Black Lives and COVID-19: Dying to Breathe

By Tiffany Grant

Health Sciences Library, Research & Data Services Unit, University of Cincinnati, Cincinnati, Ohio USA

Tiffany Grant, University of Cincinnati, Health Sciences Library, University of Cincinnati, 231 Albert Sabin Way, MSB E005LA, Cincinnati, Ohio, USA joffritm@ucmail.uc.edu

ORCiD: 0000-0001-7036-8247

Abstract

COVID-19 has illuminated how racial inequities across multiple institutions in the United States have converged and resulted in profound and lasting negative impacts on people and communities of color. These inequities have facilitated the creation of the perfect storm whereby COVID-19 has taken full advantage and ravaged communities of color. Disparities in the treatment of people of color concomitant with health disparities more prevalent in these populations have resulted in COVID-19 death rates up to 3.5 times higher than that of white counterparts and at rates that are significantly higher than their percentage of the population. Often, these individuals died, leaving loved ones to speculate that these deaths may have been prevented had quality healthcare been received. These deaths have not only resulted in a loss of physical presence, but they perpetuate the cycles that contribute to discrimination and other social injustices.

Keywords: COVID-19, social justice, health disparities, racial inequity

Introduction

In May of 2020, as the world collectively experienced the devastating reality of the COVID-19 pandemic, the world was simultaneously stunned as video of another case of police brutality emerged in the United States. On May 25, 2020, while arresting George Floyd, an unarmed, 46-year-old black male, for allegedly attempting to pass a counterfeit $20 bill as payment, a white police officer placed his knee on the neck of Mr. Floyd for over eight minutes (Oppel Jr & Barker, 2020). Although Floyd was heard saying “I can’t breathe” over 20 times, and officers called for immediate medical assistance for Floyd, the knee remained in place, and none of the officers present gave medical aid. After nearly 7 minutes, Floyd became unresponsive and motionless, and even after another officer found no pulse, the knee remained on the neck of George Floyd for more than two more minutes (How George Floyd Was Killed in Police Custody, 2020; Oppel Jr & Barker, 2020). Mr. Floyd was eventually taken by ambulance to a nearby hospital, where he was pronounced dead. His death was ruled a homicide (How George Floyd Was Killed in Police Custody, 2020), sparking worldwide outrage and protests. His murder, while shocking, was not surprising to blacks in the United States who experience racial inequities and death at the hands of the white majority so often that the Black Lives Matter foundation was created as a reminder that black lives are not negligible. The Black Lives Matter foundation seeks to affirm the humanity, contributions, and standing of Blacks in a country that has historically deemed blacks as inferior.

The Black Lives Matter Foundation was founded in 2013 after the arrest, trial, and acquittal of George Zimmerman for the murder of Trayvon Martin, an unarmed black teenager (Lebron, 2017). In the moments immediately before his death, Trayvon was carrying a bag of skittles and juice from a recent purchase and was conversing with a friend on his cell phone. Zimmerman called a non-emergency police line to report that Martin looked suspicious and was told by the dispatcher not to follow Martin. Zimmerman ignored this advice, and moments later, Martin was dead (Blow, 2012). Zimmerman was acquitted under Florida’s Stand Your Ground Law, which granted him the right to use lethal force against Martin in self-defense (Alvarez & Buckley, 2013). Martin’s death resulted in nationwide outrage and gave birth to the Black Lives Matter movement (Lebron, 2017). Black Lives Matter desires to inculcate the idea that black skin is neither inherently a weapon to be feared nor a signal to dehumanize individuals who bear it. The concept that blacks are valued less than their white counterparts dates back more than 400 years ago when Africans were brought to the United States to work as slaves. Although slaves were granted freedom over 150 years ago, and laws have been instituted to prevent race-based discrimination, there is a multi-institutional pervasive oppression of individuals of color that facilitates the systemic and structural racism that has explicitly and implicitly served to disempower and demoralize them.

Institutional oppression establishes systems that are favorable to a preferred group while simultaneously instituting barriers for members of the non-preferred group. Historically, blacks and individuals of color have been denied similar access to the economic, social, and political power enjoyed by the white majority in the United States. Laws and practices are made accordingly, allowing the oppression to occur in a continuum. Blacks have been so adversely affected by these norms that racial disparities have resulted in the inability to achieve equity on par with white America. Lavalley has put forth that nearly every aspect of American society has been impacted by racial identity and racism, and these structures are "imbued in every economic, social, political, scientific, judicial, healthcare, and religious system in the nation”(Lavalley & Johnson, 2020). In 2013 data from the Survey of Consumer Finances revealed that whites' median net worth was $143,000, while the median net worth for blacks was $8,935 (Herring & Henderson, 2016). This racial wealth gap ($134,065) more than doubles when the mean net worth for both blacks and whites is taken into account, (Herring & Henderson, 2016) and a racial wealth gap remains consistent across all income groups except the bottom 20%, where the median net worth is effectively $0 (McIntosh et al., 2020). The racial wealth gap results from decades of racial inequities and a shortage of wealth accumulation opportunities for people of color. Historically, whites have received favor in lending and ownership, allowing them to purchase homes and establish businesses while simultaneously acquiring wealth. Despite laws that were to protect against discrimination, blacks were systematically denied these same opportunities through redlining, which prevented the acquisition of mortgages, loans, insurance, and other services that would have allowed the opportunity to build wealth (Herring & Henderson, 2016; Keister, 2000; Kirp et al., 1995; Lipsitz, 2006). Consistent with the lack of wealth, unemployment and poverty rates among blacks and other people of color are more than double that of whites, and significant disparities exist in educational attainment and health (Singh et al., 2017). Consequently, many people of color live in low-income areas and experience little opportunity for economic advancement, and many of them will continue to remain subject to the social norms that promote inequities based on race.

“Racism has created a set of dynamic, interdependent, components or subsystems that reinforce each other, creating and sustaining reciprocal causality of racial inequities across various sectors of society” (Williams et al., 2019). Racism helps establish social norms that manifest in stereotypes and prejudice towards people of color and enforces the differential treatment they experience throughout multiple systems and institutions (Williams et al., 2019). It can be seen in the justice system through racial profiling and excessive sentencing of blacks compared to whites convicted of similar crimes. According to the Washington Post Database, Fatal Force, blacks and Hispanics are killed at disproportionately higher rates than whites, and blacks are killed at twice the rate of whites (Post, 2016). These killings occur in all 50 states and primarily involve black males (Post, 2016). A 2016 report indicated that blacks are incarcerated at five times that of whites, and in 12 states, blacks constitute more than 50% of the population (Nellis, 2016). This is underscored by the fact that blacks make up only 13% of the United States population. These disparities are manifestations of discriminatory practices that are pervasive and impact the everyday lives of blacks in America.

In addition to inequities in the justice and financial systems, blacks and other people of color experience inequities in the healthcare system that can have significant adverse effects on their quality of life and mortality rates. Knowledge of the social determinants of health is important to comprehend how these disparities are established and their influence on individuals and communities. "Social determinants of health are conditions in the social environment in which people are born, live, learn, work, and play that affect a wide range of health, functioning, and quality of life outcomes and risks" (Singh et al., 2017). It has already been stated that blacks experience higher poverty rates and lower educational attainment and live in low-income, disadvantaged neighborhoods. Poverty is correlated with chronic illnesses such as heart disease, diabetes, and obesity, and these illnesses are associated with poorer health outcomes and increased risk of mortality (Noonan et al., 2016; Singh et al., 2017). Chronic exposure to discriminatory acts is a significant driver of stress, which can lead to the same chronic illnesses associated with poverty (Goosby et al., 2018). Additionally, poverty and discrimination result in limited access to adequate housing, and low-income areas often lack access to healthy food and healthcare services, leading to poor eating habits and contributing to the cycle of chronic illness (Singh et al., 2017). This lack of access severely limits the ability to achieve health equity that is on par with whites and enables the health disparities prevalent in communities of color. Blacks experience health disparities at alarmingly high rates compared to white counterparts, and treatment inequities play a critical role in the establishment and retention of these health disparities in the black population.

Studies have suggested that patients of color receive differential treatment during their interactions with healthcare providers (Miller & Peck, 2019; Mitchell & Perry, 2020; B. M. Peck & Denney, 2012; Ross et al., 2012), and this treatment was often correlated with poorer health outcomes. The 2018 National Healthcare Quality and Disparities Report indicated that blacks, American Indians, Alaskan natives, and Hawaiian and Pacific Islanders received worse care in 40% of the quality measures that were assessed in the study (Health & Services, 2019), and Hispanics received worse care in 35% of the quality measures assessed (Health & Services, 2019). A systematic review evaluating implicit racial/ethnic bias among healthcare professionals found that 13 of the 15 studies concluded that healthcare professionals were more likely to associate blacks with negative words than whites (Hall et al., 2015). This same study found that implicit bias was significantly correlated with patient-provider interactions, treatment decisions, and health outcomes (Hall et al., 2015). Patients of color are more likely to experience microaggressions during interactions with their physician (Miller & Peck, 2019), causing damage to the relationship between patient and provider, contributing to health disparities (Irene V Blair et al., 2013). One study found that 67% of primary care clinicians showed bias against patients of color (Irene V. Blair et al., 2013), and others have shown that this bias is often associated with the clinician communicating with a harsher tone and allowing less time for patient questions (Cooper et al., 2012). When their symptoms are overlooked and perspectives discredited, black patients attribute this to discrimination (Cuevas et al., 2016). Taken together with decreased access to healthcare, differential access to quality health care contributes to poorer health and health outcomes in people of color. Thus, it is not surprising that health disparities are more frequently observed in communities of color, and this is only underscored by the fact that people of color are disproportionately burdened by higher rates of morbidity and premature mortality as well (Frieden et al., 2019). Consequently, blacks have a lower life expectancy, and there are marked racial/ethnic and socioeconomic disparities in overall mortality and mortality from leading causes of death (Singh et al., 2017).

Enter COVID-19

The outbreak of the COVID-19 that occurred in Wuhan, China, in 2019 rapidly made its way across the globe in 2020. The first documented case of COVID-19 in the United States occurred in Washington State in January of 2020 (Holshue et al., 2020). At the time of this writing, the United States now reports over 25 million cases of the virus and has led to an unprecedented 421,000 COVID-19 deaths (Smith et al., 2020). Horton has posited that COVID-19 is not a pandemic but rather a syndemic where “two categories of disease are interacting with specific populations” (Horton, 2020). The combination of COVID-19 and an array of non-communicable diseases cluster on a background of social and economic disparity exacerbates the adverse effects of each separate disease” (Horton, 2020), creating a synergistic epidemic. These non-communicable diseases include asthma, diabetes, and hypertension, which disproportionately affect blacks and other people of color, lead to more severe disease, and increase the mortality rates of affected individuals (Worland, 2020). Racial inequities in education, employment, financial status, and housing have direct implications for this impact. Lower socioeconomic status is associated with discriminatory practices and directly impacts health status (Yaya et al., 2020). Poor individuals are more likely to have low health literacy preventing them from understanding basic health information and making them more vulnerable (McNeely et al., 2020). The legacy of discrimination faced by blacks has placed many in low-income neighborhoods that are often replete with pollution and lack nutritious food options facilitating the development of diseases like asthma, and diabetes and contributing to obesity (Worland, 2020). Blacks and people of color are also more prone to occupational exposure to COVID-19, as they are often employed at jobs where they are deemed essential workers and are likely to take public transportation to these jobs (McNeely et al., 2020; Shamus, 2020). The health disparities induced by racial inequities in concert with COVID-19 have synergistically increased deaths in black communities at rates that neither could accomplish alone and that are disproportionately higher than any other ethnicity.

No one is immune to COVID-19, as it does not discriminate based on race. "And yet, from the very beginning of the pandemic, the virus has exposed and targeted all of the disparities that come along with being Black in America.”(P. Peck, 2020). From the beginning, COVID-19 has infected and killed blacks at alarmingly high rates. In states like Illinois, blacks constituted 37% and 45% of confirmed cases and deaths, respectively, but are only 16% of the state population (Yaya et al., 2020). Similar trends can be found in other states, and overall, 30% of COVID-19 infections occur in blacks, who only comprise 13% of the United States population (Thakur et al., 2020; Yaya et al., 2020). Health disparities plaguing communities of color contribute to these high rates, as does healthcare workers' implicit bias. Despite having apparent symptoms of COVID-19, blacks have routinely been denied testing and/or treatment for COVID-19 and have been forced to die at home (Eligon, 2020; Grubbs, 2020; Mitropoulos & Moseley, 2020; P. Peck, 2020; Shamus, 2020; Yaya et al., 2020). In many of these cases, multiple members of the same family have died within days to weeks of each other (P. Peck, 2020; Shamus, 2020). Nine-year-old Kimora Lynum presented with a 103-degree temperature, but was sent home without being tested (Grubbs, 2020). Kimora was her mother’s only child, and at the time of her death, the youngest to die from COVID-19 in Florida. Twenty-three-year-old Deshaun Taylor died after being diagnosed with COVID-19 and pneumonia. Despite being diabetic and therefore at high risk for severe disease, he was sent home twice rather than admitted for treatment (Grubbs, 2020). The implicit bias of healthcare workers against blacks has a direct impact on the death rates that blacks are experiencing from COVID-19. Similar to the knee of a police officer on the neck of George Floyd, Vannessa Grubbs has described the actions of the healthcare system in response to black people with COVID-19 as a “chokehold to black people” that directly contributes to the demise of blacks at disproportionate rates (Grubbs, 2020).

Chris’s Story

Christopher (Chris) Joffrion was born in Louisiana on June 17, 1977, the third child of four and the second son of his African American parents. I was the fourth child, the second daughter, and Chris's baby sister by 17 months. On my last birthday, I officially became older than my older brother. At 42 years old, Chris took his last breath in this world on April 6, 2020. His cause of death: COVID-19.

We grew up together in our stable middle-class family, and both of our parents worked to provide a home and affirm each of us in their way. In junior high and high school, Chris was on the debate team. He was a prolific talker and a master debater who had the trophies and awards to prove it. His ability to converse with anyone regarding most anything was one of his most endearing qualities throughout his life. Chris went to college, and though he finished much of his degree work, he left before meeting his degree's full requirements. However, during this time, he met Pamela (Pam) Johnson, the woman he would eventually marry and spend the rest of his life with. They married on January 1, 2005.

During their life together, Pam and Chris worked hard to establish a comfortable living for themselves and eventually their son, Gabriel (Gabe), who was born in June 2006. Pam described Chris as her "friend and comforter," and she said that he treated her like a queen and was teaching Gabe to be a prince. Chris was known for his frequent Facebook posts indicating that he was having dinner "with his beloved family." Chis enjoyed cooking with Gabe and would often share images of the food they had prepared together. He understood the importance of his presence in his son's life and made it no secret to Gabe that his father loved him. Birthdays and holidays were significant events in their home, and each person was made to feel special on these very days. Chris was a huge fan of the New Orleans Saints and the Chicago Cubs, and one of his most cherished gifts was a Cubs jersey gifted to him by Pam. Together Chris, Pam, and Gabe were an independent unit, filled with love, joy, and hope for their future.

Chris had a larger-than-life personality, and a laugh that some might say was funnier than any joke you may have ever heard. His laugh, smile, jovial personality, and his remarkable ability to find humor in most things were some of the things that most remember him for. Chris's figure loomed large. He was tall. He was also obese. To those that knew him, they knew him as amiable. To strangers, however, his presence was undoubtedly intimidating. As his size grew, along with the increase came the medical conditions associated with it. Over the years, one by one, he was also diagnosed with hypertension, obstructive sleep apnea, and diabetes. He also had asthma. These conditions were well controlled with medication, dietary changes, and nightly use of a continuous positive airway pressure machine. Chris and Pam had recently purchased new vehicles for themselves and were making plans to move out of their apartment into their first home as a family during the summer of 2021. COVID-19 had more sinister plans for Chris and those of us who loved him.

Chris worked from home, and therefore as COVID-19 stay-at-home orders were issued for his home state of Louisiana, he was unaffected. Pam recalls that he started feeling cold-like symptoms on Monday, March 30, 2020, and she urged Chris to call his doctor to report his symptoms. Chris reached his doctor's office and spoke to a nurse who encouraged him to take over-the-counter cold medicine and stay home. There was no concern since, at that point, he had not run a fever. By Thursday, he had developed a prominent cough and congestion. At that point, Chris went to a Quick Care Urgent Care Center, which is associated with a major healthcare network in their area. It was there that Chris was tested for strep throat, the flu, and COVID-19. The strep throat and flu tests came back negative. However, he was told that he had pneumonia and possibly COVID-19 but was sent home with antibiotics, a breathing treatment, and cough medicine. Despite his medical history, including diabetes, asthma, and hypertension, which were positively correlated with more severe disease in patients with COVID-19, there was no recommendation for a hospital admission. The results of the COVID-19 test that he took would take up to 5 days. Despite his symptoms, diagnosis of pneumonia, and health history, there was no urgency for him to receive a rapid COVID-19 test or for him to be admitted into the hospital. We are well aware that either a hospital admission or a rapid test may have altered the care he received from that point forward. With no other recourse, Chris went back home, where he quarantined alone inside the bedroom he shared with Pam and immediately started taking the medications he had been prescribed.

During this time, Pam noted that he was sleeping a lot and barely eating. An avid water drinker, he was barely ingesting fluids. When he was awake, Chris would speak to Gabe through the door, while other times, they would text and play games over the phone. Pam spent much of those days at the door doing her best to provide what was needed. She urged Chris to go back to the doctor, but he insisted that nothing would be done until the test came back. She learned this to be the case, as she called his doctor several times. Each time, she only spoke to a nurse, who simply recommended that he continue to stay home and take the medications as prescribed. It was also during this time that Chris began running low-grade fevers. During the evening of April 3, our older sister reached out to Chris because he had been uncharacteristically quiet and absent from our family chats and their personal chats. She asked him if he was sick, and he responded, "I'll tell y’all when I know just keep praying." His response was alarming, and then she asked him outright if he had the virus. Again, he responded that he was not sure and did not want to say anything until he knew with certainty. After she pressed him more, he said, "I have pneumonia, and they suspect I have coronavirus." Knowing then that Chris's chronic health issues put him at high risk for more severe COVID-19, she was admittedly afraid for his life. However, Chris did not want his parents or siblings to know what he was facing until he was confident of the diagnosis. He wanted to spare us the worry, but he had no way of knowing that in less than 72 hours, he would be gone.

Our sister shared with me screenshots of the messages that she and Chris had shared, and in the early morning hours of April 4, I called our parents and told them. Our parents spoke to Chris that afternoon, and our mother was encouraged because "he sounded like himself." I texted him Saturday evening to inquire how he was feeling, and he replied that he was okay but tired. I bombarded him with questions, as is my usual. I encouraged him to stay hydrated, but he indicated that his appetite had been suppressed and he was tired. It is an odd thing to sense the extreme fatigue he was experiencing even through text, but I did. I imagined that he was struggling to keep up the conversation, so I asked him if I could call him the next day (Sunday) to hear his voice. His reply to me was: "It's fine, Tiffany." We never spoke on Sunday. I never heard his voice again, and those were the last words my brother ever said to me. My last words to him were: "Take care, Chris," and on Sunday, "Just saying hi and I love you." While I am encouraged that these were my last words to him, I have no idea if he ever saw them.

On Monday, April 6, Pam said that he got up feeling somewhat normal and was laughing and joking with Gabe. By lunchtime Pam described him as being "foggy," and she attributed this to low blood sugar. She attempted to check it but was unable to get a reading. She gave him some orange juice, and he seemed better. However, he declined rapidly later that afternoon, exhibiting a complete lack of lucidity along with periods of confusion. As she spoke to him, he told her to be quiet because he was “with a customer”. She said he was looking around her as if she was blocking some imaginary screen he was using to assist the customer. Extremely distressed by this change in behavior, Pam knew he needed immediate medical attention. She called her sister, who lived just a couple of minutes away, and asked her to pick up Gabe. She then called 911. She asked them to do a health check on her husband, who had been tested for COVID-19 and awaiting results. She told them that he had diabetes, high blood pressure, and was acting confused. They arrived just as her sister was departing with Gabe.

She said the EMTs arrived dressed in hazmat suits. They tried to get a blood sugar reading, but similar to Pam; they were unable to get a reading. However, when they assessed his oxygen saturation, Pam indicated that they were overcome with a sense of urgency. The EMTs helped him up, and he walked down their hallway in what Pam described as an unsteady bounce. When he made it to the end of the hall, he fell. The EMTs got him on a stretcher, and Pam followed in time to see his eyes roll back, and his arms go limp. Pam said her entire body went numb from the image, and watching the ambulance remain in place with Chris inside made the feeling worse. Pam went back inside, made the necessary phone calls to family, and then called the hospital. She was told that he coded on the way to the hospital and that she needed to get to the hospital. To this day, Pam is triggered by flashing lights and sirens and has no memory of her trip to the hospital.

When she got to the hospital, she was expecting to be taken back to him, but instead was sent to another room. Pam recognized the room as the same room where she was told of the death of another family member, and in an instant, she knew what the news would be. The doctor came in and said to her that Chris had died before making it to the hospital. Yet, in the time that he arrived at the hospital and Pam arrived, they had already tested Chris for COVID-19 using a rapid test. The same test that they refused to give him on Thursday when it could have made a difference in the outcome. The rapid test was positive. Chris was dead, and nothing at all could reverse the outcome. They preferred to use a rapid test post mortem to place a cause of death on a death certificate, but when he was alive, and medical intervention could have saved his life, one was refused. Chris died on Monday, April 6, 2020, and the results of the test that he had taken the previous Thursday came back on April 9. The same nurse who insisted that Chris should not return for another assessment but that he should continue to stay home and take the medications as prescribed relayed the news to Pam. Our family will never know if Chris had advocated heavily for hospital admission when he went in on Thursday if he would still be here, but unfortunately, that decision was left solely in the hands of the medical professionals who had seemingly dismissed his suffering as inconsequential. What is painfully clear is that Chris did not have a fighting chance at home without any kind of medical intervention. On April 6, 2020, the map of my family was irreparably altered, and our hearts were irrevocably broken.

Our family is grateful that Chris spent his last moments surrounded by love and not in a hospital alone or with a stranger. It is somewhat of a consolation among a litany of complaints and “what ifs” that we will have to contend with. Pam was given only three days to plan his funeral. Chris had a life insurance policy that provided the financial means for his funeral and that has continued to provide for his family since his death. Knowing that Chris was not one to enjoy dressing up in a suit and tie, Pam decided to bury him in his beloved, never worn, Cubs jersey.

The Aftermath and Conclusions

COVID-19 unleashed a storm that has ravaged the country and decimated communities of color across the United States. Implicit and explicit biases targeted against people of color have placed them at a severe disadvantage in the fight against COVID-19. The staggering death rate of people of color from COVID-19 has magnified the vulnerability caused by the health disparities that plague people of color and that are perpetuated by the biases of the structural systems that make up the foundation of the United States. In the wake of these deaths, families are left devastated by physical and economic losses. Many families undoubtedly have lost sources of income that have plunged them into a financial hole that will be difficult to overcome. For the poor, many social determinants of health are expected to worsen due to COVID-19 and its aftermath (Shah et al., 2020). Many of these, like employment, housing, food, education, and healthcare, are already significant issues for the poor.

While very personal to his family, Chris's story is not unique. It is a story that has been repeated many times over in black families across the United States. It is a very painful reminder of the injustices people of color have faced for centuries in this country and will continue to face if allowed to continue. People of color are disproportionately harmed by mass incarceration, police brutality, poverty, and clinician bias against them. Ample evidence exists to establish the relationship between race, racism, and health status. Blacks and people of color disproportionately succumb to premature death due to health disparities and access to quality healthcare. George Floyd’s death in the backdrop of COVID-19 has raised significant awareness of these inequities. Consequently, the American Medical Association, the American Academy of Pediatrics, and the American College of Emergency Physicians have all declared racism a public health crisis, as did several states (Grubbs, 2020). However, health equity cannot be achieved until we have achieved racial equity, and in this regard, the United States has miles to go.

The very harsh reality in terms of COVID-19 outcomes is that the greatest co-morbidity for infected individuals is a darker skin tone. As the number of COVID-19 deaths continues to climb, so too does the grief and impact of these lives lost. In the case of systemic racism, there are many victims, and every victim of a crime deserves to be called by name. Just as we are encouraged to say the names of Trayvon Martin, George Floyd, Ahmaud Arbery, Breonna Taylor, and the many others who died because of racial biases against blacks, so too should we be encouraged to remember and honor the many thousands of lives lost to COVID-19 for the same reasons. For each number, there is a name. For each name, there was a family who loved them. Each of their lives mattered, and it should be criminal to think otherwise. Racial equity should demand it.

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WOC and LibMay 4, 2022