Morhaf Al Achkar, MD, PhD
Speaking as a physician with a duty to care for the health of everyone, the health care system has failed marginalized African American communities—again.
COVID-19 has disproportionately affected African Americans. While Blacks are only around 13% of the US population, 33% of those hospitalized and 34% of deaths from COVID-19 are Black. Some immediately blamed African Americans for not upholding social distancing, but a more thoughtful investigation is needed to understand then remedy this health disparity. So, as a qualitative researcher, I interviewed five Black individuals active in their own communities and well-positioned to give insights. I asked them, “Why are African American communities harder hit by this pandemic?” I also reviewed the extensive medical literature on the subject of health care racial disparity.
Media reliability is one problem. Overloads of messy and, at times, conflicting information was challenging, even for the most well-informed. It had been difficult for anyone with limited literacy to decipher what’s fact and what’s not. Reports couldn’t be relied on because some of the recommendations were inaccurate, and others were misleading. “There was a group of people listening to TV networks saying, ‘It’s not that serious, and it’s similar to the flu,’” Dr. Brown, a Black family physician from Indianapolis explained. Even when the message unified around the pandemic’s severity, some worried about ulterior political motives. Hearing what seemed like “another story blown out of proportion,” a woman from Seattle named Tamira said, people didn’t take it seriously. Tamira is the owner of a hair salon that serves mainly Black women. She has rheumatoid arthritis and only started practicing social distancing when her doctor explained the seriousness of the situation. She knows that having a doctor as a reliable source of information is “a blessing” not available to many in her community.
“There was a group of people listening to TV networks saying, ‘It’s not that serious, and it’s similar to the flu.’”
The pandemic was unprecedented, and despite witnessing other parts of the country shut down, many maintained disbelief. But skepticism wasn’t the main reason for leaving the house. Many marginalized African Americans simply cannot just stay home. Those essential workers who, as Dr. Brown, said, “live paycheck to paycheck” have to go to work. Some depend on hourly jobs, where “if you don’t work, you don’t eat.” For them, savings aren’t an available safety net.
Countless Black workers don’t have sick leave and must go to work to avoid losing their jobs, said Ben, a retired football player from Atlanta. To get to work, they may have to take public transit and thus are more exposed to the virus. They can’t isolate themselves when they get sick, either; if you live in public housing or a crowded apartment, you continue to expose others, including your loved ones. There is no spare room to quarantine in.
People have often not recognized they were sick with COVID-19. Some went to work blaming their symptoms on the flu, like Dr. Johnson’s niece’s husband did. But there’s also the self-image of invincibility. Even Dr. Johnson, a retired physician in Goshen, IN, who worked for 40 years with underserved, mostly Black patients, takes pride in very little making her fearful. She described how some in the Black community have to be strong to take care of family. “It’s your duty.” Seeing that the virus initially spared African countries supported the notion that Blacks probably “were not getting COVID-19.” But others don’t let you have that, either. You look healthy and strong, so you’re not allowed to be sick. Dr. Brown shared how a patient struggled to accept she was ill. “I saw this young, otherwise fairly healthy woman who works at Amazon. On the telemedicine visit, she looked very sick and fatigued. She wants to go back to work because ‘people tell me I’m making this up; I’m exaggerating.’” You cannot be your own advocate if you’re Black, Dr. Brown said. “People won’t take you seriously, or you’ll become the angry Black man or woman.”
The heart of the matter is racial disparity, and it’s not new.
But let’s call it out. The heart of the matter is racial disparity, and it’s not new. The health care system has done poorly at managing common chronic conditions among African Americans, including asthma, diabetes, hypertension, and obesity, which happen to be risk factors for the worst COVID-19 outcomes. Managing these conditions is a burden for Blacks who are underinsured or uninsured. Health care is costly, and when you live in poverty, Dr. Johnson explained, you sometimes have to choose between paying for health care or food. If you live in underserved urban areas, you might have a primary care doctor in an underfunded, over-stretched community health center—if you’re lucky. Many in these marginalized communities don’t have a primary doctor, so they use the emergency room when they get very sick.
The health care system failed to gain the trust of African Americans, who are left to doubt whether providers, the majority of whom do not look like them, have their best interests at heart. Historical maltreatment has left images of unethical experiments or Blacks left to die, without care. Previous encounters with doctors made others feeling their concerns weren’t taken seriously and likely never would be. The COVID-19 pandemic and response to it is not an exception. Testing was limited early on, and when it became available to essential workers, some couldn’t access it. Jasmin is an adjunct professor from Indianapolis who researches and advocates for Black women with disabilities. Jasmin was coughing and looked ill during our interview. Her mother-in-law was just in ICU with COVID-19, and her husband had a fever and all the symptoms of COVID-19, including loss of sense of smell. But he couldn’t get tested. She explained, “My husband went to three different doctors to try to get tested. But several of his co-workers have been diagnosed with COVID-19.” Jasmin wonders, “Why did other individuals in that company get tested? It’s dependent on who their doctors are, who their contacts and networks are.” It feels like “gatekeeping; you have these people in positions of authority making decisions.” Is this another manifestation of the racism that has plagued this country?
Dr. Brown started an initiative with two doctor friends to raise awareness by giving public talks. Three of her healthy patients had ended up in the ICU. She now feels her work has led to an improvement in social distancing in her neighborhood. More community-driven work is probably needed, but we need to have a systematic approach to “bringing information to these communities by people with established rapport,” as Dr. Johnson urged. It’s also time to call out prejudices and racism—this article only scratches the surface. Methodical inquiry into the social roots of the disparity and engaging, action-based research are urgently needed. This pandemic undoubtedly hits Black communities hardest, but it ultimately affects everyone, and without a collective effort, the whole ship could go down, if we do not address this health disparity.