By Charles Modlin, MD, MBA
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Early in the COVID-19 crisis, patients in my clinics frequently joked that African Americans and other minorities were immune to the coronavirus. Initial reports of those infected with SARS-CoV-2 didn’t reveal patient demographics, leading some to mistake no news for good news. Once race and ethnicity data began to be evaluated, however, we saw the stark truth.
As of early May, African Americans make up nearly 28% of COVID-19 cases in the U.S. They also account for more than 18% of COVID-19 deaths. These are startling statistics for a demographic group that represents only about 13% of the U.S. population.
In some areas of the country, the disparity has been even more striking. In April, reports from Chicago stated that African Americans made up 72% of people dying from COVID-19 although they composed only a third of the population there. Similar stories came out of Louisiana, Michigan and New York City.
Why are blacks disproportionately affected by the pandemic? The answer is multifaceted. A thorough response highlights the economic and social disparities that have affected the black community for decades. In my view, African Americans are succumbing to COVID-19 at higher rates than other Americans because of a toxic combination of:
- Predisposition to chronic disease. African Americans have higher rates of diabetes, obesity, hypertension, heart disease, asthma and other medical conditions. Many of these conditions have been linked with more severe COVID-19 infections and poorer outcomes because individuals with chronic disease states have compromised immune systems and are more susceptible to infections. Some of these diseases can be attributed at least partially to lifestyle and environmental factors, including African Americans’ higher rate of smoking and lower access to quality healthcare. But there may be genetic causes as well, such as an inherited predisposition to diabetes, hypertension, prostate cancer and other conditions.
- Greater exposure to viral infection. While U.S. residents have been instructed to use social distancing and other tactics to mitigate COVID-19 transmission, it’s easier said than done in some black communities. Many blacks live in apartments or housing complexes, where distancing from other residents is nearly impossible. Those who rely on public transportation have the same challenge. Many blacks have jobs that are not conducive to working from home. These factors make African Americans more susceptible to infection.
- Potential biological differences. More research is needed, but there has been some suggestion that African Americans may be more immunoreactive once infected with viruses or other pathogens. Perhaps this is due to compromised innate immunity in chronic disease — or perhaps there is another physiological reason, such as a greater inflammatory response to invading pathogens. Even though human bodies are mostly genetically similar, race-based medicine has begun to highlight some notable differences, such as in the metabolism of medications. African Americans require higher dosages of immunosuppressants after kidney transplant, for example. And, in many cases, African Americans are more responsive to and preferentially treated by certain classifications of antihypertensive medications than are whites.
- Lower health literacy. Understanding your risk factors and taking steps to manage them require a certain level of health literacy. The African American community tends to have a lower level of health literacy, which amplifies its susceptibility to disease, especially during a pandemic. The Minority Men’s Health Center within Cleveland Clinic’s Glickman Urological & Kidney Institute is focused on raising health literacy by providing health and wellness information, and educating the public about minority health concerns. It also provides facilitated access to culturally competent and sensitive care. Established in 2003, the Minority Men’s Health Center is open to all men regardless of race or ethnicity. Through clinical care, research, education, mentorship and outreach, the center is dedicated to addressing the vast array of unique health concerns and health disparities that disproportionately afflict African American males and men of color, contributing to their observed poorer health outcomes and lower life expectancies.
These factors are not new to COVID-19. During the H1N1 epidemic in 2009, we saw the same effect. About 30% of Americans with H1N1 flu were black, although they composed only 12% of the U.S. population. Eleven years ago, this outbreak did not receive as much media attention as today’s COVID-19 outbreak, partly because social media wasn’t as pervasive and government officials did not mandate shutdowns.
For the public, media and governmental officials, the current pandemic is highlighting the existence of health disparities and their impact on black populations, contributing to blacks’ shorter life expectancies (compared to whites) even when controlled for socioeconomic classifications.
Minority health disparities are a recurring problem and an everyday reality, pandemic or not.
A call for more culturally sensitive communication
Wash your hands, wear a mask, keep your distance and stay at home: These instructions can’t be stressed enough during the COVID-19 pandemic. They seem straightforward, but nuances in black communities, including a variety of social determinants of health, can complicate them.
I’ve heard some men say they are hesitant to wear a mask in public because, in the minds of many, face coverings worn by black men are associated with criminal behavior. Many black men have told me that they fear racial profiling, being arrested, and worse, being shot and killed if they enter business establishments wearing a face mask.
Additionally, some blacks disregard public health information due to generational distrust. Past racial discrimination, poor communication between government or healthcare entities and minorities, and lack of culturally sensitive healthcare may cause some African Americans to dismiss the importance of directives from public health and government officials related to mitigation of the COVID-19 virus or other public health matters.
This issue highlights the need for more culturally sensitive communication. One-size-fits-all messaging does not resonate with all minorities. Minority communities often respond better to messages communicated by a community member or a medical professional who looks like them (i.e., is of the same race or ethnicity). The medical community must understand this dynamic and the reasons for it in order to best disseminate important and lifesaving information to minority communities.
The role of healthcare professionals
Black medical professionals are vital to addressing the COVID-19 health disparity. While we must work harder to engage the African American community and communicate important information about COVID-19 risk factors and health-protective measures, it also is paramount to recruit respected community members (e.g., spiritual leaders, elected officials, other influencers) as spokespeople, partners and surrogates to help us more effectively disseminate such messaging.
Regardless of race, all clinicians can help protect the African American patient population by helping disseminate truths about COVID-19. Blacks are at higher risk of infection and death from the virus. The more regularly the black community hears that, the more seriously they will heed instructions to protect themselves.
Additionally, healthcare providers, healthcare institutions, health insurance providers, employers, and governmental and elected officials must work together to ensure that all individuals, including minority populations, are provided with more opportunities to access quality medical care for the prevention and management of chronic disease states. Minorities must have access to routine preventive healthcare, health screenings, immunizations and health education so that the incidence of health disparities and chronic disease states will be eliminated, thereby reducing heightened susceptibility to pandemics such as COVID-19.
About the author
Dr. Modlin is a urologist and kidney transplant surgeon at Cleveland Clinic, where he also serves as Executive Director of Minority Health. He is Founder and Director of Cleveland Clinic’s Minority Men’s Health Center and the Annual Minority Men’s Health Fair. He also is a member of Cleveland Clinic’s Board of Governors, a member of the Board of Directors & Trustees, and former President of Cleveland Clinic’s Medical Staff. Dr. Modlin has also been appointed by Ohio Governor Mike DeWine to serve on his newly created Minority Task Force which is tasked to examine the disproportionate number of African Americans afflicted with and dying from the coronavirus.