Submit a summary of six of your articles on the discussion board. Discuss one strength and one weakness for each of these six articles on why the article may or may not provide sufficient evidence for your practice change.

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,
download, or email articles for individual use.

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

© 2020, Association of Schools and
Programs of Public Health

All rights reserved.
Article reuse guidelines:

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,

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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

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

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

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://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

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

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

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

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

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

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

https://gmsp.org

https://healthpolicyresearch-scholars.org/

https://healthpolicyresearch-scholars.org/

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

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

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

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

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

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

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

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

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

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

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

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

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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

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

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

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

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://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://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://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/10.1016/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

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download, or email articles for individual use.

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.

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

© 2020 Informa UK Limited, trading as Taylor & Francis Group

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

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Social Work in Public Health

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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

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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
https://doi.org/10.1080/19371918.2020.1868371

© 2020 Taylor & Francis Group, LLC

http://orcid.org/0000-0003-2014-5998

http://www.tandfonline.com

https://crossmark.crossref.org/dialog/?doi=10.1080/19371918.2020.1868371&domain=pdf&date_stamp=2021-03-04

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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SOCIAL WORK IN PUBLIC HEALTH 127

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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

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

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 (Continued)

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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Abstract
Background
Methods
Results
Conclusions
Background
Methods
Results
Demographic information
Presenting signs and symptoms, comorbidities, and pre-admission medication
Laboratory data
Outcomes
Discussion
Conclusions
Supplementary Information
Acknowledgements
Authors’ contributions
Funding
Availability of data and materials
Ethics approval and consent to participate
Consent for publication
Competing interests
Author details
References
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