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

Abstract

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

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

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

Fear of contracting the virus is high in African-American communities. Population-based surveys estimate that 33% of African-Americans are very concerned that they will get covid-19 and require hospitalization, compared to only 18% of Whites. Further, African-Americans are 2 times more likely than Whites to know someone who has been hospitalized or has died due to covid-19 (Pew Research, 2020). Fear of the disease is pervasive even for those whose social networks have not yet been impacted, as news stories produced by most local and national news outlets since March have focused on Covid-19, often with photos and anecdotes featuring African-Americans who have been impacted by the disease. Consequently, many African-Americans have begun to experience a form of vicarious trauma, as they repeatedly witness the pain and suffering of those who look like them. This type of trauma can lead to both emotional and physical symptoms, including symptoms of anxiety, helplessness, nausea and headache.

In addition to fearing disease, many African-American community members fear racial bias and discrimination in disease testing and treatment. Racial bias in healthcare is well-documented and thought to contribute to a range of racial health disparities, including higher rates of maternal mortality (Bryant et al., 2010) and poor pain-related outcomes among African-Americans (Meghani et al, 2012). Both empirical and anecdotal evidence suggest that African-Americans presenting with symptoms of upper respiratory infection (e.g. cough, fever) have been less likely to get tested for Covid-19 than their White counterparts (Rubix Life Sciences, 2020). Additionally, there have been fewer testing centers located in African-American neighborhoods, further suggesting bias or discrimination in testing. Even after testing positive, many African-Americans fear that they may not receive life-saving assistance if they experience severe disease. As medical centers become overwhelmed with covid-19 patients, some have suggested limiting advanced care protocols for patients with less chance of recovery, such as those with underlying comorbidities. Given that African-Americans have greater prevalence of chronic health conditions, many fear being denied care due to discriminatory assumptions about their likelihood of survival. In epidemiological studies, such perceived racial discrimination has been linked to numerous adverse mental health outcomes, including greater self-reported symptoms of depression, anxiety, and psychological distress (Lewis et al., 2015). Perceived racial discrimination has also been associated with greater clinical diagnosis of post-traumatic stress disorder, generalized anxiety, and major depressive disorder (McLaughlin et. al, 2010).

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

As they cope with grief and loss, community members are not able to engage in many sociocultural practices that facilitate coping. For example, current social distancing measures have halted observance of common funeral traditions. African-American funeral traditions play an important role in managing community grief and loss. These primarily Christian traditions celebrate death as a “homegoing” rather than an ending. Large floral arrangements, celebratory music, and lengthy processions to the burial site are the norm as friends and family near and far gather to comfort grieving family members and share anecdotes about the deceased. Such traditions offer honor and respect in death to those who (due to their racial or socioeconomic background) may have had little social standing in life. In this covid-19 era, loved ones who die are buried quickly, often only in the presence of a minister and a mortician. The loss of this tradition funeral ritual disrupts the grief process, impacting how loved ones process the reality of the death, express painful thoughts and feelings, and reconcile the meaning of life and death. This disruption of the grief process further increases risk of prolonged grief disorders and bereavement-related depression.

Finally, the pandemic has unfolded within African-African communities that have already experienced significant community trauma. April 25, 2020 marked the 6^th Anniversary of the Flint Water Crisis (FWC), a public health emergency that exposed residents to lead in the municipal water supply, devastating Flint, Michigan, a city that is 56% African-American. In the aftermath of the crisis, residents experienced significant adverse mental health outcomes. In 2016 (the year when the crisis was publicly acknowledged), 23% percent of households reported unmet mental health needs, 29% percent of individuals self-reported symptoms of depression, and 33% of individuals self-reported symptoms of anxiety (Fortenberry et al., 2018). Although public health efforts since 2016 have led to improvements, residents still report poor mental health outcomes compared to the rest of the state of Michigan more than 3 years later. Even today, residents are afraid to use water from the municipal supply for drinking, cooking, or bathing. For residents, the uncertainty surrounding covid-19 is reminiscent of the Flint Water Crisis, as it similarly ignites fear and mistrust of government to protect the public against a health-related disaster. With covid-19, Flint residents are being retraumatized while still managing the fallout from the water crisis. This experience of multiple long-lasting traumatic events can lead to extreme emotion dysregulation and a range of biological changes and stress responses that can result in notable mental and physical health problems.

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

In Michigan, many steps have been taken to improve outcomes within African-American communities. State and local leaders have acknowledged the racial disparities in covid-19 related outcomes and have formed diverse multi-sector task forces to address issues of racial bias related to testing, diagnosis, and treatment. Weekly videoconferences and webinars sponsored by community groups and academic institutions have increased the dissemination of relevant disease-related information. The African-American faith community has been instrumental in providing support to community members, conducting religious services via videoconferencing and social media sites, dispatching church leaders to conduct wellness checks for vulnerable residents, and referring residents for support services. Specific services supporting mental health have also been activated. Local public mental health providers, with additional federal funding, have developed virtual crisis centers to support mental health and substance abuse screening and to mitigate treatment engagement barriers common in African-American communities. Local community leaders (in collaboration with academic clinical psychologists and public health professionals) are conducting virtual support groups and sessions, targeting those who may not be in crisis, but who may benefit from a supportive environment to discuss their fears and stressors. Additionally, evidence-informed models for processing stress and trauma are being used in non-clinical community spaces. These include mindfulness-based stress reduction and the Community Resiliency Model, a biologically-based approach that teaches a set of wellness skills designed to reduce the physical sensations of stress and trauma (Grabbe & Miller-Karas, 2018; Miller-Karas, 2015). All of these supports and services are designed to be culturally appropriate, recognizing how African-American cultural practices and traditions may impact mental health engagement. Further, they are trauma-informed, with sensitivity to the notion that the pandemic itself is an ongoing traumatic event that may retrigger trauma-related memories and feelings of powerlessness. As the pandemic endures, these approaches must be reviewed and refined in order to ensure optimal mental health and well-being within African-American communities.