Race, income and ZIP code represent hidden virus risks
It started with a headache in late March. Then came the body aches.
At first, Shalondra Rollins’ doctor thought it was the flu. By April 7, three days after she was finally diagnosed with COVID-19, the 38-year-old teaching assistant told her mom she was feeling winded. Within an hour, she was in an ambulance, conscious but struggling to breathe, bound for a hospital in Jackson, Miss.
An hour later, she was dead.
“I never in a million years thought I would get a call saying she was gone,” said her mother, Cassandra Rollins, 55. “I want the world to know she wasn’t just a statistic. She was a wonderful person. She was loved.”
Shalondra Rollins, a mother of two, had a number of factors that put her at higher risk of dying from COVID-19. Like her mother, she had diabetes. She was black, with a low-salary job.
And she lived in Mississippi, where the population is among the unhealthiest in the country.
Doctors know people with underlying health conditions — such as the 40 percent of Americans who live with diabetes, hypertension, asthma and other chronic diseases — are more vulnerable to COVID-19. So are patients without access to intensive care or mechanical ventilators.
Yet some public health experts contend that social and economic conditions are even more powerful indicators of who will survive the pandemic. A toxic mix of racial, financial and geographic disadvantage can prove deadly.
“Most epidemics are guided missiles attacking those who are poor, disenfranchised and have underlying health problems,” said Dr. Thomas Frieden, a former director of the Centers for Disease Control and Prevention.
Federal health officials have known for nearly a decade which communities are most likely to suffer devastating losses — both in lives and jobs — during a disease outbreak or other major disaster. In 2011, the CDC created the Social Vulnerability Index to rate all the nation’s counties on factors such as poverty, housing and access to vehicles that predict their ability to prepare, cope and recover from disasters.
Stretching to the South
Yet the country has neglected to respond to warning signs that these communities — where people already live sicker and die younger than those in more affluent areas — could be devastated by a pandemic, said Dr. Otis Brawley, a professor at Johns Hopkins University.
“This is a failure of American society to take care of the Americans who need help the most,” Brawley said. Although vulnerable counties are scattered throughout the country, they are concentrated across the South, in a belt of deprivation stretching from coastal North Carolina to the Mexican border and deserts of the Southwest.
Some of the most vulnerable communities are in Mississippi, which has the highest poverty rate of any state; Indian reservations in New Mexico, the secondpoorest state, where thousands of households lack running water; and cities such as Memphis, Tenn., a hot spot for asthma that recently ranked among the bottom 15 metro areas in offering safe, livable housing to its residents.
Many public health experts fear COVID-19 will follow the same trajectory as HIV and AIDS, which began as a disease of big coastal cities — New York, Los Angeles and San Francisco — but quickly entrenched in the black community and in the South, which is considered the epicenter of the nation’s HIV/AIDS outbreak today.
Like HIV and AIDS, the first COVID-19 cases in the United States were diagnosed in “jet-setters and people who traveled to Europe and other places,” said Dr. Carlos del Rio, professor of infectious diseases at the Emory University Rollins School of Public Health. “As it settles in America, (COVID-19) is now disproportionately impacting minority populations, just like
HIV.”
One in five Mississippi residents live in poverty.
It is also in the heart of the “Stroke Belt,” a band of 11 Southern states where obesity, hypertension and smoking contribute to an elevated rate of strokes. Blacks make up 38 percent of the state population — but more than half of COVID-19 infections in which race is known. They also account for nearly two-thirds of deaths from the virus, according to the state health department.
Medical and socioeconomic conditions put Mississippians at higher risk of COVID-19 in several ways, said Frieden, now CEO of Resolve to Save Lives, a global public health initiative.
People in low-income or minority communities are more likely to work in jobs that expose them to the virus — in factories or grocery stores and public transit, for example. They’re less likely to have paid sick leave and more likely to live in crowded housing. They have high rates of chronic illness. They also have less access to health care, especially routine preventive services. Mississippi is one of 14 states that have not expanded Medicaid.
Minority communities suffer the legacy of segregation, which has trapped generations in a downward economic spiral, said Dr. Steven Woolf, a professor at Virginia Commonwealth University in Richmond.
“The fact that African Americans are more likely to die of heart disease is not an accident,” Woolf said. “COVID-19 is a very fresh, vivid example of an old problem.”
Native Americans’ risk
Research shows that “stress, economic disadvantage, economic deprivation not only affect the people experiencing it, but it’s passed on from one generation to another,” Woolf said.
The coronavirus is battering impoverished communities. More than 1,200 COVID-19 cases and 48 deaths have been diagnosed in the Navajo Nation, the country’s largest Indian reservation, located on 27,000 square miles at the junction of Arizona, New Mexico and Utah.
There are few hospitals in the region, an area the size of West Virginia, and most lack intensive care units.
The communities that make up the Navajo Nation have among the worst scores on the CDC’s Social Vulnerability Index. Thirtynine percent of residents live in poverty.
With a shortage of adequate housing, many live in modest homes with up to 10 people under one roof, said Jonathan Nez, Navajo Nation president. That can make it harder to contain the virus.
“We’re social people,” Nez said. “We take care of our elders at home.”
The first residents tested positive in mid-March, and cases skyrocketed within weeks. In the eight counties comprising the Navajo, Hopi and Zuni nations, 1,930 residents have tested positive and 79 have died. That’s more cases per 100,000 residents than the Washington, D.C., area.
The Navajo Nation has taken aggressive steps to control the outbreak, including weekend curfews enforced by checkpoints and patrols.
But more than 30 percent of its households lack a toilet or running water, according to the Navajo Water Project, a nonprofit that installs plumbing in homes. Residents often drive long distances to fill containers with water, Nez said.
Health experts say these health risks could remain long after the pandemic passes.
“The question is, ‘Do we value all life equally?’ ” said Dr. James Hildreth, president and CEO of Meharry Medical College in Nashville, a historically black college. “If we do, we will find a way to address these things.”
Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente. KHN data editor Elizabeth Lucas contributed to this report.