Consequences of the Covid-19 Pandemic in
African-American Communities: Lessons From Michigan

Rodlescia S. Sneed and Kent Key
Michigan State University

Sarah Bailey
Bridges Into the Future, Inc., Flint, Michigan

Vicki Johnson-Lawrence
Michigan State University

The mental health consequences of the COVID-19 pandemic are particularly relevant in African-
American communities because African-Americans have been disproportionately impacted by the
disease, yet they are traditionally less engaged in mental health treatment compared with other racial
groups. Using the state of Michigan as an example, we describe the social and psychological conse-
quences of the pandemic on African-American communities in the United States, highlighting commu-
nity members’ concerns about contracting the disease, fears of racial bias in testing and treatment,
experiences of sustained grief and loss, and retraumatization of already-traumatized communities.
Furthermore, we describe the multilevel, community-wide approaches that have been used thus far to
mitigate adverse mental health outcomes within our local African-American communities.

Keywords: community mental health, trauma, racial disparities, coronavirus, population health

African-American communities in the state of Michigan have
been disproportionately impacted by the coronavirus 2019
(COVID-19) pandemic. Despite making up only 13% of Michi-
gan’s population, African Americans account for 32% of con-
firmed cases and 41% of pandemic related-deaths (Michigan De-
partment of Health and Human Services, 2020). In Michigan’s
primarily African-American communities, more than 10% of
COVID-19 cases end in death (Michigan Department of Health
and Human Services, 2020). A disease that was initially thought to
mostly impact older adults and the chronically infirmed has now
become a national scourge, devastating African-American com-
munities across the United States.

From a mental health perspective, the pandemic has heightened
fear in a segment of the population that already faces significant
barriers to mental health treatment. Despite having rates of mental

illness similar to Whites, African Americans experience significant
disparities in mental health treatment engagement. Among those
with any mental illness, only 31% of African Americans receive
treatment, compared with 48% of Whites (Agency for Healthcare
Research and Quality, 2016). Furthermore, when African Ameri-
cans do receive treatment, it is often due to serious mental illness
requiring hospitalization rather than mild or moderate illness that
can be managed in an outpatient setting. African Americans are
less likely than Whites to have ongoing relationships with mental
health providers; rather, they are more likely to engage with the
mental health care system through emergency departments and
primary care visits (U.S Surgeon General, 2001). These disparities
are likely due to greater stigma surrounding mental illness, lack of
culturally competent mental health care providers, general distrust
of the health care system, and lack of insurance/underinsurance
(American Psychiatric Association, 2017). Thus, any adverse men-
tal health impacts of the pandemic may be particularly devastating
in African-American communities because of these preexisting
disparities in engagement.

Fear of contracting the virus is high in African-American com-
munities. Population-based surveys estimate that 33% of African
Americans are very concerned that they will get COVID-19 and
require hospitalization, compared with only 18% of Whites. Fur-
thermore, African Americans are 2 times more likely than Whites
to know someone who has been hospitalized or has died because
of COVID-19 (Pew Research, 2020). Fear of the disease is per-
vasive, even for those whose social networks have not yet been
impacted because news stories produced by most local and na-
tional news outlets since March have focused on COVID-19, often
with photos and anecdotes featuring African Americans who have
been impacted by the disease. Consequently, many African Amer-
icans have begun to experience a form of vicarious trauma because

Editor’s Note. This commentary received rapid review due to the time-
sensitive nature of the content. It was reviewed by the Journal Editor.—KKT

This article was published Online First June 11, 2020.
X Rodlescia S. Sneed, Department of Family Medicine, and Division of

Public Health, College of Human Medicine–Flint, Michigan State Univer-
sity; X Kent Key, Division of Public Health, College of Human
Medicine–Flint, Michigan State University; Sarah Bailey, Bridges Into the
Future, Inc., Flint, Michigan; Vicki Johnson-Lawrence, Department of
Family Medicine, and Division of Public Health, Michigan State Univer-
sity, College of Human Medicine–Flint, Michigan State Universit

Correspondence concerning this article should be addressed to Rodlescia
S. Sneed, Division of Public Health, College of Human Medicine–Flint,
Michigan State University, 200 East First Street, Flint, MI 48502. E-mail:
sneedrod@msu.edu

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Psychological Trauma:
Theory, Research, Practice, and Policy

446

– 448
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000881

446

https://orcid.org/0000-0001-7732-6197

https://orcid.org/0000-0002-1625-7463

mailto:sneedrod@msu.edu

http://dx.doi.org/10.1037/tra0000881

they repeatedly witness the pain and suffering of those who look
like them. This type of trauma can lead to both emotional and
physical symptoms, including symptoms of anxiety, helplessness,
nausea, and headache.

In addition to fearing disease, many African-American commu-
nity members fear racial bias and discrimination in disease testing
and treatment. Racial bias in health care is well documented and
thought to contribute to a range of racial health disparities, includ-
ing higher rates of maternal mortality (Bryant, Worjoloh, Caughey,
& Washington, 2010) and poor pain-related outcomes among
African Americans (Meghani, Byun, & Gallagher, 2012). Both
empirical and anecdotal evidence suggest that African Americans
presenting with symptoms of upper respiratory infection (e.g.,
cough, fever) have been less likely to get tested for COVID-19
than their White counterparts (Rubix Life Sciences, 2020). Addi-
tionally, there have been fewer testing centers located in African-
American neighborhoods, further suggesting bias or discrimina-
tion in testing. Even after testing positive, many African
Americans fear that they may not receive life-saving assistance if
they experience severe disease. As medical centers become over-
whelmed with COVID-19 patients, some have suggested limiting
advanced care protocols for patients with less chance of recovery,
such as those with underlying comorbidities. Given that African
Americans have greater prevalence of chronic health conditions,
many fear being denied care because of discriminatory assump-
tions about their likelihood of survival. In epidemiological studies,
such perceived racial discrimination has been linked to numerous
adverse mental health outcomes, including greater self-reported
symptoms of depression, anxiety, and psychological distress
(Lewis, Cogburn, & Williams, 2015). Perceived racial discrimina-
tion has also been associated with greater clinical diagnosis of
posttraumatic stress disorder, generalized anxiety, and major de-
pressive disorder (McLaughlin, Hatzenbuehler, & Keyes, 2010).

Because of overrepresentation in the death tolls, Michigan’s
African-American communities are also managing significant
stress related to grief and loss. Social media sites have become
online obituary sections as community members mourn the deaths
of their friends and family members. Community members no
longer ask, “Will someone I know die of the virus?” Instead the
question has now become, “Who will die next of the virus?”
Residents are not just experiencing one loss—they are experienc-
ing multiple losses within a brief period, resulting in grief over-
load. This type of cumulative grief is known to increase risk of
pain-numbing avoidance behaviors (e.g., substance use, disordered
eating) and prolonged grief disorders.

As they cope with grief and loss, community members are not
able to engage in many sociocultural practices that facilitate cop-
ing. For example, current social-distancing measures have halted
observance of common funeral traditions. African-American fu-
neral traditions play an important role in managing community
grief and loss. These primarily Christian traditions celebrate death
as a homegoing rather than an ending. Large floral arrangements,
celebratory music, and lengthy processions to the burial site are the
norm as friends and family near and far gather to comfort grieving
family members and share anecdotes about the deceased. Such
traditions offer honor and respect in death to those who (because
of their racial or socioeconomic background) may have had little
social standing in life. In this COVID-19 era, loved ones who die
are buried quickly, often only in the presence of a minister and a

mortician. The loss of this tradition funeral ritual disrupts the grief
process, impacting how loved ones process the reality of the death,
express painful thoughts and feelings, and reconcile the meaning
of life and death. This disruption of the grief process further
increases risk of prolonged grief disorders and bereavement-
related depression.

Finally, the pandemic has unfolded within African-African com-
munities that have already experienced significant community
trauma. April 25, 2020, marked the sixth anniversary of the Flint
Water Crisis, a public health emergency that exposed residents to
lead in the municipal water supply, devastating Flint, Michigan, a
city that is 56% African American. In the aftermath of the crisis,
residents experienced significant adverse mental health outcomes.
In 2016 (the year when the crisis was publicly acknowledged),
23% of households reported unmet mental health needs, 29% of
individuals self-reported symptoms of depression, and 33% of
individuals self-reported symptoms of anxiety (Fortenberry et al.,
2018). Although public health efforts since 2016 have led to
improvements, residents still report poor mental health outcomes
compared with the rest of the state of Michigan more than 3 years
later. Even today, residents are afraid to use water from the
municipal supply for drinking, cooking, or bathing. For residents,
the uncertainty surrounding COVID-19 is reminiscent of the Flint
Water Crisis because it similarly ignites fear and mistrust of
government to protect the public against a health-related disaster.
With COVID-19, Flint residents are being retraumatized while still
managing the fallout from the water crisis. This experience of
multiple long-lasting traumatic events can lead to extreme emotion
dysregulation and a range of biological changes and stress re-
sponses that can result in notable mental and physical health
problems.

Effective management of the mental health sequelae of the
pandemic in African-American communities requires a multilevel,
community-wide approach led by culturally sensitive mental
health professionals, including those specifically skilled in helping
people maneuver through grief, loss, and trauma. This mental
health engagement must be supported by community resources to
reach those who may never seek formal care on their own. Fur-
thermore, directly addressing the valid public health threat of the
pandemic in African-American communities through education,
testing, and treatment is crucial for ultimately improving mental
health outcomes.

In Michigan, many steps have been taken to improve outcomes
within African-American communities. State and local leaders
have acknowledged the racial disparities in COVID-19 –related
outcomes and have formed diverse multisector task forces to
address issues of racial bias related to testing, diagnosis, and
treatment. Weekly videoconferences and webinars sponsored by
community groups and academic institutions have increased the
dissemination of relevant disease-related information. The
African-American faith community has been instrumental in pro-
viding support to community members, conducting religious ser-
vices via videoconferencing and social media sites, dispatching
church leaders to conduct wellness checks for vulnerable residents,
and referring residents for support services. Specific services sup-
porting mental health have also been activated. Local public men-
tal health providers, with additional federal funding, have devel-
oped virtual crisis centers to support mental health and substance
abuse screening and to mitigate treatment engagement barriers

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447AFRICAN-AMERICAN MENTAL HEALTH AND COVID-19

common in African-American communities. Local community
leaders (in collaboration with academic clinical psychologists and
public health professionals) are conducting virtual support groups
and sessions, targeting those who may not be in crisis but who may
benefit from a supportive environment to discuss their fears and
stressors. Additionally, evidence-informed models for processing
stress and trauma are being used in nonclinical community spaces.
These include mindfulness-based stress reduction and the Com-
munity Resiliency Model, a biologically based approach that
teaches a set of wellness skills designed to reduce the physical
sensations of stress and trauma (Grabbe & Miller-Karas, 2018;
Miller-Karas, 2015). All of these supports and services are de-
signed to be culturally appropriate, recognizing how African-
American cultural practices and traditions may impact mental
health engagement. Furthermore, they are trauma informed, with
sensitivity to the notion that the pandemic itself is an ongoing
traumatic event that may retrigger trauma-related memories and
feelings of powerlessness. As the pandemic endures, these ap-
proaches must be reviewed and refined to ensure optimal mental
health and well-being within African-American communities.

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Pew Research. (2020). Health concerns from COVID-19 much higher
among Hispanics and Blacks than Whites. Retrieved from https://www.
people-press.org/2020/04/14/health-concerns-from-covid-19-much-
higher-among-hispanics-and-blacks-than-whites/

Rubix Life Sciences. (2020). Covid-19 and minority health access. Re-
trieved from https://rubixls.com/2020/04/01/health-data-in-the-covid-
19-crisis-how-racial-equity-is-widening-for-patients-to-gain-access-to-
treatment/

U.S. Surgeon General. (2001). Mental health: Culture, races, and ethnic-
ity—A supplement to mental health: A report of the Surgeon General.
2001. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK44243/

Received April 30, 2020
Revision received May 18, 2020

Accepted May 18, 2020 �

448 SNEED, KEY, BAILEY, AND JOHNSON-LAWRENCE

https://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html

https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-African-Americans

http://dx.doi.org/10.1016/j.ajog.2009.10.864

http://dx.doi.org/10.1017/S1049023X18000250

http://dx.doi.org/10.1146/annurev-clinpsy-032814-112728

http://dx.doi.org/10.2105/AJPH.2009.181586

http://dx.doi.org/10.1111/j.1526-4637.2011.01310.x

https://www.michigan.gov/coronavirus/0,9753,7-406-98163_98173-,00.html

http://dx.doi.org/10.4324/9780203134115

https://www.people-press.org/2020/04/14/health-concerns-from-covid-19-much-higher-among-hispanics-and-blacks-than-whites/

https://rubixls.com/2020/04/01/health-data-in-the-covid-19-crisis-how-racial-equity-is-widening-for-patients-to-gain-access-to-treatment/

https://www.ncbi.nlm.nih.gov/books/NBK44243/

Social and Psychological Consequences of the Covid-19 Pandemic in African-American Communities: …

References

Perspective

T h e N EW ENGL A N D JOU R NA L o f M EDICI N E

november 26, 2020

n engl j med 383;22 nejm.org november 26, 2020 e121(1)

The only way out of today’s misery is for peo-ple to become worthy of each other’s trust.— Albert Schweitzer
As the race to develop a vaccine
for Covid-19 has reached phase 3
clinical trials, concerns are in-
creasing about the low rates of
trial participation in important
subgroups, including Black com-
munities. Recent data show that
although Black people make up
13% of the U.S. population, they
account for 21% of deaths from
Covid-19 but only 3% of enrollees
in vaccine trials. This problem
threatens both the validity and
the generalizability of the trial re-
sults and is of particular concern
in vaccine trials, in which differ-
ences in lifetime environmental
exposures can result in differenc-
es in immunologic responses that
could affect both safety and effi-
cacy. Despite long-standing calls
from the Food and Drug Admin-

istration (FDA) and the National
Institutes of Health (NIH) to im-
prove the participation of under-
represented subgroups in drug
trials, the problem persists.1

What are the barriers to great-
er participation of Black people
in Covid-19 trials? Although they
are multiple, a critical factor is the
deep and justified lack of trust
that many Black Americans have
for the health care system in gen-
eral and clinical research in par-
ticular. This distrust is often traced
to the legacy of the infamous syphi-
lis study at Tuskegee, in which
investigators withheld treatment
from hundreds of Black men in
order to study the natural history
of the disease. But the distrust is
far more deeply rooted, in centuries
of well-documented examples of

racist exploitation by American
physicians and researchers.2

How can these long-standing
barriers to trust be overcome? The
presidents of Dillard and Xavier
Universities, two of the 104 his-
torically Black colleges and uni-
versities (HBCUs) in the United
States, recently wrote to their com-
munities saying that they them-
selves were participating in one
of the vaccine trials and asking
their students, faculty, and staff
to consider doing the same. The
pushback from parents of some
students came quickly. One wrote
on Xavier’s Facebook page, “Our
children are not lab rats for drug
companies. I cannot believe that
Xavier is participating in this.
This is very disturbing given the
history of drug trials in the black
and brown communities.”3

Presidents of the four histori-
cally Black U.S. medical schools
recently called for measures to in-
crease the participation of Black

Trustworthiness before Trust

— Covid-19 Vaccine Trials
and the Black Community
Rueben C. Warren, D.D.S., Dr.P.H., M.Div., Lachlan Forrow, M.D., David Augustin Hodge, Sr., D.Min., Ph.D.,
and Robert D. Truog, M.D.

Trustworthiness before Trust

P E R S P E C T I V E

e121(2)

Trustworthiness before Trust

n engl j med 383;22 nejm.org november 26, 2020

patients in clinical trials, correctly
arguing that without such involve-
ment, “there will be no proof that
our patients should trust the vac-
cine.” The presidents added that
“Black doctors are the best way to
build trust in our communities”
and called on other HBCUs to join
the effort to “foster trust in com-
munities throughout the country.”4

Though we applaud these ef-
forts, we fear that once again the
responsibility for addressing the
sequelae of centuries of racism is
falling on Black people themselves.
Our country has yet to compre-
hend adequately that overcoming
racism is not primarily the re-
sponsibility of Black people; the
racist ideas and practices that
constitute today’s “structural rac-
ism” were created, and have been
sustained, primarily by White peo-
ple. It would be wrong, as well as
ineffective, to ask Black commu-
nities to simply be more trusting.
Clinicians, investigators, and phar-
maceutical companies must pro-
vide convincing evidence — suf-
ficient to overcome the extensive
historical evidence to the contrary
— that they are, in fact, trust-
worthy.

What can we do to earn and
deserve increased trust?

First, trial sponsors and regu-
latory agencies can ensure that
the informed-consent process is
exemplary, including ensuring that
all relevant aspects of the design
and conduct of the clinical trials
are maximally transparent.

Second, all clinical research
depends on people who are will-
ing to accept the risks posed by
trial participation in order to im-
prove health for the people who
come after them. Black partici-
pants who agree to enroll in these
trials have a right to expect and
trust that Black communities will

have fair access to vaccines once
they become available. The recent
guidelines from the National
Academy of Sciences (NAS) are no-
table in this regard, recommend-
ing that priority be given to “peo-
ple who are considered to be the
most disadvantaged or the worst
off,” as defined by measures such
as the Social Vulnerability Index
created by the Centers for Disease
Control and Prevention.5 Though
this approach would not directly
target people in specific racial or
ethnic groups, it is functionally
antiracist in that it prioritizes peo-
ple who have suffered from the
social determinants of poor health
that are unfortunately prevalent
in many Black communities.

Third, politicization of the vac-
cine trials has engendered wide-
spread mistrust among the gen-
eral public. The joint pledge by
nine pharmaceutical companies
that they will “stand with science”
and not submit a vaccine for ap-
proval until it has been thorough-
ly vetted for safety and efficacy is
welcome, but earning trust will
require credible evidence that this
pledge is being honored. Just as
important, however, is that the ev-
idence must not only be convinc-
ing to the general public, but —
in the words of the NAS guidelines
— also be perceived as convinc-
ing “by audiences who are socio-
economically, culturally, and ed-
ucationally diverse, and who have
distinct historical experiences with
the health system.”5

Fourth, to earn and deserve
trust from prospective trial partici-
pants, we must ensure that they
will receive appropriate medical
care if they are injured as a result
of receiving an experimental vac-
cine. In addition to often lacking
access to health care, Black peo-
ple are also disproportionately

likely to be uninsured, and phar-
maceutical sponsors in the Unit-
ed States are not required to pro-
vide compensation to people who
experience research-related inju-
ries. Even when participants have
insurance, there is no guarantee
that they will be covered for such
injuries. In many cases, injured
participants will be forced to rely
on the tort system for compensa-
tion — a situation that is morally
indefensible, especially for par-
ticipants who lack the means to
engage in this time-consuming
and expensive process. One way
to demonstrate trustworthiness
would be for the pharmaceutical
companies sponsoring these tri-
als to establish a fund to guaran-
tee health care coverage and death
benefits to patients and families
as compensation for serious vac-
cine injuries or possible deaths.

When Covid-19 vaccines are
eventually approved by the FDA,
their success in Black and other
communities will depend on
whether members of these com-
munities not only trust that they
are safe and effective, but also
believe that the organizations of-
fering them are trustworthy. Trust
could be earned more quickly by
a collaboratively designed Opera-
tion Build Trustworthiness that
matches the seriousness and scope
of Operation Warp Speed. To be
effective, this effort would need
to be firmly grounded in grass-
roots involvement of individuals
and organizations with solid, well-
earned reputations for trustwor-
thiness in Black and other mi-
nority communities, including
respected elected representatives,
trusted local and national faith
leaders, community advocates, and
others. Active, ongoing, and fully
bidirectional collaboration, learn-
ing, and communication will be

P E R S P E C T I V E

e121(3)

Trustworthiness before Trust
n engl j med 383;22 nejm.org november 26, 2020

essential. Time is running short,
and trustworthiness, not trust,
must be our first and most ur-
gent priority.

Disclosure forms provided by the au-
thors are available at NEJM.org.

From the National Center for Bioethics in
Research and Health Care, Tuskegee Uni-
versity, Tuskegee, AL (R.C.W., D.A.H.); and
the Center for Bioethics, Harvard Medical
School, Boston (L.F., R.D.T.).

This article was published on October 16,
2020, at NEJM.org.

1. Warren RC, Shedlin MG, Alema-Mensah
E, Obasaju C, Augustin Hodge D. Clinical
trials participation among African Ameri-
cans and the ethics of trust: leadership per-
spectives. Ethics Med Public Health 2019; 10:
128-38.
2. Washington HA. Medical apartheid: the
dark history of medical experimentation on
Black Americans from colonial times to the
present. New York: Doubleday, 2006.
3. Moss W. Parents concerned about vac-
cine study taking place at some HBCUs:
remembering the Tuskegee experiment.
HBCUConnectcom. September 3, 2020
(https://hbcuconnect . com/ content/ 359255/
parents – concerned – about – vaccine – study

– taking – place – at – some – hbcus – remembering
– the – tuskegee – experiment).
4. Frederick WAI, Montgomery Rice V, Car-
lisle DM, Hildreth JEK. We need to recruit
more Black Americans in vaccine trials. New
York Times. September 11, 2020 (https://
www . nytimes . com/ 2020/ 09/ 11/ opinion/
vaccine – testing – black – americans . html).
5. National Academies of Sciences, Engi-
neering, and Medicine. Framework for equi-
table allocation of COVID-19 vaccine. Wash-
ington, DC: National Academies Press,
2020.

DOI: 10.1056/NEJMp2030033
Copyright © 2020 Massachusetts Medical Society.Trustworthiness before Trust

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

1 Department of Health and Human Performance, College of Charleston,
Charleston, SC, USA

2 Department of Health Sciences, James Madison University, Harrisonburg,
VA, USA

3 Department of Health Behavior and Health Systems, University of North
Texas Health Science Center, Fort Worth, TX, USA

4 Department of Anthropology, Rollins College, Winter Park, FL, USA
5 Department of Social and Behavioral Sciences, College of Public Health,
Temple University, Philadelphia, PA, USA

Corresponding Author:
Sarah B. Maness, PhD, College of Charleston, Department of Health and
Human Performance, 24 George St, Charleston, SC 29401, USA.
Email: manesssb@ cofc. edu

Commentary

Public Health Reports
2021, Vol. 136(1) 18-22

sagepub. com/ journals- permissions
DOI: 10. 1177/ 0033 3549 20969169

journals. sagepub. com/ home/ phr

Social Determinants of Health and
Health Disparities: COVID-19 Exposures
and Mortality Among African American
People in the United States

Sarah B. Maness, PhD1 ; Laura Merrell, PhD2; Erika L. Thompson, PhD3 ;
Stacey B. Griner, PhD3 ; Nolan Kline, PhD4; and Christopher Wheldon, PhD5

The coronavirus disease 2019 (COVID-19) pandemic in the
United States provides yet another example of the enduring
and pernicious effect of social determinants of health (SDH)
on African American communities. SDH, as defined by the
Healthy People 2020 SDH framework, include domains of
economic stability, education, social and community con-
text, health and health care, and neighborhood and built
environment.1 Within each domain, key areas represent ele-
ments of focus for the decade (Box). Compared with non-
Hispanic White people, African American people have
higher rates of COVID-19 cases (2.6 times higher), hospital-
ization (4.7 times higher), and death (2.1 times higher).2-4
Although the pandemic is ongoing, it is not premature to call
attention to the root causes of health inequity in the United
States that have persisted for decades and are being high-
lighted in the current crisis.

The disparities in COVID-19 case fatality rates between
African American and White people have been referred to
as a “perfect storm.”5 Such a comparison obfuscates the
larger social and political circumstances that structure poor
health. Unlike a storm, which is a natural phenomenon that
cannot be prevented, the higher rate of COVID-19 deaths
among African American people was predictable and pre-
ventable because of racial injustice. These deaths were pre-
dictable because of the long history of health inequities in
the United States and preventable through systemic changes
to eliminate systemic racism and improve SDH. The social
and political will needed to correct these injustices histori-
cally has been, and continues to be, lacking. SDH underlie
health disparities that increase the potential for exposure to,
and higher death rates from, COVID-19 among African
American people across the United States.2-4 We provide a
framework- based explanation on how systemic racism
gives rise to differences in SDH that affect differences in
health outcomes, including COVID-19, and make a call for
change.

Social Determinants of Health and
Systemic Racism

We begin by outlining how systemic racism influences SDH
using the Healthy People 2020 Social Determinants of
Health Framework.1 SDH have been shown to contribute to
a wide range of health disparities in the United States and are
interrelated with systemic racism.1 We define systemic rac-
ism as the exploitative and discriminatory practices, unjustly
gained resources and power, and maintenance of major
resource inequalities by ideological and institutional mecha-
nisms that are controlled by White people.6 Systemic racism
underlies many aspects of SDH.

Education

Although the racist practice of educational segregation for-
mally ended in public schools in 1954, the residual effects
remain in our current educational system.7-9 Race/ethnicity,
class, and neighborhood are highly interrelated in the United
States, from where children attend school to the quality of
schools.10 African American children, on average, attend
schools where they are of the majority race, yet they also
disproportionately attend schools with the highest poverty
concentrations and lower- than- average test scores.11 Data

mailto:manesssb@cofc.edu

https://journals.sagepub.com/home/phr

https://orcid.org/0000-0003-0757-7972

https://orcid.org/0000-0002-7115-0001

https://orcid.org/0000-0002-2774-5841

http://crossmark.crossref.org/dialog/?doi=10.1177%2F0033354920969169&domain=pdf&date_stamp=2020-11-11

Maness et al 19

from fall 2015 indicate that 58% of African American stu-
dents (vs 5% of White students) enrolled in public schools
attended a school in which the combined enrollment of
racial/ethnic minority students was at least 75% of enroll-
ment.12 Disparities among African American people in edu-
cation persist into adulthood: fewer African American people
than White people enroll in college and complete a bache-
lor’s degree (26.1% vs 40.1%), which leads to income
inequalities across the lifecourse.13

Economic Status
African American people have been disproportionately affected
economically through practices of systemic racism that have
made it difficult for them to accumulate wealth over genera-
tions.14 Wealth is the total market value of all assets available to
an individual or family.15 It is created over time and has inter-
generational effects that perpetuate, provide opportunities, and

allow for the pursuit of education and increased choice in
employment. Creating wealth is particularly challenging for
African American people for multiple reasons, including sys-
temic racism that exists in employment, hiring practices, pay,
housing discrimination, and the justice system.16 African
American adults are more likely to be unemployed (11.8% men,
10.1% women) than non- Hispanic White adults (5.1% men,
4.6% women), even when controlling for differences in educa-
tion, age, and experience (data averaged from 1994 to 2016).16

Housing
Quality and stability of housing are important for human health.
Systemic racism historically has manifested in segregation and
housing discrimination in the form of “redlining.” Redlining is
the systematic denial of services (banking, insurance, health
care, retail) by the government and/or private sector to residents
of specific neighborhoods (typically based on racial/ethnic
composition), either directly or through selectively raising
prices for certain neighborhoods. A result of redlining is the de
facto racial segregation of neighborhoods, which shapes social
conditions for individuals and communities and underlies the
health disparities between African American people and White
people.17 Despite federal and state legislation to combat these
racially motivated practices, redlining is perpetuated through
the weakening of federal protections for fair financial lending,
the reduction of federal funding for community investment, and
current zoning practices, all of which disproportionately affect
African American people.18,19 The effects of these practices are
seen in the intersection of place, race, and health disparities in
chronic conditions.

Former and current redlining practices continue to shape the
built environment of predominantly African American neigh-
borhoods. African American neighborhoods are more likely
than neighborhoods of other racial/ethnic composition to be
exposed to poisonous toxins and chemicals such as lead.20 One
example is the water crisis in Flint, Michigan, where 54% of the
population is African American and 40% of the total population
lives below the federal poverty level.21,22

Community
Injustices rooted in systemic racism have been noted at every
level of the US criminal justice system, including policing, pre-
trial detention, sentencing, parole, and post- parole.23 As a result
of inequitable processes across all levels of the criminal justice
system, African American people are incarcerated at more than
5 times the rate of White people and receive longer sentences.23
In addition to injustices concomitant with the broader criminal
justice system, African American people are also more likely to
encounter lethal force from law enforcement officers than their
non- Hispanic White or Hispanic counterparts.24 Furthermore,
some police practices, such as “stop and frisk,” target African
American people. Such practices constitute a public health
problem because they perpetuate stress and trauma by

Box. Healthy People 2020 Social Determinants of Health
Framework1

Social determinants of health domains and key areas

Economic stability

Poverty

Employment

Food security

Housing stability

Education

High school graduation

Enrollment in higher education

Language and literacy

Early childhood education and development

Social and community context

Social cohesion

Discrimination

Civic participation

Incarceration

Health and health care

Access to health care

Access to primary care

Health literacy

Neighborhood and built environment

Access to healthy foods

Crime and violence

Environmental conditions

Quality of housing

Public Health Reports 136(1)20

translating Blackness into deviance.25 Mass incarceration not
only affects the people in the criminal justice system, it also
affects the families and communities left behind by causing
family disruptions, financial strain, and emotional
difficulties.26

Access to Health Care
The experience of the health care system may further exacer-
bate risks for mortality among African American people as a
result of systemic racism. Implicit bias on the part of health
care providers may affect clinical decision making in diagno-
sis, treatment, pain management, and referral.27 As a result,
the prevention and management of chronic morbidities are
affected. Persistent and well- documented inequities exist in
access to health care among African American people.
Compared with non- Hispanic White people, African
American people are less likely to be insured28 and, even
with access to health care, are less likely to use health care
services because of a distrust in health care providers rooted
in a history of systemic racism in health care.29

Social Determinants of Health and
Health Disparities Among African
American People

We now focus on how differences in SDH that are rooted in
systemic racism are responsible for persistent health dispari-
ties. When we think about limitations in access to housing,
education, economic status, health care, and equity in the
criminal justice system, one outcome is poor health. African
American people are significantly more likely than non-
Hispanic White people to receive a diabetes diagnosis and
die as a result of diabetes, 40% more likely to have high
blood pressure, and 8.4 times more likely to be diagnosed
with HIV/AIDS.30 African American women have higher
obesity rates than women of any other racial/ethnic group,
and they have a 20% higher chance of having asthma, a 40%
higher chance of dying from liver cancer, and nearly 4 times
the death rate from breast cancer than non- Hispanic White
women, despite similar rates of diagnosis.30 Survival rates
among African American men are, on average, 5 years lower
for many common cancers, and the death rate from liver can-
cer is 60% higher, than among non- Hispanic White men.30
Overall, the lifespan for African American men is 4.5 years
lower than for non- Hispanic White men.31

Social Determinants of Health and
Increased Exposure to COVID-19
Among African American People

Now we focus on how systemic racism and social determinants
of health are affecting African American people during the
COVID-19 pandemic. Social distancing, the measure that the

United States has taken as the largest effort to prevent the spread
of COVID-19, is an SDH. The ability to social distance is a
privilege linked to key areas of housing, community, and eco-
nomic status. Lower- wage jobs are often jobs that cannot be
translated to work from home, have been deemed essential, and
may involve increased interaction with the public (eg, cashiers,
sanitation workers, home health aides, food service workers).
Although African American people account for just 13.4% of
the US population,32 they account for a larger percentage
(17.1%) of the service sector, including cashiers (19.9%), bus
drivers (27.0%), taxi drivers (29.5%), housekeeping (14.4%),
janitorial staff (18.2%), and sanitation workers (18.2%).33 Such
jobs are less likely than office- based jobs to be able to be per-
formed from home via teleworking strategies, thereby increas-
ing exposure to community- acquired COVID-19. African
American people are also more likely than people of any other
racial/ethnic group to use public transit,34 which may provide
increased exposure to community- acquired infection.

In addition to social distancing, a recent Centers for Disease
Control and Prevention (CDC) guideline has been to wear
masks when going out in public. Wearing a mask is problematic
for African American people, who have expressed fear of being
mistaken for criminals; it is compounded by a longstanding
conflation of race and criminality.35 Incarceration is linked to
health disparities among African American people, through
both the disproportionate number of African American people
who are imprisoned and, during the COVID-19 pandemic, the
inability to social distance in a prison or jail setting. Inconsistent
policies have been placed across the country in terms of protec-
tions for incarcerated people during COVID-19. In one exam-
ple, it led to an ACLU class- action lawsuit against the Dallas
County Jail for its management of inmate exposure to the
virus.36

Social Determinants of Health and
COVID-19 Mortality Among African
American People

Preliminary data also indicate higher COVID-19 mortality rates
among African American people than among White people in
the United States.2-4 These deaths are likely linked to underly-
ing conditions such as type 2 diabetes, hypertension, and
asthma, from which African American people have dispropor-
tionately higher rates than non- Hispanic White people.30 CDC
has reported that risk factors for serious illness when contract-
ing COVID-19 include older age and underlying medical con-
ditions, including chronic lung disease, asthma, heart conditions,
immunocompromised states (ie, a common result of treatment
for cancer or HIV/AIDS), severe obesity, diabetes, chronic kid-
ney disease, and liver disease.37 These disparities are often a
result of race- based inequities among SDH in areas of educa-
tion, economic status, housing, community context, and access
to health care.1 When the risk of death from COVID-19 is
higher among people with underlying health conditions, it is

Maness et al 21

clear that African American people will be more at risk than
populations without higher rates of chronic disease.

Moving Toward Health Equity During the
COVID-19 Pandemic and Beyond

Systemic racism is an aspect of public health that underlies
health inequities and results in unequal health outcomes in soci-
ety. Whether past or present, overt or covert, intentional or sub-
conscious, racism must be rooted out in our society in all its
forms. By examining the relationship between systemic racism
and SDH, we call for the implementation of widespread, socie-
tal change that extends beyond the interpersonal to permeate the
systems in which racism operates. In terms of COVID-19, an
impetus for societal change will involve robust research that
collects representative data as the pandemic continues. This
information will inform government, employers, providers of
social services, and society as a whole in the ways that current
policies negatively influence SDH and outcomes of COVID-
19. This work will not only inform the current COVID-19 pan-
demic, but can also inform planning for future emerging
infectious diseases. In addition, it will highlight the ongoing
need to address SDH to reduce a multitude of health disparities
in the United States that affect the quality of life and lifespan of
African American people.

As the Healthy People 2020 goals draw to a close, SDH
should be a continued priority for the United States, as ineq-
uities in socioeconomic status and links to health outcomes
persist. This pandemic underscores the systemic racism and
disparities that have persisted for decades. Now is the time to
rework our government, our public health and medical sys-
tems, our workplaces, our criminal justice systems, and our
communities with a centering foundation of health equity for
African American people.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support with respect to the
research, authorship, and/or publication of this article.

ORCID iDs

Sarah B. Maness, PhD https:// orcid. org/ 0000- 0003- 0757- 7972
Erika L. Thompson, PhD https:// orcid. org/ 0000- 0002- 7115-
0001
Stacey B. Griner, PhD https:// orcid. org/ 0000- 0002- 2774- 5841

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Social Determinants of Health and Health Disparities: COVID-19 Exposures and Mortality Among African American People in the United States

Social Determinants of Health and Systemic Racism
Education
Economic Status
Housing
Community
Access to Health Care
Social Determinants of Health and
Health Disparities Among African American People
Social Determinants of Health and Increased Exposure to COVID-19
Among African American People
Social Determinants of Health and COVID-19 Mortality Among African American People
Moving Toward Health Equity During the COVID-19 Pandemic and Beyond
Declaration of Conflicting Interests
Funding
ORCID iDs
References

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Racial Disparities in Healthcare: How

COVID-19

Ravaged One of the Wealthiest African American
Counties in the United States

Darius D.Reed

To cite this article: Darius D.Reed (2021) Racial Disparities in Healthcare: How COVID-19
Ravaged One of the Wealthiest African American Counties in the United States, Social Work in
Public Health, 36:2, 118-127, DOI: 10.1080/19371918.2020.1868371

To link to this article: https://doi.org/10.1080/19371918.2020.1868371

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Racial Disparities in Healthcare: How COVID-19 Ravaged One of the
Wealthiest African American Counties in the United States
Darius D.Reed a,b

aDepartment of Social Work, Indiana Wesleyan University, Marion; bSchool of Social Work, Walden University

ABSTRACT
The COVID-19 pandemic swept the globe in January of 2020 causing mass
panic and extreme hysteria. While pandemics are not new, COVID-19 is
emerging as a public health crisis in nearly every household in America. In
this paper, I discuss how COVID-19 has ravaged one of the wealthiest African
American counties in the United States. Using Public Health Critical Race
Praxis (PHCR) I seek to examine how disparities exist in health care and public
funding is not equally distributed regardless of wealth and status for minor-
itized communities. Using PCHR’s framework I highlight many of the dispa-
rities that exist in health care for people of color during this global health
crisis and provide implications for improvement in federal, state, and local
funding in communities of color. This article advances scholarship on the
intersection between public health and social work particularly alluding to
the need for increased advocacy for marginalized communities.

KEYWORDS
Anxiety; COVID-19; public
health critical race praxis
(PHCR); social work; African
Americans; marginalized
communities

Introduction

First detected in Wuhan, China, a virus known as severe acute respiratory syndrome coronavirus (i.e.,
SARS-CoV-2) has presented not only an environmental-based risk but also a global response (The
Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, 2020). Since the
proliferation of this virus, public health officials have termed the subsequent disease as ”COVID-19”
(Centers for Disease Control and Prevention [CDC], 2020). Since sparking international recognition,
the field of social work practice and education has begun exploring its impact on different systems
(e.g., education, financial, health, population). As a result, under the Trump Administration, the
White House Coronavirus Task Force has commissioned key leaders within public health to combat
its upward progression within U.S. borders. Thus, this sparked social work to respond to the COVID-
19 pandemic with challenges faced across all levels, especially a public health perspective.

The mass hysteria presented by the COVID-19 pandemic impacted every sector of life across the
world. In the beginning stages of the virus many in the African American community felt that they
were immune from the virus, because media reports primarily showed White Americans contracting
the Coronavirus. The first publicized case of an African American testing positive was Donovan
Mitchell, guard for the Utah Jazz (Ellentuck, 2020). This dispelled the myth that African Americans
could not catch the virus. Since that time CDC data shows that African Americans have been
disproportionally affected by the virus at much higher levels than all other races in the United
States (Bouie, 2020). Undoubtedly, this swift change caused undue anxieties for many African
Americans related as well as health and safety concerns. Recognizing the anxiety-induced trauma
this presented for African Americans I explored how COVID-19 has affected the wealthiest African
American county in the United States.

CONTACT Darius D.Reed darius.reed@gmail.com 9205 Rice Avenue, Glenarden, MD 20706 .

SOCIAL WORK IN PUBLIC HEALTH
2021, VOL. 36, NO. 2, 118–127
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The article will address how COVID-19 has ravaged one of the wealthiest African American
County in the United States and the mental health implications that may result from the fallout. It
will also address the taken for granted perspective of public health social workers and the potential
fallout that may arise due to the fluid and ever evolving public health crisis and its subsequent impact
on the mental health of African Americans. Moreover, as an African American social worker and
educator residing in Prince Georges County Maryland, I give voice to the unrealized repercussion that
this pandemic has imposed on frontline workers such as myself. In the section that follows, I will give
a brief literature review on the evolution of COVID-19 not only locally but also globally. In that same
vein, situate the racial disparities narratives within the theoretical framework of Public Health Critical
Race Praxis (PHCR) to further elaborate on gravity this pandemic imposes an already inequitable and
under-resourced healthcare system. Finally, I hope that by nuancing this virus’s impact; particularly,
among public health social workers will inform how to further interventions and policies in the event
of another global crisis, whether it be from a social work education or practice stance.

COVID-19

As stated earlier, in the article, this virus originated within the borders of mainland China. Since its
global appearance medical and social scientists have engaged in international deliberations to pinpoint
the exact evolution of SARS-CoV-2 since December 2019 (Holshue et al., 2020). Scientists have
hypothesized that the virus may be airborne thus allowing it to spread mainly from person to person,
through respiratory droplets (e.g., sneezing, coughing, bodily fluids) produced by an infectious
person(s). Other discussion involved that due to the configuration of the virus (e.g., spike proteins)
droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs
(CDC, 2020). Therefore, the Trump Administration, and the guidance of the U.S. Surgeon General,
Jerome M. Adams, they issued a list of recommendations to combat the spread of SARS-CoV-2 in the
U.S (CDC, 2020).

For context, the first confirmed case of SARS-CoV-2 in the U.S. was reported on January 31, 2020,
in Washington State (Holshue et al., 2020). Based on current data, there are now 1,602,148 confirmed
cases as of May 23, 2020; which exceeds cases reported in all other countries in the world (CSSE, 2020).
As a result of the ever-increasing numbers local and state governments instituted “shelter-in-place” or
“stay-at-home orders” in order to decrease the number of COVID-19 cases plaguing the continental
U.S. Understandably, such orders placed an undue economic and social burdens on the United States;
however, enacting such orders was for the safety and protection of all citizens. President Trump and
his cabinet encouraged individuals to wear face masks and engage in “social distancing” where people
practice at least a 6ʹ feet distancing from one another in order to reduce the surge in COVID-19 cases
(CDC, 2020).

Having given a thorough review of this virus’s origin, it would now be fair to take into considera-
tion The White House’s response toward treating the confirmed SARS-CoV-2 cases. Through the
regular and sometimes disorganized White House briefing, Trump’s White House COVID-19
response team presented the American population with conflicting health messages in regards to
the severity of its impact as well as potential “treatments.” In one breadth, Dr. Facui delivered sound
empirical knowledge speaking to the fluidity of the virus global progression; however, in the same not
being allowed to fully desegregate myth from the fact due to socio-political constraints. President
Trump initially down-played the severity of the virus, followed by reversing course and insisting that
Americans take the virus seriously, while in the same breath expressing that it would “blow over” soon
(Milbank, 2020). As a seasoned social worker this messaged presented numerous inconsistencies and
undoubtedly resulted in the high level of coronavirus cases.

SOCIAL WORK IN PUBLIC HEALTH 119

The county

Prince George’s County is located in the U.S. state of Maryland, bordering the eastern portion of
Washington, D.C. As of the 2010 U.S. Census, the population was 863,420, making it the second-most
populous county in Maryland, behind Montgomery County (United States Census Bureau, 2010).
Current estimates for the 2020 census place the county at a population of 909,327 Americans (US
Census Bureau, 2019). Long regarded as a symbol of Black wealth and excellence with a high
population of highly educated Black professionals, entrepreneurs and government officials, where
African Americans make up 65% of households and the median household income is 81,969 USD (US
Census Bureau, 2019). In many affluent African American communities outside of the Beltway (I-495
highway that splits Prince Georges County’s inner suburban communities from outer suburban
communities), median household incomes exceed 150,000 USD (Black Entertainment Television
(BET), 2017). In comparison communities inside the beltway closer to Washington DC boast
a median income of 55,000. USD Poverty in the county sits at just under 9% (US Census Bureau,
2019).

Theoretical approaches

Critical race theory (CRT) can be used to explore what it means to center race/racism throughout
our public healthcare system. Critical race theory brings from the margins the experiences of racial
and ethnic minorities and how these groups perceive acts of institutional and structural racism
(Delgado & Stefancic, 2012) to the center in terms of social work practice. For example, a central
theme of CRT is that race is permanently present in our everyday lives (Delgado & Stefancic, 2012).
Critical race theory allows for an intersectional critique of the various ways in which minority
groups can be oppressed (Delgado & Stefancic, 2012) in this instance inequalities in healthcare stand
out. Additionally, CRT challenges the current multicultural color-blind approach in social work
education as it relates to educating future public health social work practitioners about issues of
diversity, inclusion, oppression, discrimination, power, and privilege (Gutiérrez, 1990; Ortiz & Jani,
2010). Therefore, I argue that social work educators and practitioners must consider their own
positionality within the larger scheme of societal injustices and how racism manifests itself in social
work education, practice, and healthcare systems within the United States (Abrams & Moio, 2009;
Randolph, 2010).

Encompassed within this CRT methodological analysis are the four focal theoretical tenets of Public
Health Critical Race Praxis (PHCR) which are as follows: 1) contemporary racial relations, 2) knowl-
edge production, 3) conceptualization and measurement, and 4) action (Ford & Airhihenbuwa, 2010a,
2010b, 2018c, Gilbert & Ray, 2016). Each tenet supports the mode of translating the findings not only
qualitatively but also culturally while situating the experiences of African Americans in Prince Georges
County at the intersection of race, gender, class, and health, and politics within the current American
landscape. As pointed out by Carbado and Roithmayr (2014), “Existing literature shows a small
number of critical race theorists working at the intersection of CRT and the social sciences” (p. 150).

Critical race methodology (CRM)

The broader approach from which this paper emerges focused on the following three questions: 1)
How does death transcend wealth in the wake of a public health crisis? 2) What healthcare disparities
are present in predominately African American communities? 3) What are the implications of
continued healthcare disparities in minority communities? CRT proceeds from an understanding
that while structural racism is less visible than individual racism, it is just as, if not more, influential.
Unlike individual racism, structural racism is a systemic, historically rooted form of oppression that
cannot be eradicated simply at the level of individual attitudes or behavior. Indeed, the individuals

120 D. D. REED

operating within institutions may be, in practice, nondiscriminatory, but still operate within a larger
structurally racist context (Freeman, Gwadz, & Silverman et al., 2017).

Critical race methodology (CRM) operationalizes CRT and offers a way to understand the experi-
ences of people of color (Solorzano & Yosso, 2002). As a methodology, CRM uses counter-storytelling
as an analytical tool for understanding discourses on race and the intersections of other forms of
oppression. Counter-storytelling is a type of storytelling that acts as a form of resistance to standard or
majoritarian-stories. In this instance, I dispel the myth that healthcare is distributed equitably across
the continental United States. Grounded in CRT, which argues that the voices and experiential
knowledge of people of color must be recognized, counter-storytelling is a “tool for exposing,
analyzing, and challenging the majoritarian stories of racial privilege” (Solorzano & Yosso, 2002,
p. 32). Therefore, the next section which follows is a representation of the post-oppositional theorizing
(Bhattacharya, 2016) of the COVID-19 pandemic within the realm of social work and public health.

Analysis of data

According to the Johns Hopkins Center for Systems Science and Engineering (2020), there are 13,077
cases of Coronavirus in Prince Georges County (see Table 1), the most located in the Capital Beltway
area, which consists of the District, and nearby counties in Virginia and Maryland where, thus far, 477
people have died. When compared with the rest of the state (44,424 case, 2,207 deaths) Prince Georges
County represents 33% of all cases (CSSE, 2020). One may ask how does a county with high wealth
suffer from high cases of COVID-19 and death. The reality lies in the fact that many residents are
front-line workers exposed daily to the virus, and Prince Georgians disproportionately suffer from
underlying health conditions that make the virus deadlier (Chason, Wiggins, & Harden, 2020). Nearly
14% of adults in Prince George’s have diabetes, according to county health statistics, 36% are obese,
and 64% of the county’s Medicare beneficiaries suffer from hypertension rates above national and
statewide averages (PGC Healthzone, 2017). There are fewer hospital beds and primary care doctors
than in neighboring jurisdictions, which means residents are less likely to treat medical problems early.
The county also spends less on public health efforts than its wealthier neighbors (Chason et al., 2020).

Maryland’s first coronavirus death, announced March 18, was a Prince Georges County man in his
60s with underlying health conditions. The deaths that followed have been people from poor
neighborhoods inside the Capital Beltway and wealthy subdivisions outside of it, representing that
the virus transcends all income brackets and has no specific group that it will attach to. While it is true
that the majority of deaths from COVID-19 have been African Americans, one may ask why, when the
access to healthcare is readily available in 2020. The reality is that healthcare disparities remain in high
African American and minority communities. Despite high per capita incomes, Prince George’s
County spends less on health and human services than its neighbors. With 38.94 USD per capita in
general fund investment (see table 2), it falls behind others like Baltimore County, which spends 45.13

Table 1. Washington region COVID-19 cases.

Variable N %

Maryland
Prince Georges County
Montgomery County

13,077
9,432

27.98
20.18

Anne Arundel County 3,207 6.86
Charles County 956 2.04

Washington DC
DC

7,893 16.88

Virginia
Fairfax 8,734 18.68
Arlington 1,795 3.83
Alexandria 1,657 3.55

SOCIAL WORK IN PUBLIC HEALTH 121

USD; Anne Arundel, at 90.54 USD; Howard County with 109.37 USD; and Montgomery County with
224.25 USD (Maryland, 2019).

The disparities in COVID-19 cases speak to the broader health care disparities that are often seen in
minority communities, whether in the presence of absence of Coronavirus. Healthcare can be less
available and accessible in minority areas and also some mistrust of the health care system because of
past lived experiences. These disparities transcend all economic levels and platforms throughout the
county. Despite the concentration of wealth and education in the county, there remain pockets of
poverty, and grave inconsistency in the types of fresh food options that the county attracts, which plays
a role in the healthcare of African Americans. Lower quality foods equal higher health problems over
time. Moreover, despite its wealth 11% of residents do not have insurance, higher than state and local
averages. There are 477 primary care physicians in Prince George’s, fewer than half the 1,420 in
neighboring, more affluent and whiter Montgomery County (County Health Rankings, 2020), which
has about 20% more residents. To understand this disparity, you must first understand Tax Reform
Initiative by Marylanders (TRIM) which limited county tax revenue by capping property taxes in 1978.
Followed by the recession in the 1990’s which slashed funding for health and social services. The
trickle-down effect of such resulted in years of lower funding for services that are greatly needed in
a predominately African American and minority county.

Communities of color share common social and economic factors, already in place before the
pandemic, that increase their risk for COVID-19. While disparities in healthcare remain one of the top
reasons for Coronavirus cases in Prince Georges County, I would be remiss to not mention some of the
other factors that play a role in the high number of cases. One might be the housing conditions that
many African Americans in major cities reside in. Crowded living conditions represent a difficult
challenge that is the result of longstanding racial residential segregation and prior redlining policies for
African Americans and minorities in general. It becomes difficult to put social distancing practices in
place when multiple people reside in one residence, while potentially being exposed to the virus as
a result of essential jobs that may not provide protective equipment (PPE) to their employees. Some of
these essential positions could be environmental services, food services, transportation, and healthcare
services. These services represent positions that cannot be done remotely, therefore put many African
Americans and minorities in close contact with others who may have the virus. Lastly, stress is one of
the most pressing factors that play a role in the virus manifesting itself. Studies have proved that stress
has a physiological effect on the body’s ability to defend itself against disease. Income inequality,
discrimination, violence and institutional racism contribute to chronic stress in people of color that
can wear down their immunity, making them more vulnerable to infectious disease.

I would be remiss to not mention risk factors within communities of color that contribute to poor
health outcomes such as: poor nutrition, physical inactivity, obesity, high blood pressure, and
substance abuse. Noonan, Velasco-Mondragon, and Wagner (2016) state that access to healthy
foods is a frequent problem in poor African American communities. Many African American
communities are considered “food deserts” which, describe neighborhoods without easy access to
supermarkets that sell fresh produce and other healthy foods. Black neighborhoods have significantly
fewer supermarkets than white ones (Noonan et al., 2016) and Prince Georges County is no different
despite its wealth status. This in turn results in poor nutrition which leads to other health problems

Table 2. Health and human services spending
per capita.

General Fund Spending Per Capita

County
Prince Georges County

Baltimore County
$38.94
$45.13

Anne Arundel County $90.54
Howard County $109.37
Montgomery County $224.25

122 D. D. REED

such as obesity and high blood pressure, which could be deemed an underlying health condition
related to COVID-19. Substance abuse is also included as a risk factor due to its ability to decrease an
individual’s overall quality of life and lead to severe health problems. While these risk factors are
standard across the board in all communities, White individuals have the means and access to better
healthcare and services than many communities of color, thereby improving their overall quality of
life.

Given the role that public health social workers play in maintaining continuity of care for those
existing on the margins (e.g., African Americans, Asians, Hispanics, etc.). It is indictive of policy
makers and those in charge of governance understand the depth of healthcare disparities for people of
color. The lack of PPE, inconsistent access to healthcare due to lack of insurance or underinsurance,
chronic health conditions in communities of color, and crowded living conditions is not only
troubling, but indictive of the lack of governmental investment and oversight for communities of
color. As I now begin to discuss implications for social work research, policy, and education. It is
important to put into context just how broken the United States’ healthcare truly is. Regardless of the
socio-political climate, the author’s forthcoming discussion will support the depth of how present
systems monetize “life” within the United States.

Implications

The aim of this article is to establish the relevance of application in social work practice for addressing
social justice and healthcare disparities within the social ecologies of African-Americans at risk for
COVID-19 the following theoretical frameworks: Critical Race Theory, Critical Race Methodology,
and Public Health Critical Race Praxis. The data presented in this article elucidate the multiplicity of
ways in which healthcare disparities are present for African Americans in Prince Georges County. As
highlighted above, if genuine change is to occur within the field of public health social work, we must
begin respecting the meaning-making processes of potential public health social workers who have
direct access and knowledge to healthcare disparities that African Americans and minorities experi-
ence. This can occur through the incorporation of practice-informed research which explicitly
recognizes the interlocking barriers “minoritized groups” (Harper, 2012) must traverse. As pointed
out by Corley and Young (2018), “The daily lives of racial and ethnic minoritized groups continue to
be affected by a racist system of hierarchy and inequity that characteristically advantages White
Americans while creating detrimental outcomes for People of Color” (p. 318).

Social work research and practice

Social work practice and research are reciprocally connected. However, those connections are not
culturally nuanced for African Americans. For clarity, social workers are routinely engaging African
American clients; however, not in a matter which signifies cultural attunement from both a micro and
macro perspective. Cultural attunement is vitally important to improve health disparities for people of
color. Understanding the social ecologies of people of color can challenge stereotypes and improve
healthcare disparities. I strongly advocate for the development of practice-informed research, that is
explicitly attuned for African Americans and minorities regarding the healthcare disparities that are
present in the U.S. healthcare system.

The NASW Code of Ethics (2017) has three principles that directly align with prevention efforts to
address the social injustices present in healthcare today: “(a) social workers’ primary goal is to help
people in need and to address social problems, (b) social workers practice within their areas of
competence and develop and enhance their professional expertise, and (c) social workers challenge
social justice” (NASW Code of Ethics p. 2). One of the main functions of social work is advocacy.
Therefore, social workers should advocate for increased COVID-19 testing in communities of color.
The data reflects that African American and minority communities have been disproportionately
affected by high rates of death, therefore the need for additional testing is paramount.

SOCIAL WORK IN PUBLIC HEALTH 123

Moreover, social workers in the field of public health should understand one’s perceptions of
African Americans and minorities and how these perceptions shape interventions and service delivery,
how a lack of understanding of racial dynamics can negatively racialize minorities, and understanding
elicit bias and discriminatory behaviors and their role in the continued oppression of African
Americans and minorities. social workers in the field of public health should understand one’s
perceptions of African Americans and minorities and how these perceptions shape interventions
and service delivery, how a lack of understanding of racial dynamics can negatively racialize mino-
rities, and understanding elicit bias and discriminatory behaviors and their role in the continued
oppression of African Americans and minorities. There also needs to be research informed practice
where social workers are taking the best information available to them to impact and improve
healthcare practices for people of color in the United States. From the information gathered in this
paper social workers in practice need to focus on understanding the healthcare needs of African
Americans, ways to improve their access to care, and ending the long-standing systemic inequalities
that are contributing to these disparities.

Lastly, many healthcare interventions and strategies are structured based on dominant Eurocentric
theoretical interventions. African Americans and minorities are forced to exist, rather than under-
standing the oppressive and unequal structures of society that exist within these systems. Therefore,
social work practice should acknowledge race and its significance within therapeutic practice and work
to create interventions that consider how race plays a role in the overall healthcare of minorities. It is
essential for social workers in practice to view African Americans based on the cultural experiences,
thus helping the social worker to better understand how to effectively solve some of the systemic
inequalities.

Social work education

The social work profession, inclusive of public health in social work, lacks sufficient minority inclusive
research, interventions, models, and theoretical approaches critical to improve and develop social
work practice, research, and education. More specific data on race, age, socioeconomic, sex, and
geography are needed to understand the effects of race and class on healthcare inequalities. This paper
highlights the disparities that continue to exist regardless of improvements that have been made in
education and wealth for African Americans and minorities. Social work education programs should
continue examine the disparities that exist within education, health care, the economy, environmental
justice, criminal justice and voting rights from communities of color and improve knowledge for
future social workers entering the field or those who are already working in the field through
continuing education units.

Critical race theory posits that we should seek to understand the cultural context of all races when
developing interventions. Social work education programs are beginning to include CRT into its
educational framework. With African Americans dying at alarmingly high rates, research and educa-
tion should seek to understand the social, economic, historical, and cultural injustice that are present
throughout the United States. Examining this may help enhance clinical interventions, research
designs, and policy responses to situations that directly affect African Americans and minorities.
Lastly, social workers should be educated on the role of predisposing, precipitating, and contributing
factors for health issues within communities of color. Examinations that explore how continued
systemic oppression have contributed to many of the health issues that are present in communities
of color. An examination of such, may begin to improve healthcare outcomes for communities of
color.

Social work policy

Advocacy is the cornerstone on which social work is built. It is so important that it is framed in three
sections of the NASW (2008) Code of Ethics. Advocacy for individuals, communities, and systems is

124 D. D. REED

not just a suggested activity for social workers, it is a requisite. Social workers are ethically obligated to
“engage in social and political action that seeks to ensure that all people have equal access to the
resources that they require to meet their basic human needs and to develop fully” (NASW, 2008, p. 27).
The Code of Ethics further notes that “social workers should be aware of the impact of the political
arena on practice and should advocate for changes in policy and legislation to improve social
conditions” (NASW, 2008, p. 27). African Americans and minorities have been oppressed for some
time and the COVID-19 pandemic has shed light on the continued need for advocacy for this group.
Understanding and addressing social determinants of health is essential for reducing the morbidity
and mortality rates in communities of color.

Moreover, understanding and improving the current and future public health policies to focus on
identifying and removing barriers to accessing health care and related concerns, such as lack of health
insurance or unemployment and underemployment, which leads to a lack of health insurance among
populations who have historically been subjected to health disparities. Improving access to care for
those in rural areas is also paramount. The emergence of telehealth in the wake of the COVID-19
pandemic, has widen America’s eyes to the need for non-traditional methods of care. These improve
access to care for those in less urban communities, thereby improving their overall health outcomes.

Lastly, the federal government should enact policies that work to reduce inequality and promote
decreasing the wealth gap between the majority and minority. In doing so, access to funding many
improve in predominately minority areas, thereby decreasing health disparities. States should also
consider boosting public health funding, particularly in areas that help people in distress. As noted in
this paper, Prince Georges County, one of the wealthiest African American communities in the United
States receives far less funding than its Whiter and, in some instances, poorer counterparts. This
unequal access to state public health funding is likely a big part of the high level of COVID-19 cases.
Social workers already have a presence in hospitals, on a macro scale, a larger presence in the board
room could help institutionalize these initiatives by promoting laws and policies mandating funding
parity for communities of color.

Conclusion

At present, there are still thousands of new cases of COVID-19 every day, with new viral hotspots
emerging as state and local governments lift the stay-at-home orders in response to the economic
downturn. Closed room discussions have begun among public officials within local governments as
they experience an existential financial crisis related to the shutdown. Even as we gain more insight
into this virus’s lethality, federal, state, and local governments engage in neoliberalism political
theatrics at the expense of the most vulnerable (African Americans and people of color).
Prioritizing profit over health is one of the key factors perpetuating the rising infection rates seen
within our society. This paper brings to light the need for increased public health funding in
communities of color.

As a nation we have an abundance of healthcare facilities, cutting edge technologies, and pharma-
ceuticals that are not always readily available to all communities. To address some of the disparities in
healthcare state and federal decision makers should ensure equal access to resources needed to
eliminate the burden or hospitals and facilities that serve minority populations and have higher
overall costs due to lack of insurance. This can be accomplished by expanding Medicaid and lowering
cost in the healthcare marketplace. Also increasing insurance coverage and access to providers for
underserved populations could decrease the healthcare disparities in communities of color. Another
example could be increased funds from a state and federal level for outreach and enrollment assistance,
doing so may increase coverage in communities of color. Increasing insurance coverage is just one step
in eliminating the disparities, actually establishing relationship with the community and working
toward getting healthcare organizations to think about who they employ and how they can make
connections with the community to promote health interactions with minorities and improve their
overall well-being.

SOCIAL WORK IN PUBLIC HEALTH 125

In closing, the information provided showcases why we need to begin to have more robust
discussions about reinvestment in social welfare programs and the adoption of a comprehensive social
democratic safety net for all regardless of their socio-economic status. Advocacy for marginalized
communities is of the utmost importance to enlighten those who may not be aware of the dire straits in
which minoritized communities are residing. Despite its exploratory nature, this study offers some
insights that would substantiate an in-depth inquiry in how we prioritize healthcare within the United
States. Given what we know about risk factors, it is possible that the African American community
shares some responsibility in the poor health outcomes that present in their own communities,
however it does not outweigh the fact that there are major differences in healthcare in African
American and White communities. Further work is needed to fully understand the implications of
COVID-19 pandemic on social work and public health programs; however, unless the federal
government adopts inclusive policies in health management, care, and infrastructure, equity will not
be attainable and COVID-19 related deaths will continue to rise among African American and
minority communities.

Disclosure statement

No potential conflict of interest was reported by the author.

ORCID

Darius D.Reed http://orcid.org/0000-0003-2014-5998

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Abstract

Introduction
COVID-19
The county
Theoretical approaches
Critical race methodology (CRM)
Analysis of data
Implications
Social work research and practice
Social work education
Social work policy
Conclusion
Disclosure statement
ORCID
References

African Americans and COVID-19: Beliefs, behaviors and vulnerability to
infection
Elyria Kempa, Gregory N. Pricea, Nicole R. Fullera and Edna Faye Kempb

aCollege of Business Administration, University of New Orleans, New Orleans, LA, USA; bKemp Dentistry, Indianapolis, IN, USA

ABSTRACT
In the United States, during the early outbreak of the coronavirus (COVID-19) pandemic, African
Americans experienced disproportionately high rates of infection and mortality relative to their
share of the United States population. New Orleans, Louisiana was one of the places most
heavily affected by the coronavirus during its early outbreak. The study that follows explores
the attitudes of African Americans in New Orleans toward the virus, social and normative
conditions which affected individual behaviors, as well as access to healthcare services and
COVID-19 testing. In part one of the study, qualitative responses were collected from a
sample of African Americans in the New Orleans area to garner perspective about their
attitudes and behaviors related to the coronavirus outbreak. Part two of the study builds on
findings from Study 1 with parameter estimates from a Logit regression to examine how
social, economic and physical conditions determine vulnerability to COVID-19 infection
among African Americans. Implications for how healthcare organizations can address the
needs of vulnerable populations during a health-related crisis are discussed.

ARTICLE HISTORY
Received 13 May 2020
Accepted 22 July 2020

KEYWORDS
Health equity; Social
determinants of health;
African Americans; COVID-19;
Theory of planned behavior

In 2020, the World Health Organization declared the
novel coronavirus, or COVID-19, a global health emer-
gency as it spread ferociously across the globe [1]. The
first confirmed case of the virus appeared in January
2020 in the United States [2]. Within months, the
virus sickened many and resulted in thousands of
deaths.

As more data emerges regarding the impact of
COVID-19 in the United States, it has become evident
that the virus has affected racial and ethnic minorities
at an alarmingly high rate. Specifically, African Amer-
icans have experienced disproportionately higher rates
of infection and mortality than their representative
share of the United States population [3,4]. In early
May 2020, African Americans accounted for approxi-
mately 34% of total COVID-19 deaths in states where
they represent only about 13% of the state’s population
[3]. Some states reported even more egregious dispar-
ities. For example, in Louisiana blacks accounted for
70% of the deaths from COVID-19, but only 33% of
the population. Similarly, in Alabama, blacks
accounted for 44% of COVID-19 deaths, yet only
make up 26% of the state’s population [5].

Some officials have linked the disproportionate
numbers regarding the effect of the virus on African
Americans to individual behavior (i.e. including practi-
cing unhealthy behaviors and suffering from comor-
bidities which make the coronavirus more deadly)
[6]. However, the situation is likely more nuanced.
African Americans are more likely to work in service

sector jobs and were deemed ‘essential workers’ during
the coronavirus outbreak [7]. In larger urban areas,
they are also are more likely to use public transit – all
which place them in closer contact to others and
make them more susceptible to the virus [6].

This research examines the attitudes, behaviors as
well as social and physical conditions of African Amer-
icans in New Orleans, Louisiana, and their perceived
vulnerability to COVID-19 infection. New Orleans
was one of the places most heavily affected by the cor-
onavirus during its early outbreak. In March 2020, New
Orleans experienced one of the fastest growth rates in
new cases of COVID-19 in the world [7]. By early
May, the city reported over 450 deaths from the
virus, with African Americans making up over 75%
of the deaths [8]. The study that follows explores the
attitudes of African Americans in New Orleans toward
the virus, social and normative conditions which
affected individual behaviors, as well as access to
healthcare services and COVID-19 testing. The study
applies two distinct methodological techniques to pro-
vide insight. In part one of the study, qualitative
responses were collected from a sample of African
Americans in the New Orleans area to garner perspec-
tive about their attitudes and behaviors related to the
coronavirus outbreak. Part two of the study builds on
findings from Study 1 by examining how social, econ-
omic and physical conditions determine vulnerability
to virus infection and COVID-19 testing participation.
Implications for how healthcare organizations can

CONTACT Elyria Kemp ekemp@uno.edu College of Business Administration, University of New Orleans, 2000 Lakeshore Drive, New Orleans, LA
70148, USA

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT
2020, VOL. 13, NO. 4, 303–311
https://doi.org/10.1080/20479700.2020.1801161

http://crossmark.crossref.org/dialog/?doi=10.1080/20479700.2020.1801161&domain=pdf&date_stamp=2020-11-09

mailto:ekemp@uno.edu

http://www.tandfonline.com

address the needs of vulnerable populations during a
health-related crisis are discussed.

Conceptual background

Individual behavior – attitudes, beliefs and
norms

During the early months of the coronavirus outbreak, a
significant part of containing the spread of the virus in
the United States involved following the guidelines
proposed by the Centers for Disease Control and Pre-
vention (CDC) and the White House Coronavirus
Taskforce. During March 2020, these guidelines
included avoiding social gatherings of 10 or more
people; social distancing by remaining at least 6 feet
from others in public spaces; using drive-thru, pick-
up or delivery options at restaurants and grocery stores;
avoiding discretionary travel, not visiting nursing
homes or long-term care facilities unless providing
critical assistance; and finally, practicing good hygiene,
such washing hands, avoiding touching the face, sneez-
ing or coughing on a tissue or into the elbow, and dis-
infecting surfaces (note: wearing face masks were not
recommended until April 2020) [2,9]. Government
and private entities disseminated messaging in various
media encouraging the practice of these behaviors to
help mitigate the spread of the virus.

According to the psychology literature, one’s atti-
tudes and beliefs are linked to whether one will practice
a certain behavior. For example, in the theory of
planned behavior (TPB) there are three determinants
of behavioral intention – attitude toward the behavior,
subjective norms, and perceived behavioral control
[10]. Attitudes toward the behavior address the extent
to which a person has a favorable or unfavorable
appraisal of the behavior in question. Subjective
norms are social variables that reflect the perceived
social pressure to perform or not to perform the behav-
ior. Finally, perceived behavioral control addresses the
perceived ease or difficulty in performing the behavior
and captures past experiences as well as anticipated
obstacles. The more favorable the attitude and subjec-
tive norms regarding the behavior, and the greater the
perceived behavioral control, the stronger an individ-
ual’s intention to perform the behavior in question
[10,11].

To a considerable degree, individual behavior in
adhering to the guidelines and directives of govern-
ment officials and health experts would impact the pro-
liferation of the coronavirus and the likelihood of being
infected with the virus. Thus, intentions to practice rec-
ommended behaviors to contain the virus might be
determined by considering the attitudes of individuals
about the severity of the virus and the need to control
the spread as well as social and normative pressures to
perform or not perform the recommended behaviors.

In addition, examining the perceived difficulty individ-
uals had in not practicing recommended behaviors (e.g.
having to leave home for work or to care for a loved
one) might also play a factor.

Access to health services

In addition to considering individual behavior, both
access to healthcare and the quality of health services
can influence health. Lack of access to quality health
services can affect an individual’s health status. For
example, due to limited availability to healthcare, an
individual may be less likely to participate in preventive
care as well as delay medical treatment [12].

Public health practitioners and policy makers are
beginning to consider the broader determinants of
health as part of a more inclusive approach to improv-
ing health [13]. For example, social determinants of
health are social factors and physical conditions in
the environment which impact health status and sub-
jective wellbeing. Social determinants of health are
also affected by the availability of resources to meet
daily needs, such as educational and job opportunities,
living wages, healthy foods, discrimination, social sup-
port, exposure to mass media and emerging technol-
ogies, socioeconomic conditions and transportation
options [14–16]. Addressing social determinants of
health is essential to eradicating systematic disparities
in health and achieving health equity. Health equity
is when everyone has the opportunity to realize their
full health potential, barring the inability to do so
because of social position or other socially determined
circumstances [17].

With respect to COVID-19, individual behavior,
which included adhering to the guidelines delineated
by the CDC and the White House Coronavirus Task-
force, played a central role in reducing infection
rates. As literature from the behavioral sciences
suggests, such behavior may be predicated on an indi-
vidual’s attitudes toward the behavior, social pressures,
and elements within the individual’s control to perform
the behavior [10]. In addition, social, economic and
physical conditions as they relate to access to quality
healthcare can play a role in virus detection, treatment
as well as mortality rates from the virus. The study
which follows first examines the attitudes and beha-
viors of African Americans in New Orleans as they
relate to COVID-19. It then explores how social, econ-
omic and physical conditions are related to access to
healthcare services and COVID-19 testing.

Study part I: Beliefs and behaviors

Methodology

The research participants in this study were African
Americans who reside in New Orleans. African

304 E. KEMP ET AL.

Americans comprise about 59% of the population in
New Orleans [18]. We enlisted Qualtrics, a professional
research firm for our data collection efforts. Enforced
quota constraints were applied in our sampling with
the goal of attaining a research panel demographically
representative of African Americans in the city of New
Orleans. Following appropriate ethical research
approval (from the Institutional Review Board),
responses were collected online from a panel consisting
of 104 participants from 11–22 April 2020. Sixty-seven
percent of participants were female and thirty-three
percent were male. The mean age was 40 and 35% of
participants self-reported as ‘essential workers’ during
the coronavirus outbreak (see Table 1). Participants
were asked questions concerning their attitude toward
the virus, normative and economic conditions which
may have affected their ability to comply with direc-
tives of government officials, as well as their percep-
tions regarding healthcare access.

Our data analysis enlisted a form of content
analysis where themes were identified using a cod-
ing process. The goal of this approach was to recog-
nize themes based on the experiences and
observations of participants [19]. We independently
performed a comprehensive assessment of the data
and developed themes. Next, using an iterative,
back-and-forth reading process [19,20] we achieved
general consensus on themes which repeatedly
appeared across participants’ responses. The follow-
ing are emergent themes which were consistent with
the responses from the participants. Participants
were assigned aliases.

Results: Thematic findings

Attitudes toward the virus and susceptibility
Attitudes are an organization of beliefs, feelings, and
behavioral tendencies towards significant objects,
groups, events or symbols [21]. Knowing a person’s
attitude helps predict their behavior. Many of the
respondents in our research acknowledged the serious-
ness of the coronavirus. As a result, they expressed that
they were making efforts to safeguard themselves from
possible infection. This sentiment was echoed in the
comments of many participants.

“COVID is a serious virus. I’m hoping that I don’t
catch it … but I am taking all the precautions to
protect myself.” Mary, 61, Educator

“Since I am at high risk, I really practice social distancing
and avoid all risky situations. As a private nurs,e I
only have one patient for the patient’s safety as well
as mine. My siblings also take care with associations
and practice hand safety.” Jackie, 66, Nurse

Unfortunately, some participants had lost loved
ones to COVID-19. They also expressed how the health
crisis was taking a toll on them emotionally.

“I have had at least two emotional breakdowns. It
takes a lot to remove the focus off the crisis and refo-
cus on other things.” Marguerite, 60, PBX Operator

However, younger respondents were more optimistic
about their vitality, and felt less susceptible to the virus.

“My family and I are very healthy. We have a very
[strong] immune system. So we aren’t very likely
to catch COVID-19.” Lakeisha, 21, Cashier

Attitude toward government leaders and health
experts
People expect their leaders to be consistent and model
what they advise for their constituents [22]. During the
coronavirus outbreak, trust was an important factor as
people looked to their leaders for knowledge and infor-
mation. Trust embodies a dynamic, relational link
between people and is meaningful in situations in
which one party is at risk or vulnerable [23]. Many
respondents had mixed feelings about leadership, indi-
cating some confidence in state and local political
officials, while expressing distrust in federal leadership.

“I don’t trust anyone implicitly, especially politicians! I
trust the mayor to give as much info as she can give
without causing a panic. I see how she is trying to
do as much as she can. I trust the governor as
much as I can. I see where he is trying … .As far
as federal leaders, I don’t trust them at all. Most
of what they say and do is self-serving …” Evelyn,
70, Retired Administrative Assistant

Table 1. Summary of respondents’ demographics.
Count Proportion Average

Observations 102
Male 33 32%
Age 40
18–39 53 52%
40–59 25 25%
≥60 23 23%

Single 64 63%
Education
Some high school 6 6%
High school diploma 21 21%
Some college 24 24%
College degree 27 26%
Post-grad degree 24 24%

Income $36k–$50k
≤ $25k 41 40%
$26k- $50k 24 24%
$51k- $75k 17 17%
$76k – $150k 14 14%
≥ $151k 5 5%

Essential worker 36 35%
Unemployed 21 21%
Top Industries
Arts & Entertainment 12 12%
Education 10 10%
Restaurants 8 8%
Healthcare 8 8%
Social Services 3 3%

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 305

“It’s hard to trust … I admire the job that our Mayor is
doing … Not hearing too much from the Gover-
nor. The president is trying, but he lies so much
…” John, 48, Longshoremen

Participants appeared to have more trust in health
experts and expressed sympathy and gratitude towards
front-line healthcare workers.

“I do trust the health officials. They are working under
harsh situations with limited supplies to help and
heal others. They are putting their own life and
their families in danger of the virus. They want
this to end much more than we do. I trust they
are trying to find a cure to protect us in the future.”
Sheila, 52, Educator

However, participants did exhibit some frustration
with the information they were receiving from health
officials. They acknowledged that there had been a
fair amount of equivocation regarding best practices
to combat the virus. In some ways, a modicum of dis-
trust existed with the way some things had been
handled during the nascent stages of the virus out-
break. Nonetheless, many conceded to the reality that
circumstances were novel, and that health experts
were learning new things daily.

“I know they are learning more about it every day given
that this disease hasn’t been seen before, but they
need to get their facts straight. They’re constantly
giving out information that contradicts infor-
mation they gave out previously. We’ve seen time
and time again with any infectious disease that
masks have been used to contain the spread, but
because they can’t afford to have enough mass pro-
duced for every single person they are telling us
that we don’t need them. They’ve let weeks and
weeks go by without it being required.” Carrie,
25, Self-Employed

“Most of the information [from healthcare experts] I
trust, but who knows what to believe.” Tammy, 21

Because attitudes provide meaning and knowledge,
understanding attitudes can predict behavior. Many
of the participants in this research recognized the ser-
iousness of the coronavirus. However, there were
some participants, primarily younger adults (ages 35
and under), who were not convinced about the ferocity
of the virus. Furthermore, leadership during crisis
moments plays an important role. During uncertain
times, informed and trustworthy leadership is para-
mount. Participants had a measure of distrust and
cynicism toward federal political leaders. However,
many trusted the leadership at the local and state
level. They also looked to health experts for advice
while acknowledging that the situation was fluid.

Social norms and social distancing
Subjective or social norms are variables which refer to
the belief that an important person or group of people
will approve and support a certain behavior [10,24].
Subjective norms can be measured and accessed from
the perspective of expectations set by referent groups
such as family, relatives, and friends, in terms of
whether an individual should or should not engage in
a behavior. Subjective norms may also include descrip-
tive norms, which refer to actual activities and beha-
viors others are undertaking [24]. In the case of
descriptive norms, individuals may not only be con-
cerned with what others think, but also with how
others behave.

Norms within New Orleans emphasize culture, tra-
dition and celebration. The city is known for the axiom
‘laissez les bons temps rouler,’ meaning ‘let the good
times roll.’ People in New Orleans are very ‘social.’ In
fact, the popular press has ranked New Orleans as
one of the friendliest cities in the United States
[25,26]. Given these social norms, maintaining physical
distance was challenging for some.

“I know for a fact that some are not social distancing. I
have spoken to friends who have been attending par-
ties, baby showers, crawfish boils, card games–all
with multiple people. They totally believe that the
virus is like the flu and they will recover if they get
it. It’s like they don’t know or care about the way
this virus affects us all.” Nancy, 47, Bank teller

“When I was in the store yesterday, people were walking
around like nothing is going on. A few of us had on
masks and long sleeves and so forth. But a large
group of people were out with no protection, with
kids running around and no protection, and not
adhering to any social distancing guidelines …”
Evelyn, 70, Retired Administrative Assistant

“People can say that they’re doing it, but actually aren’t
… like my neighbors playing basketball in the
street–between 8–12 guys … unbelievable…”
Diane, 62, Law Enforcement

One young adult participant was very candid about
his lack of effort to social distance.

“Not really [not social distancing],but it’s other people
opinion,” Carl, 21

Although several of the participants noticed that
other people were not social distancing, the majority
indicated that physical distancing had become the
‘new norm’ among family and friends.

“I call, email and text my friends and colleagues. My
children and grandchildren call me and text me.
They have not come over since March 13, 2020.”
Geraldine, 63, Educator

306 E. KEMP ET AL.

“The only thing I do is to go for a walk/jog, and I have
been to my students’ homes to leave a message on
their front porches and deliver Easter treats.”
Sheila, 52, Educator

Control limits and disparities
Perceived behavioral control addresses the perceived
ease or difficulty in performing a behavior and captures
anticipated obstacles. For some of the participants in
this research, self-isolation was infeasible. Specifically,
Americans were advised to work from home during
the early stages of the coronavirus outbreak; however,
according to the Economic Policy Institute, only 19.7
of African American have jobs which allow them to
work from home [27]. In our study, 35% s of partici-
pants self-reported as ‘essential workers.’ Subsequently,
some were working away from home during the
outbreak:

“My job is considered essential, but … precautions are
being taken.” John, 48, Longshoremen

Moreover, and unfortunately, income and race play
a role in determining who uses New Orleans’s public
transit systems to travel to work. In New Orleans,
91% of White/Caucasian households have at least one
car, compared with just 74% of African American
households [28]. Reliance on public transit further
decreases the likelihood of social distancing.

During the outbreak, older adults were advised to
self-isolate [29]. This included grandparents isolating
themselves from grandchildren. In New Orleans,
12.2%of African Americans 60 years and older live in
multigenerational households, compared to 3.8% of
white elders [30]. Such living conditions, where grand-
parents live with their grandchildren, might make them
more susceptible to COVID-19. One of our partici-
pants addressed this reality.

“Since I am elderly and in only fair health, I believe that
I could get the virus. I worry about my kids and
grandkids since I do have contact (at home) with
them.” Linda, Retired, 62

Health services. Given African Americans’ dispropor-
tionate COVID-19 infection and mortality rates, par-
ticipants in this research were asked about their
personal access to health care as well as their percep-
tion of the quality of healthcare they receive. In 2016,
Louisiana accepted Medicaid expansion (created in
the Patient Responsibility and Affordable Care Act
passed by the U.S. Congress in 2010). Louisiana’s Med-
icaid expansion program provided health insurance for
non-elderly adults with income less than 138% of the
Federal Poverty Level. As a result of the expansion pro-
gram, the uninsured rate in Louisiana fell by half –

from 22.7% to 11.4% – from 2015 to 2017 [31,32].
While Medicaid expansion was instrumental in extend-
ing access to healthcare, participants still questioned
the quality of care and health equity for African
Americans.

– “I am aware that some do not [receive the same level
of care as others]. I have private insurance. I
worked in health care. I see the bias shown to
the poor, homeless, mentally challenged, those
with addictions, overweight …” Harriet, 48,
Retired Healthcare Worker

– You get turned away when you can’t pay or you’re
sent to lower quality hospitals. Iris,34, Bartender

Some specifically felt that health inequities exist.

“I’m Black and people seem to not take my words as
seriously as others–even when I’m suffering.” Samuel,
29, Hospitality

“I do believe that black women have to be aggressive
about their healthcare. I have had to make sure I
bring questions with me to all my doctor visits.
Some important information is sometimes left out of
the visit. Seemingly, if I don’t ask, the doctor won’t
tell me all of the information I need.” Kay, 55,
Administrator

In summary, behavior may be predicated on an indi-
vidual’s attitude toward a behavior, social pressures,
and elements within the individual’s control to perform
the behavior [10]. The first part of this study examined
the attitudes and behaviors of African Americans in
New Orleans during the early outbreak of the corona-
virus. Many of the participants recognized the serious-
ness of the coronavirus. However, there were some
participants, primarily younger adults (ages 35 and
under), who were not compelled by the seriousness
of the virus. Furthermore, during the early stages of
the coronavirus outbreak, trust from leadership was
an important factor as people looked to their leaders
to shape attitudes about the virus. Responses from par-
ticipants reveal a measure of distrust and cynicism
toward federal political leaders. However, many trusted
local leadership as well as the health experts.

The opinions and actions of others, or subjective
norms, also affect the behavior of individuals [10]. Par-
ticipants recounted instances where they noticed others
who were not physically distancing. Nonetheless, the
majority of the participants in this research indicated
that they were taking measures to physically distance.
The ‘norm’ had been set among family and friends to
engage in this behavior.

There were some participants in this research who
discussed how their circumstances did not permit
them to completely self-isolate. For example, some
respondents indicated that living in mutigenerational
housing or having to continue to go to their ‘essential’

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 307

jobs exposed them to more people. Finally, the high
rate of African American mortality from COVID-19
was concerning for participants. At a macro level, par-
ticipants offered considerable discussion regarding the
state of healthcare for African Americans and ques-
tioned whether true health equity exists in commu-
nities. In the second part of our study, we examine
specific factors influencing access to healthcare and
health equity for African Americans in New Orleans
as it relates to COVID-19 testing.

Part II: COVID-19 testing in New Orleans

Methodology

In response to evidence that COVID-19 infections and
deaths have impacted African Americans disproportio-
nately [4,33,34], our survey data captured information
on individual characteristics that may be possible dri-
vers of racial disparities in COVID-19 infections. We
measured these individual characteristics to first deter-
mine, via a rigorous least absolute shrinkage and selec-
tion operator, or LASSO [35], the best predictors of
taking a COVID-19 test among survey respondents.
LASSO is a machine-learning algorithm to identify
regressors, via induction, that best explain/predict an
outcome – regressand – of interest [36].

Results

Table 2 reports the results of the predictive covariate
selection from the rigorous LASSO among all the
quantitative covariates in the respondent survey. We
used the RLASSO procedure in Stata 15 [37]. In gen-
eral, RLASSO selects regressors that minimize the
mean squared prediction error, subject to a penalty

on the absolute size of coefficient estimates. The pre-
dicted outcome of interest is a binary variable indicat-
ing whether a survey respondent was tested for
COVID-19. Among the quantitative covariates, the
RLASSO selected the respondent’s age, whether he/
she is an essential worker, and the respondent’s self-
reported health status as predictors.

Given the selected predictors, Table 3 reports par-
ameter estimates across five Logit specifications to
determine how these predictors matter for the prob-
ability of an individual having had a COVID-19 test.
We report Pseudo-R2 and the xs statistic for the joint
significance of all the parameters as goodness-of-fit
measures. To inform practical versus statistical signifi-
cance, we report parameters as an odds ratio, which
indicates the quantitative impact a regressor has on
the outcome of interest. An odds ratio less(greater)
than unity indicates that having a particular

Table 2. Rigorous Lasso variable selection.
Covariate Definition Selected

Age Age of respondent in years Yes
College Binary variable equal to No

unity if respondent has
a baccalaureate degree

Essential Worker Binary variable equal to Yes
if respondent is an essential worker

Health Respondent’s position in Yes
health quintile distributiona

Household Size Number of people in No
in respondent’s household

Male Binary variable equal to No
if respondent is a Male

Married Binary variable equal to No
if respondent is Married

Median Income Median Income in No
Respondent’s zip codeb

Notes: aDerived from respondent’s self-reported 1–10 health-rating, with
10 being the highest-rated measure of health. For each respondent,
the measure was converted to a position in a distribution of quintiles.

bSource: https://www.incomebyzipcode.com/louisiana/70119.

Table 3. Logit odds ratio parameter estimates: COVID-19 testing in Orleans Parish.
Specification (1) (2) (3) (4) (5)

Regressand: Respondent has been tested for COVID-19

Regressors:
Constant .467 .552 .466 .467 .466

(.706) (.775) (.613) (.577) (.317)
Age .971 .969 .971 .971 .971

(.240) (.186) (.322) (.106) (.314)
College 4.21 3.82 4.21 4.21 4.21

(.032)b (.042)b (.037)b (.042)b (.116)
Essential Worker .309 .277 .309 .309 .309

(.065)c (.040)b (.032)b (.008)a (.001)a

Health 1.64 1.74 1.64 1.64 1.64
(.124) (.101)c (.048)b (.053)c (.011)a

Standard Error Robust Zip Code Industry Household Marital
Clustering Employed Income status

Number of Observations 102 99 102 102 102
Pseudo-R2 14.49a 16.14a 11.13b 19.48a 21.65a

Ho:
∑

b i = 0 .199 .214 .199 .199 .199
(x 2 k−1)
Akaike Information Criterion 75.28 73.39 75.28 75.28 71.27

Notes: Approximate P-value in parentheses.
aSignificant at the .01 level.
bSignificant at the .05 level.
cSignificant at the .10 level.

308 E. KEMP ET AL.

https://www.incomebyzipcode.com/louisiana/70119

characteristic measured by a regressor increases
(decreases) the probability of testing for COVID-19.
We also report the value of the Akaike Information
Criterion (AIC) [38] which measures the information
discrepancy between the estimated model and the
true population model. A smaller AIC suggests less dis-
crepancy between the estimated model and the true
population model.

The first column in Table 3 reports parameter
estimates with robust standard errors. The last 4 cluster
the standard errors on a respondent’s zip code, indus-
try of employment, household income, and marital
status, which may be a source assignment into the
treatment of having been tested for COVID-19. This
mitigates bias in the parameter estimates [39]. Across
the parameter estimates, being an essential worker
and position in the health quintile are always statisti-
cally significant. More specifically, essential workers
are approximately 61% less likely to have been tested
for COVID-19, and individuals in the top quintile of
self-reported good health are approximately 64%
more likely to have been tested for COVID-19.

In general, the parameter estimates in Table 3
suggest that the disproportionate COVID-19 burden
borne by African Americans is possibly driven by
race-based testing disparities. The sign and magnitude
of the estimated odds ratio suggest that, at least in New
Orleans, Louisiana, African Americans employed as
essential workers, and those who are in poor health,
are less likely to be tested for COVID-19. As such,
the most vulnerable African American citizens are at
risk of being infected with COVID-19 and not being
treated. This increases the risk of COVID-19 related

deaths among African Americans, and contributes to
race-based disparities in COVID-19 deaths.

Discussion

During the early stages of the coronavirus outbreak,
African Americans were dying from the disease at
alarming rates [3,4]. This research examined the atti-
tudes and beliefs of African Americans in the city of
New Orleans concerning COVID-19. It also investi-
gated how social, economic and physical conditions
determine vulnerability to infection as well as
COVID-19 testing participation among African Amer-
icans. Findings in our study indicate that Americans
did recognize COVID-19 as a threat and many were
making efforts to socially distance. However, there
may have been factors beyond their control that pre-
cluded some from completely self-isolating. This
included the inability to work from home as well as liv-
ing in multigenerational housing. Further, results also
revealed that some of the most vulnerable (i.e. least
healthy and essential workers) in the study were at
risk of being infected with COVID-19 and not being
treated. This increases the risk of COVID-19 related

deaths among African Americans, and contributes to
race-based disparities in COVID-19 deaths.

Implications for healthcare organizations
Findings from this research underscore the need for
health care organizations to work to ensure that
societal decisions about the distribution of health
resources safeguard the interests of patients and pro-
mote access to health services. Especially during a
health-related crisis, individuals look to healthcare pro-
viders for information. Health care providers can
employ a collaborative, patient-centered approach
that promotes trust [40]. Health care providers should
consider how an individual’s circumstances (e.g. access
to transportation, healthy foods) impact the effective-
ness of health promotion efforts. For example, many
healthcare providers ramped up telehealth efforts
during the coronavirus pandemic. Telehealth, when
appropriate, can help close the disparity gap in tra-
ditionally underserved and vulnerable patient popu-
lations. It can facilitate health service delivery by
overcoming transportation obstacles and economic
status. In addition, mobile health clinics [41] might
be an effective way to provide health services (i.e.
COVID-19 testing) to vulnerable populations.

Further, during a health crisis such as the COVID-
19 pandemic, healthcare organizations and policy
makers should direct targeted messages at vulnerable
populations through appropriate media [42,43].
There were some young adults in our study who did
not fully accept that COVID-19 was a serious threat.
Special social marketing efforts to reach this group
might be warranted. In addition, communication
efforts should also be tailored to a group’s risk level.
Sometimes persons most affected by a disease outbreak
or health threat perceive the risk differently from health
experts.

In addition to addressing the physical needs of vul-
nerable populations during a health crisis, mental
health must also be a priority. Many of the participants
in this study were very anxious about the virus out-
break and a few had lost loved one. During crisis
moments, people may be experiencing grief, stress,
depression and worry. For some, these feelings may
become overwhelming. Making resources available to
these populations should be paramount.

Limitations and future research
Although this research provides insight on how health-
care organizations can address the needs of vulnerable
populations during a health-related crisis, future
research opportunities abound. One of the limitations
of this research is that it only explored the beliefs, beha-
viors and circumstances of one ethnic minority group
in the United States. Other ethnic minority groups
who may be at risk during a health-related crisis
might be examined. For example, Latinos also

INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 309

experienced high coronavirus infection rates in urban
areas in the United States [44]. In addition, other vul-
nerable groups, including the elderly, the disabled,
pregnant women and the impoverished should be con-
sidered in future research.

Further, this research suggests that essential workers
might be those less likely to receive appropriate medi-
cal care and attention during a health-related crisis.
Future research might embark on a more comprehen-
sive investigation regarding essential workers. More
information on how this work segment is defined,
and how their needs can be addressed during a
health-related crisis would provide insight and direc-
tion for needed public policy to ensure the safety of
these individuals.

Finally, when examining the health status of various
populations, health organizations, institutions, and
education programs are encouraged to also address
underlying elements related to social determinants of
health. This involves understanding the dynamic inter-
action between behavioral, clinical, policy, and
environmental determinants of health.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes on contributors

Elyria Kemp, PhD is Associate Professor of Marketing in the
College of Business Administration at the University of New
Orleans. She holds the Edward G. Schlieder Chair in Higher
Education and Health Initiatives and the Bank One
Endowed Professorship in Minority & Emerging Business

Gregory N. Price, PhD is Professor of Economics in the Col-
lege of Business Administration and the Urban Entrepre-
neurship & Policy Institute at the University of New Orleans

Nicole R. Fuller, PhD is Assistant Professor of Management
in the College of Business Administration at University of
New Orleans

Edna Faye Kemp, DDS is a practicing dentist at Kemp Den-
tistry and in the public healthcare sector in Indianapolis,
Indiana

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Abstract

Conceptual background
Individual behavior – attitudes, beliefs and norms
Access to health services
Study part I: Beliefs and behaviors
Methodology
Results: Thematic findings
Attitudes toward the virus and susceptibility
Attitude toward government leaders and health experts
Social norms and social distancing
Control limits and disparities
Health services

Part II: COVID-19 testing in New Orleans
Methodology
Results
Discussion
Implications for healthcare organizations
Limitations and future research

Disclosure statement
Notes on contributors
References

RESEARCH ARTICLE Open Access

Higher comorbidities and early death in
hospitalized African-American patients with
Covid-19
Raavi Gupta1* , Raag Agrawal2, Zaheer Bukhari2, Absia Jabbar2, Donghai Wang2, John Diks2, Mohamed Alshal2,
Dokpe Yvonne Emechebe2, F. Charles Brunicardi3, Jason M. Lazar4, Robert Chamberlain5, Aaliya Burza6 and
M. A. Haseeb1

Abstract

Background

: African-Americans/Blacks have suffered higher morbidity and mortality from COVID-19 than all other
racial groups. This study aims to identify the causes of this health disparity, determine prognostic indicators, and
assess efficacy of treatment interventions.

Methods

: We performed a retrospective cohort study of clinical features and laboratory data of COVID-19 patients
admitted over a 52-day period at the height of the pandemic in the United States. This study was performed at an
urban academic medical center in New York City, declared a COVID-only facility, serving a majority Black population.

Results

: Of the 1103 consecutive patients who tested positive for COVID-19, 529 required hospitalization and were
included in the study. 88% of patients were Black; and a majority (52%) were 61–80 years old with a mean body
mass index in the “obese” range. 98% had one or more comorbidities. Hypertension was the most common (79%)
pre-existing condition followed by diabetes mellitus (56%) and chronic kidney disease (17%). Patients with chronic
kidney disease who received hemodialysis were found to have lower mortality, than those who did not receive it,
suggesting benefit from hemodialysis Age > 60 years and coronary artery disease were independent predictors of
mortality in multivariate analysis. Cox proportional hazards modeling for time to death demonstrated a significantly
high ratio for COPD/Asthma, and favorable effects on outcomes for pre-admission ACE inhibitors and ARBs. CRP
(180, 283 mg/L), LDH (551, 638 U/L), glucose (182, 163 mg/dL), procalcitonin (1.03, 1.68 ng/mL), and neutrophil:
lymphocyte ratio (8.3:10.0) were predictive of mortality on admission and at 48–96 h. Of the 529 inpatients 48%
died, and one third of them died within the first 3 days of admission. 159/529patients received invasive mechanical
ventilation, of which 86% died and of the remaining 370 patients, 30% died.

Conclusions

: COVID-19 patients in our predominantly Black neighborhood had higher in-hospital mortality, likely
due to higher prevalence of comorbidities. Early dialysis and pre-admission intake of ACE inhibitors/ARBs improved
patient outcomes. Early escalation of care based on comorbidities and key laboratory indicators is critical for
improving outcomes in African-American patients.

Keywords: Health disparities, COVID-19, African-Americans, Dialysis, ACE inhibitors, Angiotensin II receptor blockers,
Comorbidities, Chronic kidney disease

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: raavi.gupta@downstate.edu
1SUNY Downstate Medical Center, Departments of Pathology and Cell
Biology, 450 Clarkson Ave. MSC #37, Brooklyn, NY 11203, USA
Full list of author information is available at the end of the article

Gupta et al. BMC Infectious Diseases (2021) 21:78
https://doi.org/10.1186/s12879-021-05782-9

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http://orcid.org/0000-0003-4647-0553

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

mailto:raavi.gupta@downstate.edu

Background
Coronavirus Disease 2019 (COVID-19), caused by infec-
tion with Severe Acute Respiratory Syndrome
Coronavirus-2, has been declared by the World Health
Organization to be a pandemic, with over seven million
confirmed cases in the United States [1, 2]. New York
State, including the New York City, became the epicen-
ter of the epidemic in the United States, accounting for
more than 23% of the total U.S. cases by the end of May,
2020 [2]. Such burden of disease is of particular concern
since it disproportionately affects communities with con-
siderable health disparities in New York City, where
African-Americans and Latinos constitute as much as
53% of the population [3]. Our medical center is located
in such a community in Brooklyn, New York.
The spectrum of COVID-19 presentation ranges from

mild influenza-like illness to life-threatening severe re-
spiratory disease requiring ventilatory support [3]. Co-
morbid conditions such as hypertension, diabetes
mellitus, pulmonary and heart diseases, and demo-
graphic factors have been reported to influence out-
comes [4–6]. However, the relative influence of each of
these comorbidities in different patient populations and
age strata has not been assessed, leading to variability in
management and outcomes. Key decisions in patient
management such as the choice of antibiotic, blood pres-
sure goals, and perhaps most importantly, airway man-
agement strategies, have remained variable across or
within hospitals.
National health statistics have documented extensive

health disparities for Black COVID-19 patients. They
suffer a three-fold greater infection rate, and a six-fold
greater mortality rate than their white counterparts [7].
However, limited clinical and laboratory data of prog-
nostic significance from Black COVID-19 patients are
available [8]. A range of cultural, linguistic, and health-
care access barriers have prevented clinical investigation.
Our hospital, located in New York City, serves a pre-
dominantly Black population, and being declared a
COVID-only facility, we were able to maintain a stand-
ard quality-of-care across all COVID-19 patients.
Here we explore the clinical aspects of COVID-19 and

its outcomes in Black patients. This study evaluated clin-
ical signs and symptoms, laboratory indicators, and man-
agement strategies to develop a data-driven COVID-19
patient-care approach. Our findings provide an
evidence-based resource for physicians to assess patient
progress in the early days of hospitalization to direct pa-
tient management decisions.

Methods
This study analyzed the electronic medical records of
COVID-19 patients hospitalized at the State University
of New York (SUNY), Downstate Medical Center,

Brooklyn, New York. The hospital was designated a
COVID-only facility by the State of New York as of
March 4th, 2020, and provided ample equipment and
supplies. The hospital is located in a majority Black
neighborhood with high rates of poverty [9]. This study
was approved by the SUNY Downstate Institutional Re-
view Board [1587476–1].
COVID-19 diagnosis was based on clinical presenta-

tion and a positive real-time reverse transcriptase poly-
merase chain reaction (rtPCR) from a nasopharyngeal
swab (Xpert Xpress SARS-CoV-2, Cepheid, Sunnyvale,
CA). Of the 1103 patients who tested positive over a 52-
day period (March 2nd – April 23rd), when the hospital
was under peak caseload; 529, who met the following
criteria were admitted and included in this study. Pa-
tients were admitted if deemed to be in respiratory dis-
tress (respiratory rate > 22 breaths/min and in need of
supplemental oxygen to maintain oxygen saturation >
92%), were encephalopathic, or were judged sufficiently
ill to require hospitalization. Patients were followed up
for up to 7 months, thus we have been able to document
an outcome (death or discharge) on all patients.
COVID-19 positive pregnant patients who came for ob-
stetrics related visit, and otherwise asymptomatic, were
excluded.
Demographic factors, comorbidities, presenting clinical

symptoms, and outcomes (discharge/death) were re-
corded for 529 patients. Complete medical history was
available for 484 of these patients, however, 45 patients
were too sick to respond or were in altered mental status
at presentation and were excluded from analyses of co-
morbidities. Laboratory data were recorded for 286 pa-
tients on admission or within 24 h of hospitalization,
and at a second time point between 48 and 96 h post-
admission. Pre-admission medications were recorded
based on admission medication reconciliation by admit-
ting physicians. Based on self-reported race/ethnicity,
patients were grouped into Black and Others (White
Hispanic/non-Hispanic and Asian). HIV-positive pa-
tients [with CD4 counts < 50% of the lower limit of the reference range (404–1612/μL)] and transplant recipi- ents were categorized as “immunocompromised”. Chronic kidney disease (CKD) was defined as kidney damage and reduced glomerular filtration rate (GFR < 60 ml/min/1.73 m2) of more than 3 months [10]. We separated patients with kidney disease into 3 groups: 1) CKD without dialysis, defined as patients who were ad- mitted with baseline CKD and did not receive dialysis during hospitalization; 2) CKD with dialysis, defined as patients with baseline CKD who started dialysis as inpa- tients because of worsened acute kidney injury; 3) ESRD, defined as patients who were on dialysis prior to admis- sion and continued dialysis as per their routine schedule during hospitalization.

Gupta et al. BMC Infectious Diseases (2021) 21:78 Page 2 of 11

Patients were treated with hydroxychloroquine (200
mg twice a day, for 5 days) and azithromycin (250 mg
once a day, for 5 days). All patients received standard
venous thromboembolism prophylaxis with low-
molecular weight heparin or direct oral anticoagulants
based on their creatinine clearance rate. Patients with el-
evated D-dimer received a full dose anticoagulation regi-
men. Hypoxia, a sign of Acute Respiratory Distress
Syndrome (ARDS), was monitored by a continuous pulse
oximeter and with arterial blood gas measurements, and
supplemental oxygen was provided as needed via nonin-
vasive ventilation. Patients with worsening respiratory
distress despite supportive care, as determined by declin-
ing pulse oximeter saturation, increasing respiratory rate,
or worsening partial pressure of arterial oxygen/percent-
age of inspired oxygen ratio) were intubated and placed
on mechanical ventilation. Patients who developed acute
kidney injury (AKI) with oliguria (< 30 ml/hr. for > 12 h)
unresponsive to diuretics or hemodynamic optimization,
or decreased creatinine clearance (CrCl < 20 ml/min) re- ceived hemodialysis [11]. Computational analysis was conducted using R (ver.

3.6.3) [12]. Continuous variables are presented as me-
dian and interquartile range (IQR). Categorical variables
such as gender or race are presented as number and per-
cent of patients with 95% confidence intervals (CI). Per-
centages are expressed based on the available data for
the subgroup relative to the total available data for that
variable.
Parametric variables were evaluated through a

Shapiro-Wilk test of normality with a significance cutoff
of P < 0.01. Non-parametric variables were compared using Mann-Whitney rank sum test, with 95% CIs re- ported. Categorical variables were evaluated using the Fisher exact test, and odds ratios (OR) alongside 95% CIs are presented. All tests were two-tailed and statis- tical significance was defined as P < 0.05. No multiple testing correction was applied. A multivariate logistic re- gression analysis was performed on comorbidities and demographic factors for in-hospital mortality, and ORs with 95% CIs are presented. Cox proportional hazards analysis for time to death was conducted on comorbidi- ties, demographic factors, and pre-admission medica- tions [(angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin II receptor blockers (ARBs)] and haz- ard ratios with 95% Cis are presented.

Results
One thousand one hundred three patients were tested
for COVID-19 over a 52-day period. After excluding 292
patients who tested negative and 282 who were treated
as outpatients, 529 inpatients with positive test results
and symptoms consistent with COVID-19 were included
in this study, and were followed-up for up to 7 months.

Demographic information
The median patient age was 70 years (Table 1). A major-
ity of patients were in the age range of 61–80 years
(53%, 281/529) and a small minority were < 40 years old (6%, 28/529). In-hospital mortality rates correlated with patient age, with the highest mortality rate recorded for the > 80-year age group (64%, 67/104) (Fig. 1). 88% of
the patients were Black (466/529) and the remaining
12% were Others. No difference in mortality rates were
found between the two groups. Male-to-female ratio was
1.17:1, with a higher mortality rate for males (52%, 148/
286). The mean BMI of patients was 30 kg/m2 (obese)
and no correlation with mortality was found. A majority
of patients (81%, 157/194) never smoked and, while not
statistically significant, mortality rate increased with any
history of smoking (Table 1).

Presenting signs and symptoms, comorbidities, and pre-
admission medication
Presenting patient complaints, grouped based on sys-
temic symptoms, were fever (42%), respiratory (76%;
cough, shortness of breath), gastrointestinal (21%; diar-
rhea, vomiting), and neurological (16%; altered mental
status, seizure, unresponsiveness).
Comorbidities were present in 98% (517/529) of pa-

tients (Table 2). The most common comorbidities were
hypertension (HT) (79%, 416/517) and diabetes mellitus
(DM) (56%, 289/517), followed by chronic kidney disease
(CKD (17%, 84/504)), (%,), hyperlipidemia (16%, 82/529),
end stage renal disease (ESRD) (10%, 50/504), history of
cancer (9%, 43/496), coronary artery disease (CAD) (8%,
42/529), chronic obstructive pulmonary disease (COPD)
(7%, 36/481), and asthma (6%, 30/475). These comorbid-
ities showed correlation with increased mortality except
for HT. Autoimmune diseases (37/495) did not affect
outcomes (Table 2). Patients with CKD on dialysis (2%,
11/504) showed lower mortality (P = 0.06) than counter-
parts with CKD without dialysis (14%, 73/504). Patients
with ESRD (all on dialysis) showed a significantly higher
survival in univariate analysis (P = 0.02) (Table 2). These
results are notable considering patients with CKD and
ESRD suffered higher mean number of comorbidities
(mean 4.2) than other patients (mean 3.3, P < 0.001). In multivariate analysis, age > 60 years and CAD were

independent predictors of mortality. CKD patients who
did not receive dialysis had a greater chance of death
than those who were dialyzed (P = 0.15, OR, 1.54), and
ESRD patients on dialysis had a lower risk of death (P =
0.07, OR, 0.52) (Fig. 2). Multivariate analysis (model 2)
shows that patients who have CKD and/or ESRD as a
comorbidity have a higher mortality, however, if dialysis
is introduced as an intervention they have a significant
survival advantage (P = 0.004) (Suppl. 1). Cox propor-
tional hazards analysis for time to death showed that

Gupta et al. BMC Infectious Diseases (2021) 21:78 Page 3 of 11

Table 1 Demographic characteristics and outcomes of Covid-19 patients admitted for treatment. The number and percentage of
patients for each variable are provided in columns “survivor” and “non-survivor”. The P values are based on comparisons between
“survivor” and “non-survivor” patients. BMI, body-mass index; CI, confidence interval

Variable Patients Survivors Non-survivors Odds Ratio (95% CI)

P value

Age – median 70 66 73 NA < 0.001

Age ranges No./total no. (%) no. (%) no. (%)

+ 80 yr. 104/529 (20) 37 (36) 67 (64) 2.21 (1.39–3.57) < 0.001

71–80 yr. 147/529 (28) 62 (44) 85 (60) 1.70 (1.11–2.53) 0.006

61–70 yr. 134/529 (25) 70 (52) 64 (48) 0.97 (0.64–1.47) 0.92

51–60 yr. 74/529 (14) 51 (70) 22 (30) 0.41 (0.23–0.72) < 0.001

41–50 yr. 42/529 (8) 30 (71) 12 (29) 0.40 (0.18–0.84) 0.009

0–40 yr. 28/529 (5.7) 24 (86) 4 (14) 0.16 (0.04–0.48) < 0.001

Race/Ethnicity no./total no. (%) no. (%) no. (%)

Black 466/529 (88) 244 (52) 222 (48) 0.77 (0.43–1.36) 0.41

Others 63/529 (12) 30 (48) 33 (52) 1.29 (0.73–2.30) 0.41

Sex no./total no. (%) no. (%) no. (%)

Male 286/529 (54) 138 (48) 148 (52) 1.37 (0.96–1.96) 0.08

Female 243/529 (46) 136 (56) 106 (44) 0.72 (0.50–1.04) 0.08

BMI mean 30 31 29 NA 0.40

BMI no./total no. (%) no. (%) no. (%)

< 29.9 133/238 (56) 46 (34) 87 (66) 1.25 (0.71–2.21) 0.41

> 30 105/238 (44) 42 (40) 63 (60) 0.79 (0.45–1.39) 0.41

Smoking Status no./total no. (%) no. (%) no. (%)

Non-smoker 161/200 (81) 82 (51) 79 (49) 0.74 (0.34–1.59) 0.47

Past/current smoker 39/200 (19) 17 (42) 22 (58) 1.34 (0.62–2.90) 0.47

Fig. 1 In-hospital mortality of COVID-19 patients in different age groups. The number of patients in each age-group are shown above the bars

Gupta et al. BMC Infectious Diseases (2021) 21:78 Page 4 of 11

Table 2 Comorbidities among Covid-19 patients admitted for treatment. The number and percentage of patients for each variable
are provided in columns “survivor” and “non-survivor”. The P values is are based on comparisons between “survivor” and “non-
survivor” patients. CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease

Comorbidities All Patients
no./total (%)

Survivors
no. (%)

Non-survivors no. (%) Odds Ratio
(95% CI)

P value

Asthma 30/475 (6) 9 (30) 21 (70) 2.77 (1.18–7.04) 0.01

Autoimmune disease 37/495 (7) 22 (59) 15 (41) 0.71 (0.33–1.47) 0.39

History of cancer 43/496 (9) 14 (33) 29 (67) 2.39 (1.18–5.03) 0.010

COPD 36/481 (7) 16 (44) 20 (56) 1.48 (0.71–3.16) 0.297

Coronary Artery Disease 42/529 (8) 10 (24) 32 (76) 3.77 (1.76–8.81) < 0.001

Congestive Heart Failure 25/529 (5) 16 (64) 9 (36) 0.59 (0.22–1.45) 0.22

CKD without dialysis 73/504 (14) 28 (38) 45 (62) 1.88 (1.11–3.27) 0.016

CKD with dialysis 11/504 (2) 9 (81) 2 (18) 0.23 (0.02–1.14) 0.06

ESRD on dialysis 50/504 (10) 34 (68) 16 (32) 0.47 (0.23–0.90) 0.02

Diabetes mellitus 289/517 (56) 139 (48) 150 (52) 1.48 (1.03–2.13) 0.03

Hyperlipidemia 82/529 (16) 34 (42) 48 (58) 1.63 (0.98–2.72) 0.05

Hypertension 416/517 (79) 212 (51) 204 (49) 1.35 (0.85–2.15) 0.184

Immune suppression 25/489 (5) 17 (68) 8 (32) 0.48 (0.17–1.21) 0.102

All patients
≥ 1 Comorbidities

517/529 (98) 271 (99) 246 (96) – –

Fig. 2 Multivariate logistic regression analysis of the demographic characteristics and comorbidities for mortality. The presented odds ratios have
been adjusted for multiple testing. CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease

Gupta et al. BMC Infectious Diseases (2021) 21:78 Page 5 of 11

COPD/Asthma had a significantly higher hazards ratio
for death (HR:1.79; CI: 1.20, 2.68; P = 0.005), and that
pre-admission ACE inhibitors (20%, 29/142) and ARBs
(25%, 35/142) had a beneficial effect (P = 0.013 and
0.036, respectively).
Complications during clinical course in 312 patients

were acute hypoxic respiratory failure (37%), AKI (15%),
cardiogenic shock (18%), neurological shock (5%), sepsis
(4%), and diabetic ketoacidosis (3%).

Laboratory data
At admission and at 48–96 h, leukocyte (8.6 K/μL, 10.6
K/μL) and neutrophil counts (7.3 K/μL, 8.9 K/μL) were
higher (P < 0.001) and lymphocyte counts (0.8 K/μL) were lower at 48–96 h (P = 0.003) for non-survivors. The median neutrophil:lymphocyte ratio (NLR) was higher both at admission and at the second time point in pa- tients who did not survive (8.3,10, P < 0.001). Platelet and hemoglobin were marginally decreased but were not significantly different in survivors and non-survivors. Blood urea nitrogen (BUN) (33, 38 mg/dL), creatinine (1.7, 1.6 mg/dL), glucose (182, 163 mg/dL), alkaline phosphatase (66, 75 U/L), and aspartate aminotransfer- ase (AST) (52, 64 μ/L) levels were higher in non- survivors at both time points (P < 0.001). Bilirubin and total protein were mildly increased in non-survivors, but were within their respective reference ranges. Albumin (3.4, 2.8 g/dL) was lower for non-survivors at both time points (P < 0.001). Lactate dehydrogenase (551, 638 U/ L), C-reactive protein (180, 283 mg/L), and procalcitonin (1.03, 1.68 ng/mL) showed significantly higher serum levels at admission and at 48–96 h (P < 0.05) for non- survivors. D-dimer (3.0 mcg/mL, 7.5 times elevation), prothrombin time (PT) (17.2 s), and international nor- malized ratio (1.4 U) were increased in non-survivors at the second time point (P < 0.05). Activated partial thromboplastin time (aPTT) was not found to be differ- ent in the two groups (Table 3).

Outcomes
Of the 529 hospitalized patients evaluated, 274 survived
and 255 (48%) died by the end of the study. Of the 529
patients examined, 159 received invasive mechanical
ventilation, of which 137 (86%) died. The remaining 370
patients who received supplemental oxygen therapy via
non-invasive mode 123 (23%) died. This also included
patients who self-declared “Do Not Intubate” (DNI), “Do
not Resuscitate” (DNR) or came to the hospital in severe
respiratory distress and died within the first few hours of
admission. Of the patients who died, 36% (92/255) died
in the first 3 days, which was similar for both Blacks (78/
218) and Others (13/34) (Fig. 3). Patients who survived
remained hospitalized from 1 to 37 (median: 6) days,
and those who died were hospitalized from 0 to 47

(median: 5) days. Median time to death for mechanically
ventilated patients was 5 days (range: 0–33) days, while
for non-ventilated patients it was 4 (range: 0–47) days
from admission.

Discussion

This study documents the demographic, clinical features,
and outcomes for patients admitted with COVID-19 at
an urban hospital located in an underserved majority-
Black neighborhood. We also identify indicators avail-
able to physicians at two early time points of evaluation
to predict outcomes and develop management plans for
appropriate levels of care.
The Black patient population in our study faces unique

obstacles such as linguistic and cultural barriers to care
and understudied comorbidities [13, 14]. Despite reports
that African-Americans face significantly greater mortal-
ity from COVID-19, recent studies have examined the
clinical outcomes in largely East-Asian or Caucasian co-
horts [13]. Here, we present an analysis of 529 patients
admitted with COVID-19, over a 52-day period at the
height of the pandemic in New York City, and have ei-
ther been discharged or died.
Older age at admission correlated with higher mortal-

ity rate, with the 60+ year age group most at risk, and
was an independent risk factor for mortality. Males suf-
fered significantly higher mortality than females, despite
identical representation at admission. Recent reports of
high plasma concentrations of ACE-2, a receptor for
coronavirus, in men may account for higher mortality
[15]. Our inpatient population had a mean BMI in the
“obese” range, higher than the national average; this
finding mirrors higher BMI amongst the Black popula-
tion nationwide [16] However, BMI was not a predictor
of survival; higher BMIs were more commonly seen
amongst younger patients. Smoking was less prevalent in
our patient population than the national average; 4%
were current smokers and 15% had quit [17]. We found
smoking to be unrelated to poor outcome.
The majority (88%) of our patients were Black. Race was

not an independent prognostic factor for survival; higher
mortality in our patient population can be attributed to a
greater number and prevalence of comorbidities common
amongst this group. Comorbidities were present in 98% of
our patients, and the presence of any comorbidity was a
strong predictor of mortality, as noted in other recent
studies [18–20]. HT and DM were the two most prevalent
preexisting conditions; prevalence of HT (79%) and DM
(56%) was considerably higher than previously reported
(up to 63 and 36%, respectively) [21–23]. In the multivari-
ate analysis, coronary artery disease was strongly associ-
ated with adverse outcome (OR,2.38 CI, 1.11–5.50, P
0.03), followed by DM (OR, 1.22, CI, 0.81–1.84, P = 0. 35).
A 2.5-fold increase in the risk of mortality from COVID-

Gupta et al. BMC Infectious Diseases (2021) 21:78 Page 6 of 11

Table 3 Laboratory data of 286 inpatients at admission and at a secondary time point between 48 and 96 h of admission. Median
and interquartile ranges are presented. The P value is calculated between patients who survived and did not survive. aPTT, activated
partial thromboplastin time; Alk Phosphatase, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase;
BUN, blood urea nitrogen; CI, confidence interval; CRP, C-reactive protein; INR, international normalized ratio; LDH, lactate
dehydrogenase; PT, prothrombin time

Laboratory values
(reference range)

Time of
determination
(n)

Survivors Non-survivors 95% CI P
value

Median (Inter Quartile Range)

Hematologic parameters

Hemoglobin
(12–16 g/dL)

At admission (286) 12.3 (11.0–14.0) 12.7 (11.3–14.3) −0.9 – 0.1 0.13

48–96 h (228) 12.0 (10.15–13.1) 11.7 (10.5–13.3) −0.6 – 0.5 0.83

Leukocyte count
(3.5–10.8 K/μL)

At admission (285) 7.2 (5.4–9.3) 8.6 (6.4–11.3) −2.3 – -0.7 < 0.001

48–96 h (228) 6.5 (5.1–9.4) 10.6 (7.8–14.3) −4.9 – -2.7 < 0.001

Neutrophil Count
(1.7–7 K/μL)

on admission (270) 5.8 (3.8–7.8) 7.3 (4.8–10.0) − 2.3 – -0.8 < 0.001

48–96 h (205) 5.4 (3.4–7.6) 8.9 (6.4–12.5) −4.8, − 2.5 < 0.001

Lymphocyte count
(0.9–2.9 K/μL)

on admission (260) 0.9 (0.7–1.1) 0.8 (0.6–1.1) −5.4e – -5, 0.2 0.04

48–96 h(205) 1.0 (0.8–1.3) 0.8 (0.5–1.2) 0.1–0.3 0.002

Neutrophil Lymphocyte count (NLR) on admission (260) 5.4 (3.7–8.1) 8.3 (5.3–13.7) −3.8 – -1.4 < 0.001

48–96 h (204) 4.7 (3.3–7.0) 10.0 (6.06–19.5) −6.7 – -3.2 < 0.001

Eosinophil count
(0.0–0.8 K/μL)

on admission (255) 0.03 (0.01–0.07) 0.02 (0.01–0.04) 0.002–0.01 < 0.001

48–96 h (203) 0.05 (0.02–0.1) 0.01 (0.01–0.04) 0.01–0.03 < 0.001

Platelet count
(130–400 K/μL)

on admission (283) 204 (158–266) 200 (147–260) −11.0 – 28 0.40

48–96 h (225) 229 (153–338) 194 (150–280) − 5.9 – 53.9 0.11

Blood Chemistry

Sodium
(136–145 mmol/L)

on admission (286) 136 (133–138) 136 (132–141) − 2.0 – 1.0 0.51

48–96 h (237) 138 (136–140) 142 (137–147) − 5.9 – -2.0 < 0.001

Potassium
(3.5–5.1 mmol/L)

on admission (286) 4.2 (3.8–4.8) 4.4 (3.9–5.0) − 0.4 – 4.9e-5 0.04

48–96 h (235) 4.3 (4.0–4.6) 4.4 (3.9–5) − 0.4 – 5.2e-5 0.05

Bicarbonate
(23.0–28.0 mmol/L)

on admission (196) 25 (22–30) 22 (19–26) 1.0–4.9 0.001

48–96 h (143) 24 (21–28) 21 (18–24) 1.6–5.0 <.0.001

Chloride
(98–107 mmol/L)

on admission (285) 100 (94–103) 100 (96–105) − 3.9 – 3.5e-5 0.09

48–96 h (238) 102 (96–106) 107 (101–113) − 8.0 – -3.0 < 0.001

Magnesium
(1.9–2.7 mg/dL)

on admission (159) 2 (1.8–2.2) 2.2 (1.9–2.6) − 0.30 – -2.9e-5 0.014

48–96 h (164) 2.2 (1.8–2.3) 2.4 (2.1–2.7) − 0.4 – -0.2 < 0.001

BUN
(7–25 mg/dL)

on admission (285) 22 (14–38) 33 (19–54) − 14.0 – -5.0 < 0.001

48–96 h (235) 20 (14–40) 38 (23–67) − 22.0 – -10 < 0.001

Serum creatinine
(0.7–1.3 mg/dL)

on admission (286) 1.3 (1.0–2.4) 1.7 (1.2–2.6) − 0.5 – -0.1 0.008

48–96 h (237) 1.2 (0.8–2.3) 1.6 (1.1–3.1) −0.6 – -0.1 0.003

Glucose – random
(70–99 mg/dL)

on admission (286) 128 (104–184) 182 (129–275) − 61.0 – -23.0 < 0.001

48–96 h (240) 103 (84–140) 163 (119–269) − 72.9 – -35.9 < 0.001

AST
(13–39 μ/L)

on admission (284) 40 (26–65) 52 (38–83) − 19.0 – -5.0 < 0.001

48–96 h (224) 49 (28–66) 64 (37.7–106.2) − 29.0 – -8.0 < 0.001

ALT
(7–52 μ/L)

on admission (284) 24 (16–38) 29 (19–44) − 7.0 – 0.1 0.11

48–96 h (224) 28 (17–52) 34 (22–57) − 10.0 – 2.0 0.22

Alk Phosphatase
(34–104 U/L)

on admission (284) 64 (49–78) 66 (54–96) − 15.0 – -1.0 0.02

48–96 h (223) 59 (46–78) 75 (52–111) − 27.0 – -7.0 < 0.001

Bilirubin
(0.3–1 mg/dL)

on admission (280) 0.5 (0.4–0.8) 0.6 (0.5–0.8) − 0.1 – 5.0e-5 0.28

48–96 h (219) 0.5 (0.4–0.8) 0.7 (0.5–.9) − 0.2 – -5.4e-5 0.002

Gupta et al. BMC Infectious Diseases (2021) 21:78 Page 7 of 11

19 in hypertensive patients has been reported, however,
this was not discernable in our patients [22]. Although
past history of cancer, HT, autoimmune diseases, and im-
munosuppression were not independent predictors of
mortality, the combined effect of these comorbidities on
multiple organ systems and resultant dysregulation of the
immune system likely increases susceptibility to COVID-
19 [23, 24].
A notable finding in multivariate analysis was that pa-

tients with CKD who were dialyzed early in the course
of treatment had better outcomes than those who did
not (2%, OR, 0.27, CI, 0.04–1.11, P = 0.10). Although not
statistically significant, we speculate that a larger number
of patients with CKD on dialysis (currently n = 11)
would allow for a definitive conclusion. These findings
are notable considering patients with CKD had more co-
morbidities as compared to all other patients in the
study. Early dialysis stands out as a potentially beneficial
treatment option for patients with CKD. It is likely that

dialysis removes inflammatory mediators, cytokines, and
other effector molecules responsible for the end-organ
damage. CKD and ESRD were more prevalent in our pa-
tient population (26%) than reported in other studies
(between 3 to 8.5%), most likely due to complications
from HT and DM [25].
We found laboratory data at admission vital for triaging

patients to receive intensive care. CRP, LDH, and procalci-
tonin were significantly increased at both admission and
at 48–96 h in non-survivors. Indicators of AKI, elevated
levels of BUN, creatinine, glucose, and reduced levels of
bicarbonate or albumin were significant predictors of ad-
verse outcome at both initial and secondary time points.
These findings correlate with reported tubular, endothe-
lial, and glomerular capillary loop injury, likely the result
of direct injury or systemic hypoxia [26]. Hypoproteinemia
and hypoalbuminemia in non-survivors may result from
renal insufficiency and suboptimal nutritional status in
critically-ill patients, or could reflect stressed state [25]. As

Laboratory values
(reference range)
Time of
determination
(n)
Survivors Non-survivors 95% CI P
value
Median (Inter Quartile Range)

Total protein
(6–8.3 g/dL)

on admission (282) 7 (6.5–7.3) 6.7 (6.4–7.2) −2.6e-5 – 0.3 0.12

48–96 h (219) 6.2 (5.9–6.6) 6 (5.5–6.7) − 6.0e-5 – 0.4 0.10

Albumin
(3.5–5.7 g/dL)

on admission (283) 3.6 (3.2–4.0) 3.4 (3.1–3.6) 0.1–0.3 < 0.001

48–96 h (223) 3.0 (2.7–3.2) 2.8 (2.5–3.0) 0.1–0.3 < 0.001

LDH
(14–271 U/L)

on admission (201) 379 (280–500) 551 (411–743) 106.0–22,849 < 0.001

48–96 h (82) 406 (278–553) 638 (444.5–867) 106.9–339.0 < 0.001

CRP
(< 10 mg/L)

on admission (201) 117 (63–197) 180 (128–283) −97.0 – -36.9 < 0.001

48–96 h (85) 96 (41–185) 283 (188–338) −200.0 – -88.9 < 0.001

Troponin I
(<=0.15 ng/mL)

on admission (170) 0.03 (0.02–0.12) 0.08 (0.02–0.21) 3.6e-5 – 0.06 0.010

48–96 h (61) 0.11 (0.02–0.26) 0.15 (0.06–0.40) − 0.03 – 0.18 0.30

Ferritin
(14–233 ng/mL)

on admission (190) 654.5 (303–1151) 955 (539.0–2114.6) 118.5–566.5 0.002

48–96 h (95) 768.5 (439–1821) 1614.1 (499.7–2801.5) − 37.3, − 1036.7 0.08

Procalcitonin
(0–0.10 ng/mL)

on admission(172) 0.32 (0.10–0.96) 1.03 (0.36–3.78) 0.19–0.88 < 0.001

48–96 h (69) 0.34 (0.25–2.47) 1.68 (0.41–7.35) 4.75e-5 – 2.77 0.049

D-dimer
< 0.4 mcg/ml

on admission (50) 3.3 (1.3–5.2) 1.5 (0.5–5.2) −1.02 – 2.6 0.39

48–96 h (43) 0.5 (0.5–1.5) 3.0 (1.1–7.5) − 4.5 – -0.2 < 0.001

Coagulation Parameters

aPTT
(25.4–38.6 s)

on admission (126) 29.9 (28.4–32.4) 29.0 (26.9–33.6) −1.9 – 1.5 0.68

48–96 h (44) 30.7 (28.0–36.2) 31.1 (27.9–39.0) − 6.3 – 6.3 0.99

PT
(10.8–13.7 s)

on admission (113) 13.0 (12.2–13.7) 13.5 (12.6–15.4) 5.1–1.3 0.04

48–96 h(43) 13.1 (11.9–15.2) 17.2 (13.3–20.2) 4.94e-5 – 6.7 0.04

INR (1 U) on admission (113) 1.1 (1.0–1.1) 1.1 (1.0–1.3) − 7.12e-6 – 0.10 0.07

48–96 h (41) 1.0 (1.0–1.2) 1.4 (1.1–1.6) 7.49e-6 – 0.50 0.02

Gupta et al. BMC Infectious Diseases (2021) 21:78 Page 8 of 11

reported elsewhere, we found hyperglycemia to be a pre-
dictor of adverse outcome in COVID-19 patients, regard-
less of their history of diabetes [27]. Multivariate analysis
of laboratory data was not performed due to sample size
limitations.
Peripheral blood analysis showed that a high median

NLR at admission and at 48–96 h was an independent
predictor of adverse outcome in COVID-19 patients, as
had been reported in other studies [28]. The presence of
COVID-19 associated coagulopathy (CAC), a condition
characterized by elevation in fibrinogen and D-dimer
levels, high PT, relatively normal aPTT, and mild
thrombocytopenia without evidence of microangiopathy,
was confirmed in our study [29]. The mechanisms
underlying CAC remain poorly understood, but it can
possibly result from activation of extrinsic coagulation
pathway, leading to excess consumption of Factor-VII
following endothelial cell infection by the virus [30, 31]
Elevated D-dimer levels at the second evaluation time
point were associated with higher mortality, likely
reflecting coagulation activation from sepsis, “cytokine-
storm”, or impending organ failure.
By the end of our study, 48% of the inpatients had

died, including 86% who received invasive mechanical
ventilation. Reported mortality rates from other retro-
spective cohort studies ranged from 21% (New York

metropolitan area) to 26% (Lombardy region, Italy) and
33% (UK) [4, 6, 32]. Relative to other studies, the mortal-
ity rate among our patients was elevated, which we be-
lieve is due to the largely poor and disadvantaged
neighborhood where our hospital is located. Race was
not found to be an independent predictor of mortality.
Patients from similar underprivileged communities tend
to present at an advanced stage of the disease leading to
increased morbidity and mortality [33]. Rate ratios of
hospital admission and mortality in US patients show a
4.7 and 2.1 times higher prevalence among Blacks as
compared to Whites [34].
Our patients from a minority and underserved popula-

tion had an unusually high burden of co-morbidities
some of which proved to be independent predictors of
the observed in-hospital high mortality; 1/3 of the pa-
tients died within the first 3 days of admission. We
found some of the early laboratory data, together with
demographics and co-morbidities, pivotal in predicting
the clinical course of COVID-19. Early institution of dia-
lysis in patients with chronic renal insufficiency reduced
mortality significantly.
Our study has limitations. It examined a predomin-

antly Black patient cohort, which makes comparisons to
other races and ethnicities difficult to quantify. This
study was carried out on patients admitted at the height

Fig. 3 Days from admission to death of 255 consecutive inpatients. More than one third of patients (92/255) died within 3 days of admission for
both Blacks (78/218) and Others (13/34)

Gupta et al. BMC Infectious Diseases (2021) 21:78 Page 9 of 11

of the pandemic in New York City, admissions were re-
stricted to the most seriously ill and hospital resources
were under strain, which may have contributed to an in-
crease in overall mortality rates. Initiation of dialysis
during admission occurred at the discretion of treating
physicians, and there may be unmeasured differences be-
tween patients started on dialysis and those not-started
on dialysis that are not accounted for in this analysis. As
knowledge and understanding of COVID-19 was devel-
oping during March and April, complete laboratory
studies were not systematically ordered for all patients.
The routine use of steroids and Remdesivir were not
established yet during the time of this study and so these
findings, particularly the mortality rate, should be taken
in that context. BMI was not included in the multivari-
ate regression model as BMI was available in only a sub-
set of patients.

Conclusions
In our predominantly Black cohort we have recorded an
in-hospital mortality rate from COVID-19 which is sig-
nificantly greater than that reported in other studies.
While race was not an independent predictor of death,
this population had a greater burden of comorbidities
than the national average and the prevalence of these
chronic comorbidities contributed to both disease sever-
ity and higher mortality. Our study identified that early
escalation of care is important in patients from minority
neighborhoods as one third of the admitted patients die
within the first 3 days of admission. Laboratory indica-
tors at admission are predictors of outcome and can be
utilized by physicians to triage patients and monitor dis-
ease course Early institution of dialysis in patients with
chronic renal insufficiency trended toward association
with lower mortality.

Supplementary Information

The online version contains supplementary material available at https://doi.
org/10.1186/s12879-021-05782-9.

Additional file 1: Suppl 1. Multivariate logistic regression analysis of
the demographic characteristics and comorbidities for mortality. Dialysis
has been added as a covariate for patients with ESRD and CKD. The
presented odds ratios have been adjusted for multiple testing. CKD,
chronic kidney disease; COPD, chronic obstructive pulmonary disease;
ESRD, end-stage renal disease.

Acknowledgements

Not applicable.

Authors’ contributions

RG and MAH conceived and designed the study. RG, RA, and MAH designed
the statistical analysis plan. RG, RA, and MAH analyzed the data and
developed the figures and Tables. RG, ZB, AJ, DW, JD, MA, and DYE collected
data from electronic health records. CFB, JL, RC, and AB provided clinical
consultation throughout the study course. All authors contributed
intellectual content during the drafting and revision of the work and
approved the final version.

Funding

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.

Ethics approval and consent to participate

SUNY Downstate Institutional Review Board (IRB) approved the study
[1587476–1]. SUNY Downstate IRB granted waiver of consent to access raw
patient database mentioned in the methods.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

1SUNY Downstate Medical Center, Departments of Pathology and Cell
Biology, 450 Clarkson Ave. MSC #37, Brooklyn, NY 11203, USA. 2Department
of Pathology, SUNY Downstate Medical Center, Brooklyn, USA. 3Department
of Surgery, SUNY Downstate Medical Center, Brooklyn, USA. 4Division of
Cardiology, Department of Medicine, SUNY Downstate Medical Center,
Brooklyn, USA. 5Department of Anesthesiology, SUNY Downstate Medical
Center, Brooklyn, USA. 6Division of Pulmonary Medicine and Critical Care,
Department of Medicine, SUNY Downstate Medical Center, Brooklyn, USA.

Received: 6 July 2020 Accepted: 11 January 2021

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aldosterone inhibitors. Eur Heart J 2020;41(19):1810–1817.

16. Fryar CD, Kruszon-Moran D, Gu Q, Ogden CL. Mean body weight, height,
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17. Creamer MR. Tobacco product use and cessation indicators among adults
— United States, 2018. MMWR Morb Mortal Wkly Rep. 2019;68(45):1013–9.

18. Wang B, Li R, Lu Z, Huang Y. Does comorbidity increase the risk of patients
with COVID-19: evidence from meta-analysis. Aging. 2020 Apr 8;12(7):6049–57.

19. Killerby ME, Link-Gelles R, Haight SC, et al. Characteristics associated with
hospitalization among patients with COVID-19 – metropolitan Atlanta, Georgia,
march-April 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):790–4.

20. Guan W, Liang W, Zhao Y, Liang H, Chen Z, Li Y, et al. Comorbidity and its
impact on 1590 patients with Covid-19 in China: A Nationwide Analysis. Eur
Respir J. 2020 Jan 1 [cited 2020 May 16]; Available from: https://erj.
ersjournals.com/content/early/2020/03/17/13993003.00547-2020

21. Garg S. Hospitalization rates and characteristics of patients hospitalized with
laboratory-confirmed coronavirus disease 2019 — COVID-NET, 14 states,
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22. Lippi G, Wong J, Henry BM. Hypertension in patients with coronavirus
disease 2019 (COVID-19): a pooled analysis. Pol Arch Intern Med. 2020;
130(4):304–9.

23. Leoncini G, Viazzi F, Storace G, Deferrari G, Pontremoli R. Blood pressure
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Hypertens. 2013 Nov;27(11):663–70.

24. Restrepo MI, Sibila O, Anzueto A. Pneumonia in patients with chronic
obstructive pulmonary disease. Tuberc Respir Dis. 2018 Jul;81(3):187–97.

25. Su H, Yang M, Wan C, Yi L-X, Tang F, Zhu H-Y, et al. Renal histopathological
analysis of 26 postmortem findings of patients with COVID-19 in China.
Kidney Int. 2020 [cited 2020 May 16];0(0). Available from: https://www.
kidney-international.org/article/S0085-2538(20)30369-0/abstract

26. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of
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27. Li X, Xu S, Yu M, Wang K, Tao Y, Zhou Y, et al. Risk factors for severity and
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2020 Jul;146(1):110–8.

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Neutrophil-to-lymphocyte ratio as an independent risk factor for mortality
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html

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Overcoming Barriers to
COVID-19 Vaccination
in African Americans:
The Need for Cultural
Humility
Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASPC

ABOUT THE AUTHOR

Keith C. Ferdinand is with the Department of Medicine, Tulane University School of Medicine,
New Orleans, LA.

See also Benjamin, p. 542, and Rodenberg, p. 588.

“Rescue work by helicopter was slow.

That stopped at dark about 7 o’clock

. . . people began to panic. I told

Kenneth and Keith and those around

me that we may as well make the

best of it, for no one knows we are

here . . . help won’t come until

morning. The rain fell so hard that I

had to take off my glasses & hide my

head. . . . The water, still slowly rising,

had two more inches to go before it

reached the rooftop. We learned:

that communication [and] coopera-

tion are necessary factors for survival

in a disaster.”

—Letter from Inola Copelin Ferdinand

to her sister, Narvalee, after our family

and others spent days amid the

drowning death of my paternal grand-

father and many of her neighbors,

abandoned on rooftops in the Lower

Ninth Ward, New Orleans, LA, during

Hurricane Betsy, September 9, 1965

Racial/ethnic minorities suffer dis-

proportionately from US COVID-19–as-

sociated deaths.1 The tragically higher

COVID-19 mortality among African

Americans from multiple conditions, in-

cluding cardiovascular diseases (CVD)

and certain cancers, highlights deep-

rooted, unacceptable failures in US

health care. The social determinants of

health (limited finances, healthy food,

education, health care coverage, job

flexibility) make disadvantaged commu-

nities more vulnerable to COVID-19 in-

fectivity and mortality and amplify higher

comorbid conditions.2 The Healthy

People 2020 Social Determinants of

Health include the Economic Stability

domain, with employment as a key issue.

Suboptimal job benefits such as health

insurance, paid sick leave, and parental

leave can affect the health of employed

individuals, and African Americans are

more likely to work in blue-collar service

jobs.3 This toxic gumbo of suboptimal

health and adverse environments pro-

foundly diminishes overall African

American longevity, fueling a decades-

long White–Black death gap, with African

American men having the shortest life

expectancy.2 Although December 2020

Pew Research data note that a growing

share of Americans report they probably

or definitely will accept COVID-19 vac-

cination, African Americans continue to

stand out as less inclined to get vacci-

nated: 42% would do so, compared with

63% of Hispanic and 61% of White adults.4

MISTRUST: A CRITICAL
BARRIER TO OVERCOME

Effective public health messaging and

mitigation efforts are required to opti-

mize acceptance of COVID-19 vaccina-

tion and minimize subsequent mortality.

Unfortunately, mistrust in orthodox

health care is a substantial barrier to

COVID-19 vaccine acceptance, and with-

out widespread uptake, the societal ben-

efits of immunization, even with very

effective, safe vaccines, will not be realized.

Despite recent attention to the impact of

structural racism across a wide range of

health conditions in the United States, the

COVID-19 pandemic further unmasks

these inequities. The scandalous history of

orthodox medicine and public health to-

ward African Americans demands recog-

nition or will remain a formidable obstacle

to acceptance of vaccination.

HISTORICAL RACISM IN US
HEALTH CARE AND PUBLIC
HEALTH

The multigenerational African American

mistrust reflects a legacy of real-life ex-

periences and the shameful historical

racism in medicine and public health.

Since the mid-19th century, and well into

the 20th century, physicians and public

health officials were apologists, and

even advocates, for the less-than-

humanistic care and racist theories

that supported the subjugation and

586 Editorial Ferdinand

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OPINIONS, IDEAS, & PRACTICE

http://ascopubs.org/doi/full/10.2105/AJPH.2021.306215

http://ascopubs.org/doi/full/10.2105/XXX

dehumanization of African slaves and,

later, Black US citizens.

In 1851, Samuel Cartwright, a

leading medical authority, maintained

that a slave must be submissive to his

master. He identified drapetomania,

the “disease” of running away, with

specific remedies: removal of both big

toes and “whipping the devil out of

them.”5 The extensive history of Blacks

receiving violent medical treatment

and experimentation includes medical

schools utilizing enslaved Black bod-

ies as “anatomical material,” early

gynecologists experimenting on

enslaved women, compulsory sterili-

zation, and the saga of Henrietta

Lacks, whose cancerous cells, taken in

the segregated Johns Hopkins ward,

were experimented on, reproduced,

and disseminated without her knowl-

edge or consent.6

Most prominently, the infamous

“Tuskegee Study of Untreated Syphilis

in the Negro Male” remains a symbol of

African American mistreatment, deceit,

conspiracy, malpractice, and neglect

by the medical establishment. Social

scientists and medical researchers

have repeatedly pointed to this un-

ethical study as a reason many African

Americans remain wary of mainstream

medicine and participation in clinical

trials, and why there are fewer phy-

sician interactions among African

Americans and increased mortality for

older African American men, as has

been consistently documented.7

GOVERNMENTAL
PROGRAMS FOR EQUITY
IN COVID-19

Organized government initiatives are

essential to link scientific understanding

of SARS-CoV-2 to public health policy and

social justice. Institutionalized strategies

at a national level include the National

Institutes of Health’s Community En-

gagement Alliance (CEAL) against COVID-

19 disparities, which targets African

Americans, Hispanics/Latinos, and

American Indians/Alaska Natives, who

account for over half of all reported US

cases.8 Specifically, CEAL’s community

outreach efforts are designed to increase

clinical trial diversity and to overcome

misinformation and mistrust regarding

treatments, diagnostics, and vaccines.8

This ongoing program seeks to identify

and connect with some of the hardest-hit

communities.

Furthermore, state, territorial, and

tribal perspectives may swiftly identify

disparities and problem areas in COVID-

19 incidence, burden, and vaccination

and more precisely deliver culturally

appropriate messaging. One example,

Louisiana’s COVID-19 Health Equity Task

Force (www.sus.edu/lacovidhealthequity),

was initiated after an alarmingly high Af-

rican American mortality rate was identi-

fied in the state. It has reported to the

governor multiple recommendations for

testing, monitoring COVID-19’s impact,

and policy changes aimed to reduce in-

equities for multiple statewide racial/

ethnic communities.

CULTURAL HUMILITY

The best path forward to controlling the

pandemic and achieving health equity

will require specific, targeted programs

and public health engagement pro-

mulgated with the spirit of “cultural

humility.”9 More than traditional “cultural

competency,” a detached mastery of a

theoretically finite body of knowledge,

cultural humility is a communication

imperative, originally described as an

ongoing process requiring physicians

to engage in conversations with pa-

tients, communities, colleagues, and

themselves. Notable aspects of cultural

humility include self-reflection and self-

critique, learning from patients (avoiding

cultural stereotyping), developing and

maintaining respectful partnerships,

and actively continuing these positive

relationships.

Consequently, vaccination concerns

in communities of color must be

addressed with cultural humility, as

opposed to simply deeming reluctant

individuals as solely uninformed, fool-

ishly recalcitrant, or merely antivaxxers.

Identifying and overcoming vaccination

hesitancy in a multicultural America is

not simply a social nicety, but rather an

essential action to achieve national

levels of immunity and eventually elimi-

nate disparate outcomes among diverse

cultures and racial/ethnic backgrounds.

To communicate the risk–benefit of

COVID-19 vaccines, it is essential to have

input from the mass media, public health

services, policymakers, and “trusted

messengers” (individuals with a prior

history of service and goodwill in the

underserved and minority communities).

According to established international

law, the United States must ensure

equality and nondiscrimination in its

dissemination of new COVID-19 vaccines.

Individual decisions about accepting

vaccination are not simply technical cal-

culations, but value decisions that this

particular intervention is intended to help

and not harm themselves and their loved

ones. Culturally sensitive, literacy-level

appropriate education, delivered with

cultural humility, is optimally respectful

communication, with feedback and

evaluation of the messaging.

CONCLUSION

The best path forward to overcoming the

COVID-19 pandemic in the United States

requires specific, targeted programs and

Editorial Ferdinand 587

OPINIONS, IDEAS, & PRACTICE
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http://www.sus.edu/lacovidhealthequity

public health engagement that promote

diversity in clinical research and partner-

ships with communities of color. The un-

acceptable devastating death and disability

from COVID-19 will be eliminated only by

effectively and respectfully delivering miti-

gation, prevention, early diagnosis, effective

acute care, and, finally, immunization to the

increasingly diverse US populations. Inher-

ent in this challenge, culturally humility is a

crucial component.

CORRESPONDENCE

Correspondence should be sent to Keith C. Ferdi-
nand, MD, Cardiology, Tulane University School of
Medicine, 1430 Tulane Ave, #8548, New Orleans, LA
70112 (e-mail kferdina@tulane.edu). Reprints can
be ordered at http://www.ajph.org by clicking the
“Reprints” link.

PUBLICATION INFORMATION

Full Citation: Ferdinand KC. Overcoming barriers to
COVID-19 vaccination in African Americans: the

need for cultural humility. Am J Public Health.
2021;111(4):586–588.

Acceptance Date: December 15, 2020.

DOI: https://doi.org/10.2105/AJPH.2020.306135

CONFLICTS OF INTEREST

The author has no conflicts of interest to
declare.

REFERENCES

1. Gold JA, Rossen LM, Ahmad FB, et al. Race, ethnicity,
and age trends in persons who died from COVID-
19—United States, May–August 2020. MMWR Morb
Mortal Wkly Rep. 2020;69(42):1517–1521. http://dx.
doi.org/10.15585/mmwr.mm6942e1

2. Ferdinand KC, Nasser SA. African-American COVID-
19 mortality: a sentinel event. J Am Coll Cardiol. 2020;
75(21):2746–2748. https://doi.org/10.1016/j.jacc.
2020.04.040

3. US Dept of Health and Human Services, Office
of Disease Prevention and Health Promotion.
Employment. Healthy People 2020. Available at:
https://www.healthypeople.gov/2020/topics-
objectives/topic/social-determinants-health/
interventions-resources/employment#36.
Accessed December 12, 2020.

4. Funk C, Tyson A. Intent to get a COVID-19 vaccine
rises to 60% as confidence in research and

development process increases. Pew Research
Center. 2020. Available at: https://www.
pewresearch.org/science/2020/12/03/intent-to-get-
a-covid-19-vaccine-rises-to-60-as-confidence-in-
research-and-development-process-increases.
Accessed December 12, 2020.

5. Cartwright SA. Report on the diseases and physical
peculiarities of the negro race. New Orleans Med
Surg J. 1851:691–715.

6. Nuriddin A, Mooney G, White AIR. Reckoning with
histories of medical racism and violence in the USA.
Lancet. 2020;396(10256):949–951. https://doi.org/
10.1016/S0140-6736(20)32032-8

7. Alsan M, Wanamaker M. Tuskegee and the health
of black men. Q J Econ. 2018;133(1):407–455.
https://doi.org/10.1093/qje/qjx029

8. National Institutes of Health. Community Engagement
Alliance (CEAL) against COVID-19 disparities. 2020.
Available at: https://covid19community.nih.gov.
Accessed January 25, 2021.

9. Tervalon M, Murray-Garcia J. Cultural humility vs
cultural competence: a critical distinction in defin-
ing physician training outcomes in multicultural
education. J Health Care Poor Underserved. 1998;9(2):
117–125. https://doi.org/10.1353/hpu.2010.0233

To Work With
Marginalized
Populations, Empathy
Is Key
Howard Rodenberg, MD, MPH

ABOUT THE AUTHOR

Howard Rodenberg is with Baptist Hospital, Jacksonville, FL.

See also Benjamin, p. 542, and Ferdinand, p. 586.

Many years ago, I was told never tofollow a great speaker, as there’s
no way to look good in comparison. So

I’m hesitant to add an opinion to Keith

Ferdinand’s moving account of his

family’s rooftop rescue from their

flooded New Orleans home. The tale

reveals the fear we have when

confronted with uncontrollable cir-

cumstances, such as natural disasters

or pandemics. It also encapsulates the

hopelessness and desperation we

might feel when we don’t have the

ability to care for our friends, our

families, and ourselves. Many of us

have likely felt this way during the

COVID-19 crisis; more still within dis-

advantaged communities.

Incidents of racist thought and prac-

tice within the House of Medicine have

been well documented, and the negative

impact of adverse social determinants of

health has become clear. These factors

complicate public health programming

within marginalized populations, espe-

cially when public health products or

services come from outside rather than

originating within the community itself.

Given the chronic distrust that results

when policymakers seem unwilling or

unable to correct these ills, is it any

wonder there’s skepticism about a

government-backed coronavirus

vaccine?

It has been noted that people of color

have a right to be suspicious of public

health professionals. We can argue

among ourselves how many of today’s

current health disparities within minority

populations are related to centuries of

institutional racism or contemporary

588 Editorial Rodenberg

OPINIONS, IDEAS, & PRACTICE
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mailto:kferdina@tulane.edu

http://www.ajph.org

https://doi.org/10.2105/AJPH.2020.306135

http://dx.doi.org/10.15585/mmwr.mm6942e1

https://doi.org/10.1016/j.jacc.2020.04.040

https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/employment#36

https://www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases

https://doi.org/10.1016/S0140-6736(20)32032-8

https://doi.org/10.1093/qje/qjx029

https://covid19community.nih.gov

https://doi.org/10.1353/hpu.2010.0233

http://ascopubs.org/doi/full/10.2105/AJPH.2021.306215

http://ascopubs.org/doi/full/10.2105/XXX

Capstone Topic Summary

My preceptor Ms. Wilder and I discussed the needs of the community we both serve. Living in South Florida where there is a strong presence of African American population who is underserved by the health care community. The topic I chose will help serve this population. I recently relocated to Georgia which also have a large African American population. The evidence-based topic for the capstone change proposal will focus on the African American population and COVID 19. The category my topic and intervention falls under the community branch. I want to educate the African American population on the benefits of getting the COVID vaccine. History has shown that African American have a sincere distrust in the health care system due to health disparities and previous unconsented experiments performed by the medical community. The pandemic has disproportionately impacted African Americans. But yet this population is reluctant to receive the vaccine. Whether it is from social determents (limited finances, education, insurance or lack of) or health conditions (i.e. hypertension, diabetes), there is need for education to prevent higher mortality rates among the African American population.

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