Abstract:
Older Black, Indigenous, and Latinx adults are at a higher risk of negative COVID-19 outcomes relative to older non-Latinx White adults. Mounting evidence regarding the disproportionate impact of COVID-19 on communities of color lays bare the effects of long-standing and deeply rooted structural racism in American society. Residential and occupational segregation and unequal access to health-promoting resources such as education, income, wealth, and quality healthcare have exposed and amplified pre-existing racial/ethnic health disparities. To achieve population health equity, transformative actions aimed at addressing structural racism are necessary to reduce social and health inequities in the United States.
Key Words:
COVID-19, structural racism, minority aging, health equity
Early on in the COVID-19 pandemic, it became clear that older Black, Indigenous, and Latinx adults (hereafter, people of color) were at a higher risk of infection, hospitalization, and death from the coronavirus than were non-Latinx Whites (hereafter, Whites) (Centers for Disease Control and Prevention, 2021).
Despite the substantial growth of research linking structural racism and the unequal distribution of resources in our society to racial/ethnic health disparities in the United States (Gee and Ford 2011; Williams, Lawrence and Davis 2019), many in the media, as well as in government, resorted to politicizing the pandemic by placing the blame largely on individuals. Consistent with the ideology of personal responsibility, early explanations for the COVID-19 crisis often emphasized individual-level factors such as social distancing and healthy behaviors.
This has been particularly true of the early messages from governments and media, which targeted communities of color. For example, in his April 10, 2020, White House press conference statement about ways to protect the health of older Black and Latinx adults, former U.S. Surgeon General Dr. Jerome Adams invoked inaccurate racial/ethnic tropes, advising people of color to avoid abusing drugs and alcohol—even though minorities are similarly or less likely to engage in these risky behaviors.
The role of underlying health conditions in communities of color has also been highlighted as a key contributing factor to higher COVID-19 infection and mortality rates in these populations. Importantly, individual-level explanations for elevated COVID-19 risk among people of color have largely ignored or minimized the fact that proximate risk factors that increase minority exposure and susceptibility to negative COVID-19 outcomes are rooted in structural racism.
These framings were quickly challenged by researchers, health professionals, and community advocates who highlighted the role of structural racism and socioeconomic deprivation in shaping pre-existing health conditions, including factors such as inadequate access to quality healthcare and health-promoting resources such as education, income, and wealth (Garcia et al. 2021; Laster Pirtle 2020).
With the changing of administrations, the federal response has aimed to address racial/ethnic inequities, for instance, President Biden established a COVID-19 Health Equity Task Force. To address health equity, it is important to recognize that people of color are more likely than Whites to experience “pre-existing pathological social conditions” such as discrimination and marginalization in education, employment, housing, and healthcare systems across the life course. These conditions drive weathering processes (i.e., earlier onset of disease and a steeper health decline with age), which results in a greater burden of disease that contributes to COVID-19 disparities (Garcia et al. 2021).
These long-standing and deeply rooted inequalities motivate this article’s focus on how structural racism results in an accumulation of socioeconomic and health disadvantages that have shaped the experience of older people of color during the COVID-19 pandemic. It discusses disparities in historical and societal conditions that result in an increased risk of exposure to COVID-19 in residential, occupational, and long-term care settings, to explain how structural racism shapes negative pandemic outcomes for older adults. It then highlights disparities in vaccine distribution and concludes by advocating for the need for a health equity framework to address short- and long-term health inequalities.
The Role of Structural Racism in COVID-19 Infection
As with many age-related diseases, older adults of all races are at an increased risk of serious illness, hospitalization, and death from COVID-19 compared to their younger counterparts (Centers for Disease Control and Prevention, 2020). This higher risk is due in part to age-related changes that compromise the immune system and the presence of certain underlying health conditions that increase the risk of COVID-19 infection. The greater risk of negative COVID-19 outcomes is particularly concerning for older people of color as they are more likely than Whites to have underlying health conditions (e.g., cancer, diabetes, heart disease, hypertension, and obesity) (Brown 2018; Garcia, Garcia and Ailshire 2018).
‘Proximate risk factors that increase minority exposure and susceptibility to negative COVID-19 outcomes are rooted in structural racism.’
Moreover, despite Medicare/Medicaid coverage availability for people ages 65 and older, older adults of color may face challenges accessing healthcare. This can lead to decisions to forgo or delay necessary medical care, the result being health deterioration and adverse COVID-19 outcomes.
Social science and public health research increasingly show that population health is a mirror that reflects societal arrangements. Thus, to understand racial/ethnic inequalities in health among older adults, it is critical to consider the role of social context.
Structural racism refers to how contemporary and historical institutions and public policies normalize the mistreatment and acceptance of worse outcomes for people of color in American society (Gee and Ford 2011; Williams, Lawrence and Davis 2019). One of the mechanisms through which structural racism may lead to increased exposure to COVID-19 for people of color is residential segregation. Neighborhood composition is extremely important as it underscores the significance of socioeconomic and environmental conditions that influence health over the life course, and in the context of the COVID-19 pandemic shapes exposure to infection (Hargrove, García and Cagney 2020).
Specifically, residential segregation directly shapes differential exposure and vulnerability to COVID-19 by contributing to pre-existing health conditions such as asthma, hypertension, and obesity (Sewell 2016), as well as crowded and subpar housing. Residential segregation also likely shapes racialized susceptibility to the coronavirus indirectly through pathways such as higher rates of poverty, fewer healthcare and health-promoting resources, limited access to good-paying stable jobs, opportunities for wealth accumulation, green space, and nutritional foods. Moreover, residential segregation heightens the exposure to social stressors and environmental toxins (Gee and Ford 2011; Sewell 2016).
Researchers have found that counties with higher levels of structural racism (including racial segregation) have more than double the number of reported COVID-19 infections and more than triple the number of COVID-19–related deaths, compared to counties with lower levels of structural racism and racial segregation (Tan, DeSouza and Raifman 2021).
Economics Resources Key Risk Factors to COVID-19 Exposure
It also is important to consider the historical aspects of structural racism, as older people of color who are alive today have lived through periods of institutionalized racism (e.g., the Jim Crow era of overt and de jure racism) that have limited social and economic opportunities throughout their life course (Krieger 2020). The negative consequences of racism then accumulate over the life course and result in poorer health outcomes and lower levels of economic security for older people of color relative to older Whites. Economic resources are key factors determining the risk of COVID-19 exposure, as older people of color are less likely to have paid sick leave or the ability to work remotely.
Moreover, due to economic necessity (i.e., paying rent/mortgage, purchasing food and medications, etc.), many older people of color must continue to work, often in high public contact occupations such as food, health, retail, service, and transportation industries that are deemed “essential,” which increases their risk of exposure. In addition, persons of color with low income often lack or have limited economic resources to purchase personal protective equipment (PPE) such as effective masks or services such as grocery delivery that may help reduce infection due to exposure.
Furthermore, due to structural racism in the United States, which affects socioeconomic status, residential segregation, and housing density and quality, older people of color are less able to easily practice physical distancing or social isolation initiatives aimed at “flattening the curve.” Mandated or voluntary “shelter in place” initiatives are difficult for many frontline workers who do not qualify for paid sick leave or have the luxury of working from home. Many of these individuals put themselves and their families at risk of exposure to COVID-19 every time they leave their homes, particularly those who require public transportation to get to work. In addition, with many schools moving to remote instruction, older adults have been tasked with assisting in childcare, which increases their risk of COVID-19 exposure.
‘Counties with higher levels of structural racism (including racial segregation) have more than double the number of reported COVID-19 infections.’
Although Medicare and Medicaid are available to most older adults of color, limited coverage policies may contribute to vast inequalities in healthcare access. Also, older adults of color are less likely to receive quality healthcare due to implicit bias, discrimination, and systemic racism. The above practices lead to a distrust of medical professionals that are deeply rooted in historical practices of discrimination. There has been a long legacy of discrimination and exploitation of African American bodies in the United States, resulting in the disparaging treatment of African Americans (i.e., not believing their pain and receiving less effective treatment) in modern-day medical settings.
Racial/ethnic segregation in nursing homes and long-term care facilities has also contributed to adverse COVID-19 outcomes among older people of color. Nursing homes have historically been and remain highly segregated by race/ethnicity, with facilities serving predominantly residents of color more likely to report lower staffing and nursing ratios, high numbers of deficiencies, and lower quality of care (Mack et al. 2020). The constellation of these factors has resulted in older adults of color experiencing higher COVID-19 infection due to these facilities having fewer resources to ensure the safety of their residents (Shippee et al. 2020).
For example, nursing homes with predominantly Black and Latinx residents were twice as likely to experience a COVID-19 outbreak compared to facilities with predominantly White residents. Multiple studies have found that facilities with higher nurse staffing levels were more successful in containing COVID-19 infections than facilities with lower staffing levels (Chapman and Harrington 2020). Additional studies have documented that older adults in the community who relied on home health aides due to functional, cognitive, or social limitations were similarly at a high risk as there is considerable overlap in home health workers and those providing nursing home care (Allison, Oh and Harrison 2020), which contributes to the increased risk of COVID-19 transmission among communities of color.
Testing Access and Rates, Vaccine Availability and Uptake All Lower in Communities of Color
Not only are older people of color at greater risk of exposure to COVID-19, but in many cases, they also lacked access to testing in their communities. Unequal access to testing places entire communities with limited resources at a greater risk of asymptomatic spread as individuals do not know they have the virus. Early in the pandemic, stories of racial discrimination in access to testing and in testing site location raised concerns about how such factors may contribute to racial/ethnic disparities in COVID-19 cases.
Researchers found that between March and September 2020, neighborhoods with higher social vulnerability, which also happen to have higher proportions of people of color, had lower rates of COVID-19 testing, higher positivity ratios, and higher mortality rates (Bilal et al. 2021). Such inadequate access to COVID-19 testing for the most vulnerable populations is another indicator of how structural factors continue to disadvantage populations of color.
Having observed the disproportionate effect of the pandemic on people of color, researchers and public health officials advocated for equitable vaccine distribution. As a result, the National Academies of Sciences, Engineering, and Medicine (NASEM) formed a committee to create a framework for equitable vaccine allocation. Drawing on this report, the Centers for Disease Control and Prevention (CDC) in December 2020 issued a recommendation for vaccine prioritization when the first vaccine was granted emergency approval.
Healthcare workers and long-term-care facility residents were placed in the highest priority group. Although most states have followed this recommendation, some have modified their classification to include other individuals in this high-priority group. Recent evidence suggests some states are varying even further from these recommendations as they move on to lower priority groups.
The World Health Organization (WHO) and the NASEM have both suggested that vaccine distribution should take race/ethnicity into account to prevent exacerbating existing inequalities. However, as of April 2021, only three states have prioritized people of color as an increased risk group for COVID-19 complications in their vaccination plan—Montana for Indigenous Americans, Vermont for Black adults (Tolbert 2021), and California for race/ethnic minority groups and people from tribal communities.
The lack of prioritization for populations of color has led to racial/ethnic inequities in COVID-19 vaccine access, with Whites receiving a disproportionate share of the initially limited supply, even in predominantly non-White neighborhoods. The Biden administration aimed to increase vaccination efforts and pledged to distribute 200 million doses within the first 100 days in office. These efforts emphasized health equity by establishing federally run mass vaccination clinics in high-risk areas to offset racial/ethnic inequalities.
Despite meeting the above goal for mass vaccinations by the ninety-second day in office, fewer people of color have been inoculated compared to Whites. As of May 25, 2021, the percentage of White adults who received at least one vaccination dose was 43 percent, compared to 32 percent for Latinx adults and 29 percent for Black adults (Ndugga et al., 2021). These low vaccination rates have been attributed in part to the complex vaccine sign-up process that requires navigating an online website to obtain an appointment, which disadvantages older people of color who are less likely to have internet access, experience obstacles with transportation, and have concerns about the potential cost. Moreover, for many immigrant families, concerns regarding eligibility, language barriers, and risk of law enforcement action for those who are undocumented make the process more challenging (Artiga 2021).
In addition to inequities in vaccine distribution, public health officials also must address issues of vaccine hesitancy. A January 2021 Kaiser Family Foundation national poll found a higher percentage of Black and Latinx adults are taking a “wait and see” approach to determine the effectiveness of the vaccine; although these differences are not large enough to explain the emerging disparities in vaccination (Ndugga et al. 2021).
The WHO and the NASEM have suggested that vaccine distribution should take race/ethnicity into account to prevent exacerbating inequalities.
Historical underpinnings and consequences underlie mistrust in the healthcare system that stem from a long history of abuses shaping vaccine hesitancy in communities of color. The legacy of these experiences, combined with continued medical mistreatment of people of color further drive the level of mistrust in medical institutions. A societal-wide shift in the medical treatment of people of color may be needed to bridge this gap.
Vaccine hesitancy may be particularly acute in long-term care settings, where approximately one-third of workers have refused vaccination (Gharpure et al. 2021). The most frequently reported reason for vaccine hesitancy has been concerns regarding side effects. However, high staff turnover and issues related to education and outreach efforts also may contribute to vaccine challenges among these workers. Fortunately, vaccination has been higher among residents in long-term care facilities, with approximately 78 percent of residents having received at least one dose (Gharpure et al. 2021).
A Health Equity Approach Needed in Vaccine Distribution and to Address Reluctance
Applying a health equity lens can be used to draw attention to discriminatory practices that underpin existing health disparities, such as those observed during the COVID-19 pandemic. Health equity is about ensuring equal outcomes by removing unfair obstacles (i.e., poverty, discrimination) and providing individuals and communities with the resources they need to achieve a healthy life.
Given older people of color have been disproportionately impacted by COVID-19 mortality (Sáenz and Garcia 2021), all states should attempt to modify their vaccine distribution plan to follow the recommendations put forth by NASEM. This proposal suggests that 10 percent of all vaccines be reserved for areas identified as vulnerable, based on fifteen social factors (below poverty, unemployed, income, no high school diploma, ages 65 and older, ages 17 and younger, civilian with a disability, single-parent households, minority, speaks English “less than well,” multiunit structures, mobile homes, crowding, no vehicle, and group quarters) identified in the CDC’s Social Vulnerability Index (SVI), including racial/ethnic distribution (National Academies of Sciences and Medicine 2020).
Within these areas, resources should be allocated for outreach to older adults of color. To ensure equitable vaccination rollout among older people of color, the following must be considered: vaccination outreach cannot solely be electronic, as older people of color are less likely to have access to the internet (vaccine outreach efforts would be more effective incorporating multimodal forms of communication such as a dedicated telephone line with interpreters to translate multiple languages, disseminating information through ethnic media outlets, and conducting outreach through community-based organizations.); mobile vaccination sites need to be set up in community centers and at trusted and easily accessed locations near communities of color to help alleviate difficulty with distance from their residence; and transportation resources must also be provided, particularly for older people of color who are living in isolation and/or have mobility challenges due to functional limitations or disability.
As vaccine production continues to increase, the United States will soon reach a point where supply outpaces demand. However, education and outreach efforts must continue to reach individuals who experience issues with transportation, limited English proficiency, and other social or economic barriers, to increase the number of adults who are willing to get the vaccine.
The COVID-19 pandemic has made visible the stark reality that structural racism is a major source of health disparities in the United States. If we aim to create effective change, we must put forth every effort to dismantle the racist structures underlying our healthcare system and society more broadly. Now is the time to reform social policies to address structural racism so that when the next crisis comes, we are not witnessing the same groups being disproportionately disadvantaged again and again. Several proposals have been put forth to help address these social and economic inequalities that underlie health disparities. First, we must recognize the role of structural racism in limiting the opportunities of people of color to work toward a more just society that will have the political will to enact policies aimed at reducing inequality. Governmental policies historically have been used to create and maintain racial inequality; however, change is possible.
Three important policy proposals aimed at reducing racial inequality include: baby bonds, increasing the minimum wage, and universal healthcare coverage. Baby bonds are federally managed accounts set up at birth for children with assets that grow over time. Research suggests that baby bonds can be an effective strategy at reducing the racial wealth gap (Hamilton and Darity Jr 2010).
The federal minimum wage has not kept pace with the rising costs of living in the United States. Thus increasing the federal minimum wage may help reduce economic stress-related health outcomes that would then help reduce income inequality, particularly among populations of color (Andrea et al. 2020).
Finally, a universal healthcare policy would provide a much-needed safety net for the health and well-being of people of color. People of color are more likely to be uninsured and lack access to high-quality healthcare. Providing universal healthcare would reduce the stress and stigma that may lead to worse health outcomes for these populations. These bold policy proposals aimed at reducing social and economic inequality for people of color are a first step at providing the economic resources needed to ensure a healthy and resilient community that can weather future public health crises.
Marc A. Garcia, PhD, is an assistant professor in the Department of Sociology and Maxwell School of Citizenship & Public Affairs at Syracuse University, and an affiliate at the Aging Studies Institute, Center for Aging and Policy Studies and the Lerner Center for Public Health Promotion at Syracuse University, in Syracuse, New York. Adriana M. Reyes, PhD, is an assistant professor of Policy Analysis and Management at Cornell University in Ithaca, New York. Catherine García, PhD, is an assistant professor of Human Development and Family Science at Syracuse University and an affiliate at the Aging Studies Institute, Center for Aging and Policy Studies, and the Lerner Center for Public Health Promotion at Syracuse University.
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