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COVID-19 in African American communities

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SciLine interviewed: Dr. Sharrelle Barber, a social epidemiologist and faculty member in the Department of Epidemiology and Biostatistics at the Drexel University Dornsife School of Public Health. Her research focuses on the intersection of place, race, and health, and examines the role of structural racism – through, for example, concentrated economic disadvantage and residential segregation – in shaping the health of Black Americans.

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What is structural racism?  


[0:00:28] 

SHARRELLE BARBER: So structural racism is such a – it’s a word that’s being used – or a phrase that’s being used a lot now. And so I’ve been grounding or using the definition from Dr. Camara Jones, who is a physician, scientist, epidemiologist, who’s been studying racism and health for over 20 years. She’s also a former APHA past president. And she defines it like this. She calls it a system of structuring opportunity and assigning value based on the social interpretation of how one looks. That’s what we call race here in America. And I like her definition because she describes it as doing at least three things – one, unfairly disadvantaging some individuals and communities, unfairly advantaging other individuals and communities.  

And then this final point, I think, is really critical, is that saps the strength of the whole society through the waste of human resources. I’ve gone on to say that racism really is about these interlocking systems of racism found within the context of health care, the housing market, the job market, criminal justice and the carceral state. And all of these are rooted in, you know, the legacy of slavery that dates back over 400 years. And these interlocking systems are maintained by racist policies and practices that construct and reinforce inequitable access to power and resources for Blacks, right? So that’s a lot (laughter). 

And in addition to Blacks, we also have to think about other marginalized racial groups in this country. So Indigenous populations, Native Americans, who experienced extreme levels of genocide at the birth of this nation. The Latino population, who has in so many ways experienced these different levels of discrimination. All of these marginalized racial groups have experienced racism within this country. And really, it is kind of woven into the fabric, if you will, the foundation, of this society. And so it wreaks havoc on marginalized racial groups in so many different ways.  


How does structural racism shape the health of Black Americans? 


[00:02:50] 

SHARRELLE BARBER: I’d like to begin that – answering that question by providing some statistics because, you know, we’re in the middle of this COVID-19 pandemic that has just really exposed the ways in which racism have shaped health and health inequities, and I’ll get to that later.  

But, you know, before the pandemic hit, you know, Black Americans, Blacks were experiencing higher rates of mortality and morbidity across a wide range of health outcomes. So, for example, Black women have three times the maternal mortality rate compared to white women. And that’s after you even control for socioeconomic status, right? So we’re seeing these inequities emerge even among Blacks who have a college education. And in the case of maternal mortality – so, you know, instances of discrimination within the health care system, you know – limited access to quality health care have been cited as just a few of the ways in which racism operates. We see this again for infant mortality. We also see higher prevalence of chronic conditions – such as hypertension, diabetes – among Black Americans.  

But, again, you can’t understand those racial inequalities without understanding the conditions in which Blacks find themselves. So the neighborhood context – many Blacks live in neighborhoods that have limited access to healthy foods, you know, chronic stressors within their environment that, again, produce these inequitable distribution of diseases, right? And so – and those exposures are linked to things like racial residential segregation, which dates back to racist policies from the 1930s like redlining, right? And so, again, structural racism is shaping the conditions in which people live, and that’s having a huge impact on their health. You think about things like asthma rates and the higher level of asthma rates among particularly Black kids in the United States. Again, environmental racism – you know, exposure to toxins and pollutants in the air, the placement of toxins in Black communities because they, you know, lack the kind of political power to be able to keep those toxic exposures from being placed in their communities. You know, lead poisoning – that’s not just a Flint, Mich., issue, but it’s an issue around cities across this country, right? So all of those – again, that’s environmental racism that influences health and health inequalities.  

And then, finally, I’ll just point to the city of Philadelphia, which is where I currently live. You know, in some communities, there’s upwards of a 15-year life expectancy difference between some of the poorest, predominantly Black communities in Philadelphia compared to the wealthiest white communities in Philadelphia – 15-year life expectancy difference, again, driven by the structural factors, again, that shape health and really, you know, have a devastating impact on Black communities throughout this country.  


In what ways is COVID-19 having a disparate impact on African Americans? 


[00:06:11] 

SHARRELLE BARBER: So I’ll just give you a few of the latest numbers that I’ve seen. First, what we’re seeing is that Black Americans continue to have the most striking racial inequities when it comes to COVID-19. So Blacks – data from the APM Research Lab show that Blacks are 3.8 times more likely to die from COVID-19. But we also know from, also, recent data that was analyzed that Blacks are also more likely to be infected with COVID-19. And so it’s not just that they’re dying more; they’re also being infected more. And then – and those rates, the higher rates both in terms of cases and in terms of deaths, are for a number of, again, interlocking systems. So, for example, we know that Blacks as well as Latinos are disproportionately represented among essential workers who, during this pandemic, have been having to go into work and being the – what I say is the most exposed but the least protected because they haven’t been given the proper personal protective equipment, paid sick leave, hazard pay and other protections within the workplace that would protect them from this virus. And we’re seeing that kind of play out with this virus.  

But also, the housing conditions – you know, many Blacks live in racially segregated communities across cities in this country, housing conditions that are crowded. And they’re crowded because of, you know, that high – the lack of affordable housing, which, again, has its – is woven into the – kind of the fabric of, you know, the housing market and the ways in which it disproportionately impacts Black communities. So living in crowded housing, also environmental exposures within racially segregated communities, transportation, infrastructure that’s disjointed that also may increase exposure – and a host of other things. That is then compounded by limited access to health care in poor and Black communities, you know, instances of racial discrimination once they interact with the health care system, which might prevent them from getting testing and proper treatment. You know, again, all of these interlocking systems are at play when thinking about exposure.  

Additionally, you know, we have to talk about what’s happening in our prison populations. You know, prisons themselves are these petri dishes for the propagation of a virus like COVID-19. And so the fact that we have, you know, mass incarceration in this country that disproportionately, again, impacts Black and Latino individuals – and the risk they are at because they’re in confined areas, because of the lack of sanitation and because the – we have not put in place policies for the kind of compassionate release that could be taking place during this pandemic. All of that, again, is leading to outbreaks in prisons across this country. And so I could go on and on about how this virus is wreaking havoc. But as I mentioned before, it’s just really exposing those interlocking systems of racism that were here before the crisis and, really, have to be addressed if we’re going to mitigate the racial inequities among Blacks and other marginalized racial groups.  


What are some of the causes of those disparities? 


[00:09:50] 

SHARRELLE BARBER: So when we think about the causes of the racial inequities that are emerging among Blacks and, again, other marginalized racial groups, we have to really think about the structures and the structural drivers because that’s really – those large structural drivers that impact so many individuals are really what’s really driving the racial inequities. And so I’ll give you a couple of examples. One, we have to think about workers and what’s happening, particularly among low-wage essential workers. So we know from research that Blacks and Latino individuals are more likely to have jobs within the kind of service industry, as well as the production industry. We also know that Black women are also more likely to have these jobs as well.  

And so, you know, throughout this pandemic, they have in many ways – you know, second only to health care workers – been the most exposed and the least protected because they’ve been forced to continue their jobs with very little, if any, personal protective equipment, no income protections such as paid sick leave, hazard pay, and also been forced to work in conditions that are not conducive to limiting exposure to the virus. And so crowded working conditions and these conditions, you know, have led to higher rates of exposure. And we’re seeing that data play out in places like meatpacking plants, etc. And so, again, that’s one mechanism by which, you know, Blacks are being more exposed.  

In addition to that, we have to think about the housing conditions in which people have to return to. And so I’ve often said that workers are not isolated individuals. They return to families in houses that are oftentimes crowded because of the lack of affordable housing options in many cities. You know, there’s data that suggests that people who, you know, make a minimum wage aren’t able to afford a two-bedroom apartment in most cities across this country, in any city across this country, right? And so due to that, you have multigenerational, oftentimes crowded housing conditions, which, again, increases the likelihood of transmission to family members.  

And families aren’t isolated because they live in communities, often racially segregated communities. And these racially segregated communities are that way because of racist policies like redlining that date back to the 1930s, predatory lending practices and a host of other racist policies at the local, state and federal level that produce and reproduce inequities in segregated communities, right? So all of these are coming together within the context of the COVID-19 pandemic to increase exposure.  

In addition to that, that, you know, increased exposure is compounded by the fact that Blacks have limited access to health care, whether it is the ability to access health care within their communities or lack of health insurance that would allow them to have access. So that means they limit access to testing, which means that they may go undetected in terms of knowing they have COVID-19. That means they have limited access to follow-up treatment if necessary -right? – which may, again, put them at a higher risk for more severe complications that lead to death. And then when they access the health care system, oftentimes – and this is well documented and reported – Blacks experience discrimination within the health care system.  

And again, this may lead to, you know, what we’re seeing in terms of anecdotal evidence that says that Blacks have been turned away even when they present with severe symptoms related to COVID-19. Again, all of these factors are coming together to produce the higher rates of COVID-19 but also to produce the higher risk of mortality in this group. And then finally, because I know that a lot of folks say, well, what about underlying chronic conditions and comorbidities – absolutely. You know, we’re seeing data that suggests that these factors lead to more severe cases and subsequent death. But, again, these underlying chronic conditions, such as diabetes, hypertension and other chronic conditions, are more prevalent among Blacks because of the structural conditions, like lack of access to healthy foods, like chronic stressors that disregulate multiple physiological systems that lead to these, you know, chronic conditions. You know, so many other factors are at play to produce these kind of underlying chronic conditions, and they are a result and a byproduct of, you know, structural racism in this country.  

So, again, interlocking systems of racism, structures that increase exposure, increase transmission and increase likelihood of death are really leading to the widespread racial inequities that we’re seeing among Blacks.  


As an epidemiologist, what do you think is missing from the conversation about the disparate impacts of COVID-19? 


[00:15:03] 

SHARRELLE BARBER: Back in April is when we began to see these data emerge on racial inequities. And as an epidemiologist, you know, part of my job is to, you know, help to track, you know, what’s happening in – you know, in places. So, for example, colleagues and I at Drexel produced a brief looking at segregation and COVID-19 and showed that Blacks in the most segregated communities in Philadelphia had two times the rates of COVID-19. So, again, it’s important to document, you know, the inequities that are being – that are emerging and to really look at what the determinants of those are. But we’re really at a point where we need to be thinking about not just observing these racial inequities, but what are the policies that we can put in place to mitigate and eliminate the inequities in this pandemic and beyond?  

And so, you know, we’re at a point where we’re seeing a resurgence of cases or new outbreaks in places, you know, in the South and in the West. These are places that are going to be inundated because of the existing inequities that are present in those places. So, for example, lack of access to health care, high prevalence of, you know, comorbidities, etc. And we need to be thinking about policies that protect workers, policies that provide testing and the necessary testing in certain communities that provide health care for those who do not have it. We need to be thinking about comprehensive policies that address the structural drivers of the inequities so that we can actually mitigate it.  

So, again, what I – you know, what I’m – the point I’m trying to make is you can’t just observe these racial inequities; we need to be thinking about how we mitigate these inequities and the policy solutions at the federal, the state and the local level that are necessary to really move the needle on this because we’re going to be dealing with this pandemic for some time. It’s not going away. And so what are the ways that we can – as I said, you know, for the Smithsonian, you know, public health is designed to prevent death, to prevent suffering. So what are the prevention strategies we’re going to use, the structural factor – by addressing the structural factors that we’re going to use, you know, to really mitigate these inequities. 


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Dr. Sharrelle Barber

Drexel University Dornsife School of Public Health

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