As the coronavirus pandemic continues to grip the nation, its disproportionate impact on African American residents is obvious even as the primary underlying reason is rarely acknowledged.
Of course, numbers tell part of the story. The Centers for Disease Control and Protection recently reported death rates from COVID-19 among African Americans between the ages of 55-64 are higher than those for white Americans ages 65-74. The death rates for African Americans ages 65-74 are higher than for white Americans ages 75-84, and so on. The most striking difference is among those ages 45-54, with African Americans dying at a rate six times higher than white Americans.
Those higher death rates among older African Americans have been attributed to their higher rates of underlying conditions such as asthma, obesity, diabetes, chronic kidney disease and coronary artery disease. And those disparities didn’t suddenly appear in old age — racial disparities in health and death begin to show up in African Americans in their 20s, 30s, and 40s.
So on the surface, it seems reasonable to attribute the disproportionate number of COVID-19 deaths among older African Americans to their underlying health conditions. But the most significant underlying condition that increases their chances of dying from COVID-19 is racism.
Racism is the primary driver that determines the social conditions in which older African Americans are born, work, live and age. Social conditions are often recognized as social determinants of health. Few can argue that access to decent employment, safe and supportive neighborhoods and communities, quality schools and food, clean air and water is important for our health and well-being.
Imagine three concentric circles, like the bullseye in the Target sign. The circle in the center represents our individual health behaviors like consuming alcohol, smoking cigarettes, exercising, getting enough sleep and eating healthy food. This circle gets the most attention when the medical community explains why older African Americans have such high rates of diabetes, hypertension, heart disease, obesity and deaths from COVID-19.
Moving out from the center, the next concentric circle features social conditions influencing our health behaviors. These conditions determine whether there are resources to support our health behaviors, such as access to quality employment, housing and educational opportunities, close proximity to grocery stores and other sources of fresh, healthy foods. The availability and quality of public transportation, parks, and health care providers are also located in this circle. Public health officials are more likely than medical professionals to mention some of these social factors when explaining the high prevalence of chronic health conditions and death among older African Americans.
Yet these factors are rarely considered when public health officials make recommendations for avoiding COVID-19. For example, one of the main strategies for avoiding infection is social distancing. But social distancing is nearly impossible for the 27% of African Americans aged 65–79 and the 36% of those age 80 and over who live in multigenerational households. By comparison, the shares of older white adults living in multigenerational households are just 14% and 18%, respectively.
Many older African Americans also reside with family members who are essential workers forced to put themselves and their families at additional risk of getting COVID-19. Black workers make up 11.9% of the workforce, but they make up 17% of all front-line workers in essential industries such as groceries, public transit and social services.
The outer circle of the bullseye is where power and privilege are located. External forces determine where and how older African Americans live, work and age. The Black codes of the 19th century detailed when, where, how, and for what compensation formerly enslaved African Americans would work. The Jim Crow laws of the 20th century continued the segregation and disenfranchisement of African Americans. Redlining — local, state, and federal housing policies that enforced segregation until the 1960s — is still contributing today to the racial wealth gap.
The bottom line: The impact of COVID-19 on older African Americans and their families was predetermined. They were systematically denied access to the very health-promoting resources needed to survive the COVID-19 pandemic.
That isn’t news to health care experts. The COVID-19 Community Vulnerability Index combines indicators specific to COVID-19, such as health status and health care availability, with the CDC’s Social Vulnerability Index, which has themes like socioeconomic status, minority status and language, housing type and transportation, household composition and disability. Together, the COVID map accounts for 34 social determinants of health.
The CDC created the Social Vulnerability Index in 2011 to measure the expected negative impact of disasters of any type. That means federal health officials have known which communities — down to the level of a city block — are most likely to suffer devastating losses from the coronavirus for nearly a decade. Yet older African Americans have often been neglected in the pandemic response even though it’s obvious COVID-19 testing sites should be established in the poorest communities first, not the richest ones.
When the American Public Health Association declared racism a public health crisis, it opened the door for states, cities and counties to name racism as a determinant of health. Many of these declarations make a commitment to eliminate racial disparities in social, economic, environmental and criminal justice policies, practices and investments, and to prioritize racial equity in decision making. While this is a step in the right direction, questions remain regarding how and perhaps more importantly, who, will be responsible and accountable for making changes.
There are several useful frameworks. For example, the Families USA Health Equity Task Force’s Framework for Advancing Health Equity and Value offers guidelines for setting priorities, targets and outcomes. Those guidelines can be used to measure progress and spotlight unintended consequences of policies and programs designed to eliminate racism and achieve health equity.
As communities combat the coronavirus pandemic and health disparities, they should prioritize the needs of older African Americans who have one of the longest histories of racial injustice. All Black Lives Matter. Old Black Lives have mattered longer.
Karen D. Lincoln is an associate professor at the Suzanne Dworak-Peck School of Social Work at the University of Southern California. This is part of a series funded by a grant from the Rita Allen Foundation to report and present stories about the disproportionate impact of the virus on people of color, Americans living in poverty and other vulnerable groups.