This is the sixth story in a series by MedPage Today examining the impact of COVID-19 on vulnerable populations. Past stories reported on the homeless, immigrants in detention, the undocumented, nursing home residents, and incarcerated individuals.

With limited national data available to track COVID-19 outcomes by race, states and local municipalities started releasing their own numbers one by one.

In Louisiana, African Americans accounted for 70% of COVID-19 deaths, while comprising 33% of the population. In Michigan, they accounted for 14% of the population and 40% of deaths, and in Chicago, 56% of deaths and 30% of the population. In New York, black people are twice as likely as white people to die from the coronavirus.

Comorbidities like hypertension and diabetes, which are tied to COVID-19 complications, disproportionately affect the black community. But the alarming rates at which COVID-19 is killing black Americans extends beyond these comorbidities and can be attributed to decades of spatial segregation, inequitable access to testing and treatment, and withholding racial/ethnicity data from reports on virus outcomes.

“There is nothing different biologically about race. It is the conditions of our lives,” said Camara Phyllis Jones, MD, PhD, former president of the American Public Health Association. “We have to acknowledge that now and always.”

Fewer Protections to Prevent Exposure

Predominantly black U.S. counties are experiencing a three-fold higher infection rate and a six-fold higher death rate than predominantly white counties.

Many of these communities are located in poor areas with high housing density, limited access to education, and high unemployment rates. Low socioeconomic status is independently a risk factor for poorer health outcomes and is forcing some individuals residing in these communities out of their homes and into the workforce.

African Americans are overrepresented in frontline jobs like the postal service or home health aid industry, leading to higher rates of exposure, Jones said.

In New York City, the national epicenter, 75% of frontline workers are people of color.

“People are starting to recognize these people as being part of the essential workforce and those people are disproportionately black and brown,” Jones told MedPage Today. “We have not honored the essential nature of that work, just as we have not equipped respiratory technicians, nurses, and doctors in the hospital with the [personal protective equipment] they need.”

During a White House press briefing on April 10, U.S. Surgeon General Jerome Adams, MD, MPH, told people of color to “step up and help stop the spread so that we can protect those who are most vulnerable.”

Asking individuals to shoulder the burden of COVID-19 response assumes they have the privilege of participating in social distancing measures and remote working, and ignores the environment they are living in that plays such a large role in determining the types of choices they are able to make, said Lawrence Brown, PhD, of the University of Wisconsin-Madison Population Health Institute.

“When we say ‘at-risk populations,’ we aren’t just looking at the people, we are looking at the conditions that people are placed in and the health outcomes that are a reflection of that,” Brown told MedPage Today. “We owe it to ourselves to put personal responsibility into a spatial and historical context.”

Legacy of Spatial Segregation

African Americans shoulder a higher burden of chronic disease, with 40% higher rates of hypertension and 60% higher rate of diabetes than white Americans, both of which have been tied to negative COVID-19 outcomes.

This is partially because spatial segregation has forced many into housing areas with limited access to healthy foods, clean air, and green space. These social determinants of health are contributing to poorer COVID-19 outcomes among people of color.

“Once infected, we carry the burden of living in disinvested communities,” Jones said.

Where these vulnerable populations are living cannot be separated from the COVID-19 outcomes being reported, and speak to a long legacy of spatial and occupational segregation, Brown said.

Take Shelby County, Tennessee, for example, which deployed testing in the east side, where most healthcare facilities were located, when it saw its first uptick in cases, Brown said. But the majority of the county’s African-American population resides in the west side of the county, and had to travel further to access testing. Once COVID-19 demographic data was released and this disparity was realized, more testing was deployed to underserved areas.

Avoiding Policies That Penalize Black Populations

Black individuals who test positive for COVID-19 may face disparate outcomes when seeking treatment as well. Anecdotally, African Americans have reported avoiding treatment because they fear missteps, or even being turned away when they do seek treatment.

Bias was shown to permeate the medical treatment of black patients long before the pandemic, said Junia Howell, PhD, a sociologist at the University of Pittsburgh.

“[There is] both historical and contemporary discrimination in the healthcare system, which can’t be separated from employment and racial segregation,” Howell told MedPage Today.

Amidst ventilator and personal protective equipment shortages in hospital settings, many states and professional organizations have begun to release Crisis Standards of Care guidelines, which, designed to help physicians rationing equipment to patients who need it most, are typically driven by potential patient life years saved.

But these algorithms, without controlling for the higher burden of chronic disease in African-American communities, can be inherently biased, said Jossie Carreras Tartak, MD, a resident working on the frontlines at Massachusetts General Hospital in Boston.

“If you’re saying people with comorbidities are going to be penalized when it comes to resource allocation, you’re still in effect penalizing these people of color,” Tartak told MedPage Today.

Deploying Equitable Containment Measures

To reduce disproportionate COVID-19 outcomes, public health officials must identify who is at risk and who has been exposed through testing and contact tracing efforts.

Louisiana, the first state to begin reporting deaths by race, launched a health equity task force on April 24. Similar programs designed to bridge the gap of services provided to racial/ethnic minorities have recently been created in Michigan, Massachusetts, and other states.

Public health interventions must involve members of these at-risk communities so that they are tailored to meet their needs, said Rebekah Gee, MD, MPH, a member of the Louisiana task force and CEO of Louisiana State University Health Care Services in New Orleans.

For example, when the state initially launched drive-through testing, it became clear — when one 90-year-old woman walked a mile in the heat to get tested — this would not be accessible to many low-income individuals who didn’t have cars, Gee said.

So public health officials targeted zip codes where the highest rates of COVID-19 deaths were reported and deployed testing there.

“We are seeing a lot of success with approaches that are more place-based and reflective of where the data shows us people need care,” Gee told MedPage Today.

Including community leaders in areas hit the hardest by the virus in policy making will be particularly important as states begin to reopen businesses and loosen stay-at-home measures.

As Georgia Gov. Brian Kemp (R) forges ahead with plans to reopen tattoo parlors, hair salons, and bowling alleys, for example, the state’s National Association for the Advancement of Colored People (NAACP) chapter criticized that decision, saying it would disproportionately affect people of color. Newly released CDC data showed more than 80% of hospitalized COVID-19 patients in the state were black.

The timing of the release of race/ethnicity data and states reopening may also make African Americans most affected by the virus feel they are not adequately being considered in the COVID-19 response, Jones said. “To us, it is another signal that maybe our lives are not valued.”

A Lack of Data

Deploying high numbers of population-based testing and contact tracing in a public health approach will allow states to predict where they need to allocate resources, get in front of the virus, and control its spread, Jones said.

However, evidence-based interventions are only possible when there is data to inform them. Public health officials need to know who is at highest risk, and where, to deploy containment measures.

On March 27, Democratic lawmakers called on Health and Human Services Secretary Alex Azar, the CDC, and other federal agencies to release COVID-19 race/ethnicity data. The American Medical Association, joined by six other professional organizations, followed suit with a letter addressed to Azar on April 8.

It wasn’t until the first week of April that the CDC began including race/ethnicity data in its Morbidity and Mortality Weekly Report (MMWR).

By April 17, racial data was still missing from 75% of CDC data, according to a report on racial disparities and COVID-19 released April 30 by the Democratic Policy and Communications Committee (DPCC). About half of U.S. states have yet to release demographic data on deaths.

The federal government may withhold racial data in part because it can be misinterpreted and used to back racist policies, Howell said. On the other hand, withholding the data can meet that same end, exposing the inequities already present in U.S. systems.

“This amount of racial inequality is always with us and we rarely care until it comes up in our face and then we say it’s shameful and ask who’s fault it is,” Howell said.

In the DPCC report, lawmakers pushed for guaranteed equitable access to testing and vaccines as they move forward in clinical trial development. The authors of the report also said they would introduce legislation requiring federal agencies to release demographic COVID-19 data and establish a Heroes Fund to increase pay and protection for frontline workers.

Sen. Kamala Harris (D-Calif.) introduced a bill earlier this week that would create a national health equity task force to address these disparities.

The virus may be exploiting inequities in the U.S., but it does not discriminate by race, and will spread to all communities if it is not contained in the most vulnerable populations, Jones said.

“These excess numbers of black people dying from COVID-19 … are piling up so fast we can’t normalize it and we can’t ignore it,” Jones said. “This happens again and again where the nation wakes up and then falls back into what I call the slumber of racism denial. What we cannot afford to do as a nation is fall back.”