Black and Hispanic residents are more likely than white residents to become infected by the coronavirus and Black residents are more likely to die from it. Dr. Sherita Hill Golden, vice president and chief diversity officer for Johns Hopkins Medicine, talked with me this week about why that is the case.
She discussed the impact of systemic racism, dispelled some myths and highlighted ways health care institutions and government can respond to make a difference.
Here are the highlights of our conversation, which has been edited and condensed for clarity.
Tim Nickens: Statistics show Black and Hispanic residents are more likely to become infected by the COVID-19 virus and more likely to die from it. Why is that?
Dr. Sherita Hill Golden: There are several contributing factors. I think of them in three buckets, and two of them are historical. One is that there are historical practices that were embedded in our medical and health care environments. During slavery, African American slaves were often experimented upon without their consent and without anesthesia. Even in modern-day medicine, there are some erroneous beliefs that somehow Blacks are more tolerant of pain and need less pain medication. That’s an example of a bias that still exists in the health care system that results in inadequate pain control during hospitalization.
There were also situations like the Guatemala syphilis experiment (in the 1940s) and the Tuskegee syphilis experiment (from the 1930s to 1972) where Hispanics and African Americans were withheld treatment so scientists could learn the natural history of syphilis. The Tuskegee experiment wasn’t uncovered until 1972. That’s fairly recent in our country’s history. All of those things led to a distrust among minority populations of our medical system.
At the turn of the last century, there were also racial and ethnic groups that were considered biologically inferior to others — African Americans, Latinos, and recent immigrants to the U.S. We know today that is absolutely not true. There is no scientific foundation that there are any groups that are genetically inferior to others.
All of those things have contributed to minority patients experiencing bias in the health care system resulting in less likelihood of seeking care and poor experiences in the health care setting. So we now have African American and Latino patients who may be getting sick but not coming into the health care system because they may have had poor experiences before, or coming to the health care system and not being believed when they are presenting symptoms of COVID-19.
Second, there is a social context, policies that have been in place in our country that started after the Civil War era that have contributed to structural and institutional racism in things like housing, jobs and education. African Americans were coming from the South to settle in cities in the north, and a lot of those neighborhoods would become redlined and African Americans were often subjected to predatory loans. City governments would stop investing in public works in those neighborhoods, stop investing in the school system, and stop investing in economic development. So today we have neighborhoods that still have a lot of housing instability, food insecurity where there isn’t access to healthy foods, and a lack of access to parks for physical activity and recreation. We know those factors increase the risk of chronic diseases that have been associated with COVID-19.
The third bucket is that African American and Latino residents are more likely to be working in jobs in the service sector that are considered essential during the pandemic — the food service industry, environmental services, security, public transportation. They have had to continue to go to work, often without proper personal protective equipment, especially at the beginning of the pandemic, so they were more likely to be exposed. Many of them are also living in crowded, multigenerational housing.
All of those things contribute to increased COVID exposure. Then if the population is also more likely to have a risk of diabetes, heart disease and lung disease because of these historical issues, and on top of that they are more likely to be exposed to and infected by COVID, that is going to result in worse outcomes. It’s not so much that these diseases make you more susceptible to infection; it’s that they contribute to a poorer outcome once you get infected.
Nickens: Does it frustrate you that some believe Black and Hispanic residents are more likely to be infected by COVID-19 because of genetics?
Golden: There’s nothing genetic about being housing insecure, food insecure, or living in an environment where you have exposure to chemicals that increase your risk of chronic diseases. Those are social and institutional contributors to health that have nothing to do with a person’s genetics.
Nickens: Are the lifestyle changes needed to guard against the virus harder to make in poorer neighborhoods?
Golden: They can be. Fortunately, now there are all kinds of masks available. Washing your hands frequently is critical. But if you are living in crowded housing, it can make social distancing difficult to impossible.
One thing important to recognize in the African American community is that everybody who is dying from COVID is not low-income and living in these types of circumstances. There are well-off African Americans who also have diabetes, obesity or cardiovascular disease who are dying from COVID. Even when you are in a situation where you can implement those public health practices, this population is still very much at risk.
Nickens: A lot has been written about historical stress contributing to this situation.
Golden: I think it is a significant contributor. African Americans are more likely to contract COVID and more likely to die. The Hispanic population is more likely to get COVID, but the death rate is not as high and is closer to that of white people. Part of the reason is that Hispanics who are getting infected are younger. But I also think the difference is that African Americans have been exposed to generational stress that results from dealing with discrimination in every aspect of life. Our Latino immigrant community has come to the U.S. more recently, so there hasn’t been the same amount of time for that chronic stress to perhaps have as significant impact in terms of mortality.
We really should be thinking about how we eliminate that discriminatory stress for all of our vulnerable communities.
Nickens: What have you seen from the government and the medical community that has been effective in helping people of color and low-income communities deal with the virus?
Golden: Meeting people where they are in the community is key. Those who are undocumented immigrants don’t have access to all of the usual benefits that citizens have. In Baltimore, we have established partnerships with community organizations and corporations to get meals delivered to them. We are also using our Johns Hopkins excess testing capacity to provide mobile testing in the community where there are hot spots.
If you are partnering with trusted community partners, they can also help you with contact tracing. People are often uncomfortable about wanting to say who they have been in contact with, but we have to know who they have been in contact with if they are infected so that we can make quarantine and isolation recommendations to stop the spread of the virus.
Nickens: Do you have any hope for positive structural change to come out of this pandemic as these disparities are highlighted?
Golden: I’ve been a doctor for 26 years. When you’re in medical school, you’re told you are going to use this medicine to treat this disease and the patient is going to get better. Then you start practicing, and you realize there are all of these extraneous factors that contribute to the ability of the patient to get the medicine and to take the medicine. We have to really think about how we use our policies and legislation to address these structural, social determinants of health.
One fire hydrant is required for so many houses in a neighborhood. It seems like for so many houses, there should be a store where you can get affordable fresh fruits and vegetables and healthy food. How do we use our power of legislation to address these issues? As we think about good health, much of this needs to happen in collaboration with the health care system but also outside of it. That’s a very different way of thinking than when I was in medical school in the early ’90s.
Nickens: From the news coverage you have seen on racial disparities regarding the virus, are there any particular points where the coverage is off-base or where journalists could be more thoughtful about how they approach the issue?
Golden: It is important for journalists to report on and raise awareness about the contribution of structural racism to the social determinants of health that are foundational to the disparities in COVID-19 and the chronic medical conditions that worsen outcomes from COVID-19. This will prevent reporting suggesting that it is just the chronic diseases and that it is the fault of the vulnerable populations for making poor health choices. I recall seeing such reports early during the pandemic, and they were very upsetting because they assume that everyone lives in an environment where they can make healthy choices; unfortunately, that is not the case.
It is also important to emphasize that it is not only poor African Americans who are dying from COVID-19 but also those who are adequately resourced, further shedding light on the generational impact of racism and the resulting stress on health.
Nickens: What have we missed in this conversation?
Golden: I’m an African American physician. I have been shocked by how many people have died from COVID-19. I’m flabbergasted that we could have this many deaths and a quarter of them are in my own community. My husband and I both know people who have had COVID-19 or have died from it. It’s horrible, but if it can actually wake us up to think about what we really need to do to deliver adequate care to people and advocate for environmental justice, that would be a great outcome.
Dr. Sherita Hill Golden is vice president and chief diversity officer for Johns Hopkins Medicine. Her expertises include cardiovascular diseases, diabetes, diabetes mellitus, endocrinology and lipid disorders.
Tim Nickens recently retired as editor of editorials for the Tampa Bay Times. He and a colleague won the 2013 Pulitzer Prize for editorial writing that successfully persuaded Pinellas County to resume adding fluoride to drinking water. 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.