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# ‘Essential and undervalued: health disparities of African American women in the COVID-19 era’

Accepted 22 Oct 2020
Published online: 15 Nov 2020

ABSTRACT

## Objectives

Transforming the landscape of American healthcare, COVID-19 has had unprecedented effects on the African American community. African Americans are more likely to contract COVID-19, develop complications and die from the virus. Amid the growing research on COVID-19, this manuscript pays particular attention to African American women who are disproportionately represented as ‘essential’ or frontline workers, yet often lack job security and risk contagion. Faced with limited testing centers, they are also at risk of having their symptoms minimized or dismissed by medical practitioners even when they show visible symptoms of COVID-19.

## Methods

Using the theoretical framework of intersectionality developed by scholars like Kimberlé Crenshaw and Patricia Hill Collins, this manuscript examines the impact of COVID-19 on African American women. It emphasizes that African American women are vulnerable to COVID-19 due to the twin legacies of racism and sexism. Intersectionality theory espouses that racism and sexism often combine with social determinants of health such as economic stability and socio-environmental factors to shape health outcomes. Within the context of COVID-19, this work underscores that African American women are susceptible to the virus due to their higher likelihood of co-morbidities like obesity, diabetes and high blood pressure. They are also likely to face eviction and homelessness if they are laid off or furloughed as a result of the pandemic.

## Conclusion

This manuscript asserts that decades of racism and discrimination have isolated communities of color and made them particularly vulnerable to the COVID-19 virus. As many African American women deal with unemployment or continue to work as ‘essential workers’, the intersectionality framework sheds light on the continued legacies of racism and sexism. It asserts that targeted policy interventions are needed to mitigate the effects of COVID-19 and lessen the devastating impact(s) it has had on African American communities.

## Introduction

Disease outbreaks often expose and exacerbate long standing inequities which cut across gender, race and social class. As more data pours in regarding SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) also known as COVID-19, stark realties begin to emerge. For instance, Williams (2020) observes that the pandemic has disproportionately affected the African American community with complications and deaths from the virus almost 3 times greater than that of whites. In Maryland, African Americans make up 31% of the population but account for 52% of the deaths from COVID-19. In Michigan, African Americans are 14% of the population but 40% of the COVID-19 deaths. In Louisiana they account for 70.5% of deaths despite comprising 32% of the population. Ratios are even higher in states such as Wisconsin and Kansas where African American deaths are more than 4 times as high as their share of the population (Centers for Disease Control and Prevention 2020; Ford, Reber, and Reeves 2020). Nationally, African Americans have some of the largest COVID-19 infection rates. They are also more likely to be hospitalized and suffer from complications than other racial groups (Goody and Wood 2020). Given the disproportionate representation of African American workers in frontline jobs which put them at greater risk of exposure to COVID-19, it is not unsurprising that a greater %age of mortalities are found among African Americans and their families (Cohn, Ruiz, and Wood 2020; Mauger and MacDonald 2020). Yet despite this, research has not studied the complex intersectionality of race and gender in relation to the COVID-19 virus. Laurencin and McClinton (2020) state that the pandemic has a predominantly ‘non-white’ female face where African American women in particular are situated within overlapping systems of oppression which facilitate losses of life and income during the pandemic. Kalev (2020) posits that women and minorities are among the hardest hit by the virus due to their overrepresentation within jobs such as retail, hospitality and manufacturing. Yet despite the dominance of women of color in ‘essential’ frontline work, many lack job security and many have been furloughed or laid off due to COVID-19 (Eligon and Burch 2020; Williams 2020). For African American women, the pandemic lays bare underlying gender and racial inequalities in a number of arenas. First, when African American women experience symptoms related to COVID-19 and seek medical attention, they are often denied life-saving care. In the last few months, there have been several cases such as that of Rana Zoe Mungin a 30 year old Brooklyn school teacher who died in April 2020 after being denied COVID-19 testing twice. Mungin was refused testing despite having standard COVID-19 symptoms, including fever and shortness of breath (Collman 2020). In Michigan, another African American woman – Deborah Gatewood a 63 year old healthcare worker died from COVID-19 complications after being denied testing 4 times (Eligon and Burch 2020). Likewise, in Georgia, Rushia Johnson a 65 year old retired music teacher died from COVID-19 after being sent home from the hospital (Lindsey 2020). Laurencin and McClinton (2020) state that African American women routinely face the reality of not being believed by medical practitioners in addition to the structural and pervasive discrimination that their communities face in the healthcare system.

As such, many lawmakers are concerned that COVID-19 cases are underreported or untreated in African American communities. Since the pain and discomfort of African Americans is often trivialized or viewed as less severe than described, Lindsey (2020) states that this has often resulted in patients being systematically under-treated for pain. When compounded with gendered racism and social class, lower income African American women face substantial barriers to receiving care especially when shortages of ventilators or hospital beds occur. For many women, the combined trio of exposure risk, lack of access to testing and pre-existing conditions such as high blood pressure, diabetes, and cardiovascular disease make COVID-19 particularly life-threatening. Williams (2020) adds that the clustering of African American populations within residentially segregated areas has led many to access clinics and hospitals which are under-resourced and understaffed. It has also meant that many are limited to facilities which are short on supplies including COVID-19 testing kits. Adding to the deleterious effects of residential segregation, Sutton et al. (2020) describe the rise in the number of pregnant women testing positive for COVID-19. Given pre-pandemic maternal morbidity rates, many African American mothers face a heightened risk of dying during pregnancy (Amankwaa et al. 2018). Stress from gendered racism and discrimination during pregnancy will more than likely escalate during the pandemic. Low income mothers in high poverty areas face glaring health disparities and structural racism. As the pandemic accelerates, these risks become even greater.

Paying attention to the broader medical landscape, Mehta, Salmon, and Ibrahim (2020) also draw attention to the many African American women living with lupus. Lupus is an autoimmune disorder and African American women develop it at an earlier age than their white counterparts. However, in the COVID-19 pandemic, many women have been unable to access drugs such as Plaquenil (hydroxychloroquine) to treat some of the effects of the disease. Pharmacies are running out of this medication and African American women are increasingly harmed by this inaccessibility (Mehta, Salmon, and Ibrahim 2020). As research begins to emerge on the COVID-19 pandemic, it is important to understand the unique experiences of African American women. Paying attention to the intersections of gender, race and social class this manuscript sheds light on some of the structural inequalities which existed before the pandemic and how these inequalities have magnified in the COVID-19 era.

## Social determinants of health and structural inequalities

For African Americans, inequality manifests in different forms with race-related health disparities being some of the starkest and most resistant to change. Being African American and female amplifies these disparities –a reality which COVID-19 has brought into clearer focus. An examination of the social determinants of health (conditions which people have that affects health) reveals that African American women are more likely to experience maternal mortality or pregnancy related mortality. Scott, Britton, and McLemore (2019) reveal that African American women are disadvantaged across every health indicator. For instance, they are more likely to die from complications related to venous thrombosis, preeclampsia, cardiomyopathy and hemorrhage than white women (Amankwaa et al. 2018; Tangel et al. 2019). As a whole, health disparities among African American women become noticeable during adolescence and continue through the life course. Uzogara (2019) states that while African Americans tend to experience poorer health conditions than their white counterparts when indicators such as socioeconomic status are considered, the race gap is even wider among women. There are five recognized social determinants of health: (1) social environment; (2) socioeconomic stability; (3) biology and genetics; (4) nutrition and (5) physical/geographic location (Blas et al. 2008; Thornton et al. 2016). For African American women, these social determinants are closely related to long standing institutional systemic racism and trauma. In a time of COVID-19, these social determinants often translate into a greater exposure to the virus due to the overrepresentation of African American women in ‘essential’ frontline jobs which cannot be done remotely at home (Laurencin and McClinton 2020; Williams 2020).

The intersectionality of race, socioeconomic status and gender coupled with poor health status due to comorbidities has led to increased fatalities during the COVID-19 pandemic. Williams, Priest, and Anderson (2016) state that social environments play a large role in health outcomes as African American women are likely to live in neighborhoods characterized by poverty, high crime and a greater exposure to toxicants. Using the minority stress model which posits that marginalized groups experience greater incidents of stress (based on race, sexuality, gender, disability, etc.) the theory affirms that African American women deal with stressors influenced by racism and sexism. While research finds support for the uniqueness of stressors related to health outcomes among minority groups (Mays, Cochran, and Barnes 2007; Bryant et al. 2010), others state that these effects are not fleeting, but have long-term consequences (Walker, Williams, and Egede 2016; Brewer et al. 2017). As a result of institutional and interpersonal discrimination, African American women experience greater vulnerabilities to disease and risk factors to health. Hardeman et al. (2018) state that racism itself is a public health issue. Those who experience racism are likely to suffer from depression and are more likely to rate their physical health as poor (Williams, Priest, and Anderson 2016). This is particularly problematic for African American women who experience both racism and sexism. Hardeman et al. (2018) state that this is evident when African American communities become increasingly isolated by poverty. For those seeking care in medical facilities, Bryant et al. (2010) describe the impact of maternal stressors on the fetuses of unborn children. For many African American mothers, intrauterine stress has played a significant role in conversations about maternal mortality. Likewise, these stressors are suggested to increase the risk of the child developing cardiovascular, metabolic or neuropsychiatric disorders later in life (Brewer et al. 2017; Tangel et al. 2019).

‘Funding gets cut, we don’t have the things we need, but [administrators] know we’ll still come in and work to get our patients what they need … It makes me feel exploited. It makes me feel like Mammy, honestly. Because we empathize – no one has more empathy than black women. But that’s not rewarded in the structure of how medicine works. So we just keep on working and working with less and less.’

Jenna’s comments draw attention to the taxing climate healthcare providers have to work through – a crisis exacerbated with the COVID-19 pandemic. Highlighting the impacts of social determinants of health, Figure 1 illustrates intersectionalities with racism and sexism. The figure also illustrates how these intersectionalities affect COVID-19 exposure.

Figure 1. Conceptual Model of Social Determinants of Health and COVID-19.

## Theoretical framework: intersectionality, structural inequality and COVID-19

Whether it pertains to the social determinants of health or discrimination based on social inequality and disadvantage, race and gender converge in the lives of African American women to shape their wellbeing. As Figure 1 illustrates, racism and sexism simultaneously diminish the likelihood of African American women receiving effective medical care. This also extends into the diminished care they receive when they show symptoms of COVID-19 (Lindsey 2020). Access to healthcare is critical for African American women since it contributes to longer, healthier lives. Despite this, African American women are vulnerable to the intersecting effects of racism and sexism which makes their lives both ‘raced’ and ‘gendered’ (Lewis et al. 2017; Uzogara 2019). Within the framework of intersectionality, Crenshaw (1991) posits that multiple social classifications (i.e. race and gender) reflect interlocking systems of privilege and oppression. Rooted in black feminist scholarship, legal scholar Kimberlié Crenshaw coined the term intersectionality to describe that one identity alone i.e. gender cannot explain disparate outcomes on different identities (Crenshaw 1991; Collins 2002, 2019). To illustrate, Collins and Bilge (2016, 8) assert that:

‘Using intersectionality as an analytic lens highlights the multiple natures of individual identities and how varying combinations of class, gender, race, sexuality, and citizenship categories differentially position every individual.’

The COVID-19 pandemic has serious implications for all racial minorities in the United States. Yet crises are not experienced equally. Above all, the COVID-19 pandemic has revealed how inequitable policies and structural deficiencies are worsening existing disparities. As a result of the intersection of several disadvantaged statuses (i.e. African American, female), the intersectionality framework draws attention to the many ways discrimination results in worse health outcomes for those who have less power, less control over their environment, less control over the types of jobs they hold (i.e. as essential workers), and whether or not they are believed when they are treated by medical practitioners. Kaba (2008) describes African American women as a ‘model minority’ in that they have higher rates of college enrollment than African American males, lower suicide rates, lower rates of cigarette smoking and alcohol use than African American and white males. Still, Hardeman et al. (2018) state that despite being employed at higher rates than women of other races, African American women have a historical disadvantage of economic marginalization which persists over the life course. This economic marginalization often culminates in lower wages and retirement incomes than African American men and white women. Even for women with bachelor’s degrees, Belgrave and Abrams (2016) state that racial differences in net worth still persist. Data on median household net worth illustrates that in 2016, the net worth of a typical white family was nearly 10 times greater than that of an African American family. The Brookings Institute estimates this disparity in net worth to be an estimated $171,000 for a white family and$17,150 for an African American family (McIntosh et al. 2020). Racial gaps in wealth reveal the effects of accumulated inequality since wealth cushions families against emergencies and provides opportunities to climb the economic ladder.

Adding to disparities in net worth, Belgrave and Abrams (2016) state that another reason for economic inequality comes from the fact that African American women are less likely to marry than their white counterparts. Marriage is a valued status in American society because of the economic security and emotional support it provides. However, statistics on both marriage and childbirth reveal that African American women are less likely to marry and to remain married than white women. Raley, Sweeney, and Wondra (2015) reveal that about 60% of white women who have ever married are still married in their early 40s, compared to 55% of Latina women but only 45% of African American women. On childbirth, Wildsmith, Manlove, and Cook (2018) find that between 1990 and 2016 the% of births that occurred outside of marriage increased for African American women from 63 to 69% (a 9% increase). In The Truly Disadvantaged, Wilson (1987) hypothesized that low marriage rates in the 1970s and 1980s among African American women were due to a deficit of marriageable men. Coupled with the enormous decline in unskilled manufacturing jobs, the black–white unemployment gap rapidly widened. They state that the unemployment rate for African American men aged 25–54 was almost two times higher than it was for white men in the same age range. Adding to this, African American men were also much likely to be incarcerated than white men. In particular, African American men’s rates of incarceration increased significantly in the 1980s and continued through the 1990s, 2000s and the 2010s. Western and Wildeman (2009) and Schnittker, Massoglia, and Uggen (2011) acknowledge that the vast rate of African American male incarceration points to systemic discrimination and racism in arrests and sentencing which remain relevant today.

Given the lower rates of marriage and the higher rates of children born outside of marriage, a large percentage of African American women head single-parent households where they are primary caregivers. Parenthood can be especially challenging for African American mothers since they are likely to be parenting under financially stressful conditions (Bryant et al. 2010; Belgrave and Abrams 2016). As such, many African American mothers are ‘essential’ frontline workers, who cannot afford to take time off from work leaving them vulnerable to COVID-19 exposure. African American women in frontline jobs tend to lack job security and yet have to keep working during the pandemic. Despite this, Bowleg (2020) found that African American women are twice as likely to say that they had been laid off, furloughed or had their hours reduced due to the COVID-19 pandemic. More than 58% of African American women reported these hardships compared to 31% of white men. So for those who are employed, it is a struggle to keep working, risk exposure and pay for basic needs such as groceries, rent and transportation for all household members (Goody and Wood 2020). As an example, Keith and Brown (2010, 303) illustrate that African American women often continue to work despite illness or disability. As sole breadwinners, they take on enormous responsibilities in running a household. From a focus group conducted, one participant who had been recently diagnosed with breast cancer said:

‘Could not even think about it (breast cancer) because of taking care of my mother ... there was just too much happening. It was a shock when I found out. ... I was in denial. I can’t believe this is happening. I’m taking care of too many people, you know ... the grandkids... my mother, and I don’t really even have the time’

In the face of COVID-19, the disproportionate amount of deaths of African American workers has come alongside the fact that many cannot work from home. The amount of low-income minority workers in COVID-19 hotspots has left many at risk of contagion, hospitalization or death. From an intersectional framework, social issues rarely occur in a vacuum. The pandemic has exposed the underlying gendered and racial inequalities within society. The disparate racial impact is deeply rooted in long term racial and gendered injustices. Adding to this, residential and physical environments have enormous impacts on the overall wellbeing of African American women. From a combination of structural and residential segregation, race, gender as well as social class tend to circumscribe the likelihood of living in deprived substandard urban and rural neighborhoods (Wilson 1987; Crenshaw 1991; Collins and Bilge 2016). Living in substandard housing leads to a greater exposure to asbestos, lead poisoning and an exposure to polluted air inside and outside the home (Conley 2010; Keith and Brown 2010). As such, low income residents are likely to develop asbestos-related diseases or mesothelioma. When mesothelioma is diagnosed, low income patients are often in the later stages when prognosis is poor. Hardeman et al. (2018) state that in addition to environmental factors like pollution, it is exceedingly difficult for African American women living in low income neighborhoods to find affordable healthy food. They are more likely to live in food deserts which are bursting with junk food options but lack healthy food choices. For instance, Mobley et al. (2006) and Dietz (2019) find positive correlations between residents of low income neighborhoods and high rates of obesity. Belgrave and Abrams (2016) also find African American women at risk for cardiovascular disease, diabetes and hypertension at younger ages than their white counterparts. They state that many women live in neighborhoods which are unsafe, with no parks, gyms or fresh food outlets. Convenience stores sell processed junk foods which are cheaper and easier to find than fresh fruit, dairy products and vegetables.

All things considered, these overarching social determinants of health add to the intersectionality framework and give credence to the myriad of challenges which African American women face. With higher incidences of pre-existing conditions like heart disease, hypertension and diabetes, the COVID-19 pandemic is particularly challenging (Williams 2020; Wingfield 2020). Likewise, African American women also report higher incidences of HIV/AIDS and lupus than white women (Harris 2018; Mehta, Salmon, and Ibrahim 2020). As such, race and gender present a complex and interconnected understanding of the structural deficiencies in healthcare. They also present an understanding of how the virus has affected African American women. It also means that they are more likely to report economic hardships if they are laid off or furloughed as a result of the pandemic. Conversely, if they are working they are overrepresented as ‘essential’ frontline workers who cannot work from home and are exposed to the virus. Without job security or safety nets, many risk contagion and also risk infecting loved ones at home of whom they are the primary caregivers.

## Conclusion and policy implications

The health issues faced by African American women are immense and the COVID-19 pandemic has compounded existing inequalities and vulnerabilities. Just like other pressing social justice issues, combating COVID-19 requires an intersectional approach. The persistence of health disparities for African American women means that health equity is vital. An immediate answer would be the rapid expansion of Medicaid and Medicare, yet access to healthcare is only one small piece of a complex dynamic that compromises the health of African American women. As interlocking systems, race, gender and social class affect morbidity and mortality. Unlike white women, African American women are likely to be penalized by their race as well as their gender and this ultimately affects their health. Intersectionality elucidates interlocking social positions and underscores the need for targeted interventions. Using this framework means understanding that African American women are particularly vulnerable to COVID-19 since many are dealing with co-morbidities such as obesity, diabetes and hypertension in addition to life’s usual stressors. For instance, Cohen and Noble (2020) state that African American women are about 44% of those who are evicted from their homes in urban areas. As such, they disproportionately experience depression and homelessness. With the COVID-19 outbreak, many African American women work on the frontlines as grocery cashiers, delivery workers, mail carriers and bus drivers (Bowleg 2020; Lindsey 2020). Yet many lack job security and cannot afford to take time off. For those laid off or furloughed, the situation is even more dire.

Addressing the health disparities of African American women is a complex undertaking which must consider how the social determinants of health interact with macro and micro level factors. Some of these include access to quality affordable care, education and income. Good health often means that working mothers have to worry less about monthly bills, costs of childcare and dealing with family emergencies. Confronting the myriad of public health issues will also mean eliminating disparities and discrimination when it comes to treating patients of color. This means fostering trust in communities that have been historically underserved or under-treated for ailments. It also means that repairing health disparities will require deep structural – not superficial changes. COVID-19 has shed light on the many health inequities faced by African Americans. It has also shed light on the fact that African American women are doubly disadvantaged due to their experiences with racism and sexism. As such, if communities experience difficulties accessing care, resources should be allocated to ensure that healthcare facilities are located within their neighborhoods. Also, facilities must have personnel who are well trained and not understaffed or overworked. Anti-discrimination policies are needed to eradicate decades of unjust policies which have marginalized communities of color. Diversity training initiatives may not fully address structural micro- aggressions. Oftentimes, white healthcare providers may not recognize the micro-aggressions they present to female African American patients. Still, hospitals and clinics can ensure that healthcare providers reflect the interests and experiences of the communities which they serve.

Undoubtedly public health organizations and medical practitioners need to be prepared for challenging times ahead. Still, the application of an intersectionality-informed stance can facilitate the development of targeted intervention strategies. An understanding of the social determinants of health means that medical practitioners will have to share the best policies to ameliorate the harsh effects of this public health emergency. Amid the rhetoric of ‘flattening the curve,’ bold interventions must be taken in order to protect essential workers and those most vulnerable to COVID-19 exposure. For African American women, targeted intervention means an elimination of long-term barriers to health screenings and childcare services. Likewise, policies are also needed to address food deserts and the overconcentration of fast food stores in communities of color. The effects of COVID-19 have exposed harsher truths about health inequities in American healthcare. These truths reveal that historical practices of racial exclusion and discrimination have contributed to race-based disparities in health. So, addressing the spread of COVID-19 must include a closer examination of the legacies of discrimination which have shaped African American communities. It is not an easy feat, but by bringing pragmatic interventions to the fore, future research and policy can reform entrenched structural disparities in healthcare.

## Disclosure statement

No potential conflict of interest was reported by the author(s).

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