Older Black Americans during COVID-19: Race and Age Double Jeopardy

Abstract

This article discusses the concept of ‘double jeopardy’—being both old and black—in relation to the disproportionate impacts of COVID-19 on older Black adults and how the linked effects of racism and ageism shape higher risks for disease and poorer outcomes. First, we review current information on COVID-19 morbidity and mortality profiles for older Black adults. These data indicate that Black people and older adults are the two most impacted groups. Consequently, older Black adults are doubly impacted and at particularly high risk for disease and death. Following this, we discuss risk and protective profiles for coronavirus and COVID-19 in major life areas (i.e., family and household composition, social isolation and loneliness, racial residential segregation, nursing homes and congregate living arrangements, and faith communities). We use a race- and age-informed framework to identify how practices and policies associated with Black race and older age are reflected in life circumstances and resources. The double jeopardy perspective is useful for underscoring long-standing race- and age-based inequities and social vulnerabilities and their role in producing the devastating deaths and injuries experienced by older Black Americans during the COVID-19 pandemic. Assessing race- and age-based inequities and social vulnerabilities can identify important risks and protective factors and assist in developing policies and actions to protect the health of older Black Americans during the COVID-19 pandemic.

In a ground-breaking report published over fifty years ago (National Urban League, 1964), Inabel Lindsey discussed the concept of double jeopardy to characterize the plight of older Negro adults (i.e., Black Americans). Double jeopardy (a precursor to intersectionality frameworks) reflects the combined negative impacts of racism and ageism and race- and age-based discrimination on older Black adults. Lindsey argued that Black older adults’ experience of “double jeopardy” is reflected in poorer health profiles, higher rates of poverty, and fewer years of formal education compared to their age and race counterparts.

In this article, we explore the concept of ‘double jeopardy’—being both old and Black—to contextualize the life experiences of older Black Americans and identify important risk and protective factors for their physical and mental health during the COVID-19 pandemic. Recent op/eds, commentaries, and analyses have identified racism, ageism and long-standing discriminatory policies and practices as drivers of inequality and vulnerabilities for Black American and older populations in the U.S. (Schulz et al., 2020). Similarly, we present emerging information concerning how disproportional impacts of COVID-19 among older Black adults are associated with 1) family and household composition, 2) social isolation and loneliness, 3) racial residential segregation, 4) nursing homes and congregate living settings, and 5) faith communities. Throughout our discussion we highlight race- and age-based inequities and social vulnerabilities in life circumstances that jeopardize the health of older Black Americans. We discuss the confluence of COVID-19 risk and protective factors and their peculiar juxtapositions whereby a social characteristic or behavior can embody a health risk or a health protection depending on the outcome in question (e.g., social distancing as protective factor against exposure to COVID-19, but a risk factor for loneliness and poor health).

Older Black Adults and COVID-19.

The concept of double jeopardy and its impact on older Black Americans is readily visible in data illustrating race and age distributions of serious morbidity and deaths from COVID-19. From the earliest data on the pandemic, being of older age was identified as an especially high-risk category. Older adults are at greater risk of death due to reduced immune function (i.e., immuno-senescence) and higher rates of co-morbid health conditions such as hypertension, diabetes, and obesity. Black Americans, both young and old, experience poorer health profiles (i.e., diabetes, hypertension, asthma) and life circumstances (poverty, environmental pollution) that are associated with higher mortality rates from COVID-19 (Centers for Disease Control and Prevention, 2020). Analysis by the APM Research Lab found that race and ethnicity was reported for 95% of the 171,000 Americans who have died of COVID-19 as of August 18, 2020. The COVID-19 mortality rate for Blacks was higher than the rate for Indigenous, Latinx, non-Hispanic Whites and Asians (APM Research Lab, 2020; data as of August 18, 2020). The age-adjusted COVID-19 mortality rates indicate that the mortality rate for Blacks was 3.6 times higher than the rate for non-Hispanic whites. Further analysis by the APM Research Lab indicates that if Blacks had the same COVID-19 mortality rate as Whites, at least 19,500 Black Americans would still be alive today (APM Research Lab, 2020; data as of August 18, 2020). Analyses of CDC data (current to August 19, 2020) indicate higher rates of COVID-19 deaths for Blacks across all age groups including stark disparities for persons 65 years and above.

Family and Household Composition.

In efforts to slow the spread of coronavirus infection, local community and state governments have enacted social distancing guidelines to restrict social contact. Under requirements to ‘stay home, stay safe,’ visits to businesses, restaurants, and entertainment venues are prohibited. More personally, social distancing measures are meant to reduce direct contact with family members residing outside of the home which deprives older Black adults of opportunities for face-to-face interaction with family and participation in important family events (birthdays, anniversaries, graduations). While protecting the public’s health, social distancing measures have challenged families’ capacities to interact with and to provide emotional and tangible support to older relatives who reside in separate households. Social supports, face to face interactions, and companionship are important protections against social isolation, loneliness and associated mental health problems (e.g., depression) (Nguyen et al., 2020).

Black Americans are more likely than non-Hispanic whites to reside in multigenerational and extended family households that include grandparents, cousins, aunts, and uncles (Centers for Disease Control and Prevention, 2020; Cross, 2018). During the COVID-19 pandemic, living in multigenerational family households embodies both protective and risk factors. Co-residential family members can provide emotional support and companionship for older Black adults and perform activities and essential errands outside of the household (e.g., shopping for groceries and prescription medicines). However, residing in a multigenerational household can be a risk factor for contracting COVID-19 for Black elders. Black Americans are much more likely to be employed as essential workers as bus drivers, grocery store clerks, and nursing home assistants—jobs that require daily travel and interaction with others outside the home and increase risk for virus exposure (Centers for Disease Control and Prevention, 2020). Essential health care workers in nursing homes such as certified nursing assistants (CNAs) have especially high risk of coronavirus exposure. Further, due to low wages, many health care attendants work in multiple nursing homes, thus increasing their potential coronavirus exposure (Walker, 2020). Consequently, older Black adults who share residence with one or more relatives who are essential workers have a higher risk of being exposed to coronavirus and developing COVID-19.

As a highly transmissible disease, risk of coronavirus infection increases in situations involving close contact with others, such as family households. Given this, both coronavirus infections and COVID-19 deaths tend to be clustered in families with co-resident members who experience multiple illnesses and deaths (Ghinai et al., 2020). This includes situations in which older couples develop COVID-19, are hospitalized together, and eventually die a few days apart (Bunao, 2020). These traumatic losses of family members exact a heavy emotional toll and burden for grieving older adults. Unfortunately, due to quarantine and lock-down guidelines, opportunities to gather together to support family members through illness and to grieve together following a death are curtailed. The higher COVID-19 mortality rates for Black Americans will likely have lasting impacts by decreasing family structure and size, changing family roles and responsibilities, and worsening family financial status, which will increase the number and intensity of stressors experienced by older Black adults and their families (Umberson, 2017).

Social Isolation and Loneliness.

The COVID-19 pandemic and social distancing practices has necessitated major changes in contact and interactions with family, friend, and other relationships. One of the unintended consequences of social distancing measures, especially for primary social groups such as family and friends, is the increase in social isolation and loneliness. Social isolation and loneliness are particularly harmful for physical and mental health and are associated with a 25–30% increase in mortality risk and have health effects comparable to smoking 15 cigarettes per day (Holt-Lunstad et al., 2010, 2015). Social isolation and loneliness are also associated with worsening mental health and well-being (Cacioppo et al., 2006; Cornwell & Waite, 2009; Nguyen et al., 2020), particularly among older adults (Taylor, et al., 2018). It is important to clarify that living alone does not mean that older adults are not in contact with their family and friends (Chatters et al., 2018). However, the pandemic makes interacting with family and friends more difficult.

Middle-class older adults who live alone have the ability to adapt to social distancing by interacting with family and friends by Zoom, Skype and other video conferencing platforms. However, Black Americans are significantly less likely to have home broadband services (66%) compared to non-Hispanic White adults (79%). Further, while close to 80% of adults under the age of 65 have access to these services, only 59% of adults 65 and older have access to home broadband services (Pew Research Center, 2019). Taken together, older Blacks adults are less likely to have internet access as a means to remain socially connected to others and to obtain critical information during the COVID-19 pandemic. For those who live alone and have limited access to information and communication technologies, maintaining social distancing can be particularly challenging and difficult. This situation clearly underscores how the race- and age-based “digital divide” can create and heighten social isolation and loneliness among older Black adults.

Racial Residential Segregation.

Racial residential segregation (RRS) represents one of the most profound and pernicious set of policies and practices that have limited Black Americans’ access to resources and societal opportunities that promote health (Williams & Collins, 2016). Through ‘redlining’ and related exclusionary processes, neighborhoods characterized by racial segregation experienced systematic disinvestment in infrastructure, declines in property values and business investments, and a resulting shift in racial (Black) and economic composition. RRS limits access to opportunities in multiple areas (e.g., education, employment, neighborhood and housing quality, food environments, beneficial environmental conditions, and community amenities and medical services), which negatively impact residents’ capacity to build health. Connections between RSS, harmful living circumstances, and poor physical and mental health outcomes are well documented for Black populations of all ages (Armstrong-Brown, et al., 2015; Kershaw & Albrecht, 2015; LaVeist, 2003; White & Lawrence, 2019; Williams & Collins, 2016; Williams et al., 2019). However, Black older adults are more likely than their white counterparts to live in neighborhoods characterized by RRS (Armstrong-Brown et al., 2015). Although RRS negatively impacts the health of Blacks of all ages, evidence suggests that the harmful effects of residing in segregated areas accumulate over a lifetime of exposure (White & Lawrence, 2019; Williams, 2001; LaVeist, 2003).

Finally, it is important to recognize that age-related and place-based factors interact synergistically to place older Black adults at increased risk for coronavirus and COVID-19. Physiological and physical changes (e.g., immunosuppression) associated with aging and chronic health conditions have known associations with COVID-19 morbidity and mortality outcomes. Place-based factors associated with racial residential segregation (Williams et al., 2019) including environmental exposures (e.g., air pollution), lack of health-relevant resources (e.g., COVID-19 testing and information, medical resources) and inadequate infrastructure (access to clean water, public transportation, and healthy food access) constitute significant environmental barriers to health for older Black adults.

Nursing Homes and Congregate Living Settings.

Nursing homes have been a prominent location for the COVID-19 pandemic for reasons related to structural factors (close proximity and shared spaces), poor oversight, lack of coronavirus testing, and poor adherence to public health standards (Aronson, 2020; Kohn, 2020). A recent analysis (Shippee et al., 2020) of long-term services and supports (LTSS e.g., nursing homes, nurse aides) documents long-standing racial and ethnic disparities in financing, access, and quality that result in lower levels of oversight and clinical care in nursing homes serving communities of color. These disparities in LTSS jeopardize the health of nursing home residents, a situation that is exacerbated during the COVID-19 pandemic and leads to worsened morbidity and mortality disparities. Current evidence indicates that nursing homes where African Americans make up a significant proportion of residents (25% or more) are twice as likely to have COVID-19 cases than nursing homes where the proportion of residents is at least 95% white (Gebeloff et al., 2020). This racial disparity remains regardless of size, location in the country, and the governmental rating of the nursing home (Gebeloff et al., 2020).

Older Black adults living independently in low-income senior housing communities are also at risk for disproportionate impacts of COVID-19 (Graham, 2020). The older age of residents of low-income senior housing is itself an acknowledged risk for adverse COVID-19 health outcomes. Further, COVID-19 disease spreads easily and quickly throughout enclosed indoor areas. Individual units and shared common spaces (e.g., elevators, staircases, laundry rooms) and facilities in low income housing communities are often poorly maintained and cleaned. Without rigorous cleaning protocols and social distancing measures, older adults in low-income senior housing communities are at risk for coronavirus exposure.

Congregate living situations intersects with social isolation in unexpected ways. Even though senior housing communities are congregate living settings, social isolation from others does occur (Taylor et al., 2016; Wang, et al., 2018). Available evidence suggests that rates of social isolation in senior housing communities may be higher than national prevalence rates among community dwelling older adults (Chatters et al., 2018; Taylor et al., 2016). As noted previously, social isolation and loneliness are themselves important social risk factors for poor mental health outcomes among older Black adults (Nguyen et al., 2020; Taylor, et al., 2018). Efforts to contain the COVID-19 pandemic, including social distancing and staying indoors, have the unintended consequence of preventing older adults who are experiencing COVID-19 symptoms from seeking assistance. Unfortunately, these combined factors create opportunities for COVID-19 to spread rapidly among older Black adults living in low-income senior housing.

Faith Communities.

Many older Black adults have life-long connections to religious institutions, having attended religious services and been members of congregations for most of their lives. As compared to younger adults and other racial groups, older Blacks have the highest levels of religious involvement including church attendance (Taylor et al., 2007). Older Black adults have strong and enduring personal relationships within the church, receive social supports from their religious networks, and derive a sense of pride and purpose from attending. Further, research indicates that emotional support that older Black adults receive from congregation members is protective for depressive symptoms and psychological distress (Chatters et al., 2015).

Due to alterations and restrictions in social contacts and social routines necessitated by social distancing, older Black adults have not been able attend religious services and other activities. Social distancing restrictions can be particularly difficult because service attendance and other social events in faith communities (choir practice, Bible study) are integral parts of social routines and activities. Church members are an integral part of older adults’ support networks and an important resource in preventing loneliness (Taylor, 2020). Being unable to meet regularly with church members, particularly during the COVID-19 pandemic, represents an additional challenge that places older Black adults at higher risk for experiencing social isolation and loneliness and associated mental health challenges (e.g., depression).

The significant racial disparities in COVID-19 infections, morbidities, and death, means that churches are bearing a significant burden of sickness and loss of their members. Deaths within the church community and social networks may additionally place older Black adults at greater risk for experiencing social isolation and loneliness. Outreach and visiting to members who are sick and shut-in and traditional communal practices and social norms for physical contact (e.g., ‘sharing the peace’) must now be accomplished with social distancing considerations in mind. Several Black churches have adapted to the challenges of social distancing by holding services outside while observing physical distancing measures. For churches that are well-resourced, YouTube, Zoom, and other media platforms and communication technologies can be used to stream services to members in their homes. Unfortunately, as described previously, older Black adults who lack the required knowledge, skills, and technical capacity (i.e., smart phones, broadband internet service) will not be able to take advantage of these services. Despite these restrictions, faith communities have developed innovative outreach efforts in responding to COVID-19 (e.g., providing COVID-19 information, organizing testing sites, distributing food), helping members cope with the uncertainty and tremendous grief associated with the pandemic, and being an ongoing source of hope and faith for Black communities (Gecewicz, 2020).

Conclusion.

Recent articles, commentaries and op/eds on the disproportionate impacts of the COVID-19 pandemic has exposed deep and long-standing social, economic, and health inequities within the U.S. The concept of ‘double jeopardy’—being both old and Black—foregrounds racism and ageism as prominent and highly ingrained beliefs systems and practices that produce and maintain systematic social exclusions and discrimination affecting older Black Americans. Risk and protective factors for older Black adults’ physical and mental health were discussed in relation to family and households, experiences with social isolation and loneliness, nursing homes and congregate living arrangements, and faith communities. These topics are illustrative, but not exhaustive, as other issues (e.g., incarceration and older Black adults) and lenses (e.g., gender) could be explored to understand the experiences of older Black adults during the pandemic. As Inabel Lindsey noted over 50 years ago, linking Black race and older age provides a more nuanced understanding of the social and life circumstances confronting older Black adults. Assessing the combined impact of race- and age-based inequities and social vulnerabilities can promote a better understanding of important risks and protective factors and guide the development of policies and actions that protect the health of older Black Americans during the COVID-19 pandemic.