Why are Black people in the United States facing severe COVID-19 infections and death at higher rates than white Americans?

The short answer is Black Americans have a disproportionate number of pre-existing, chronic conditions and those conditions—like heart disease, diabetes, lung conditions, and hypertension—are the biggest risk factors for severe and deadly COVID-19 infections.

What underlies those increased rates of pre-existing conditions? And why are those conditions and COVID-19 cases heavily concentrated in lower-income communities of color?

There is no one answer. It's a lack of transportation, good-paying jobs, grocery stores, and healthcare facilities in those communities. It's a lifetime of inconsistent health insurance and the chronic stress of being Black in America. It's racism in the U.S. healthcare system and toxins in the air and soil. They're collectively known as social determinants of health.

Racist laws and policy over hundreds of years segregated U.S. cities and concentrated wealth in white families and communities. Practices like redlining, blockbusting, urban renewal, and racist loan lending were foundational to the physical construction of neighborhoods. It amass Black people into certain areas of town and syphoned resources from those communities, which in turn concentrated poverty. 

Related: “Seeing Red: Mapping 90 years of redlining in Memphis”

“What COVID has been able to highlight as part of a national conversation is the fact that the way that health care is designed in the United States doesn't work,” said Rachel Deborah Schmidt, quality and research coordinator for the Memphis-based nonprofit Church Health. 

Church Health provides low-cost healthcare for low- to moderate-income residents without insurance. 

“Healthcare delivery in the United States doesn't work for everybody. It's no surprise to me that the pandemic response wouldn't work for everyone either,” she continued. “It's certainly exacerbated inequities that were there already.”

Locally, the highest rates of chronic conditions are found in North and South Memphis.

In this final installment of a three-part series, two medical experts who work with patients in North and South Memphis link COVID-19 with chronic poverty, a lack of stable insurance, and neighborhoods that can no longer provide the basics of health—nutritious food, quality jobs and education, and safe and unbiased medical care. 

Parts one and two of this series connected COVID-19 and pre-existing conditions with the toxic outdoor and in-home environments that pervade low-income Black communities.

“You can't talk about health without talking about the environments that people live in and the agency and options that people have in order to pursue better health and better care,” said Schmidt.

She said there are certainly individual factors to health, like food choices and genetics, but trends across whole neighborhoods can’t be ignored.

“Health outcomes of a neighborhood can be lifted together based on the resources that are there,” said Schmidt.
Memphis Health Center is located at 360 East EH Crump Boulevard in South Memphis. (Memphis Health Center)

You Can't Always Get What You Need
Dr. Latonya Simpson is a physician and chief medical officer with Memphis Health Center, Inc. They have medical facilities in the Whitehaven area and Rossville, Tennessee, but their main site is located on E.H. Crump Boulevard in South Memphis.

Any patient can benefit from the two most basic steps towards better health—being more active and eating better—but many patients at the South Memphis location don't have ready access to nutritious foods and safe spaces to exercise.

“I tell my patients, you need to go walk,” said Simpson. “You got to be able to feel safe enough to go walk 30 minutes a day.”

Most of North and South Memphis are food deserts or areas with no nearby access to grocery stores selling fruits, vegetables, and lean meats. The stores are casualties of racist housing policies that began in the 1940s. As wealthier residents, most white but not all, moved out of the center city, businesses including grocery stores followed them.

Related: "Video series explores worldwide divides, spotlights Memphis for unequal food access."

Now, if residents want to stop by the store, they have to leave their communities. From South Memphis, going a few miles by bus to a grocery store and back can take hours, and a person can only purchase what they can carry home.

If utility shut offs are also a concern, less nutritious but shelf-stable items are safer.

The Dangers of Getting Tested
Rossville is a rural town in Fayette County about 35 minutes from South Memphis. Most of Simpsons’ patients there are white, wealthier, and better insured than those in South Memphis. When it comes to COVID-19 testing, Simpson said they’re far more likely to take a test.

“When you have some folks that are living paycheck to paycheck, and you have this pandemic, it may keep some folks from actually getting a test,” Simpson said.

For lower-income Memphians, a positive test and a two-week quarantine could mean job loss and financial ruin. From a financial standpoint, the unknown is safer. From a community health perspective, Simpson said it makes the virus far harder to contain.

“They don't have those same financial strains that you might see here on Crump,” she said of her Rossville patients. “They will more likely be tested because regardless of the test results, they're going to be okay. [They] can take off and recuperate.”

She said some people may also be distrustful of COVID-19 testing. Healthcare in the United States offers plenty of examples of racial bias, discrimination, eugenics, exploitation, and secret experimentation. There is widespread distrust among Black Americans of medical professionals and procedures.

Simpson and Schmidt both said it’s important that trusted, existing clinics and providers in majority-Black communities, like Memphis Health Center and Christ Community Health Services, be a part of testing and education outreach. 

Healthcare Matters
Inconsistent and low-quality healthcare over an individual's lifetime is a contributing factor to chronic conditions. Chronic conditions take years worth of steady care for proper preventative measures and symptom management can progress faster and with more severity when untreated.

In the U.S. healthcare system, quality and consistency of coverage are largely dependent on private coverage through an employer. Lower-income people are disproporationately represented among those who work multiple part-time jobs, shift workers, and frontline workers. Those jobs are less like to come with health benefits and higher risk of contracting the . Meanwhile, subsidized government healthcare can be complicated and inadequate with strict requirements for qualifications.

Healthcare facilities have dwindled alongside grocery stores. Without personal transportation, regular doctors appointments can be difficult. 

“I think the lack of a health facilities in our neighborhood would affect the neighborhood with or without COVID,” said Simpson.

As a result, lower-income patients are more likely to seek emergency care in place of primary care, in part because they’re required to stabilize patients regardless of their insurance status. They may also delay primary and preventative care long enough that their condition becomes acute and does require emergency care.

“We're talking about patients that really would only have access to very expensive emergency room, urgent care access and certainly not to the preventative services that established primary care provides. In particular, access to sub-specialty care, which is more expensive if you're paying out of pocket,” said Schmidt.

Big Barriers
“The things that I think about are transportation; money; access to fresh foods, vegetables,” said Simpson. “They can't do the diet plans that you want if they can't get to the food, afford their medication, and keeping up follow up appointment.”

Schmidt agreed that medication access and compliance are big factors in overall health and susceptibility to opportunistic disease like COVID-19.

“We're hearing all these stories within the past few years about diabetics rationing insulin because they're unable to afford their medication. None of those stories are, unfortunately, unique. That's what's happening on population levels. And of course, it’s accumulating in these kind of ZIP codes and areas that are really known for chronic disease and mortality and cancer and strokes.”

Simpson said overcrowding in households is another concern in the pandemic. Lower-income households are more likely to be over-full and multi-generational. Simpson said she recently had a patient who lived in a four-generation household with eight to 10 people. The elders were careful about potential exposures but the younger people were not. They contracted the virus and infected the household. Their grandmother did not survive her fight against COVID-19.

“That's one factor that you may have with people with lower social-economic status, as far as COVID. You might have more people in that household than you have in Germantown where you’ve got a 3,000-square-foot house and three people living in there,” she said.

The Crump clinic works to combat barriers to care by offering as many services as they can in one place. They can also offer assistance paying for medications.

“We have behavioral health. We have a pharmacy, a lab, x-ray, monography. We're pretty much a one-stop shop. We are a COVID testing site,” she said.

The Crump clinic also takes healthcare directly to the people.

“We have our outreach department that goes out in the neighborhood. We try to hit some of the needed areas,” she said. “We try to do our part.”

Working Together
Memphis Health Center, Inc. stays connected to the wider healthcare community at weekly Memphis and Shelby County COVID-19 Joint Task Force meetings. Church Health is also a key partner on the task force.

Part of Schmidt’s job is to lead research on where testing centers should be placed based on metrics like testing density, infection rates, and social vulnerability. She said it’s important that the measures include those social risk factors like access to healthcare facilities and transportation barriers. The county’s COVID-19 task force can then allocate resources objectively and work with existing, trusted providers in the area to administer tests.

“We knew in the beginning that we were going to need to be able to speak as a cohesive group for the needs of our patients. We knew that they were going to be inequitably affected by this urgent health care need,” said Schmidt.

[This article is the last in a three-part series funded by Google on the intersections of race, environment, healthcare, and the novel coronavirus pandemic.]