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Racial Inequity, Poverty, and COVID-19
DILARA K. ÜSKÜP AND RYON J. COBB
Black Americans are nearly three times as likely to be hospitalized and nearly twice as likely to die from COVID-19 as their white, non-Hispanic counterparts (Centers for Disease Control and Prevention 2021). These disparate outcomes are not unique to the COVID-19 pandemic. In fact, across multiple health conditions, Black Americans have an earlier onset of disease and worse outcomes than white Americans (Adams and Simoni 2016). In contrast to their white counterparts, Black Americans experience severe disparities in overall well-being and health, having “higher rates of impairment, illness and death” (D. Williams 2012).
We define health disparities as “differences in health outcomes that are closely linked with social, economic, and environmental disadvantage—[often] driven by the social conditions in which individuals live, learn, work and play” (World Health Organization 2021). We differentiate health disparities from health inequities, which are the results of structural and institutional factors and systems of oppression that disproportionately harm certain groups over others. As such, a health inequity is a state of unfairness.
Health inequities can perpetuate racial health disparities. The racial disparities in COVID-19 health outcomes are inextricably tied to Black Americans’ prior experiences in the health care system, preexisting health conditions, and historical racial oppression. This chapter examines the ways preexisting social determinants of health and medical mistrust created a ripe environment among already vulnerable communities for the COVID-19 pandemic to result in disproportionate rates of infection, hospitalization, and death. This environment further suffered from failures at the federal level, where former president Trump’s COVID-19 response was to spread false information, de-emphasize scientific public health approaches, and emphasize conspiracy theories in lieu of a concerted federal effort. While minorities may not have approved of Trump and been distrustful of Trump’s false COVID-19 assertions, they remained reluctant to become vaccinated and had serious reservations about the vaccine. Medical mistrust specific to COVID-19 has been prevalent during the pandemic, particularly among Black Americans (Bogart et al. 2021). This mistrust has extended to COVID-19 vaccines. In a poll conducted by MassINC Polling Group in Massachusetts in December 2020, only 20 percent of Black women and 20 percent of Latina women opted to take the COVID-19 vaccine as soon as possible. Participants cited concerns that the vaccine had not been thoroughly tested and expressed a disinclination to trust the U.S. government on health care issues.
In this chapter, our discussion will focus on Black Americans’ disproportionate COVID-19 burden and health inequities. We will touch on how Latino communities have been adversely affected by racial/ethnic oppression and the COVID-19 pandemic. Finally, we will consider the role of clergy in the COVID-19 pandemic by utilizing the March and October 2020 survey data from Djupe, Lewis, and Burge to examine whether Americans trust clergy and health professionals to have their health interests at heart.
Preexisting Pandemic Conditions
Entrenched institutional and social factors influence health behavior, health care access, and health status, setting the stage for pandemic vulnerability. The COVID-19 pandemic precipitated social, economic, and environmental factors that existed before the pandemic that led to increased risk of contraction of and death from COVID-19 within Black and Latino communities. These factors are the social determinants of health—the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks (U.S. Department of Health and Human Services 2021). Figure 5.1 groups the six domains of the social determinants of health: (1) economic stability, (2) neighborhood and physical/built environment, (3) education quality and access, (4) food quality and access, (5) community and social context, and finally (6) coverage of and access to high-quality health care.
The social determinants of health directly contributed to COVID-19 racial and ethnic disparities. Working in essential fields that were not easily transferred to remote work, a situation significantly more common among Black and Latino Americans than their white counterparts (U.S. Bureau of Labor Statistics 2020), led to increased exposure to the virus. Racial/ethnic disparities in educational attainment drive employment type and limit access to higher-paying jobs with benefits. In frontline roles disproportionately occupied by Black or Latino Americans, such as warehouse, trucking, postal service, and building cleaning services jobs, individuals are more likely to continue working through illness, as many do not have access to worker’s compensation or leave policies (Rho et al. 2020).
Figure 5.1 Social Determinants of Health (Source: Artiga and Hinton 2018.)
Neighborhood and physical environment also directly impacted exposure and infection. Residential crowding brought on by racial segregation, redlining, and a lack of affordable housing multiplies the number of individuals in a given area and increases the risk of virus spread. On the macro level, discrimination, structural and institutional racism, income inequality, and violence also contribute to chronic stress, wearing down immunity and making the body susceptible to infectious diseases (Bae et al. 2019). Racism, in particular, has negative effects on mental and physical health (Williams and Mohammed 2013). Finally, lack of access to health insurance (including the affordability of routine visits, medication, and medical devices/equipment to manage chronic disease) and underinsurance coupled with chronic and preexisting conditions, including unmanaged asthma or diabetes, to result in increased risk for more severe or deadly coronavirus infections (Maragakis 2020).
Even when people of color can access health care, they may experience provider bias. Provider bias is a form of implicit bias, attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. Provider bias can impact health outcomes—examples include undertreating pain (Hirsh et al. 2015) and ignoring birth complications in the case of Black maternal and infant health and mortality (Maina et al. 2018). People of color tend to be less satisfied with their interactions with health care providers, as “dominant communication styles, fewer demonstrated positive emotions, infrequent requests for input about treatment decisions, and less patient-centered care seem to characterize patient provider interactions involving people of color” (Hall et al. 2015).
While we recognize people of color may experience higher burdens of chronic health conditions, including lung disease, heart disease, and asthma, that may be associated with poorer outcomes from COVID-19, the social determinants of health provide a framework to shift our analysis from the individual to the broader system. Social factors influence health outcomes, both directly through the living conditions they create and indirectly by shaping individual behaviors, creating a chronic cycle where health inequities lead to health disparities. In this next section, we specifically discuss how racism and discrimination have led to medical mistrust, which impacted health outcomes in the Black community.
Historical Discrimination Leads to Mistrust
Medical mistrust is animated by a distrust of medical providers, treatments, and health care systems. The absence of trust creates an environment wherein patients become skeptical that providers and organizations genuinely care for patients’ interests, are honest, practice confidentiality, or have the proficiency to produce the best achievable outcomes. Medical mistrust is not just a lack of trust in the medical system and personnel but the belief that medical professionals are willingly acting with ill intent toward them. This mistrust often extends to the pharmaceutical industry and government. It is considered “an active response to direct or vicarious (e.g., inter-generational or social network stories, collective memory) marginalization” (Benkert et al. 2019).
Experiencing actual or perceived discrimination is associated with higher mistrust. Mistrust is not necessarily harmful. In fact, skepticism can be healthy when it leads to seeking second opinions, asking questions, seeking additional explanations, or further services. Mistrust can empower individuals for change when channeled effectively. Also, mistrust can serve as a protective or survival mechanism in the face of historical and ongoing oppression.
Yet mistrust can have devastating impacts on health behaviors and outcomes, especially among groups that are already socially and economically marginalized: “Whether the genesis of the mistrust is based on fact or fallacy, the results may be similar. There are myriad negative consequences associated with medical mistrust, including lower utilization of healthcare and poorer management of health conditions” (Jaiswal 2019). Mistrust explains the association between discrimination and certain health behaviors (e.g., longer time between medical exams, lack of seeking treatment, or nonadherence to treatments). Medical mistrust is an important, albeit not exclusive, explanation for staggering racial health disparities and COVID-19–related outcomes.
Among Black Americans, high levels of medical mistrust are a response to historical injustices, ongoing discrimination, and systemic racism. While the medical and public health literature largely cites the U.S. Public Health Service and the Centers for Disease Control and Prevention study at Tuskegee University1 as the primary provocation for “persistent health-related mistrust among people of color and other groups who experience social and economic vulnerability” (Jaiswal et al. 2019), we briefly outline below additional, historical events and oppression that contributed to ongoing medical mistrust among Black Americans.
The period of African enslavement in America was a medically managed enterprise. Doctors “inspected” people who were enslaved before they were forcibly taken to slave ships. Moreover, doctors were employed to ensure the “cargo” remained alive and healthy during transport. In fact, the Dolben Act (referred to as the Slave Carrying Bill) in 1788 mandated all English slave ships have a doctor on board (Rediker 2008). Capitalism served as the catalyst for medical practice during enslavement, and doctors were rewarded: “The more you [the doctor] preserve of them [people who were enslaved] for the Plantations the more Profit you [the doctor] will have, and also the greater reputation and Wages another voyage” (Sheridan 1985).
Medical practice was integral to the economic success of the plantation, too. The partnership between the slaveowner and doctor played a key role in establishing “soundness at the auction block.” When people who were enslaved became ill or died, this was considered a significant financial loss for the slaveowner. To reduce costs incurred by the owner, slaveowners sought to avoid professional medical care for people who were enslaved (Washington 2006). Thus, people who were enslaved were often first attended to by other people who were enslaved using traditional methods passed down over generations. People who were enslaved avoided harsh “treatments” from their owners. If a doctor was called and unable to provide assistance, people who were enslaved were admitted to poorly resourced “slave hospitals.” At most plantations, enslaved Black women were designated as midwives to attend births of enslaved women, as well as slaveowners’ wives and mistresses, and were assigned to care for their babies and children.
Moreover, medical experimentation was common on enslaved Black people. The “Father of Modern Gynecology,” Dr. J. Marion Sims, founded the New York Women’s Hospital (Washington 2006). He owned slaves and did experiments on them without anesthesia, including on eleven Black women, to develop and refine the repair of vesicovaginal fistula. He also conducted surgical experimentation on babies to learn about “newborn” tetanus. Black bodies sustained abuse by the medical establishment even after death (Clark 1998). The panicked need for bodies to practice various procedures and anatomy created an appetite at the expense of Blacks and poor whites. This made Black and poor white people wary about going to hospitals—that they would be unnecessarily experimented on or allowed to die so they could be used for practice. The practice of “grave robbing” and worry about the “night doctors” emerged. These bodies were often shipped to medical schools in the North as well—medical schools advertised that they had “dissecting material.”
Up until the 1960s, hospitals were rigidly segregated by race (Duke University 2021). In the south, per Jim Crow laws, separate hospitals existed for Black patients, where Black doctors could train. In the North, training opportunities and staff privileges at historically white institutions were offered only to whites, helping ensure separate and unequal care. The emergence of Black hospitals called “the Black Hospital Movement” (1865–1960s), established by the Medical Division of the Freedmen’s Bureau, was brought on to improve the health of Black people (Duke University 2021).
With the passage of the Medicare program in the 1960s, desegregation of hospitals was swift. While the Johnson administration’s Office of Equal Health Opportunity sought to ensure that hospitals were in compliance with the law, and thus eligible for federal funds, other medical injustices remained. The legacy of medical experimentation without informed consent continued until 1974 (Washington 2006) with the passage of the National Research Act, which established Institutional Review Boards. Specific, unethical experiments include the “Tuskegee Study of Untreated Syphilis in the Negro Male” (Brandt 1978) conducted by the U.S. Public Health Service and the Centers for Disease Control and Prevention (1932–1972), untreated syphilis on Guatemalan prison inmates and psychiatric patients in the 1940s (Selyukh 2011), Henrietta Lacks’s cervical cancer cells taken without her consent becoming the first immortalized cell line in 1951 (Skloot 2011), and “the pill” studies in Puerto Rico in 1955 (Roberts 1998).
Eugenics and reproductive coercion were at the center of “reproductive health care” in the twentieth century. “Well-born” (i.e., eugenics) and other government-sanctioned programs (Washington 2006) throughout most of the twentieth century included compulsory surgical sterilizations of communities considered “unfit” to reproduce—disproportionately Black women. The North Carolina Eugenics Commission sterilized 8,000 mentally disabled persons throughout the 1930s; 5,000 were Black. The Southern Poverty Law Center estimates 100,000–150,000 women were sterilized annually for decades using federal funds, half of whom were Black (Day 2001). Many sterilizations, however, happened outside of the law at the discretion of physicians, referred to euphemistically as a “Mississippi appendectomy.” Governmental public assistance programs also linked sterilizations to welfare benefits (Roberts 1998).
Margaret Sanger, founder of Planned Parenthood, moved from women’s reproductive rights to eugenics. Her American Birth Control League merged with another organization and developed the “Negro Project,” which set up birth control clinics in Black neighborhoods around the country. The pill and other contraceptive methods were made available to Black women with low incomes for free or at low cost through government-sponsored Planned Parenthood clinics. This raised community concerns about a de facto genocide in these clinics (Roberts 1998). In 1990, the first new contraceptive in twenty-five years was brought to market. Legislation in some states proposed to “incentivize” Norplant use for people on public assistance, and North Carolina even mandated it for women on Medicaid who had an abortion. Legislators also made Norplant expensive to remove. Medicaid reimbursed providers for removals only if Norplant had been in for five years. Norplant was promoted throughout urban areas, leading to a groundswell of opposition by advocates and community groups. Eventually, Norplant was discontinued in 2002 after multiple class-action lawsuits and concerns about its adverse side effects.
These historical injustices directly contribute to a sustained, engrained memory of racial oppression. Medical “mistrust, which originates in systemic racism, is a rational coping response to centuries of oppression, starting with slavery, and includes historical and ongoing police brutality, high incarceration rates, poverty, and racial residential segregation of Black people” (Bogart et al. 2021).
Impacts of Politics on Public Health Beliefs
The unique political landscape of the COVID-19 response intensified mistrust. The politicization of virus reduction efforts, including social distancing, mask wearing, and stay-at-home orders, directly contributed to the spread of the virus. Then president Donald Trump even contracted COVID-19 after failing to wear a mask or social distance and attending rallies en masse. In a COVID-19 and mistrust survey conducted by Bogart (2020), nearly all participants (97 percent) endorsed at least one general COVID-19–related mistrust belief, and over half endorsed at least one COVID-19 treatment or future vaccine hesitancy belief. Almost two-thirds reported at least one negative, social, economic, or health-related impact from COVID-19 (Bogart et al. 2021). Health care and social service providers were more likely to be trusted than other sources of information, including elected officials, who were more likely to be thought of as dishonest. Government was the least trusted source. This is unsurprising as former president Trump made unsubstantiated claims such as “the virus would just go away” (Rev 2020), called the virus “the China virus” manufactured in a “Chinese lab” (Rev 2020), touted the benefits of hydroxychloroquine to treat and prevent COVID-19 (Cathey 2020), suggested that bleach and UV light can treat COVID-19 (News 2020), and provided inadequate resources because “increased testing” would lead to more “COVID-19 cases” (Trump 2020a).
COVID-19–related mistrust includes conspiracy beliefs/theories around the origin, prevention, and treatment of COVID-19 (e.g., COVID-19 is manmade; a cure is being withheld from Black people; and vaccines change the structure of DNA). Conspiracy beliefs, much like mistrust, do not necessarily have to be false, harmful, unjustified, or irrational; however, when medical mistrust and conspiracy beliefs impact health outcomes, they can become harmful. The manifestations of these phenomena include lower health care / primary care utilization, greater delays in age-appropriate screens and other preventive services, and lower adherence to medical advice, prescription refills, and treatments (Bogart et al. 2021). With respect to COVID-19, medical mistrust may persist among Black Americans due to concerns about inequitable treatment vis-à-vis whites. Moreover, mistrust may influence vaccine hesitancy, with those reporting higher levels of mistrusting the government response and the origins of the pandemic being more reluctant to seek treatment or vaccines (Bogart et al. 2021).
Having explored the history and impact of medical mistrust in the Black community, we now turn to the role of the Black church. The Black church has long been known as a protective organization for the community, addressing individual needs as well as representing the community’s interests to the public (Lincoln and Mamiya 1990). Nowhere has this been more apparent than during the Civil Rights movement, and many Black clergy have run for public office, including the late John Lewis, Jesse Jackson, and Raphael Warnock, among many others. Given the threat the coronavirus posed to the Black community, we suspect that clergy addressed the issue with their congregations. We get a sense for whether clergy promoted cooperation with health professionals or skepticism by assessing whether trust in clergy regarding individuals’ health interests is positively or negatively associated with trust in medical professionals. If the relationship is negative, that suggests clergy may be fostering medical skepticism or that the church may be seen as a substitute for medical professionals.
We draw on data collected in March and October 2020 by Djupe, Lewis, and Burge that has been discussed extensively in this volume (see Chapter 1). What is particularly useful for this analysis is that they asked for agreement or disagreement with the statements “I trust clergy to have my best health interests at heart” and “I trust the medical professionals and scientists who have sounded the alarm about the dangers of the coronavirus.” With sizable samples (and weights in October 2020), we can assess how extensive trusts are and how they are linked across racial groups.
Kindly note that despite the pandemic, Americans found a way to connect with their clergy. Trust is not contingent on in-person interaction, but large numbers of Americans contacted clergy through worship at the height of the pandemic in the fall. In the October survey, 37 percent of attenders (those who attend more often than never) indicated that in-person worship had not been canceled, and 32 percent were attending in person. Also, among attenders, 61 percent of attenders suggested their congregation offered online services in the past six months, and 49 percent of attenders said they attended those online services. Online options were slightly higher among white respondents by 10 percent or less (only 5 percentage points less for Black respondents), though these differences were not significant. This evidence suggests that many kept a connection with their congregation and clergy through this difficult period.
Trust and Admiration in 2020
While our goal is to assess patterns of trust, we start by looking for signs that the pandemic was an object of concern. Toward that end, we determine the proportion of Asian, Black, Latino, and white respondents who reported their clergy addressed the COVID-19 outbreak in their houses of worship in March and October 2020. In March, Asian and Black Americans were more likely than whites to report hearing their clergy discuss the pandemic (the survey language was “the coronavirus”). Given the willingness of clergy serving Black and Asian respondents to address COVID-19, these clergy could serve as key partners in COVID-19 health promotion and disease mitigation. However, their concern evidently waned across the year; we see large drop-offs in Asian and Black respondents’ reports of hearing their clergy address COVID-19 by October 2020. In contrast, whites and Latinos remained unchanged in their reports of their clergy discussing the pandemic between March and October 2020. It is also notable that no group had a majority of respondents report that their clergy addressed the pandemic and that this measure of concern dropped to below one-third by October for all respondent groups except Latinos.
With these results in mind, we might expect variation by and within racial groups in whether they trust their clergy with their health interests. That is what Figure 5.2 shows, though overall trust in clergy is much higher than we might anticipate given that no group had a majority of respondents report that their clergy addressed the pandemic. There are very few respondents from any racial group who outright disagree that clergy have their best health interests at heart—no more than 25 percent. Conversely, thin majorities agree that they do trust clergy in this way, and there is little variation across racial groups in March. Most groups retain majority agreement except for Asian Americans, whose trust plummets 20 percentage points over the period from March to October. It is also worth noting that all groups except Black Americans express more disagreement in October compared to March. In both surveys, clergy who were heard addressing the pandemic received more trust, so it is likely that the decline in hearing clergy’s concern contributed to the somewhat greater distrust late in 2020. It is also worth noting that a large number of respondents (about one-third) were either ambivalent about clergy or had no opinion—they took the middle option of the response options (“Neither agree nor disagree”).
Since a majority of respondents trusts their clergy with their health, clergy can serve as trusted liaisons translating medical information and as voices of reason when misinformation exists within their congregations. This may be especially effective with the most engaged congregational members. Respondents who are engaged in their faith community trust their clergy most to help them with their health.
Arguably the most important results are in Figure 5.3, where we examine whether people trust medical professionals and scientists by race. There is considerably more fluctuation in trust of medical professionals and scientists across 2020—it was much higher in March 2020 (over 75 percent reported trust across all racial groups) than in October 2020. By October, trust reported by Black and Latino Americans had declined significantly. Whites and Asians maintained higher trust, though still evidenced a decline. While there were few respondents in either survey who outright distrusted health professionals, ambivalence clearly grew by October across all racial groups, especially among Latinos. Still, trust of medical professionals and scientists is considerably higher than trust of clergy. Accordingly, leveraging trust of medical professionals, scientists, and clergy within the setting of a congregation could be useful for relaying information about COVID-19 and mitigating disease.
Figure 5.2 Whether People Trust Their Clergy with Their Health, by Race and Survey: “I trust clergy to have my best health interests at heart.” (Source: March and October 2020 surveys.)
Figure 5.3 Whether People Trust Medical Professionals, by Race and Survey: “I trust the medical professionals and scientists who have sounded the alarm about the dangers of the coronavirus.” (Source: March and October 2020 surveys.)
Next, we assess whether the two are linked—is trust in clergy a substitute for trust in medical professionals or a complement? In Figure 5.4, we examine whether trust in clergy is linked to trust in medical professionals and scientists by race. There is a positive relationship between the two beliefs in March, where more trust in clergy is linked to greater trust in medical professionals, yet the relationship changes by October in revealing ways. In most cases, there is a noticeable decrease in trust in medical professionals by October, except, among Black Americans (and maybe Latinos), trust in clergy may help buoy trust in medical professionals. While it is surprising that as the election nears, the Democratic candidate, Joe Biden, emphasizes the seriousness of the COVID-19 pandemic and the Republican candidate, Donald Trump, de-emphasizes COVID-19, we assert that reduction in Black Americans’ and Latinos’ trust of medical professionals and scientists is likely motivated by overall medical mistrust and not partisan attitudes and beliefs. Clergy-distrusting Black and Latino Americans show the greatest decrease in trust in medical professionals, while the clergy-trusting maintain similar levels to March of trusting medical professionals. Among whites and Asians, however, trust in the two groups starts to delink and appears closer to uncorrelated by October. Thus, trust in medical professionals drops the most for whites and Asians among those who trust their clergy the most. These findings could reflect a growing opposition to health orders over the course of the pandemic (for examples, see the Introduction and Chapters 7, 8, and 9).
Figure 5.4 Is Trust in Clergy Linked to Trust in Medical Professionals? By Race across Surveys (Source: March and October 2020 surveys.)
Conclusion: On Building Trust and Beyond
Since COVID-19 arrived in the United States in March 2020, the country’s Black and Latino communities have been hardest hit. Their disproportionate representation as essential workers and other systemic, institutional, and social factors have left their communities more susceptible to disease and death from the virus. COVID-19 disparities will continue to widen unless public health officials earnestly engage with “culturally congruent, tailored approaches, including effective strategies, sources, and messaging, to deliver evidence-based information and overcome mistrust around COVID-19” (Bogart et al. 2021). Studies on medical mistrust related to COVID-19 using large-scale nationally representative samples of Black Americans and small-scale, in-depth, qualitative focus groups are needed to inform interventions and policy solutions at both structural and individual levels to address mistrust and reduce COVID-19 disparities.
The bioethical principle of justice and a commitment to elimination of health inequity are critical to this effort. Trust building and trustworthiness are processes that build on principles of ethical community engagement and community-based participatory research. Efforts to partner with community agencies, social organizations, and faith-based/placed organizations are key to providing a sound and timely response to COVID-19 in Black and Latino communities.
Our survey results highlight that clergy are reserves of goodwill, though they are not nearly infinite; nor have they been immune to the challenges of the pandemic. There was little decline in trust in clergy and a significant decline in trust in the medical community across 2020. Similarly, trust in clergy may have acted to sustain trust in medical professionals, though not quite evenly across racial groups. To our surprise, it is in the Black and Latino communities where trust in clergy appears to have played the strongest role in maintaining trust in medical professionals—the very groups that have the most troubled history with medical practitioners. Overall, we see little evidence that Americans are choosing either clergy or medical professionals to trust. When they trust one, they trust the other, reflecting the power of social organizational involvement, such as that offered by the Black church.
Finally, we cannot allow those that are hardest hit to be hardly reached. While several efficacious vaccines have been developed and are being disseminated, Black and Latino communities remain at the back of the line. Black and Latino communities must be prioritized to reverse the pandemic’s devastating effects.