En español | When Theirrien Clark's wife dropped him off at Maryland's Howard County General Hospital on March 20 for a quick imaging test and waited in the parking lot for his return, neither was unduly concerned. The couple had been diagnosed with COVID-19 a few days earlier but were experiencing relatively mild symptoms while recovering at home. Clark's doctor ordered the test as a precaution because his cough wasn't getting better.
Only Clark, 58, never came back to the car that night. A chest X-ray showed he was in lung failure; the doctors needed to insert a breathing tube immediately.
"I was halfway out of it from the medication and let me tell you, my eyes woke up really quickly when they said that,” says Clark, who was transferred to Johns Hopkins Hospital in Baltimore, where he remained on a ventilator for four weeks and stayed for 46 days.
Clark is part of a demographic that has been devastated by the coronavirus since the start of the pandemic: He's 50-plus and Black.
Ninety-five percent of COVID-19 deaths in the U.S. have occurred in adults 50 and older, according to data from the Centers for Disease Control and Prevention (CDC). Add to that the fact that Black Americans are nearly five times more likely to be hospitalized for COVID-19 compared to their white peers. They're also twice as likely to die from it.
"When you put that together, it's not hard [to see]: Older Blacks are at the highest risk of mortality for this disease,” says Robert Joseph Taylor, the Harold R. Johnson endowed professor of social work and director of the Program for Research on Black Americans at the University of Michigan.
In fact, a Kaiser Health News analysis of federal data found that Black Americans ages 65 to 74 died of COVID-19 five times as often as white people in the same age group between Feb. 1 and Aug. 8. For people ages 75 to 84, the death rate for Blacks was 3.5 times higher.
"It really is unconscionable that Black people are, in many ways, bearing the brunt of COVID-19. The impact of this pandemic will last for years to come; not only because of the morbidity and mortality caused, but also because of the economic devastation suffered by these families,” says Edna Kane Williams, senior vice president for multicultural leadership at AARP. “We really must use this terrible experience to become better prepared for the future. This shouldn't and can't happen again."
Insurance, income influence treatment
When Clark was wheeled out of the intensive care unit at Johns Hopkins Hospital, the doctors and nurses who kept him alive while his body battled the infection lined the hallways to cheer him on. “They were clapping and crying,” he says. “I was their longest and sickest patient that they had in the ICU.”
But Clark acknowledges that the top-notch medical care he received — where the hospital staff became like “family” when he was separated from his own — is not available to everyone.
"We have a lot of family and friends who just didn't have that same experience because, you know, different resources and different economic factors,” says Marcy Clark, his wife, who in part credits her husband's survival to good health insurance and proximity to health services.
"If you don't have insurance, you might not even be able to afford to get tested, let alone be able to get to a good hospital for good treatment,” she adds.
Black adults under 65 are less likely than whites to have health insurance. And among older adults on Medicare, the rate of poverty is much higher among Blacks than whites, according to data from the Kaiser Family Foundation. Significantly more Black Americans are dually enrolled in Medicare and Medicaid — the federal program that covers medical costs for low-income individuals — than in Medicare alone. The opposite is true for white Americans.
These stark differences in insurance status and economic standing are a key reason why Black Americans are faring worse during the pandemic, experts say.
Limited access to care affects health
Maureen Bell, M.D., medical director and chair of the emergency department at Howard University Hospital in Washington, D.C., has seen the influence income has on health, firsthand. And COVID-19 has brought the disparity into even sharper focus.
As of Nov. 8, nearly 490 of the 655 coronavirus deaths in D.C. have been Black residents. The vast majority of these deaths have taken place in the city's poorest neighborhoods, which are also predominantly Black and miles from the region's high-performing hospitals, including Howard.
"These are the communities that have been hit the hardest because sometimes these patients have pre-existing conditions that they're not even aware that they have,” Bell says. “They have to travel longer distances to see even their primary care providers.” Combine that with inflexible work schedules and lack of transportation, and it “increases your chances of missing that appointment,” Bell adds.
Underlying health conditions play a big role in increased risk for severe illness from COVID-19. If left unmanaged, the consequences can be deadly. A CDC report found that hospitalizations for people with COVID-19 were six times higher for patients with underlying health conditions, compared to otherwise healthy individuals. Deaths were 12 times higher.
Chronic health conditions are more common in older adults, and many are also more prevalent in Black Americans. What's more, older adults across all races suffer from weaker immune systems, which makes them more susceptible to infections and less capable of fighting them off.
Jobs, housing play a role in virus spread, too
While many COVID-19 patients at Howard have been older Black adults, Bell and her colleagues have also cared for severely ill individuals in their 30s and 40s — and she points to their jobs as the reason.
"A lot of those patients are essential workers, the people who work in the grocery stores or work in health care facilities. Those are the people who have had to keep working in spite of stay-at-home orders,” she notes.
In fact, Black workers are more likely than other workers to be in front-line jobs where they are at increased risk for exposure to the coronavirus, according to an analysis from the Economic Policy Institute. And this affects older adults because “African Americans are more likely to live in extended family households,” Taylor explains. “The essential worker may be more likely to spread the disease within a particular household, especially to the more vulnerable older person,” he adds.
Often, these essential jobs pay low wages, “and because of that, they're not only more likely to have more exposure to the virus and bring it home, they're also more likely to work in two or three different facilities,” further increasing exposure to the virus and their risk for contracting and spreading it, Taylor notes.
Like Black Americans, Hispanics also make up a significant share of the essential workforce and are more likely than whites to live in multigenerational households, according to research from Pew Research Center. Their rates of coronavirus infections, hospitalizations and deaths are higher than their white peers, as well, especially among Black Hispanics, a recent study out of Boston Medical Center shows.
Older Black people who don't live with family members “are much more likely to live in nursing homes that have poor levels of quality” that are “probably less likely to be able to do the types of rigorous training protocols and social distancing measures that others can implement,” Taylor says. A New York Times analysis found that nursing homes with a high number of Black and Hispanic residents have been twice as likely to get hit by the coronavirus, compared to facilities where the population is mostly white, regardless of the home's government rating.
Solutions lie in ‘improving baseline health care for everyone'
The disproportionate burden that COVID-19 has had on older Black adults isn't limited to physical health; the virus has had a harmful effect on their mental well-being, as well. With churches, community centers and long-term care facilities limiting in-person gatherings and visits, many have relied on smartphones and computers to keep in touch with loved ones.
"But there is a digital divide between African Americans and whites, with African Americans having lower access to the internet, which obviously means lower access to things like Zoom and other communication devices,” Taylor says. Plus, while nearly 80 percent of younger adults have access to high-speed internet at home, only 59 percent of adults 65 and older do, according to a report from Pew Research Center.
Just as there isn't one factor to blame for the high rate of COVID-19 infections, hospitalizations and deaths among older Black Americans, there isn't one single solution that can reverse the trends. But more standardized reporting on race and ethnicity among COVID-19 patients is a good place to start, experts say.
"If we can't measure it, it's really hard to explain what's going on and capture it in a way that forces change,” says Sarah Kimball, M.D., an assistant professor at Boston University School of Medicine and codirector of the Immigrant & Refugee Health Center at Boston Medical Center.
Implementing stricter safety measures for essential workers and increasing access to personal protective equipment is also key, Taylor notes. So is expanding access to health care services and “looking at some of the policies that have led to discriminatory outcomes,” Kimball says.
"As a country, as a community, we are only as healthy as the most vulnerable among us,” Howard University Hospital's Bell adds. “And so in order for us to deal with this pandemic, then we actually need to be focused on improving baseline health care for everyone.”
Until that happens, the Clarks are encouraging older Black adults to take preventive health and mitigation efforts seriously: “Wear your mask, wear your gloves, [practice] safe distancing,” Theirrien Clark says. “We preach this all the time.”