THE STATE OF Black AMERICA AND COVID-19 A TWO-YEAR ASSESSMENT

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Carol R. Oladele, PhD, MPH
Equity Research and Innovation Center (ERIC)

Yale University School of Medicine

Tonyka L. McKinney, DrPH, MPH

Satcher Health Leadership Institute (SHLI)

Morehouse School of Medicine

Destiny Tolliver, MD
National Clinician Scholars Program

Yale University School of Medicine

Reed Tuckson, MD
Black Coalition Against COVID

Daniel Dawes, JD
Satcher Health Leadership Institute (SHLI)

Morehouse School of Medicine

Marcella Nunez-Smith, MD, MHS
Equity Research and Innovation Center (ERIC)

Yale University School of Medicine

Report Sponsored by

The Black Coalition Against Covid:

A special thanks to Real Chemistry and 21GRAMS for their kind support in producing this report.

We commissioned this two-year assessment because we believe it is essential to examine the consequences of the pandemic for Black America.

On Behalf of the Black Coalition Against COVID

Washington, DC

In April 2020, a group of Washington DC community activists came together to mount a grassroots campaign to support local government efforts to combat the COVID-19 pandemic. Shortly thereafter, they helped to create a national effort with the leadership of Howard University; the Morehouse School of Medicine; the Meharry Medical College; the Charles R Drew University Medicine of Science; the National Medical Association; the W. Montague Cobb Institute of the NMA; the National Black Nurses Association; the National Urban League; and BlackDoctor.org. In addition, this coalition of health advocates and institutions regularly coordinated their work with partners from the faith community such as Choose Healthy Life and The Values Partnership, in addition to Black fraternal, sorority, and civic philanthropic organizations such as The Links, Incorporated.

Acting individually and collectively over the past two years, these deeply committed organizations mounted numerous educational forums and town halls; conducted vaccine clinical trials enrollment and administration programs; sponsored COVID-19 testing centers; disseminated masks and other personal protective equipment; and led advocacy efforts for the federal and local government financial and programmatic support necessary to protect the lives of the Black community.

As of this report’s release, we understand that there remains unfinished work yet to do to save and protect our communities from the COVID-19 pandemic. We commissioned this two-year report because we believe it is important to examine the consequences of the pandemic for Black America. However, because we have a profound respect for Black life and survival, and indeed for all life, we understand that even after the pandemic resolves, the disparities in health status experienced by the Black community prior to the pandemic must be urgently addressed. In fact, as this report documents, those disparities have actually worsened over the past two years. All of the organizations that have come together under this coalition are committed to working tirelessly until this pandemic ends as well as vigorously addressing the preexisting health challenges that have plagued our community for far too long. On behalf of the sponsors of the report, I take this opportunity to thank Dr. Tonyka McKinney from the Satcher Health Leadership Institute and Drs. Carol Oladele and Destiny Tolliver from Yale School of Medicine for their tireless efforts to bring the report to fruition.

Reed Tuckson MD

We hope to bring attention to the continued burden of COVID-19 in the Black community, even as we as a nation have made incredible progress overall.

Forward

We are pleased to share this report about the state of the Black community amid the COVID-19 pandemic from the Black Coalition Against COVID (BCAC), the Equity Research and Innovation Center at Yale School of Medicine, and the Satcher Health Leadership Institute at Morehouse School of Medicine. The BCAC—under the leadership of Dr. Reed Tuckson—commissioned this report in recognition of the fact that in January of 2022, rates of COVID-19 hospitalization for Black Americans were the highest they have been since the pandemic’s start. We hope to bring attention to the continued burden of COVID-19 in the Black community, even as we as a nation have made incredible progress overall. Even as we celebrate achievements towards COVID-19 equity, we know there is more work to do.

As we reflect on two years of lived experience and myriad data sources, we know COVID-19’s toll on Black Americans is ongoing. This report draws attention to the continued disproportionate burden experienced by members of the Black community and will help guide advocacy and policy efforts to address these inequities—both during the current pandemic and beyond.

This report shares the arc of the pandemic for Black Americans, highlights areas for immediate focus and attention, and presents a set of expert-generated recommendations for action. Given generations of systemic disinvestment in the health of Black communities in the United States, the starkly disproportionate rates of COVID-19 illness and death are not surprising. This report situates alarming pandemic-related disparities within these deeper societal inequities, and provides guidance to move towards sustained change.

It was an immense honor to serve as Chair of the historic Presidential COVID19 Health Equity Task Force. We worked urgently to answer our charge and provided a final report inclusive of recommendations, an implementation plan, and an accountability framework as a roadmap for every sector and every level of government. It is also an honor to be commissioned by the Black Coalition Against COVID (BCAC) to produce this brief report and continue to shine a light on the path to health justice.

I want to extend my deep appreciation to the Black Coalition Against COVID (BCAC), the Satcher Health Leadership Institute at Morehouse School of Medicine, and my colleagues here at Yale for their continued commitment to improving the health and wellbeing of the Black community, and of all those experiencing health inequities, and the ongoing work of this coalition to close the equity gap in our great nation.

Marcella Nunez-Smith MD, MHS

C.N.H. Long Professor of Internal Medicine, Public Health, and Management

Associate Dean, Health Equity Research

Director, Office for Health Equity Research and Equity Research and Innovation Center, Yale University

Chair, Presidential COVID-19 Health Equity Task Force

One in 310 Black children lost a parent or caregiver, compared to one in 738 White children between April 2020 and June 2021.

COVID-19 by the Data: Then and Now

THEN

Black Americans experienced a disproportionate COVID-19 burden in the early months of the pandemic and beyond. Data available in the early months of the pandemic indicated age-adjusted COVID-19 rates of infection, hospitalization, and death were highest among Black Americans.1,2 Also striking was the limited data available on COVID-19 outcomes by race/ethnicity across the country.3,4 Over time, the quality and completeness of race/ethnicity data improved and revealed a disproportionate pandemic burden across all structurally marginalized and minoritized groups.5,6 The risk for severe and negative impacts from COVID-19 remained high for Black Americans.7,8

Beyond the burden of infection, hospitalization, and death, Black Americans experienced significant economic, social, educational, and behavioral health crises. Black communities were disproportionately impacted by financial strain, loss of caregivers and elders, deficiencies in educational learning, and food insecurity. Half of Black respondents included in one 2020 survey reported experiencing financial challenges.9 More than one in six Black workers lost jobs between February and April 2020.10 A September 2020 analysis found that 13 percent (two million) fewer Black Americans were predicted to be enrolled in employerbased health insurance.11 Older Black Americans (65-74) were five times more likely to die compared to White Americans.12 Those 75-84 years died almost four times as often as their White counterparts.12 One in 310 Black children lost a parent or caregiver, compared to one in 738 White children between April 2020 and June 2021.13 Relevant to the substantial loss of life, Black Americans reported pandemic-related mental health concerns at a rate approximately 10 percentage points higher than White Americans.14,15 Learning loss among Black and other students of color was estimated to be 12 months compared to 4-8 months for White students.16 Twenty-one percent of Black Americans experienced food insecurity, making them twice as likely as White Americans to experience food insecurity.17,18 Those who experienced food insecurity prior to the pandemic experienced more severe food insecurity.19,20 The confluence of these factors contributed to the extraordinary COVID-19 related burden faced by Black Americans.

Pre-existing structural and social inequities that have long driven disparities were key risk factors for COVID-19.

COVID-19 Cases, Hospitalization, and Deaths rates per 100,000-March 2020 to May 2020

The severity of COVID-19 among Black Americans was the predictable result of structural and societal realities, not differences in genetic predisposition. Black Americans are overrepresented in essential worker positions which increased their risk of getting COVID-19.21-23 For example, 25 percent of employed Black Americans work in service jobs compared to 16 percent of White Americans.23 They account for 30 percent of licensed practical and vocational nurses.23 Black Americans are also more likely to live in multi-generational homes, live in crowded conditions, be incarcerated, and reside in densely populated urban areas compared to White Americans, which made social distancing difficult.23-26 Pre-existing structural and social inequities that have long driven disparities were key risk factors for COVID-19. Those factors included exposure to environmental toxins, obesity, hypertension, diabetes, and chronic kidney disease—contributing to greater risk for infection and serious illness.8,27-29 The higher prevalence of these risk factors is a result of differential access to high quality care and health promoting resources necessary to prevent, diagnose, and appropriately manage chronic conditions.30-33
Black Americans faced discrimination and bias when seeking COVID-19 related health care. In the earliest days of the pandemic, Black Americans faced structural barriers to testing and quality care for COVID-19. Drive-up testing launched in many areas of the country limited access to individuals with vehicles. Many testing locations were not accessible to Black Americans without transportation, those living in rural communities, and people living with disabilities.34-38 Results from a 2020 national poll of Black Americans showed that most respondents anticipated experiencing discrimination and receiving disparate treatment when seeking care for COVID-19.39 Sixty-three percent of respondents agreed that Black American patients with COVID-19 would be less likely to have everything done to save their lives.39 Evidence subsequently demonstrated Black Americans seeking care at emergency departments were less likely to be given a COVID-19 test when indicated, less likely to be admitted when diagnosed, and less likely to receive emerging therapies.39

The COVID-19 pandemic took advantage of these cross-sectoral inequities to hamper health-promoting resilience.

Early vaccination eligibility guidelines threatened equitable access for Black Americans. There was a consistent 10-percentage point gap between Black and White adults in the initial months following the availability of vaccines.40 This was largely fueled by deep seated historical and contemporary mistrust of American government, political, social and medical institutions as well as disjointed policy guidance and misinformation. In addition, differences in approaches to vaccine rollout across states added yet another layer of access challenges for Black Americans. Vaccination rates from May 2021, 5 months into vaccine rollout, showed that Black Americans were less likely to be vaccinated compared to their White counterparts.41

The harsh realities of COVID-19 were superimposed upon generational systems of disadvantage. The deep-seated history of marginalization and discrimination against Black Americans underlie inequities in education, employment, housing, nutrition, credit markets, health care, and the carceral system. The COVID-19 pandemic took advantage of these cross-sectoral inequities to hamper healthpromoting resilience in the face of the global pandemic.

Organizational trustworthiness served to build confidence across the communities served.

NOW

The primary series fully vaccinated rate for adult Black Americans is on par with other racial/ethnic groups. Since September 2021, the gap in adult vaccination rates has narrowed. The gap for Black Americans 65 and older closed prior to September 2021. Based upon the most recent available data, the rate of vaccination against COVID-19 among adult Black Americans is 80 percent.41

Concerted efforts and targeted partnerships, often lead by Black Americans, resulted in more equitable access to COVID-19 resources. Cross-sector coordination, across levels of government, with public-private partnerships, community and faith-based organizations at the fore were critical to advocacy efforts and tangible support for Black Americans. Partnerships were crucial to gains made in accessible testing and vaccination locations, ensuring access to personal protective equipment, therapies, and adequate representation in COVID-19 clinical trials. Organizational trustworthiness served to build confidence across the communities served, which resulted in thousands more people of color making the decision to become vaccinated.

There is already evidence of disparities in diagnosis and access to treatment, which suggests increased likelihood of future disparities.

Educational and economic interventions strive to limit longer-term harm from COVID-19 for Black Americans. Several interventions target educational and economic recovery to counter the unequal pandemic toll on Black and other communities of color. Resources directed to schools to support safe reopening narrowed racial gaps in opportunities for in-person instruction.42,43 This also slowed the widening achievement gap observed for Black American children attributable to prolonged virtual learning. The temporary expansion of the Child Tax Credit is an economic intervention estimated to reduce poverty among Black children by 50%.44,45 This also supported guardian families of Black children, who were 2.4 times as likely as White children to be orphaned because of the pandemic.13
Inequities in Long COVID are emerging for Black Americans. COVID-19 infection has been linked to long-term symptoms that can emerge weeks to months after primary infection.46 There is anticipation of racial and ethnic disparities in Long COVID given the higher burden of COVID-19 infection among Black Americans. There is already evidence of disparities in diagnosis and access to treatment, which suggests increased likelihood of future disparities.46,47
Black Americans recently experienced the highest rate of hospitalization for any racial/ethnic group since the inception of the pandemic. (Figure 1) During the week ending on January 8, 2022, the hospitalization rate for Black Americans was 64 per 100,000.48 This was the highest weekly rate of any race and ethnicity at any point during the pandemic. This is more than double the highest weekly rate (26 per 100,000) seen in January 2021.48 This occurred during a time when major media messages touted that the COVID-19 variant was significantly less severe than previous versions. Contributing factors are likely multifactorial. Lagging rates of booster uptake and pediatric/adolescent vaccination present opportunity for additional public health interventions.49 The rate of hospitalization for Black Americans has dramatically declined in the two months following the January 8, 2022 peak.41
Black Americans are facing significant behavioral health challenges as a result of COVID-19. Greater experiences of pandemic stressors such as job loss and economic insecurity are correlated with sharp increases in anxiety, depression, and substance use.14,15,50 Evidence shows Black Americans are more likely to report experiencing anxiety and/or depression because of the pandemic compared to White Americans.14 Substance use disorders have also increased due to pandemic stressors, especially among those with existing disorders. One study identified that opioid overdoses increased among Black Americans by as much as 52.1 percent while it decreased 24 percent among White Americans.51 Other studies are consistent in demonstrating higher increases among Black Americans.50 Stressors responsible for these behavioral health challenges are likely to have continued influence.

Figure 1. Laboratory-Confirmed COVID-19 Associated Hospitalizations

If we are going to effectively address health equity among Black Americans, having access to the most precise data is vital.

FOCUS AREAS

The following section presents select areas for targeted solutions to drive equity in health outcomes and health status for Black Americans. Several opportunities remain to support Black Americans’ recovery from the disproportionate impact of the pandemic. The availability of data that accurately capture experiences that are important for equity monitoring and accountability is key to acting on the points outlined.4 This includes access to reliable data on race, ethnicity, and other intersecting identities.

Data collection Persistent inadequacies in the systematic collection of data on race and ethnicity suggests that the true burden among Black Americans is underestimated. Though data collection has improved over the course of the pandemic, significant disparities remain across the nation in the data systems that capture and report data by race. As of March 14, 2022, an average of 34.4% of COVID cases in United States were reported with an unknown race or ethnicity (See Figure 2). The ability to collect, disaggregate, analyze and disseminate data by race and ethnicity are essential to accurately measure the disparities present. If we are going to effectively address health equity among Black Americans, having access to the most precise data is vital.

Boosters Forty-six percent of booster-eligible Black adults had received a booster dose compared to 61 percent and 56 percent among Asian and White adults respectively as of January 2022, with the lowest booster rates present among Black adults between the ages of 18–49.41 Hispanic adults are the only group with a lower rate at 42 percent. Increasing booster uptake, particularly among older and medically-vulnerable Black Americans, must be a top priority.41
Children and Adolescents Twenty-seven percent of children 5–11 years old and 58 percent of adolescents 12–17 years old are fully vaccinated across all groups.52 The limited race and ethnicity data available for vaccination among 5–17 year-olds suggest Black children have the lowest vaccination rates.52 Efforts should continue to focus on cross-sector partnerships, with local communitybased organizations and those that predominantly serve children as key to increasing vaccination.

Testing The most recent surges underscored the importance of continued testing regardless of vaccination status. Equitable and affordable access to all testing modalities, including at-home testing, should continue to be prioritized.

Therapies Black Americans have been less likely to benefit from novel therapies and treatments.53 As we move forward, efforts are needed to ensure equitable and affordable access to all therapies. It is essential to require representation in the clinical trials that give rise to the scientific discoveries that should benefit all.

Long COVID Solutions are needed to increase equitable and affordable access to Long COVID care and supportive resources. Efforts are also needed to ensure inclusion of Black Americans in Long COVID trials, treatment programs, and registries given the systematic biases that led to increased burden of infection and decreased access to the testing that can often be required as proof of prior primary infection.

Education Studies consistently project learning loss will be most significant among low-income, Black students who were less likely to have had access to high-quality remote learning, a conducive learning environment, highspeed internet, and parental academic supervision.16,54,55 Resources to support districts that predominantly serve children of color and students with the greatest learning gaps should continue to be prioritized. In addition, innovative educational solutions are needed to ensure that Black children graduate with the necessary skillset as the pandemic effect on educational loss will continue to influence achievement for years to come.

Community investment The historic and contemporary disinvestment in Black communities contributed to high rates of poverty and poor health, both factors that increase vulnerability to the adverse effects of COVID-19. Increased focus on partnerships and resilience will inspire community-driven solutions. Economic and health investments are key to addressing underlying social and structural contributing factors.

Economic opportunity Black Americans were more likely to report experiencing pandemic-related economic challenges.2,10 Efforts will be needed to support workforce reentry and increase the availability of jobs with family-sustaining wages.

Healthcare workforce The healthcare workforce, inclusive of communitybased workers, should reflect the communities served. Investing in healthcare workforce diversity and providing educational opportunities across all health careers is paramount.

Pandemic readiness The pandemic revealed vulnerabilities of the existing public health infrastructure and the strained capacity to execute pandemic response activities. Continuing support for underfunded agencies is needed to sustain workforce and other capacity promoting changes implemented for pandemic response.

Figure 2. Share of Total COVID-19 Cases with Unknown Race or Ethnicity by State

Preliminary weekly rates as of March 5, 2022

Vigilance and intentionality remain critical to ensure an equitable recovery for Black Americans.

ACTION STEPS

Despite increasing optimism, the pandemic is not yet over. Vigilance and intentionality remain critical to ensure an equitable recovery for Black Americans and the establishment of an adequate, integrated, and sustainable community and public health infrastructure ready to respond to future public health crises. 

The specific recommendations below reflect the collective views of countless leaders advocating for COVID-19 equity, convened through the Black Coalition Against COVID (BCAC).

We recommend that all sectors of American society be held accountable for doing all in their power to engage Black people with fairness and respect. Given historical and contemporary racist practices in American medicine, this plea for humanism is especially urgent for all industries that provide health and medical care. There is a climate of distrust of American institutions in general, and of the health enterprise in particular. This distrust is pervasive and impacts the ability of civic and medical institutions to respond to community needs.

We recommend that federal and local governments establish funding mechanisms that will facilitate the sustainable community infrastructures necessary to address the complex array of health and medically relevant social challenges. Specifically, we must confront the reality that Black medical, faith, and community-based organizations and local coalitions have traditionally been hampered by inadequate, episodic, and unstable funding. We further recommend that funding be made immediately available for organizing, scaling, and sustaining networks of faith-based organizations and other nonprofit organizations that employ effective navigators and community health workers to address the social determinants of health and other contributors to health disparities.

We recommend that local governments adopt a “Health Justice in All Policies” approach to governance, and that collaborative efforts be instituted to address key determinants—including education, housing, childcare, food insecurity, carceral system involvement, and transportation—across society, with a particular focus on supporting the needs of the most marginalized people to improve health equity.

We recommend that local departments of public health provide the race and other demographic data and assessments necessary to identify high target priorities. They should also convene, with local Black community leaders, planning forums necessary to recruit and coordinate public, private, and philanthropic assets from across the jurisdiction.

We recommend that a more intensive research education and recruitment effort be conducted and funded in concert with Black scientists and academic institutions. The pandemic highlighted the importance of Black participation in clinical trials to realize necessary confidence in the safety and efficacy of new products.

We recommend that Black fraternal, social, faith-based, and civic philanthropic organizations be funded to continue to advocate for up-to-date COVID-19 booster vaccination of the Black American community nationwide, with a special emphasis on pediatric vaccination. We further recommend that until hospitalization rates in our communities signify that viral spread is not a significant threat, Black Americans should continue consistent utilization of all mitigation tools (i.e., hand hygiene, indoor masking, and physical distancing). This framework will be essential to fighting disparities in the months to come.

We recommend that a national campaign be launched, with the engagement of social media companies, to provide mechanisms and opportunities to bring trusted and expert voices to counteract COVID-19 misinformation targeted at Black Americans.

We recommend that science and math teachers in Black and under-resourced communities be funded and supported to prepare students to participate as responsible adults in the modern healthcare system, which is grounded in genetics and other highly innovative science-based principles and discovery.

We recommend that an urgent and well-funded campaign with federal and other resources be launched that builds upon proven models, especially in K-12 schools, to enhance the supply of the Black health professional workforce. We also recommend that federal dollars support medical schools and hospital systems to achieve levels of diversity that reflect the communities they serve.

We recommend the immediate expansion of the Black nursing workforce through enhanced recruitment in junior and senior high schools, fair admission policies into schools of nursing, and tuition support, especially for students interested in public health nursing, school nursing, and mental health services. We further recommend that nurses be supported in fully applying the expertise afforded to them through their licenses and professional training.

We recommend that there be parity in compensation for telehealth services and that broadband capability and community training be augmented as necessary ingredients for success in health services availability and access.

We recommend the heightening of access to necessary health care and social resources to address current and future chronic health, psychological, and social needs.

The time is now to recognize health equity is the work of everyone and for each one of us to do our part on the journey.

CONCLUSION

This report is a call to action to address the continued COVID-19 burden and highlight the need for continued vigilance to ensure equity for Black Americans. Our reflection over the course of the COVID-19 pandemic revealed a myriad of challenges and disparities across several indicators of well-being. This was unsurprising since Black Americans experienced disproportionate disease burden prior to the pandemic, a result of longstanding social and structural inequities. The trajectory of the COVID-19 burden among Black Americans showed overall declines; however, Black Americans continued to experience disparate burden from infection, hospitalization, death, and incidence of long-COVID compared to other racial and ethnic groups. Other pandemicrelated effects such as food and economic insecurity, loss of life, educational achievement gaps, behavioral health disorders, and increased need for mental health care services disproportionately affected Black Americans.

Policy and practice interventions have emerged over the course of the pandemic to alleviate suffering experienced by Black and other communities of color. This report highlights ten focus areas and twelve action steps to support equitable COVID-19 care and sustain recovery efforts for Black communities.

The work ahead will be more challenging than ever and requires well designed, adequately funded, and strategically coordinated efforts at the national, regional, state, and local levels. The time is now to recognize health equity is the work of everyone and for each one of us to do our part on the journey.

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