3

Disproportionate Impact of COVID-19 on Black Communities

Mark Alexander, M.D., served as the moderator for the second session of the workshop. He first acknowledged the previous session’s moderator, Hannah Valantine, M.D., for her mentorship of Black physicians and scientists, the prototype of what the Roundtable is trying to accomplish.

COVID-19 is “one more heartache for the Black community,” he said, coining the term from a song by Marvin Gaye in the 1960s. This session was designed to discuss its disproportionate impact on Black communities. Presentations by Clyde Yancy, M.D., of Northwestern University; Cato Laurencin, M.D., Ph.D., of the University of Connecticut; and Camara Jones, M.D., M.P.H., Ph.D., past president of the American Public Health Association, were followed by a discussion among the presenters and with workshop participants.

COVID-19: A BELLWETHER EVENT TO ADDRESS HEALTH DISPARITIES

To frame the discussion, said Dr. Yancy, it is important to consider COVID-19 as the base case that exposes the depth of the social divide and how consequential the social determinants of health are on health outcomes in vulnerable communities. A situation in New Orleans engaged him in how this plays out in reality. The Zulu Club, a group of Black men that has been part of the New Orleans community for decades, continued its tradition of participating in a Mardi Gras parade in late February 2020.¹ Of the 40 men who came together, 10 are dead from COVID-19 and another 10 were desperately ill as of the time of the workshop. “There should be no circumstance where the mere idea of socializing leads to a 25 percent mortality rate, maybe higher. This painfully identifies the disproportionality that is the focus of this workshop,” Dr. Yancy said.

A Los Angeles Times reporter interviewed Dr. Yancy about the juxtaposition of COVID-19 and racism as a cause of death.² He said he told her, “I’ve spent the last several months of my professional time imploring and exhorting people to protect themselves to reduce the spread of this virus and save lives, but it dawned on me that my greatest personal risk is not COVID-19. It’s the color of my skin.”

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¹ For more information, see https://www.nytimes.com/2020/04/29/magazine/racial-disparities-covid-19.html.

² See https://www.latimes.com/science/story/2020-06-02/cause-of-death-covid-19-police-violence-or-racism.

The Power of Place

Looking nationally, the American Public Media Research Lab regularly aggregates and publishes data on COVID-19 mortality rates by race and ethnicity.³ Race and ethnicity data are known for 89 percent of COVID-19 cases in the 40 states that report these data. As of May 27, 2020, 1 in 1,850 Black Americans had died or 54.6 deaths per 100,000 people. This compares with 1 in 4,000 Latino Americans (24.9 deaths per 100,000); 1 in 4,200 Asian Americans (24.3 deaths per 100,000); and 1 in 4,400 white Americans (22.7 deaths per 100,000). Stated otherwise, the mortality rate for Black Americans is 2.4 times higher than for whites and 2.2 times higher than for Asians and Latinos.

A look at the mortality rates in New York City and Chicago further illustrates this disparity. In New York, Blacks account for 28 percent of the deaths, although they represent 22 percent of the population; Hispanics account for 34 percent of the deaths, although they represent 29 percent of the population. It is starker in Chicago, where 50 percent of the cases and nearly 70 percent of the deaths involve Black individuals, although Blacks make up only 30 percent of the population.⁴ And more sobering, Dr. Yancy continued, the deaths are concentrated in only five neighborhoods on the city’s South Side. He noted:

In a viewpoint article published in JAMA, Dr. Yancy (2020) summarized the data above and concluded, “The U.S. has needed a trigger to fully address health-care disparities; COVID-19 may be that bellwether event.” Others have also published on this, he noted, including another article in the same issue of JAMA (Owen, Carmona, and Pomeroy, 2020) in which the authors stated, “We propose that the overarching cause of these tragic statistics is decades of the effects of adverse social determinants of health…. People must make good choices, but they must have good choices to make.”

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³ See https://www.apmresearchlab.org/covid/deaths-by-race for updated figures. As of December 10, 2020, 1 in 800 Black Americans had died of COVID-19, or 123.7 deaths per 100,000.

⁴ These figures were current at the time of the workshop.

As Dr. Yancy pointed out, “If there are not appropriate choices to advantage health where people live, there can be some disturbing outcomes.”

He quoted from an editorial on COVID-19 and health equity (Williams and Cooper, 2020) that pointed out, “Compared with white individuals, African American individuals have higher rates of uninsurance and underinsurance. Segregation of health care also contributes to disparities in health care with access to primary and especially specialty care physicians more limited in communities of color.” They further said the data highlight that social inequities are patterned by place, and “the problem of segregation is not residing among persons of the same race but the clustering of social disadvantage and systematic disinvestment in marginalized communities.” Dr. Yancy underscored, “This is what makes place so problematic for COVID-19.”

A Different Definition of Herd Immunity

Rather than aim for “herd immunity” against COVID-19, Williams and Cooper (2020) urged a different kind of herd immunity, “whereby resistance to the spread of poor health in the population occurs when a sufficiently high proportion of individuals, across all racial, ethnic, and social class groups, are protected from and thus ‘immune’ to negative social determinants.”

The disparities begin in childhood, Dr. Yancy said. Adversity in childhood and adolescence can lead to adverse cardiometabolic outcomes in adulthood (Suglia et al., 2018). Research in the United Kingdom (Obi, McPherson, and Pollock, 2019) has found that adverse risk for adult cardiovascular diseases begins in childhood. These conditions, Dr. Yancy explained, can put people at greater risk for COVID-19.

In addressing the importance of the social determinants of health, Dr. Yancy noted that the American Hospital Association has found a tremendous effect of these determinants on an individual’s health regardless of age, race, or ethnicity. Socioeconomic factors—including education, job status, family/social support, income, and community safety—account for 40 percent or more of the overall health consequence for an individual. A scientific statement from the American Health Association (Havranek et al., 2015), for which Dr. Yancy served as senior author, identifies socioeconomic position, race, social support, culture and language, access to care, and residential environment as contributing to this burden that can advantage or disadvantage health. Another study (Hamad et al., 2020)

found an association of low socioeconomic status with premature coronary heart disease in U.S. adults. Only 40 percent of the burden could be explained by traditional risk factors, while the other 60 percent tracked with socioeconomic status.

Dr. Yancy urged public health initiatives and ubiquitous testing in high-risk communities as a way to address social vulnerabilities, using the Social Vulnerability Index (SVI) developed by the Centers for Disease Control and Prevention (CDC) as a guide.⁵ The index is based on 15 U.S. census variables at the tract level. It assigns to a census tract a score from 0 (lowest vulnerability) to 1 (highest vulnerability), and thus indicates if a neighborhood is more or less resilient to disruptive events. In several tracts in the South Side of Chicago, the SVI is 0.9371; in other words, these neighborhoods are highly vulnerable to an outsized disruption such as COVID-19. Overlaying a map of cases of COVID-19 in Chicago by zip code, the majority of the city’s cases are in the areas with the highest SVI scores. As Dr. Yancy explained:

FACTORS THAT MAY EXPLAIN THE DISPROPORTIONATE IMPACT OF COVID-19

In addition to his work as an orthopedic surgeon and physician, Dr. Laurencin is a core faculty member of the Africana Studies Department at the University of Connecticut and editor-in-chief of the Journal of Racial and Ethnic Health Disparities. As published in the journal (Laurencin and McClinton, 2020a) in April and discussed throughout the workshop, COVID-19 has devastated the world, and the projected mortality and economic devastation rate are unprecedented in the United States. The examination of coronavirus in Black America by Dr. Laurencin and coauthor Aneesah McClinton, M.D., began in March. In searching the internet with the keywords “COVID-19” and “Blacks,” myths surfaced that purported

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⁵ For more information, see https://svi.cdc.gov.

Black immunity to COVID-19. Logically, they realized, there should not be an immunity, and that the impact of COVID-19 on the Black community would be exacerbated by disproportionate levels of poverty, mass incarceration, infant mortality, limited health-care access, and many health-related conditions (Laurencin and McClinton, 2020a).

He noted other reasons the levels would be higher in contracting the coronavirus. Blacks are more likely to work in service industry jobs that put them in close contact with others, making social distancing more difficult. Blacks are overrepresented compared with the overall population in the food service, hotel, and transportation industries, again putting them in closer contact with others and unable to work from home. Another major factor relates to the spread of inconsistent and insufficient information. About 60 percent of Blacks live in the South, where guidance from governors on how to stay safe has been inconsistent with the guidelines of the federal government, he said.

A First Look at Disaggregated Data

Lack of reported and accessible data on the racial and ethnic composition of who has been infected has also contributed to the spread. The risk is that historically marginalized groups, who normally shoulder an even greater impact of disease, will be in a more vulnerable position without early and effective data to measure and track.

The April article (Laurencin and McClinton, 2020a) contained the first data from Connecticut that showed that Blacks were contracting and dying from the coronavirus at higher rates than the general population. Looking at other locations also shows hot spots in cities where a larger proportion of Black Americans reside, including New York, New Orleans, Boston, Chicago, Detroit, and Philadelphia. The CDC reported that Black Americans comprise 33 percent of the hospitalizations in its COVID-19–Associated Hospitalization Surveillance Network (COVID-NET), while they make up 18 percent of the analyzed population. Majority Black counties had 3 times the rate of infections and 6 times the rate of deaths as majority white counties, he added.

“A complex list of factors are involved, with limited access to health care also being a factor,” Dr. Laurencin observed, noting that hospitals in predominantly Black neighborhoods are more likely to close down than those in predominantly white neighborhoods. In addition, unconscious bias and racism exist in the health-care system (e.g., as reported by Maina

et al., 2018). It can take the form of stereotypes or preferences that are held by health-care providers who are unaware of their biases, leading to health inequities, poorer outcomes, and disparities in care. A recent case involved a young woman named Rana Zoe Mungin, who was twice denied COVID-19 testing and lost her life to the disease. Possibly earlier testing would have led to a different outcome, Dr. Laurencin commented. He noted that Ms. Mungin’s experience sheds light on entrenched power dynamics and systems of racial bias, as well as longstanding disparities in Blacks’ access to health care and the manner in which they are treated once they are within the system. This unconscious bias may be contributing to disproportionate Black deaths because of unequal treatment (Milam et al., 2020). A pilot study by Rubix Life Sciences (2020) compared the reporting of COVID-19 symptoms during hospital visits with treatments received, and found that Black patients reporting those symptoms were less likely to get treatment or testing than white patients.

Higher rates of underlying health conditions that predispose Blacks to the more serious complications of COVID-19 include heart disease, diabetes, stroke, kidney disease, respiratory illness, and HIV. Racial disparities in housing also put Black lives at greater risk for contracting an illness such as COVID-19. Densely populated and multigenerational housing make social distancing difficult. Older buildings and those in polluted areas, such as near highways or other pollutants, mean that children are more likely to suffer from asthma.

The Role of Allostatic Load on Health

Racism has a major “wear-and-tear” role that impacts health, Dr. Laurencin continued. It impacts social stratification and the ability of Blacks to be healthy, and contributes to chronic illnesses and mental health challenges at higher rates. Two types of aggression may be encountered: microaggressions, or the subtle, everyday negative messages to a person of a different race, and macroaggressions that involve an overt act against every person of a certain race. Both types can result in physiologically compromising systems that are critical in fending off disease and can influence such chronic illnesses as heart attacks, neurodegenerative disease, and metastatic cancer, he said.

The accumulation of physiological chemical and nonchemical stressors that can explain much of the residual Black-white disparity in mortality rates is known as allostatic load (Kenrik Duru et al., 2012). Chronic stressors,

such as food insecurity, living in substandard housing (i.e., leading to higher exposure to lead), inadequate access to health care, and greater exposure to violence are higher among people with low socioeconomic status, regardless of race. In addition, both poor and nonpoor Blacks share other stressors, such as interaction with institutionalized and personalized racism, and this also impacts the allostatic load. Allostatic load burden explains higher mortality of Blacks, independent of socioeconomic status and health behaviors, and it underscores the importance of chronic chemical and nonchemical stressors as a negative influence on the health and lifespan of Blacks in the United States, Dr. Laurencin said. One study that measured allostatic load scores found that Blacks had higher scores than whites, particularly from age 35 to 64 (Geronimus et al., 2006). These differences are not explained by poverty, he said, but by living in a race-conscious society. Poor and nonpoor Black women had the highest and second-highest probability of high scores when compared with Black males and with white counterparts of both sexes.

Returning to his review of data in Connecticut, the death rate per 100,000 for Blacks was higher than for whites and Hispanics. Connecticut, he pointed out, serves as a useful microcosm for the country as it has about the same percentages of Blacks and Latinos, rural and urban, and other characteristics as nationally. He noted:

According to Dr. Laurencin, a key takeaway is “proactively, we have to make sure the Black community is aware of COVID-19 and its dangers, especially in this time when there is a lot of relaxation of the distancing and other rules.” In his talks in the community, he urges people to obtain and wear personal protective equipment, and to know how to use and remove them safely. He and Dr. McClinton also launched a new way to greet others that minimizes direct skin contact (Laurencin and McClinton, 2020b) but is culturally appropriate.

Inadequate testing is one of the reasons that COVID-19 has continued to have such an impact. He applauded Dr. Garth Graham’s work with Aetna/CVS Health to increase testing in vulnerable communities. He also urged more tracing to seek first-degree contacts. Care, in addition to hospitals, might include pop-up facilities and home care. Experiences of other countries have shown that early care has been key. In Equatorial Guinea, for example, hotels were rented out for patients and providers. Pop-up mini-hospitals could ease the burden. If testing is not available, strict clinical criteria should be used and symptoms should be treated proactively. In Shenyang, China, individuals were immediately quarantined and treated, and very few, if any, in that study needed to go on a ventilator.

In August 2019, Dr. Laurencin and Dr. McClinton wrote a paper on what they termed “Medical Surprise Anticipation and Recognition Capability” (Laurencin and McClinton, 2019). He related that they pointed to the ability to proactively think about medical surprises and planning for them. The paper was inspired by work done after 9/11 to create a framework for preparedness and prevention, and he noted its relevance now.

NAMING RACISM

In early April, recognition of the disproportionate impact of COVID-19 began to grow, first on Blacks, based on data from Milwaukee, and subsequently on indigenous, Pacific Islander, and other communities, said Dr. Jones. Yet, she pointed out, COVID-19 is a new virus to which no one was immune in December 2019. The nation startled into the idea that something big was going on and began talking about structural racism. After the deaths of Ahmaud Arbery, Breonna Taylor, George Floyd, Rayshard Brooks, and others occurred, more people began “naming racism.” However, she said, many well-intentioned people conceptualize racism as white supremacist culture or the actions of individuals. While those actions are part of racism, she said it must be made clear that racism is a system. Dr. Jones shared a definition of racism and illustrated how it operates on three levels to lead to COVID-19 and other health disparities.

The message she said she wanted to stress is that

Defining Racism

Racism is a system of power, Dr. Jones said, not an individual character flaw, moral failing, or psychiatric illness (Jones, 2003). It is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what is called “race”). It is not biology, she noted, as conclusively proven by the mapping of the human genome. It is not based on social class, although there are differences in class based on race, nor is it a measure of culture. Race is the substrate on which racism operates day-to-day, she said. That same substrate or racial classification is what, for example, is marked on a form in the emergency room, what a police officer notices, or what a judge, a teacher, and others react to.

The system of racism has many impacts, Dr. Jones continued. It unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole of society through the waste of human resources. Not only do “Black lives matter,” she said, “but Black lives are genius, precious, are leaders, managers, creators. Each time a Black life is sacrificed through undereducation or through disproportionate incarceration or police violence, the loss of that life shakes families affected but also the whole society through the waste of human resources.” She noted that many people will acknowledge two states of being, which they might consider “disadvantaged” and “normal.” The country is ahistorical, she said, and most people do not recognize that so-called normal is built on history of being advantaged.

Dr. Jones identified three levels of racism that could impact health outcomes (Jones, 2000): institutionalized, personally mediated, and internalized. Institutionalized racism is the constellation of practices, norms, and values that, taken together, result in differential access to the goods, services, and opportunities of society, by “race.” There is no identifiable perpetrator because it has been institutionalized in laws and customs, shows up as inherited disadvantage or advantage, and manifests in material conditions and

access to power, such as differential access to housing, education, employment, and income; medical facilities; clean environment; and information, resources, and voice in decision-making.

Some people consider these conditions a matter of social class, rather than race, Dr. Jones noted. She said she points out that people of color are overrepresented in poverty, while white people are overrepresented in wealth. For each marginalized group, she said, there has been some historical injustice that builds on and perpetuates inequalities. Present-day circumstances are part of these historical roots, and structural racism explains the association between social class and race, she stressed. When she is accused of not caring about poor white people, she responds that she cares about all people living in poverty, but it is not an either-or between an antipoverty strategy and an antiracism strategy. “If we only try to address poverty without being antiracist, we will never succeed,” she stated.

The second type is personally mediated racism, which is a set of differential assumptions about the abilities, motives, and intents of others by race, and differential actions based on those assumptions. This is prejudice and discrimination, which most people think of when thinking of racism, she said, and it can have an impact on health outcomes. Directly, it can be seen in the difficulty in getting tested or admitted to the hospital for COVID-19. In addition, microaggressions, such as shopkeeper vigilance or waiter indifference, may cumulatively be related to elevated blood pressure in communities of color and to higher allostatic load.

The third type is internalized racism, or acceptance by a stigmatized race of negative messages about their own abilities and intrinsic worth. Self-devaluation may mean a person may not try for a higher-level job or education, or acceptance of the “white man’s ice is colder” syndrome in preferring white doctors or other professionals over Blacks. It may result in resignation, helplessness, and hopelessness, and people accepting limitation of their full humanity.

An Allegory about Racism

Dr. Jones illustrated these three types of racism with an allegory that she has shared on other occasions, which she calls “A Gardener’s Tale.”⁶ It came from an observation at her own home that seeds planted in rich

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⁶ A fuller accounting of this allegory, and its ability to open discussion, can be found in Jones, 2000.

fertile soil have a better chance to flourish than those planted in poor, rocky soil. If a gardener prefers red flowers but has seeds for both red and pink flowers, she may plant the red seeds in the rich soil and the pink seeds in the poor soil. Over the years, the red flowers fare far better than the pink ones. As with institutionalized racism, this history of planting in different quality soil perpetuates inequity. The gardener prefers the red flowers since they look more vigorous and perhaps cuts the pink flowers since they are not thriving (akin to personally mediated racism). Finally, the pink flowers may come to wish they, too, could be red (internalized racism). She noted that workshops or other interventions may address personally mediated and internalized racism but do not change the underlying structure; in the allegory, this would require mixing the different qualities of soil or at least enriching the poor, rocky soil.

To extend the allegory, Dr. Jones suggested people think in specific situations about who the “gardener” is: that is, the entity who has power to decide and act and who has control of resources. It could be government, media, corporations, or others in power. It is dangerous when the gardener—or entity in power—is allied with only one group and not concerned with equity, she pointed out.

To understand how racism is operating in a particular situation, she urged a look at different mechanisms, including structures (the “who, what, when, and where” of decision-making); policies (the written “how”); practices and norms (the unwritten “how”); and values (the “why”). In the context of COVID-19, she said, excess deaths may occur because Blacks are more exposed and less protected, thus more likely to become infected, and once infected, more likely to die because they are more burdened by chronic diseases with less access to health care. To intervene, she suggested identifying the structures, such as racial segregation of housing, education, jobs, and disproportionate incarceration; policies, such as limited personal protective equipment (PPE) and paid sick leave; practices, such as testing that requires doctor’s orders, requires a car for a drive-up test, or is located in more affluent areas; and strategies, such as only testing people who are already symptomatic. Norms, such as racism denial, and values, such as creating a hierarchy of valuation by work role, age, or existence of chronic disease, may also play a role.

DISCUSSION

Dr. Alexander related a question from a participant about hypertension, an important risk factor for many African Americans. He asked

Dr. Yancy whether a person who has hypertension under control is at less risk for COVID-19 complications. Concomitant hypertension alone is a risk factor, Dr. Yancy replied, although there are no conclusive data related to controlled hypertension and COVID-19 risk.

Another participant commented on the allostatic load that may result from chronic stressors and the lived experience of African Americans. Dr. Yancy pointed to the concept of weathering, which reflects the aggregate burden of stress and distress in communities. He noted published data have shown that Black women who report discrimination over the preceding decade have shorter telomeres (sequences at the end of a chromosome that protect it) and shorter life expectancy. Similarly, studies have shown that Black men who inculcate anti-Black assessments and racism to have a lesser opinion of themselves also show evidence of shorter telomeres. Relief from racism may help lessen the exposure to disease and achieve the kind of herd immunity described by Williams and Cooper (2020).

A participant asked about the role of vitamin D deficiency in COVID-19. Dr. Laurencin said it is an important condition to look at and is at higher levels in Blacks, but the data are still out on a correlation between vitamin D deficiency and COVID-19. Dr. Yancy noted that one of the statements that drove the discussions about vitamin D was on a preprint server. “This identifies another point of tension,” he said. “There is noise, and there is data. Until we see things that are truly peer reviewed, we can’t extract from what is tantamount to hearsay and introduce it into any treatment algorithm.” Dr. Jones said it was more important to think of frontline workers’ exposures. She warned against “biologizing” the disease, which narrows the causes to the individual and away from the systemic causes.

The presenters were asked about best practices for testing and tracing in communities of color. Dr. Yancy said finding data-driven solutions remains a challenge. Dr. Laurencin suggested looking at some successful examples from Africa. He noted articles in the media in February predicted tens of millions of deaths in Africa, but the numbers do not currently look like this level. He noted African countries’ experience with infectious disease and seriousness about testing, contact tracing, and using PPE. “They are using the resources they have, and they have de-politicized the process,” he said, which he learned at a meeting of the Organisation of African Unity in February.

The presenters were asked about the role of cytokines and COVID-19. Dr. Laurencin explained it is the level of response that takes place locally that can become devastating and creates local tissue damage. Dr. Yancy said there may reach a point in which there is massive release of cytokines against

the virus, which is a difficult biological phenomenon to overcome. He suggested paying attention to the data on use of dexamethasone in people with advanced complications, which has been peer reviewed. Cytokine response, based on the data, is very important and tracks very closely with morbidity and mortality, he said.

Dr. Alexander asked Dr. Jones if she has experienced changed reactions in academia to her work in this time of COVID-19 and more exposed racism. She noted that when she started her career as an assistant professor at Harvard School of Public Health, she was encouraged to change “racism” to “discrimination” in her grant proposals, which was not what she intended. She went on to the CDC and helped establish the Racism and Health Work Group, although some parts of CDC did not want to provide the room for naming racism and clamped down on her efforts. (She said the work group still officially exists but is not operating.) Now, however, the National Institutes of Health and other agencies are calling for work to address racism. “Everyone has a statement against racism now,” she said. “That is why I am heartened but also aware that we cannot fall back to somnolent denial.”

A participant asked Dr. Yancy about his level of optimism in elimination of negative social determinants of health. He expressed concern that it will not happen, noting to do so requires redistribution of investment and tectonic shifts touching all aspects of life, not just iterative change. He said he has come to agree with the statement that “all public policy is health policy,” whether related to education, housing, food, recreation, the built environment, or other areas beyond medicine. As a clinician scientist, he said access to healthy foods would be an important first step, but it is only one piece of a complex matrix that needs to be completely reconfigured.

Dr. Jones called for an antiracism policy for the nation, which she said should include reparations to descendants of Africans enslaved in the United States, decarceration, and massive investment in communities using the principle of providing resources according to need. She said a mark of success would be that the term “disadvantaged child” has no meaning, but she agreed that it will take massive redistribution of wealth.

Dr. Laurencin called for grassroots work to build the health of communities and support healthy living and lifestyles. For example, at the University of Connecticut, the Just Us Moving Program encourages physical activity in Black and Latinx communities to treat diabetes and heart disease.⁷ He said

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⁷ For more information, see https://health.uconn.edu/connecticut-convergence-institute/just-us-moving-project/.

America is at a watershed moment in facing racism. Racism has a tremendous, permeative medical effect, he continued, and referred participants to a coauthored paper about racial profiling as a public health and health disparity issue (Laurencin and Walker, 2020). He also noted issues related to housing, first redlining and later loans at higher interest rates that devastated Black communities, and school discipline. Studies have shown that Black children are suspended 3.5 times more often than white children in preschool and 2.5 times more in K–12. In one study, he said, principals were given scenarios with names often associated with Black and white children; children with the “Black-sounding names” received much harsher punishment for the same actions that the children with “white-sounding names” carried out. “We have to fight in areas such as education, housing, and policing,” he said. “We have the opportunity to understand systemic racism and the possibility of making change.”

REFERENCES

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Milam, A. J., D. Furr-Holden, J. Edwards-Johnson, et al. 2020. Are clinicians contributing to excess African American COVID-19 deaths? Unbeknownst to them, they may be. Health Equity 4(1), 139–141.

Obi, I., K. McPherson, and J. S. Pollock. 2018. Childhood adversity and mechanistic links to hypertension risks in adulthood. British Journal of Pharmacology 176(2), 1932–1950. DOI: 10.1111/bph.14576.

Owen, W. F., Jr., R. Carmona, and C. Pomeroy. 2020. Failing another national stress test on health disparities. JAMA 323(19), 1905–1906.

Rubix Life Sciences. 2020. Health Data in the COVID-19 Crisis: How Racial Equity Is Widening for Patients to Gain Access to Treatment. https://rubixls.com/wp-content/uploads/2020/04/COVID-19-Minority-Health-Access-6.pdf.

Suglia, S., et al. 2018. Childhood and adolescent adversity and cardiometabolic outcomes: Scientific statement from the American Heart Association. Circulation 137(5), e15–e28.

Williams, D., and L. Cooper. 2020. COVID-19 and health equity—A new kind of “herd immunity.” JAMA 323(24), 2478–2480.

Yancy, C. 2020. COVID-19 and African Americans. JAMA 323(19), 1891–1892.