COVID-19 Disparities and the Black Community: A Health Equity–Informed Rapid Response Is Needed

Black Americans represent 13% of the US population but account for one third of COVID-19 cases and are twice as likely to die from this disease.¹ Unaddressed social determinants of health exacerbate this health disparity. However direct routes to address and improve health outcomes for Blacks remain unclear. Reporting racial/ethnic health outcomes is now recommended, but data collection is a fraction of the challenge. How do we create a policy framework that accounts for social determinants of health in the short term with the at-large goal of improving both health outcomes and health equity for Black Americans?

Here are five actionable strategies to ensure a health equity–informed COVID-19 response.

DEMOCRATIZE SCREENING

Despite increasing testing efforts, access to screening is inequitable. Many states failed to capture ethnic identifiers, and, as a result, systemic problems associated with ethnicity (e.g., variable allocation of tests, biased eligibility protocols) remained obscured. In the Black community, drive-in testing and telehealth screening are complicated by lack of transportation and technology, poor literacy, and geographic segregation.

Cost creates another barrier. The Families First Coronavirus Response Act mandates Medicare and Medicaid and private insurers to cover coronavirus testing.² However, an emergency department visit requiring additional services or care beyond the coronavirus test can still generate a bill; fear of these unanticipated costs may hinder the uninsured from seeking care. Finally, some testing sites require proof of identity or citizenship as part of registration, which creates a hurdle for some seeking care.

We recommend maximizing equity and minimizing obstacles to testing. Funding should benefit underserved communities, whose residents have a high prevalence of chronic conditions and poor access to health services. Furthermore, we recommend partnerships among academic institutions, community-based organizations, and local nonprofits to fast-track screening sites and resource centers in areas of need. Finally, there should be a standardized approach to counseling and support services; a thorough explanation of health risks, including a modified goals of care discussion; and an evaluation of living conditions for all individuals who test positive for COVID-19.

EXECUTE A COMPREHENSIVE STIMULUS

The federal aid package (the Coronavirus Aid, Relief, and Economic Security Act [CARE]) and expansion of the Family Medical Leave Act (the Families First Coronavirus Relief Act [FFCRA]) has holes that disproportionately leave members of the Black community uncovered. Of the $2 trillion CARE stimulus, only 28% aided individuals; this one-time $1200 stipend with $500 additional per child does not meet the needs of communities barely making a living wage.³ Furthermore, the stipend hinged on citizenship, filed taxes, banking status, and ability to navigate the claim system—all factors that may place members of Black communities at a disadvantage.

Although the FFCRA extends two weeks of paid sick leave and 12 weeks of partially paid family leave for businesses with 25 to 500 employees,⁴ the Black community is overrepresented in occupations excluded by this mandate. Health care workers are excluded, and Blacks have their highest representation in unskilled nursing, psychiatric aides, and home health. Blacks are also overrepresented in industries such as food service, packaging, and manufacturing, where telework is not an option and job site closure, even if owing to sheltering, leaves them uncovered by the FFCRA. Furthermore, most essential workers, a disproportionate number of whom are Black and have an increased risk for SARS-CoV-2 exposure, are at companies either too big or too small to benefit from FFCRA.⁵ Yet with no alternative streams of income or cash reserves, hazardous work becomes mandatory.

We recommend a relief act that intentionally targets vulnerable populations commensurate with their risk and a federal mandate that essential industries offer paid sick leave. Finally, independent contractors and small business owners from communities of color should receive financial support and structured guidance on federal grant applications.

MORATORIUM ON EVICTIONS AND FORECLOSURE

Unstable housing leads to poor health outcomes. The double burden of disproportionate illness and economic hardship makes it difficult to pay monthly rent or mortgage. But evictions and foreclosures counteract the practices of social distancing and self-quarantine. If evicted, many will be forced into cohousing or suboptimal conditions, exacerbating risk and prematurely reintroducing carriers to other populations.

Roughly 40% of the total population experiencing homelessness is Black.⁶ When members from Black communities are displaced, they face secondary and tertiary challenges, such as health compliance, increased interaction with law enforcement, and increased discrimination in accessing shelter resources. Some cities have plans for the undomiciled but lack uniformity in supporting those unable to seek designated housing and unable to shelter among individuals chronically experiencing homelessness. Housing insecurity potentiates the COVID-19 mortality risk of Blacks compared with their White counterparts beyond twofold.

Many jurisdictions have followed the leads of New York and California by instituting temporary moratoriums. We recommend moratoriums on evictions and foreclosures across all states beyond the minimum of 60 days. This protects against housing insecurity and lowers the aggregate risk of exposure to SARS-CoV-2 in vulnerable populations.

RELEASE NONVIOLENT OFFENDERS

Incarcerated populations are among the most vulnerable for COVID-19 exposure. Suboptimal living conditions and overcrowding make preventive recommendations difficult to enforce. The volume of inmates is an additional strain on correctional resources and increases contact rate among individuals living in dormitories. Blacks are overrepresented in jails and prisons,⁷ deepening potential disparities.

We recommend data transparency (screening, cases, and deaths stratified by ethnicity) among incarcerated populations. We also recommend safely and effectively reducing the populations in prisons. Detainees incarcerated for nonviolent offenses should be immediately released. Other feasible mechanisms include supervised release programs, electronic monitoring for those awaiting trial, granting or extending probationary periods for minor parole violations, and commuting sentences for those who have served the bulk of their sentence.

EXPEDITE FUNDING

Despite the contributions of social determinants of health research, federal dollars for programs that promote health equity remain scarce. COVID-19 exposed the downstream effects of underfunding and deprioritizing health disparities interventions.

We recommend expedited funding for initiatives that actively address social determinants of health in Black communities. An increase in funding validates health equity insight through capital and activates other stakeholders to invest resources in COVID-19–related disparities. Additionally, this allows content experts to quickly expand capacity and operate as a network of focused problem solvers. Finally, funding can convert vetted infrastructures (e.g., community-based health organizations) into trusted testing sites, data hubs, and resource centers in real time.

CONCLUSIONS

The national COVID-19 response coopted strategies from China and Italy, two countries that are racially and socially dissimilar to the United States; therein exists a fatal misstep that led to disproportionately negative health outcomes for Blacks. Nonmedical drivers of poor health outcomes have permeated the Black community for decades; this pandemic magnified the historical context of health disparities. Americans are now confronting the reality that wellness is social and structural and that health sees color through the same lens as our legislative and judicial systems.

We define health equity as the assurance that every person has the same opportunity to achieve optimal health. Communities of color contribute significantly to the fabric of society and deserve an equitable chance at survival—especially amid a global health crisis. The next permutation of our COVID-19 response can be both swift and equitable. But most of all it can value Black lives through the timely execution of these equity-informed steps.