Practice Tip of the Week: COVID-19 Shines a Light on Racial Inequalities
Tuesday, May 19, 2020
Posted by: Shanna Howard
By Whitney Thurman, PhD, RN and Edtrina Moss, PhD, RN-BC, NE-BC, CLSSGB
It has been said that viruses are equal opportunity predators, not caring whom they infect. As the coronavirus pandemic plays out, however, it is increasingly clear that the risks of exposure, severe illness, and death from COVID-19 are far from equal in the U.S. Data from across the country clearly demonstrate the startling, disproportionate and unacceptable burdens that communities of color face. For example, in Chicago approximately 72% of the city’s deaths due to COVID-19 involved black residents, a group that makes up 30% of the city’s total population. And, in Richmond, VA, 94% of deaths due to COVID-19 were in black residents who comprise just 48% of the city’s population.
Preliminary data reveal that black patients were six times less likely to get treatment or testing than white patients. Additionally, in many locations across the country, coronavirus screening is happening in predominantly white, wealthy suburbs instead of communities hardest hit. Examining the social determinants of health can reveal how these inequalities affect morbidity and mortality in different ethnic groups, as well as how nurses have a role to play in addressing systemic racial disparities.
This distribution of testing and location of testing sites reflects the persistent disparities in access to medical care that minority communities in the U.S. face. That communities of color are not being tested at levels commensurate with their level of risk for COVID-19 also suggests that the burden of illness in these communities may be even higher than current data indicate. Critically, it also means that the core public health interventions of contact tracing and quarantining individuals who test positive cannot happen, contributing to ongoing spread.
Inadequate testing in minority communities is doubly problematic because Black and Latinx Americans are more likely to be part of our “essential workforce” in industries such as health care, elder care, child care, transportation, food services, public utilities and delivery services. Therefore, many individuals most at risk of poor outcomes related to COVID-19 cannot adhere to social distancing guidelines. That Black and Latinx populations are overrepresented in service-sector jobs is a direct reflection of the continued racial segregation in our educational systems, labor markets and residential neighborhoods.
These inequitable systems not only contribute to economic inequality but also result in greater risk for chronic stress and earlier onset of chronic illness such as diabetes or heart disease—the very conditions that place individuals at greater risk for poor COVID-19 outcomes. This is a critical point for nurses to understand: Many individuals are placed at higher risk for COVID-19 because of social and economic realities that have nothing to do with biological differences or personal choice.
The data showing wide racial disparities in COVID incidence and mortality and the previously discussed differential treatment of African Americans seeking testing and treatment likely reinforce longstanding feelings of mistrust of the medical community by minority communities. This mistrust can deter people from seeking care, placing them at even higher risk and perpetuating the cycle of mistrust and poor outcomes. Nurses must understand the implications of this long-standing history in order to understand that marginalized individuals may choose different care due to fear of medical mistreatment.
As part of the most trusted profession for 18 consecutive years, nurses have a responsibility to examine their own implicit biases in providing safe, effective and quality care to all people, regardless of socioeconomic or ethnic background. As frontline responders to COVID-19, nurses are experiencing new and stressful conditions. Studies show stressful conditions can increase biased behavior. Therefore, nurses must pay even more attention to their own thoughts and actions to ensure high quality and equitable care.
Nurses must recognize that a colorblind approach to nursing care is inherently inequitable. This perceived “colorblind” strategy minimizes racism and upholds the racial status quo in promoting health inequality. Nurses have an obligation and ethical duty to eliminate and correct disparities and inequities. Recognizing personal biases that may lead to inequities is the first step.
Addressing Workplace Biases
Every nurse can take an active role in creating plans to examine biased behaviors and understand the social context in which patients live so that care can be tailored appropriately.
One evidence-based approach is through mindfulness: the total awareness of your thoughts and behaviors in the present moment to improve decision-making and emotional regulation. Nurses can tap into other awareness and control strategies such as self-reflection, perspective-taking and stereotype replacement.
Health care organizations also have a responsibility to examine and critically appraise their organizational policies regarding who gets tested and treated for COVID-19. Is there an equitable, evidence-based determination for who gets tested and when? Is there an evidence-based standard of care in the treatment plan for all patients that also considers the role of social determinants of health in disparate outcomes? These are crucial questions health care organizations must answer in their approach to address the inequities that exist because of this pandemic.
Revised policies that include a health justice approach and examine factors leading to poor health and higher prevalence of chronic disease will help answer these questions and serve as a catalyst for addressing disparities. Policies must address the need for data tracking of racial and ethnic infection and mortality with COVID-19. Recommendations for policy considerations include identifying possible disparities in telemedicine access, mitigating resource and digital literacy barriers, removing barriers created by health systems and advocating for changes to support sustainable and equitable access.
The COVID-19 global pandemic shines a glaring and sobering light on the social and racial injustices of minorities and people of color in America. These injustices are pervasive in health care and require the entire health care system to self-assess its actions in providing care quality and equity. The novel coronavirus makes no distinction of gender, race, ethnicity and socioeconomic status, but the system we practice in does. Will we accept a health care system where providers discriminate and act on implicit biases? It is up to each nurse, physician, allied health care worker and organization to individually and collectively recognize these biases and hold each accountable for taking appropriate actions to mitigate them in the treatment of COVID-19 and all other diseases and illnesses.