Capstone Topic Summary
My preceptor Ms. Wilder and I discussed the needs of the community we both serve. Living in South Florida where there is a strong presence of African American population who is underserved by the health care community. The topic I chose will help serve this population. I recently relocated to Georgia which also have a large African American population. The evidence-based topic for the capstone change proposal will focus on the African American population and COVID 19. The category my topic and intervention falls under the community branch. I want to educate the African American population on the benefits of getting the COVID vaccine. History has shown that African American have a sincere distrust in the health care system due to health disparities and previous unconsented experiments performed by the medical community. The pandemic has disproportionately impacted African Americans. But yet this population is reluctant to receive the vaccine. Whether it is from social determents (limited finances, education, insurance or lack of) or health conditions (i.e. hypertension, diabetes), there is need for education to prevent higher mortality rates among the African American population.
Overcoming Barriers to
COVID-19 Vaccination
in African Americans:
The Need for Cultural
Humility
Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASPC
ABOUT THE AUTHOR
Keith C. Ferdinand is with the Department of Medicine, Tulane University School of Medicine,
New Orleans, LA.
See also Benjamin, p. 542, and Rodenberg, p. 588.
“Rescue work by helicopter was slow.
That stopped at dark about 7 o’clock
. . . people began to panic. I told
Kenneth and Keith and those around
me that we may as well make the
best of it, for no one knows we are
here . . . help won’t come until
morning. The rain fell so hard that I
had to take off my glasses & hide my
head. . . . The water, still slowly rising,
had two more inches to go before it
reached the rooftop. We learned:
that communication [and] coopera-
tion are necessary factors for survival
in a disaster.”
—Letter from Inola Copelin Ferdinand
to her sister, Narvalee, after our family
and others spent days amid the
drowning death of my paternal grand-
father and many of her neighbors,
abandoned on rooftops in the Lower
Ninth Ward, New Orleans, LA, during
Hurricane Betsy, September 9, 1965
Racial/ethnic minorities suffer dis-
proportionately from US COVID-19–as-
sociated deaths.1 The tragically higher
COVID-19 mortality among African
Americans from multiple conditions, in-
cluding cardiovascular diseases (CVD)
and certain cancers, highlights deep-
rooted, unacceptable failures in US
health care. The social determinants of
health (limited finances, healthy food,
education, health care coverage, job
flexibility) make disadvantaged commu-
nities more vulnerable to COVID-19 in-
fectivity and mortality and amplify higher
comorbid conditions.2 The Healthy
People 2020 Social ...
Capstone Topic SummaryMy preceptor Ms. Wilder and I discusse
1. Capstone Topic Summary
My preceptor Ms. Wilder and I discussed the needs of the
community we both serve. Living in South Florida where there
is a strong presence of African American population who is
underserved by the health care community. The topic I chose
will help serve this population. I recently relocated to Georgia
which also have a large African American population. The
evidence-based topic for the capstone change proposal will
focus on the African American population and COVID 19. The
category my topic and intervention falls under the community
branch. I want to educate the African American population on
the benefits of getting the COVID vaccine. History has shown
that African American have a sincere distrust in the health care
system due to health disparities and previous unconsented
experiments performed by the medical community. The
pandemic has disproportionately impacted African Americans.
But yet this population is reluctant to receive the vaccine.
Whether it is from social determents (limited finances,
education, insurance or lack of) or health conditions (i.e.
hypertension, diabetes), there is need for education to prevent
higher mortality rates among the African American population.
Overcoming Barriers to
COVID-19 Vaccination
in African Americans:
The Need for Cultural
Humility
Keith C. Ferdinand, MD, FACC, FAHA, FNLA, FASPC
2. ABOUT THE AUTHOR
Keith C. Ferdinand is with the Department of Medicine, Tulane
University School of Medicine,
New Orleans, LA.
See also Benjamin, p. 542, and Rodenberg, p. 588.
“Rescue work by helicopter was slow.
That stopped at dark about 7 o’clock
. . . people began to panic. I told
Kenneth and Keith and those around
me that we may as well make the
best of it, for no one knows we are
here . . . help won’t come until
morning. The rain fell so hard that I
had to take off my glasses & hide my
head. . . . The water, still slowly rising,
had two more inches to go before it
reached the rooftop. We learned:
that communication [and] coopera-
tion are necessary factors for survival
3. in a disaster.”
—Letter from Inola Copelin Ferdinand
to her sister, Narvalee, after our family
and others spent days amid the
drowning death of my paternal grand-
father and many of her neighbors,
abandoned on rooftops in the Lower
Ninth Ward, New Orleans, LA, during
Hurricane Betsy, September 9, 1965
Racial/ethnic minorities suffer dis-
proportionately from US COVID-19–as-
sociated deaths.1 The tragically higher
COVID-19 mortality among African
Americans from multiple conditions, in-
cluding cardiovascular diseases (CVD)
and certain cancers, highlights deep-
rooted, unacceptable failures in US
health care. The social determinants of
4. health (limited finances, healthy food,
education, health care coverage, job
flexibility) make disadvantaged commu-
nities more vulnerable to COVID-19 in-
fectivity and mortality and amplify higher
comorbid conditions.2 The Healthy
People 2020 Social Determinants of
Health include the Economic Stability
domain, with employment as a key issue.
Suboptimal job benefits such as health
insurance, paid sick leave, and parental
leave can affect the health of employed
individuals, and African Americans are
more likely to work in blue-collar service
jobs.3 This toxic gumbo of suboptimal
health and adverse environments pro-
foundly diminishes overall African
American longevity, fueling a decades-
5. long White–Black death gap, with African
American men having the shortest life
expectancy.2 Although December 2020
Pew Research data note that a growing
share of Americans report they probably
or definitely will accept COVID-19 vac-
cination, African Americans continue to
stand out as less inclined to get vacci-
nated: 42% would do so, compared with
63% of Hispanic and 61% of White adults.4
MISTRUST: A CRITICAL
BARRIER TO OVERCOME
Effective public health messaging and
mitigation efforts are required to opti-
mize acceptance of COVID-19 vaccina-
tion and minimize subsequent mortality.
Unfortunately, mistrust in orthodox
health care is a substantial barrier to
6. COVID-19 vaccine acceptance, and with-
out widespread uptake, the societal ben-
efits of immunization, even with very
effective, safe vaccines, will not be realized.
Despite recent attention to the impact of
structural racism across a wide range of
health conditions in the United States, the
COVID-19 pandemic further unmasks
these inequities. The scandalous history of
orthodox medicine and public health to-
ward African Americans demands recog-
nition or will remain a formidable obstacle
to acceptance of vaccination.
HISTORICAL RACISM IN US
HEALTH CARE AND PUBLIC
HEALTH
The multigenerational African American
mistrust reflects a legacy of real-life ex-
periences and the shameful historical
7. racism in medicine and public health.
Since the mid-19th century, and well into
the 20th century, physicians and public
health officials were apologists, and
even advocates, for the less-than-
humanistic care and racist theories
that supported the subjugation and
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dehumanization of African slaves and,
later, Black US citizens.
In 1851, Samuel Cartwright, a
leading medical authority, maintained
that a slave must be submissive to his
master. He identified drapetomania,
the “disease” of running away, with
specific remedies: removal of both big
toes and “whipping the devil out of
them.”5 The extensive history of Blacks
receiving violent medical treatment
and experimentation includes medical
schools utilizing enslaved Black bod-
9. ies as “anatomical material,” early
gynecologists experimenting on
enslaved women, compulsory sterili-
zation, and the saga of Henrietta
Lacks, whose cancerous cells, taken in
the segregated Johns Hopkins ward,
were experimented on, reproduced,
and disseminated without her knowl-
edge or consent.6
Most prominently, the infamous
“Tuskegee Study of Untreated Syphilis
in the Negro Male” remains a symbol of
African American mistreatment, deceit,
conspiracy, malpractice, and neglect
by the medical establishment. Social
scientists and medical researchers
have repeatedly pointed to this un-
ethical study as a reason many African
10. Americans remain wary of mainstream
medicine and participation in clinical
trials, and why there are fewer phy-
sician interactions among African
Americans and increased mortality for
older African American men, as has
been consistently documented.7
GOVERNMENTAL
PROGRAMS FOR EQUITY
IN COVID-19
Organized government initiatives are
essential to link scientific understanding
of SARS-CoV-2 to public health policy and
social justice. Institutionalized strategies
at a national level include the National
Institutes of Health’s Community En-
gagement Alliance (CEAL) against COVID-
19 disparities, which targets African
Americans, Hispanics/Latinos, and
11. American Indians/Alaska Natives, who
account for over half of all reported US
cases.8 Specifically, CEAL’s community
outreach efforts are designed to increase
clinical trial diversity and to overcome
misinformation and mistrust regarding
treatments, diagnostics, and vaccines.8
This ongoing program seeks to identify
and connect with some of the hardest-hit
communities.
Furthermore, state, territorial, and
tribal perspectives may swiftly identify
disparities and problem areas in COVID-
19 incidence, burden, and vaccination
and more precisely deliver culturally
appropriate messaging. One example,
Louisiana’s COVID-19 Health Equity Task
Force (www.sus.edu/lacovidhealthequity),
12. was initiated after an alarmingly high Af-
rican American mortality rate was identi-
fied in the state. It has reported to the
governor multiple recommendations for
testing, monitoring COVID-19’s impact,
and policy changes aimed to reduce in-
equities for multiple statewide racial/
ethnic communities.
CULTURAL HUMILITY
The best path forward to controlling the
pandemic and achieving health equity
will require specific, targeted programs
and public health engagement pro-
mulgated with the spirit of “cultural
humility.”9 More than traditional “cultural
competency,” a detached mastery of a
theoretically finite body of knowledge,
cultural humility is a communication
13. imperative, originally described as an
ongoing process requiring physicians
to engage in conversations with pa-
tients, communities, colleagues, and
themselves. Notable aspects of cultural
humility include self-reflection and self-
critique, learning from patients (avoiding
cultural stereotyping), developing and
maintaining respectful partnerships,
and actively continuing these positive
relationships.
Consequently, vaccination concerns
in communities of color must be
addressed with cultural humility, as
opposed to simply deeming reluctant
individuals as solely uninformed, fool-
ishly recalcitrant, or merely antivaxxers.
Identifying and overcoming vaccination
14. hesitancy in a multicultural America is
not simply a social nicety, but rather an
essential action to achieve national
levels of immunity and eventually elimi-
nate disparate outcomes among diverse
cultures and racial/ethnic backgrounds.
To communicate the risk–benefit of
COVID-19 vaccines, it is essential to have
input from the mass media, public health
services, policymakers, and “trusted
messengers” (individuals with a prior
history of service and goodwill in the
underserved and minority communities).
According to established international
law, the United States must ensure
equality and nondiscrimination in its
dissemination of new COVID-19 vaccines.
Individual decisions about accepting
15. vaccination are not simply technical cal-
culations, but value decisions that this
particular intervention is intended to help
and not harm themselves and their loved
ones. Culturally sensitive, literacy-level
appropriate education, delivered with
cultural humility, is optimally respectful
communication, with feedback and
evaluation of the messaging.
CONCLUSION
The best path forward to overcoming the
COVID-19 pandemic in the United States
requires specific, targeted programs and
Editorial Ferdinand 587
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17. acute care, and, finally, immunization to the
increasingly diverse US populations. Inher-
ent in this challenge, culturally humility is a
crucial component.
CORRESPONDENCE
Correspondence should be sent to Keith C. Ferdi-
nand, MD, Cardiology, Tulane University School of
Medicine, 1430 Tulane Ave, #8548, New Orleans, LA
70112 (e-mail [email protected]). Reprints can
be ordered at http://www.ajph.org by clicking the
“Reprints” link.
PUBLICATION INFORMATION
Full Citation: Ferdinand KC. Overcoming barriers to
COVID-19 vaccination in African Americans: the
need for cultural humility. Am J Public Health.
2021;111(4):586–588.
Acceptance Date: December 15, 2020.
DOI: https://doi.org/10.2105/AJPH.2020.306135
CONFLICTS OF INTEREST
The author has no conflicts of interest to
declare.
REFERENCES
18. 1. Gold JA, Rossen LM, Ahmad FB, et al. Race, ethnicity,
and age trends in persons who died from COVID-
19—United States, May–August 2020. MMWR Morb
Mortal Wkly Rep. 2020;69(42):1517–1521. http://dx.
doi.org/10.15585/mmwr.mm6942e1
2. Ferdinand KC, Nasser SA. African-American COVID-
19 mortality: a sentinel event. J Am Coll Cardiol. 2020;
75(21):2746–2748. https://doi.org/10.1016/j.jacc.
2020.04.040
3. US Dept of Health and Human Services, Office
of Disease Prevention and Health Promotion.
Employment. Healthy People 2020. Available at:
https://www.healthypeople.gov/2020/topics-
objectives/topic/social-determinants-health/
interventions-resources/employment#36.
Accessed December 12, 2020.
4. Funk C, Tyson A. Intent to get a COVID-19 vaccine
rises to 60% as confidence in research and
development process increases. Pew Research
Center. 2020. Available at: https://www.
pewresearch.org/science/2020/12/03/intent-to-get-
a-covid-19-vaccine-rises-to-60-as-confidence-in-
research-and-development-process-increases.
Accessed December 12, 2020.
5. Cartwright SA. Report on the diseases and physical
peculiarities of the negro race. New Orleans Med
Surg J. 1851:691–715.
6. Nuriddin A, Mooney G, White AIR. Reckoning with
histories of medical racism and violence in the USA.
Lancet. 2020;396(10256):949–951. https://doi.org/
19. 10.1016/S0140-6736(20)32032-8
7. Alsan M, Wanamaker M. Tuskegee and the health
of black men. Q J Econ. 2018;133(1):407–455.
https://doi.org/10.1093/qje/qjx029
8. National Institutes of Health. Community Engagement
Alliance (CEAL) against COVID-19 disparities. 2020.
Available at: https://covid19community.nih.gov.
Accessed January 25, 2021.
9. Tervalon M, Murray-Garcia J. Cultural humility vs
cultural competence: a critical distinction in defin-
ing physician training outcomes in multicultural
education. J Health Care Poor Underserved. 1998;9(2):
117–125. https://doi.org/10.1353/hpu.2010.0233
To Work With
Marginalized
Populations, Empathy
Is Key
Howard Rodenberg, MD, MPH
ABOUT THE AUTHOR
Howard Rodenberg is with Baptist Hospital, Jacksonville, FL.
See also Benjamin, p. 542, and Ferdinand, p. 586.
Many years ago, I was told never tofollow a great speaker, as
there’s
no way to look good in comparison. So
I’m hesitant to add an opinion to Keith
Ferdinand’s moving account of his
20. family’s rooftop rescue from their
flooded New Orleans home. The tale
reveals the fear we have when
confronted with uncontrollable cir-
cumstances, such as natural disasters
or pandemics. It also encapsulates the
hopelessness and desperation we
might feel when we don’t have the
ability to care for our friends, our
families, and ourselves. Many of us
have likely felt this way during the
COVID-19 crisis; more still within dis-
advantaged communities.
Incidents of racist thought and prac-
tice within the House of Medicine have
been well documented, and the negative
impact of adverse social determinants of
health has become clear. These factors
21. complicate public health programming
within marginalized populations, espe-
cially when public health products or
services come from outside rather than
originating within the community itself.
Given the chronic distrust that results
when policymakers seem unwilling or
unable to correct these ills, is it any
wonder there’s skepticism about a
government-backed coronavirus
vaccine?
It has been noted that people of color
have a right to be suspicious of public
health professionals. We can argue
among ourselves how many of today’s
current health disparities within minority
populations are related to centuries of
institutional racism or contemporary
22. 588 Editorial Rodenberg
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mailto:[email protected]
http://www.ajph.org
https://doi.org/10.2105/AJPH.2020.306135
http://dx.doi.org/10.15585/mmwr.mm6942e1
http://dx.doi.org/10.15585/mmwr.mm6942e1
https://doi.org/10.1016/j.jacc.2020.04.040
https://doi.org/10.1016/j.jacc.2020.04.040
24. download, or email articles for individual use.
RESEARCH ARTICLE Open Access
Higher comorbidities and early death in
hospitalized African-American patients with
Covid-19
Raavi Gupta1* , Raag Agrawal2, Zaheer Bukhari2, Absia
Jabbar2, Donghai Wang2, John Diks2, Mohamed Alshal2,
Dokpe Yvonne Emechebe2, F. Charles Brunicardi3, Jason M.
Lazar4, Robert Chamberlain5, Aaliya Burza6 and
M. A. Haseeb1
Abstract
Background: African-Americans/Blacks have suffered higher
morbidity and mortality from COVID-19 than all other
racial groups. This study aims to identify the causes of this
health disparity, determine prognostic indicators, and
assess efficacy of treatment interventions.
Methods: We performed a retrospective cohort study of clinical
features and laboratory data of COVID-19 patients
admitted over a 52-day period at the height of the pandemic in
the United States. This study was performed at an
urban academic medical center in New York City, declared a
COVID-only facility, serving a majority Black population.
Results: Of the 1103 consecutive patients who tested positive
for COVID-19, 529 required hospitalization and were
included in the study. 88% of patients were Black; and a
majority (52%) were 61–80 years old with a mean body
mass index in the “obese” range. 98% had one or more
26. reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in
this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article's Creative
Commons
licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy
of this licence, visit
http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to
the
data made available in this article, unless otherwise stated in a
credit line to the data.
* Correspondence: [email protected]
1SUNY Downstate Medical Center, Departments of Pathology
and Cell
Biology, 450 Clarkson Ave. MSC #37, Brooklyn, NY 11203,
USA
Full list of author information is available at the end of the
article
Gupta et al. BMC Infectious Diseases (2021) 21:78
https://doi.org/10.1186/s12879-021-05782-9
http://crossmark.crossref.org/dialog/?doi=10.1186/s12879-021-
05782-9&domain=pdf
http://orcid.org/0000-0003-4647-0553
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
mailto:[email protected]
27. Background
Coronavirus Disease 2019 (COVID-19), caused by infec-
tion with Severe Acute Respiratory Syndrome
Coronavirus-2, has been declared by the World Health
Organization to be a pandemic, with over seven million
confirmed cases in the United States [1, 2]. New York
State, including the New York City, became the epicen-
ter of the epidemic in the United States, accounting for
more than 23% of the total U.S. cases by the end of May,
2020 [2]. Such burden of disease is of particular concern
since it disproportionately affects communities with con-
siderable health disparities in New York City, where
African-Americans and Latinos constitute as much as
53% of the population [3]. Our medical center is located
in such a community in Brooklyn, New York.
The spectrum of COVID-19 presentation ranges from
mild influenza-like illness to life-threatening severe re-
spiratory disease requiring ventilatory support [3]. Co-
morbid conditions such as hypertension, diabetes
mellitus, pulmonary and heart diseases, and demo-
graphic factors have been reported to influence out-
comes [4–6]. However, the relative influence of each of
these comorbidities in different patient populations and
age strata has not been assessed, leading to variability in
management and outcomes. Key decisions in patient
management such as the choice of antibiotic, blood pres-
sure goals, and perhaps most importantly, airway man-
agement strategies, have remained variable across or
within hospitals.
National health statistics have docume nted extensive
health disparities for Black COVID-19 patients. They
suffer a three-fold greater infection rate, and a six-fold
28. greater mortality rate than their white counterparts [7].
However, limited clinical and laboratory data of prog-
nostic significance from Black COVID-19 patients are
available [8]. A range of cultural, linguistic, and health-
care access barriers have prevented clinical investigation.
Our hospital, located in New York City, serves a pre-
dominantly Black population, and being declared a
COVID-only facility, we were able to maintain a stand-
ard quality-of-care across all COVID-19 patients.
Here we explore the clinical aspects of COVID-19 and
its outcomes in Black patients. This study evaluated clin-
ical signs and symptoms, laboratory indicators, and man-
agement strategies to develop a data-driven COVID-19
patient-care approach. Our findings provide an
evidence-based resource for physicians to assess patient
progress in the early days of hospitalization to direct pa-
tient management decisions.
Methods
This study analyzed the electronic medical records of
COVID-19 patients hospitalized at the State University
of New York (SUNY), Downstate Medical Center,
Brooklyn, New York. The hospital was designated a
COVID-only facility by the State of New York as of
March 4th, 2020, and provided ample equipment and
supplies. The hospital is located in a majority Black
neighborhood with high rates of poverty [9]. This study
was approved by the SUNY Downstate Institutional Re-
view Board [1587476–1].
COVID-19 diagnosis was based on clinical presenta-
tion and a positive real-time reverse transcriptase poly-
merase chain reaction (rtPCR) from a nasopharyngeal
swab (Xpert Xpress SARS-CoV-2, Cepheid, Sunnyvale,
29. CA). Of the 1103 patients who tested positive over a 52-
day period (March 2nd – April 23rd), when the hospital
was under peak caseload; 529, who met the following
criteria were admitted and included in this study. Pa-
tients were admitted if deemed to be in respiratory dis-
tress (respiratory rate > 22 breaths/min and in need of
supplemental oxygen to maintain oxygen saturation >
92%), were encephalopathic, or were judged sufficiently
ill to require hospitalization. Patients were followed up
for up to 7 months, thus we have been able to docume nt
an outcome (death or discharge) on all patients.
COVID-19 positive pregnant patients who came for ob-
stetrics related visit, and otherwise asymptomatic, were
excluded.
Demographic factors, comorbidities, presenting clinical
symptoms, and outcomes (discharge/death) were re-
corded for 529 patients. Complete medical history was
available for 484 of these patients, however, 45 patients
were too sick to respond or were in altered mental status
at presentation and were excluded from analyses of co-
morbidities. Laboratory data were recorded for 286 pa-
tients on admission or within 24 h of hospitalization,
and at a second time point between 48 and 96 h post-
admission. Pre-admission medications were recorded
based on admission medication reconciliation by admit-
ting physicians. Based on self-reported race/ethnicity,
patients were grouped into Black and Others (White
Hispanic/non-Hispanic and Asian). HIV-positive pa-
tients [with CD4 counts < 50% of the lower limit of the
reference range (404–1612/μL)] and transplant recipi-
ents were categorized as “immunocompromised”.
Chronic kidney disease (CKD) was defined as kidney
damage and reduced glomerular filtration rate (GFR <
60 ml/min/1.73 m2) of more than 3 months [10]. We
separated patients with kidney disease into 3 groups: 1)
30. CKD without dialysis, defined as patients who were ad-
mitted with baseline CKD and did not receive dialysis
during hospitalization; 2) CKD with dialysis, defined as
patients with baseline CKD who started dialysis as inpa-
tients because of worsened acute kidney injury; 3) ESRD,
defined as patients who were on dialysis prior to admis-
sion and continued dialysis as per their routine schedule
during hospitalization.
Gupta et al. BMC Infectious Diseases (2021) 21:78 Page
2 of 11
Patients were treated with hydroxychloroquine (200
mg twice a day, for 5 days) and azithromycin (250 mg
once a day, for 5 days). All patients received standard
venous thromboembolism prophylaxis with low-
molecular weight heparin or direct oral anticoagulants
based on their creatinine clearance rate. Patients with el -
evated D-dimer received a full dose anticoagulation regi-
men. Hypoxia, a sign of Acute Respiratory Distress
Syndrome (ARDS), was monitored by a continuous pulse
oximeter and with arterial blood gas measurements, and
supplemental oxygen was provided as needed via nonin-
vasive ventilation. Patients with worsening respiratory
distress despite supportive care, as determined by declin-
ing pulse oximeter saturation, increasing respiratory rate,
or worsening partial pressure of arterial oxygen/percent-
age of inspired oxygen ratio) were intubated and placed
on mechanical ventilation. Patients who developed acute
kidney injury (AKI) with oliguria (< 30 ml/hr. for > 12 h)
unresponsive to diuretics or hemodynamic optimization,
or decreased creatinine clearance (CrCl < 20 ml/min) re-
ceived hemodialysis [11].
Computational analysis was conducted using R (ver.
31. 3.6.3) [12]. Continuous variables are presented as me-
dian and interquartile range (IQR). Categorical variables
such as gender or race are presented as number and per-
cent of patients with 95% confidence intervals (CI). Per-
centages are expressed based on the available data for
the subgroup relative to the total available data for that
variable.
Parametric variables were evaluated through a
Shapiro-Wilk test of normality with a significance cutoff
of P < 0.01. Non-parametric variables were compared
using Mann-Whitney rank sum test, with 95% CIs re-
ported. Categorical variables were evaluated using the
Fisher exact test, and odds ratios (OR) alongside 95%
CIs are presented. All tests were two-tailed and statis-
tical significance was defined as P < 0.05. No multiple
testing correction was applied. A multivariate logistic re-
gression analysis was performed on comorbidities and
demographic factors for in-hospital mortality, and ORs
with 95% CIs are presented. Cox proportional hazards
analysis for time to death was conducted on comorbidi-
ties, demographic factors, and pre-admission medica-
tions [(angiotensin-converting enzyme (ACE) inhibitors
and/or angiotensin II receptor blockers (ARBs)] and haz-
ard ratios with 95% Cis are presented.
Results
One thousand one hundred three patients were tested
for COVID-19 over a 52-day period. After excluding 292
patients who tested negative and 282 who were treated
as outpatients, 529 inpatients with positive test results
and symptoms consistent with COVID-19 were included
in this study, and were followed-up for up to 7 months.
Demographic information
32. The median patient age was 70 years (Table 1). A major-
ity of patients were in the age range of 61–80 years
(53%, 281/529) and a small minority were < 40 years old
(6%, 28/529). In-hospital mortality rates correlated with
patient age, with the highest mortality rate recorded for
the > 80-year age group (64%, 67/104) (Fig. 1). 88% of
the patients were Black (466/529) and the remaining
12% were Others. No difference in mortality rates were
found between the two groups. Male-to-female ratio was
1.17:1, with a higher mortality rate for males (52%, 148/
286). The mean BMI of patients was 30 kg/m2 (obese)
and no correlation with mortality was found. A majority
of patients (81%, 157/194) never smoked and, while not
statistically significant, mortality rate increased with any
history of smoking (Table 1).
Presenting signs and symptoms, comorbidities, and pre-
admission medication
Presenting patient complaints, grouped based on sys-
temic symptoms, were fever (42%), respiratory (76%;
cough, shortness of breath), gastrointestinal (21%; diar-
rhea, vomiting), and neurological (16%; altered mental
status, seizure, unresponsiveness).
Comorbidities were present in 98% (517/529) of pa-
tients (Table 2). The most common comorbidities were
hypertension (HT) (79%, 416/517) and diabetes mellitus
(DM) (56%, 289/517), followed by chronic kidney disease
(CKD (17%, 84/504)), (%,), hyperlipidemia (16%, 82/529),
end stage renal disease (ESRD) (10%, 50/504), history of
cancer (9%, 43/496), coronary artery disease (CAD) (8%,
42/529), chronic obstructive pulmonary disease (COPD)
(7%, 36/481), and asthma (6%, 30/475). These comorbid-
ities showed correlation with increased mortality except
for HT. Autoimmune diseases (37/495) did not affect
outcomes (Table 2). Patients with CKD on dialysis (2%,
33. 11/504) showed lower mortality (P = 0.06) than counter-
parts with CKD without dialysis (14%, 73/504). Patients
with ESRD (all on dialysis) showed a significantly higher
survival in univariate analysis (P = 0.02) (Table 2). These
results are notable considering patients with CKD and
ESRD suffered higher mean number of comorbidities
(mean 4.2) than other patients (mean 3.3, P < 0.001).
In multivariate analysis, age > 60 years and CAD were
independent predictors of mortality. CKD patients who
did not receive dialysis had a greater chance of death
than those who were dialyzed (P = 0.15, OR, 1.54), and
ESRD patients on dialysis had a lower risk of death (P =
0.07, OR, 0.52) (Fig. 2). Multivariate analysis (model 2)
shows that patients who have CKD and/or ESRD as a
comorbidity have a higher mortality, however, if dialysis
is introduced as an intervention they have a significant
survival advantage (P = 0.004) (Suppl. 1). Cox propor-
tional hazards analysis for time to death showed that
Gupta et al. BMC Infectious Diseases (2021) 21:78 Page
3 of 11
Table 1 Demographic characteristics and outcomes of Covid-19
patients admitted for treatment. The number and percentage of
patients for each variable are provided in columns “survivor”
and “non-survivor”. The P values are based on comparisons
between
“survivor” and “non-survivor” patients. BMI, body-mass index;
CI, confidence interval
Variable Patients Survivors Non-survivors Odds Ratio (95% CI)
P value
35. Smoking Status no./total no. (%) no. (%) no. (%)
Non-smoker 161/200 (81) 82 (51) 79 (49) 0.74 (0.34–1.59) 0.47
Past/current smoker 39/200 (19) 17 (42) 22 (58) 1.34 (0.62–
2.90) 0.47
Fig. 1 In-hospital mortality of COVID-19 patients in different
age groups. The number of patients in each age-group are shown
above the bars
Gupta et al. BMC Infectious Diseases (2021) 21:78 Page
4 of 11
Table 2 Comorbidities among Covid-19 patients admitted for
treatment. The number and percentage of patients for each
variable
are provided in columns “survivor” and “non-survivor”. The P
values is are based on comparisons between “survivor” and
“non-
survivor” patients. CKD, chronic kidney disease; COPD,
chronic obstructive pulmonary disease; ESRD, end-stage renal
disease
Comorbidities All Patients
no./total (%)
Survivors
no. (%)
Non-survivors no. (%) Odds Ratio
(95% CI)
P value
37. 0.102
All patients
≥ 1 Comorbidities
517/529 (98) 271 (99) 246 (96) – –
Fig. 2 Multivariate logistic regression analysis of the
demographic characteristics and comorbidities for mortality.
The presented odds ratios have
been adjusted for multiple testing. CKD, chronic kidney
disease; COPD, chronic obstructive pulmonary disease; ESRD,
end-stage renal disease
Gupta et al. BMC Infectious Diseases (2021) 21:78 Page
5 of 11
COPD/Asthma had a significantly higher hazards ratio
for death (HR:1.79; CI: 1.20, 2.68; P = 0.005), and that
pre-admission ACE inhibitors (20%, 29/142) and ARBs
(25%, 35/142) had a beneficial effect (P = 0.013 and
0.036, respectively).
Complications during clinical course in 312 patients
were acute hypoxic respiratory failure (37%), AKI (15%),
cardiogenic shock (18%), neurological shock (5%), sepsis
(4%), and diabetic ketoacidosis (3%).
Laboratory data
At admission and at 48–96 h, leukocyte (8.6 K/μL, 10.6
K/μL) and neutrophil counts (7.3 K/μL, 8.9 K/μL) were
higher (P < 0.001) and lymphocyte counts (0.8 K/μL)
were lower at 48–96 h (P = 0.003) for non-survivors. The
median neutrophil:lymphocyte ratio (NLR) was higher
38. both at admission and at the second time point in pa-
tients who did not survive (8.3,10, P < 0.001). Platelet
and hemoglobin were marginally decreased but were not
significantly different in survivors and non-survivors.
Blood urea nitrogen (BUN) (33, 38 mg/dL), creatinine
(1.7, 1.6 mg/dL), glucose (182, 163 mg/dL), alkaline
phosphatase (66, 75 U/L), and aspartate aminotransfer-
ase (AST) (52, 64 μ/L) levels were higher in non-
survivors at both time points (P < 0.001). Bilirubin and
total protein were mildly increased in non-survivors, but
were within their respective reference ranges. Albumin
(3.4, 2.8 g/dL) was lower for non-survivors at both time
points (P < 0.001). Lactate dehydrogenase (551, 638 U/
L), C-reactive protein (180, 283 mg/L), and procalcitonin
(1.03, 1.68 ng/mL) showed significantly higher serum
levels at admission and at 48–96 h (P < 0.05) for non-
survivors. D-dimer (3.0 mcg/mL, 7.5 times elevation),
prothrombin time (PT) (17.2 s), and international nor-
malized ratio (1.4 U) were increased in non-survivors at
the second time point (P < 0.05). Activated partial
thromboplastin time (aPTT) was not found to be differ-
ent in the two groups (Table 3).
Outcomes
Of the 529 hospitalized patients evaluated, 274 survived
and 255 (48%) died by the end of the study. Of the 529
patients examined, 159 received invasive mechanical
ventilation, of which 137 (86%) died. The remaining 370
patients who received supplemental oxygen therapy via
non-invasive mode 123 (23%) died. This also included
patients who self-declared “Do Not Intubate” (DNI), “Do
not Resuscitate” (DNR) or came to the hospital in severe
respiratory distress and died within the first few hours of
admission. Of the patients who died, 36% (92/255) died
in the first 3 days, which was similar for both Blacks (78/
218) and Others (13/34) (Fig. 3). Patients who survived
39. remained hospitalized from 1 to 37 (median: 6) days,
and those who died were hospitalized from 0 to 47
(median: 5) days. Median time to death for mechanically
ventilated patients was 5 days (range: 0–33) days, while
for non-ventilated patients it was 4 (range: 0–47) days
from admission.
Discussion
This study documents the demographic, clinical features,
and outcomes for patients admitted with COVID-19 at
an urban hospital located in an underserved majority-
Black neighborhood. We also identify indicators avail -
able to physicians at two early time points of evaluation
to predict outcomes and develop management plans for
appropriate levels of care.
The Black patient population in our study faces unique
obstacles such as linguistic and cultural barriers to care
and understudied comorbidities [13, 14]. Despite reports
that African-Americans face significantly greater mortal-
ity from COVID-19, recent studies have examined the
clinical outcomes in largely East-Asian or Caucasian co-
horts [13]. Here, we present an analysis of 529 patients
admitted with COVID-19, over a 52-day period at the
height of the pandemic in New York City, and have ei-
ther been discharged or died.
Older age at admission correlated with higher mortal-
ity rate, with the 60+ year age group most at risk, and
was an independent risk factor for mortality. Males suf-
fered significantly higher mortality than females, despite
identical representation at admission. Recent reports of
high plasma concentrations of ACE-2, a receptor for
coronavirus, in men may account for higher mortality
[15]. Our inpatient population had a mean BMI in the
40. “obese” range, higher than the national average; this
finding mirrors higher BMI amongst the Black popula-
tion nationwide [16] However, BMI was not a predictor
of survival; higher BMIs were more commonly seen
amongst younger patients. Smoking was less prevalent in
our patient population than the national average; 4%
were current smokers and 15% had quit [17]. We found
smoking to be unrelated to poor outcome.
The majority (88%) of our patients were Black. Race was
not an independent prognostic factor for survival; higher
mortality in our patient population can be attributed to a
greater number and prevalence of comorbidities common
amongst this group. Comorbidities were present in 98% of
our patients, and the presence of any comorbidity was a
strong predictor of mortality, as noted in other recent
studies [18–20]. HT and DM were the two most prevalent
preexisting conditions; prevalence of HT (79%) and DM
(56%) was considerably higher than previously reported
(up to 63 and 36%, respectively) [21–23]. In the multivari-
ate analysis, coronary artery disease was strongly associ -
ated with adverse outcome (OR,2.38 CI, 1.11–5.50, P
0.03), followed by DM (OR, 1.22, CI, 0.81–1.84, P = 0. 35).
A 2.5-fold increase in the risk of mortality from COVID-
Gupta et al. BMC Infectious Diseases (2021) 21:78 Page
6 of 11
Table 3 Laboratory data of 286 inpatients at admission and at a
secondary time point between 48 and 96 h of admission. Median
and interquartile ranges are presented. The P value is calculated
between patients who survived and did not survive. aPTT,
activated
partial thromboplastin time; Alk Phosphatase, alkaline
41. phosphatase; ALT, alanine aminotransferase; AST, aspartate
aminotransferase;
BUN, blood urea nitrogen; CI, confidence interval; CRP, C-
reactive protein; INR, international normalized ratio; LDH,
lactate
dehydrogenase; PT, prothrombin time
Laboratory values
(reference range)
Time of
determination
(n)
Survivors Non-survivors 95% CI P
value
Median (Inter Quartile Range)
Hematologic parameters
Hemoglobin
(12–16 g/dL)
At admission (286) 12.3 (11.0–14.0) 12.7 (11.3–14.3) −0.9 - 0.1
0.13
48–96 h (228) 12.0 (10.15–13.1) 11.7 (10.5–13.3) −0.6 - 0.5
0.83
Leukocyte count
(3.5–10.8 K/μL)
At admission (285) 7.2 (5.4–9.3) 8.6 (6.4–11.3) −2.3 - -0.7 <
0.001
45. on admission (284) 40 (26–65) 52 (38–83) − 19.0 - -5.0 < 0.001
48–96 h (224) 49 (28–66) 64 (37.7–106.2) − 29.0 - -8.0 < 0.001
ALT
(7–52 μ/L)
on admission (284) 24 (16–38) 29 (19–44) − 7.0 - 0.1 0.11
48–96 h (224) 28 (17–52) 34 (22–57) − 10.0 - 2.0 0.22
Alk Phosphatase
(34–104 U/L)
on admission (284) 64 (49–78) 66 (54–96) − 15.0 - -1.0 0.02
48–96 h (223) 59 (46–78) 75 (52–111) − 27.0 - -7.0 < 0.001
Bilirubin
(0.3–1 mg/dL)
on admission (280) 0.5 (0.4–0.8) 0.6 (0.5–0.8) − 0.1 - 5.0e-5
0.28
48–96 h (219) 0.5 (0.4–0.8) 0.7 (0.5–.9) − 0.2 - -5.4e-5 0.002
Gupta et al. BMC Infectious Diseases (2021) 21:78 Page
7 of 11
19 in hypertensive patients has been reported, however,
this was not discernable in our patients [22]. Although
past history of cancer, HT, autoimmune diseases, and im-
munosuppression were not independent predictors of
46. mortality, the combined effect of these comorbidities on
multiple organ systems and resultant dysregulation of the
immune system likely increases susceptibility to COVID-
19 [23, 24].
A notable finding in multivariate analysis was that pa-
tients with CKD who were dialyzed early in the course
of treatment had better outcomes than those who did
not (2%, OR, 0.27, CI, 0.04–1.11, P = 0.10). Although not
statistically significant, we speculate that a larger number
of patients with CKD on dialysis (currently n = 11)
would allow for a definitive conclusion. These findings
are notable considering patients with CKD had more co-
morbidities as compared to all other patients in the
study. Early dialysis stands out as a potentially beneficial
treatment option for patients with CKD. It is likely that
dialysis removes inflammatory mediators, cytokines, and
other effector molecules responsible for the end-organ
damage. CKD and ESRD were more prevalent in our pa-
tient population (26%) than reported in other studies
(between 3 to 8.5%), most likely due to complications
from HT and DM [25].
We found laboratory data at admission vital for triaging
patients to receive intensive care. CRP, LDH, and procalci -
tonin were significantly increased at both admission and
at 48–96 h in non-survivors. Indicators of AKI, elevated
levels of BUN, creatinine, glucose, and reduced levels of
bicarbonate or albumin were significant predictors of ad-
verse outcome at both initial and secondary time points.
These findings correlate with reported tubular, endothe-
lial, and glomerular capillary loop injury, likely the result
of direct injury or systemic hypoxia [26]. Hypoproteinemia
and hypoalbuminemia in non-survivors may result from
renal insufficiency and suboptimal nutritional status in
47. critically-ill patients, or could reflect stressed state [25]. As
Table 3 Laboratory data of 286 inpatients at admission and at a
secondary time point between 48 and 96 h of admission. Median
and interquartile ranges are presented. The P value is calculated
between patients who survived and did not survive. aPTT,
activated
partial thromboplastin time; Alk Phosphatase, alkaline
phosphatase; ALT, alanine aminotransferase; AST, aspartate
aminotransferase;
BUN, blood urea nitrogen; CI, confidence interval; CRP, C-
reactive protein; INR, international normalized ratio; LDH,
lactate
dehydrogenase; PT, prothrombin time (Continued)
Laboratory values
(reference range)
Time of
determination
(n)
Survivors Non-survivors 95% CI P
value
Median (Inter Quartile Range)
Total protein
(6–8.3 g/dL)
on admission (282) 7 (6.5–7.3) 6.7 (6.4–7.2) −2.6e-5 - 0.3 0.12
48–96 h (219) 6.2 (5.9–6.6) 6 (5.5–6.7) − 6.0e-5 - 0.4 0.10
Albumin
(3.5–5.7 g/dL)
50. 48–96 h(43) 13.1 (11.9–15.2) 17.2 (13.3–20.2) 4.94e-5 - 6.7
0.04
INR (1 U) on admission (113) 1.1 (1.0–1.1) 1.1 (1.0–1.3) −
7.12e-6 - 0.10 0.07
48–96 h (41) 1.0 (1.0–1.2) 1.4 (1.1–1.6) 7.49e-6 - 0.50 0.02
Gupta et al. BMC Infectious Diseases (2021) 21:78 Page
8 of 11
reported elsewhere, we found hyperglycemia to be a pre-
dictor of adverse outcome in COVID-19 patients, regard-
less of their history of diabetes [27]. Multivariate analysis
of laboratory data was not performed due to sample size
limitations.
Peripheral blood analysis showed that a high median
NLR at admission and at 48–96 h was an independent
predictor of adverse outcome in COVID-19 patients, as
had been reported in other studies [28]. The presence of
COVID-19 associated coagulopathy (CAC), a condition
characterized by elevation in fibrinogen and D-dimer
levels, high PT, relatively normal aPTT, and mild
thrombocytopenia without evidence of microangiopathy,
was confirmed in our study [29]. The mechanisms
underlying CAC remain poorly understood, but it can
possibly result from activation of extrinsic coagulation
pathway, leading to excess consumption of Factor-VII
following endothelial cell infection by the virus [30, 31]
Elevated D-dimer levels at the second evaluation time
point were associated with higher mortality, likely
reflecting coagulation activation from sepsis, “cytokine-
storm”, or impending organ failure.
51. By the end of our study, 48% of the inpatients had
died, including 86% who received invasive mechanical
ventilation. Reported mortality rates from other retro-
spective cohort studies ranged from 21% (New York
metropolitan area) to 26% (Lombardy region, Italy) and
33% (UK) [4, 6, 32]. Relative to other studies, the mortal -
ity rate among our patients was elevated, which we be-
lieve is due to the largely poor and disadvantaged
neighborhood where our hospital is located. Race was
not found to be an independent predictor of mortality.
Patients from similar underprivileged communities tend
to present at an advanced stage of the disease leading to
increased morbidity and mortality [33]. Rate ratios of
hospital admission and mortality in US patients show a
4.7 and 2.1 times higher prevalence among Blacks as
compared to Whites [34].
Our patients from a minority and underserved popula-
tion had an unusually high burden of co-morbidities
some of which proved to be independent predictors of
the observed in-hospital high mortality; 1/3 of the pa-
tients died within the first 3 days of admission. We
found some of the early laboratory data, together with
demographics and co-morbidities, pivotal in predicting
the clinical course of COVID-19. Early institution of dia-
lysis in patients with chronic renal insufficiency reduced
mortality significantly.
Our study has limitations. It examined a predomin-
antly Black patient cohort, which makes comparisons to
other races and ethnicities difficult to quantify. This
study was carried out on patients admitted at the height
Fig. 3 Days from admission to death of 255 consecutive
52. inpatients. More than one third of patients (92/255) died within
3 days of admission for
both Blacks (78/218) and Others (13/34)
Gupta et al. BMC Infectious Diseases (2021) 21:78 Page
9 of 11
of the pandemic in New York City, admissions were re-
stricted to the most seriously ill and hospital resources
were under strain, which may have contributed to an in-
crease in overall mortality rates. Initiation of dialysis
during admission occurred at the discretion of treating
physicians, and there may be unmeasured differences be-
tween patients started on dialysis and those not-started
on dialysis that are not accounted for in this analysis. As
knowledge and understanding of COVID-19 was devel-
oping during March and April, complete laboratory
studies were not systematically ordered for all patients.
The routine use of steroids and Remdesivir were not
established yet during the time of this study and so these
findings, particularly the mortality rate, should be taken
in that context. BMI was not included in the multivari-
ate regression model as BMI was available in only a sub-
set of patients.
Conclusions
In our predominantly Black cohort we have recorded an
in-hospital mortality rate from COVID-19 which is sig-
nificantly greater than that reported in other studies.
While race was not an independent predictor of death,
this population had a greater burden of comorbidities
than the national average and the prevalence of these
chronic comorbidities contributed to both disease sever -
ity and higher mortality. Our study identified that early
53. escalation of care is important in patients from minority
neighborhoods as one third of the admitted patients die
within the first 3 days of admission. Laboratory indica-
tors at admission are predictors of outcome and can be
utilized by physicians to triage patients and monitor dis-
ease course Early institution of dialysis in patients with
chronic renal insufficiency trended toward association
with lower mortality.
Supplementary Information
The online version contains supplementary material available at
https://doi.
org/10.1186/s12879-021-05782-9.
Additional file 1: Suppl 1. Multivariate logistic regression
analysis of
the demographic characteristics and comorbidities for mortality.
Dialysis
has been added as a covariate for patients with ESRD and CKD.
The
presented odds ratios have been adjusted for multiple testing.
CKD,
chronic kidney disease; COPD, chronic obstructive pulmonary
disease;
ESRD, end-stage renal disease.
Acknowledgements
Not applicable.
Authors’ contributions
RG and MAH conceived and designed the study. RG, RA, and
MAH designed
the statistical analysis plan. RG, RA, and MAH analyzed the
data and
developed the figures and Tables. RG, ZB, AJ, DW, JD, MA,
and DYE collected
54. data from electronic health records. CFB, JL, RC, and AB
provided clinical
consultation throughout the study course. All authors
contributed
intellectual content during the drafting and revision of the work
and
approved the final version.
Funding
Not applicable.
Availability of data and materials
The datasets used and/or analyzed during the current study are
available
from the corresponding author on reasonable request.
Ethics approval and consent to participate
SUNY Downstate Institutional Review Board (IRB) approved
the study
[1587476–1]. SUNY Downstate IRB granted waiver of consent
to access raw
patient database mentioned in the methods.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1SUNY Downstate Medical Center, Departments of Pathology
and Cell
Biology, 450 Clarkson Ave. MSC #37, Brooklyn, NY 11203,
USA. 2Department
of Pathology, SUNY Downstate Medical Center, Brooklyn,
USA. 3Department
55. of Surgery, SUNY Downstate Medical Center, Brooklyn, USA.
4Division of
Cardiology, Department of Medicine, SUNY Downstate Medical
Center,
Brooklyn, USA. 5Department of Anesthesiology, SUNY
Downstate Medical
Center, Brooklyn, USA. 6Division of Pulmonary Medicine and
Critical Care,
Department of Medicine, SUNY Downstate Medical Center,
Brooklyn, USA.
Received: 6 July 2020 Accepted: 11 January 2021
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detailsReferencesPublisher’s Note
African Americans and COVID-19: Beliefs, behaviors and
vulnerability to
infection
Elyria Kempa, Gregory N. Pricea, Nicole R. Fullera and Edna
Faye Kempb
aCollege of Business Administration, University of New
Orleans, New Orleans, LA, USA; bKemp Dentistry,
Indianapolis, IN, USA
ABSTRACT
In the United States, during the early outbreak of the
coronavirus (COVID-19) pandemic, African
Americans experienced disproportionately high rates of
infection and mortality relative to their
share of the United States population. New Orleans, Louisiana
64. was one of the places most
heavily affected by the coronavirus during its early outbreak.
The study that follows explores
the attitudes of African Americans in New Orleans toward the
virus, social and normative
conditions which affected individual behaviors, as well as
access to healthcare services and
COVID-19 testing. In part one of the study, qualitative
responses were collected from a
sample of African Americans in the New Orleans area to garner
perspective about their
attitudes and behaviors related to the coronavirus outbreak. Part
two of the study builds on
findings from Study 1 with parameter estimates from a Logit
regression to examine how
social, economic and physical conditions determine
vulnerability to COVID-19 infection
among African Americans. Implications for how healthcare
organizations can address the
needs of vulnerable populations during a health-related crisis
are discussed.
ARTICLE HISTORY
Received 13 May 2020
Accepted 22 July 2020
KEYWORDS
Health equity; Social
determinants of health;
African Americans; COVID-19;
Theory of planned behavior
In 2020, the World Health Organization declared the
novel coronavirus, or COVID-19, a global health emer-
gency as it spread ferociously across the globe [1]. The
first confirmed case of the virus appeared in January
65. 2020 in the United States [2]. Within months, the
virus sickened many and resulted in thousands of
deaths.
As more data emerges regarding the impact of
COVID-19 in the United States, it has become evident
that the virus has affected racial and ethnic minorities
at an alarmingly high rate. Specifically, African Amer-
icans have experienced disproportionatel y higher rates
of infection and mortality than their representative
share of the United States population [3,4]. In early
May 2020, African Americans accounted for approxi-
mately 34% of total COVID-19 deaths in states where
they represent only about 13% of the state’s population
[3]. Some states reported even more egregious dispar-
ities. For example, in Louisiana blacks accounted for
70% of the deaths from COVID-19, but only 33% of
the population. Similarly, in Alabama, blacks
accounted for 44% of COVID-19 deaths, yet only
make up 26% of the state’s population [5].
Some officials have linked the disproportionate
numbers regarding the effect of the virus on African
Americans to individual behavior (i.e. including practi -
cing unhealthy behaviors and suffering from comor-
bidities which make the coronavirus more deadly)
[6]. However, the situation is likely more nuanced.
African Americans are more likely to work in service
sector jobs and were deemed ‘essential workers’ during
the coronavirus outbreak [7]. In larger urban areas,
they are also are more likely to use public transit – all
which place them in closer contact to others and
make them more susceptible to the virus [6].
This research examines the attitudes, behaviors as
67. http://crossmark.crossref.org/dialog/?doi=10.1080/20479700.20
20.1801161&domain=pdf&date_stamp=2020-11-09
mailto:[email protected]
http://www.tandfonline.com
address the needs of vulnerable populations during a
health-related crisis are discussed.
Conceptual background
Individual behavior – attitudes, beliefs and
norms
During the early months of the coronavirus outbreak, a
significant part of containing the spread of the virus in
the United States involved following the guidelines
proposed by the Centers for Disease Control and Pre-
vention (CDC) and the White House Coronavirus
Taskforce. During March 2020, these guidelines
included avoiding social gatherings of 10 or more
people; social distancing by remaining at least 6 feet
from others in public spaces; using drive-thru, pick-
up or delivery options at restaurants and grocery stores;
avoiding discretionary travel, not visiting nursing
homes or long-term care facilities unless providing
critical assistance; and finally, practicing good hygiene,
such washing hands, avoiding touching the face, sneez-
ing or coughing on a tissue or into the elbow, and dis-
infecting surfaces (note: wearing face masks were not
recommended until April 2020) [2,9]. Government
and private entities disseminated messaging in various
media encouraging the practice of these behaviors to
help mitigate the spread of the virus.
68. According to the psychology literature, one’s atti-
tudes and beliefs are linked to whether one will practice
a certain behavior. For example, in the theory of
planned behavior (TPB) there are three determinants
of behavioral intention – attitude toward the behavior,
subjective norms, and perceived behavioral control
[10]. Attitudes toward the behavior address the extent
to which a person has a favorable or unfavorable
appraisal of the behavior in question. Subjective
norms are social variables that reflect the perceived
social pressure to perform or not to perform the behav-
ior. Finally, perceived behavioral control addresses the
perceived ease or difficulty in performing the behavior
and captures past experiences as well as anticipated
obstacles. The more favorable the attitude and subjec-
tive norms regarding the behavior, and the greater the
perceived behavioral control, the stronger an individ-
ual’s intention to perform the behavior in question
[10,11].
To a considerable degree, individual behavior in
adhering to the guidelines and directives of govern-
ment officials and health experts would impact the pro-
liferation of the coronavirus and the likelihood of being
infected with the virus. Thus, intentions to practice rec-
ommended behaviors to contain the virus might be
determined by considering the attitudes of individuals
about the severity of the virus and the need to control
the spread as well as social and normative pressures to
perform or not perform the recommended behaviors.
In addition, examining the perceived difficulty individ-
uals had in not practicing recommended behaviors (e.g.
having to leave home for work or to care for a loved
one) might also play a factor.
69. Access to health services
In addition to considering individual behavior, both
access to healthcare and the quality of health services
can influence health. Lack of access to quality health
services can affect an individual’s health status. For
example, due to limited availability to healthcare, an
individual may be less likely to participate in preventive
care as well as delay medical treatment [12].
Public health practitioners and policy makers are
beginning to consider the broader determinants of
health as part of a more inclusive approach to improv-
ing health [13]. For example, social determinants of
health are social factors and physical conditions in
the environment which impact health status and sub-
jective wellbeing. Social determinants of health are
also affected by the availability of resources to meet
daily needs, such as educational and job opportunities,
living wages, healthy foods, discrimination, social sup-
port, exposure to mass media and emerging technol-
ogies, socioeconomic conditions and transportation
options [14–16]. Addressing social determinants of
health is essential to eradicating systematic disparities
in health and achieving health equity. Health equity
is when everyone has the opportunity to realize their
full health potential, barring the inability to do so
because of social position or other socially determined
circumstances [17].
With respect to COVID-19, individual behavior,
which included adhering to the guidelines delineated
by the CDC and the White House Coronavirus Task-
force, played a central role in reducing infection
rates. As literature from the behavioral sciences
suggests, such behavior may be predicated on an indi-
70. vidual’s attitudes toward the behavior, social pressures,
and elements within the individual’s control to perform
the behavior [10]. In addition, social, economic and
physical conditions as they relate to access to quality
healthcare can play a role in virus detection, treatment
as well as mortality rates from the virus. The study
which follows first examines the attitudes and beha-
viors of African Americans in New Orleans as they
relate to COVID-19. It then explores how social, econ-
omic and physical conditions are related to access to
healthcare services and COVID-19 testing.
Study part I: Beliefs and behaviors
Methodology
The research participants in this study were African
Americans who reside in New Orleans. African
304 E. KEMP ET AL.
Americans comprise about 59% of the population in
New Orleans [18]. We enlisted Qualtrics, a professional
research firm for our data collection efforts. Enforced
quota constraints were applied in our sampling with
the goal of attaining a research panel demographically
representative of African Americans in the city of New
Orleans. Following appropriate ethical research
approval (from the Institutional Review Board),
responses were collected online from a panel consisting
of 104 participants from 11–22 April 2020. Sixty-seven
percent of participants were female and thirty-three
percent were male. The mean age was 40 and 35% of
participants self-reported as ‘essential workers’ during
71. the coronavirus outbreak (see Table 1). Participants
were asked questions concerning their attitude toward
the virus, normative and economic conditions which
may have affected their ability to comply with direc-
tives of government officials, as well as their percep-
tions regarding healthcare access.
Our data analysis enlisted a form of content
analysis where themes were identified using a cod-
ing process. The goal of this approach was to recog-
nize themes based on the experiences and
observations of participants [19]. We independently
performed a comprehensive assessment of the data
and developed themes. Next, using an iterative,
back-and-forth reading process [19,20] we achieved
general consensus on themes which repeatedly
appeared across participants’ responses. The follow -
ing are emergent themes which were consistent with
the responses from the participants. Participants
were assigned aliases.
Results: Thematic findings
Attitudes toward the virus and susceptibility
Attitudes are an organization of beliefs, feelings, and
behavioral tendencies towards significant objects,
groups, events or symbols [21]. Knowing a person’s
attitude helps predict their behavior. Many of the
respondents in our research acknowledged the serious-
ness of the coronavirus. As a result, they expressed that
they were making efforts to safeguard themselves from
possible infection. This sentiment was echoed in the
comments of many participants.
“COVID is a serious virus. I’m hoping that I don’t
catch it … but I am taking all the precautions to
72. protect myself.” Mary, 61, Educator
“Since I am at high risk, I really practice social distancing
and avoid all risky situations. As a private nurs,e I
only have one patient for the patient’s safety as well
as mine. My siblings also take care with associations
and practice hand safety.” Jackie, 66, Nurse
Unfortunately, some participants had lost loved
ones to COVID-19. They also expressed how the health
crisis was taking a toll on them emotionally.
“I have had at least two emotional breakdowns. It
takes a lot to remove the focus off the crisis and refo-
cus on other things.” Marguerite, 60, PBX Operator
However, younger respondents were more optimistic
about their vitality, and felt less susceptible to the virus.
“My family and I are very healthy. We have a very
[strong] immune system. So we aren’t very likely
to catch COVID-19.” Lakeisha, 21, Cashier
Attitude toward government leaders and health
experts
People expect their leaders to be consistent and model
what they advise for their constituents [22]. During the
coronavirus outbreak, trust was an important factor as
people looked to their leaders for knowledge and infor-
mation. Trust embodies a dynamic, relational link
between people and is meaningful in situations in
which one party is at risk or vulnerable [23]. Many
respondents had mixed feelings about leadership, indi -
cating some confidence in state and local political
officials, while expressing distrust in federal leadership.
73. “I don’t trust anyone implicitly, especially politicians! I
trust the mayor to give as much info as she can give
without causing a panic. I see how she is trying to
do as much as she can. I trust the governor as
much as I can. I see where he is trying … .As far
as federal leaders, I don’t trust them at all. Most
of what they say and do is self-serving …” Evelyn,
70, Retired Administrative Assistant
Table 1. Summary of respondents’ demographics.
Count Proportion Average
Observations 102
Male 33 32%
Age 40
18–39 53 52%
40–59 25 25%
≥60 23 23%
Single 64 63%
Education
Some high school 6 6%
High school diploma 21 21%
Some college 24 24%
College degree 27 26%
Post-grad degree 24 24%
Income $36k–$50k
≤ $25k 41 40%
$26k- $50k 24 24%
$51k- $75k 17 17%
$76k - $150k 14 14%
≥ $151k 5 5%
Essential worker 36 35%
Unemployed 21 21%
74. Top Industries
Arts & Entertainment 12 12%
Education 10 10%
Restaurants 8 8%
Healthcare 8 8%
Social Services 3 3%
INTERNATIONAL JOURNAL OF HEALTHCARE
MANAGEMENT 305
“It’s hard to trust … I admire the job that our Mayor is
doing … Not hearing too much from the Gover-
nor. The president is trying, but he lies so much
…” John, 48, Longshoremen
Participants appeared to have more trust in health
experts and expressed sympathy and gratitude towards
front-line healthcare workers.
“I do trust the health officials. They are working under
harsh situations with limited supplies to help and
heal others. They are putting their own life and
their families in danger of the virus. They want
this to end much more than we do. I trust they
are trying to find a cure to protect us in the future.”
Sheila, 52, Educator
However, participants did exhibit some frustration
with the information they were receiving from health
officials. They acknowledged that there had been a
fair amount of equivocation regarding best practices
to combat the virus. In some ways, a modicum of dis-
trust existed with the way some things had been
handled during the nascent stages of the virus out-
75. break. Nonetheless, many conceded to the reality that
circumstances were novel, and that health experts
were learning new things daily.
“I know they are learning more about it every day given
that this disease hasn’t been seen before, but they
need to get their facts straight. They’re constantly
giving out information that contradicts infor-
mation they gave out previously. We’ve seen time
and time again with any infectious disease that
masks have been used to contain the spread, but
because they can’t afford to have enough mass pro-
duced for every single person they are telling us
that we don’t need them. They’ve let weeks and
weeks go by without it being required.” Carrie,
25, Self-Employed
“Most of the information [from healthcare experts] I
trust, but who knows what to believe.” Tammy, 21
Because attitudes provide meaning and knowledge,
understanding attitudes can predict behavior. Many
of the participants in this research recognized the ser-
iousness of the coronavirus. However, there were
some participants, primarily younger adults (ages 35
and under), who were not convinced about the ferocity
of the virus. Furthermore, leadership during crisis
moments plays an important role. During uncertain
times, informed and trustworthy leadership is para-
mount. Participants had a measure of distrust and
cynicism toward federal political leaders. However,
many trusted the leadership at the local and state
level. They also looked to health experts for advice
while acknowledging that the situation was fluid.
Social norms and social distancing
76. Subjective or social norms are variables which refer to
the belief that an important person or group of people
will approve and support a certain behavior [10,24].
Subjective norms can be measured and accessed from
the perspective of expectations set by referent groups
such as family, relatives, and friends, in terms of
whether an individual should or should not engage in
a behavior. Subjective norms may also include descrip-
tive norms, which refer to actual activities and beha-
viors others are undertaking [24]. In the case of
descriptive norms, individuals may not only be con-
cerned with what others think, but also with how
others behave.
Norms within New Orleans emphasize culture, tra-
dition and celebration. The city is known for the axiom
‘laissez les bons temps rouler,’ meaning ‘let the good
times roll.’ People in New Orleans are very ‘social.’ In
fact, the popular press has ranked New Orleans as
one of the friendliest cities in the United States
[25,26]. Given these social norms, maintaining physical
distance was challenging for some.
“I know for a fact that some are not social distancing. I
have spoken to friends who have been attending par-
ties, baby showers, crawfish boils, card games–all
with multiple people. They totally believe that the
virus is like the flu and they will recover if they get
it. It’s like they don’t know or care about the way
this virus affects us all.” Nancy, 47, Bank teller
“When I was in the store yesterday, people were walking
around like nothing is going on. A few of us had on
masks and long sleeves and so forth. But a large
group of people were out with no protection, with
kids running around and no protection, and not
77. adhering to any social distancing guidelines …”
Evelyn, 70, Retired Administrative Assistant
“People can say that they’re doing it, but actually aren’t
… like my neighbors playing basketball in the
street–between 8–12 guys … unbelievable...”
Diane, 62, Law Enforcement
One young adult participant was very candid about
his lack of effort to social distance.
“Not really [not social distancing],but it’s other people
opinion,” Carl, 21
Although several of the participants noticed that
other people were not social distancing, the majority
indicated that physical distancing had become the
‘new norm’ among family and friends.
“I call, email and text my friends and colleagues. My
children and grandchildren call me and text me.
They have not come over since March 13, 2020.”
Geraldine, 63, Educator
306 E. KEMP ET AL.
“The only thing I do is to go for a walk/jog, and I have
been to my students’ homes to leave a message on
their front porches and deliver Easter treats.”
Sheila, 52, Educator
Control limits and disparities
Perceived behavioral control addresses the perceived
ease or difficulty in performing a behavior and captures
78. anticipated obstacles. For some of the participants in
this research, self-isolation was infeasible. Specifically,
Americans were advised to work from home during
the early stages of the coronavirus outbreak; however,
according to the Economic Policy Institute, only 19.7
of African American have jobs which allow them to
work from home [27]. In our study, 35% s of partici-
pants self-reported as ‘essential workers.’ Subsequently,
some were working away from home during the
outbreak:
“My job is considered essential, but … precautions are
being taken.” John, 48, Longshoremen
Moreover, and unfortunately, income and race play
a role in determining who uses New Orleans’s public
transit systems to travel to work. In New Orleans,
91% of White/Caucasian households have at least one
car, compared with just 74% of African American
households [28]. Reliance on public transit further
decreases the likelihood of social distancing.
During the outbreak, older adults were advised to
self-isolate [29]. This included grandparents isolating
themselves from grandchildren. In New Orleans,
12.2%of African Americans 60 years and older live in
multigenerational households, compared to 3.8% of
white elders [30]. Such living conditions, where grand-
parents live with their grandchildren, might make them
more susceptible to COVID-19. One of our partici-
pants addressed this reality.
“Since I am elderly and in only fair health, I believe that
I could get the virus. I worry about my kids and
grandkids since I do have contact (at home) with
them.” Linda, Retired, 62
79. Health services. Given African Americans’ dispropor-
tionate COVID-19 infection and mortality rates, par-
ticipants in this research were asked about their
personal access to health care as well as their percep-
tion of the quality of healthcare they receive. In 2016,
Louisiana accepted Medicaid expansion (created in
the Patient Responsibility and Affordable Care Act
passed by the U.S. Congress in 2010). Louisiana’s Med-
icaid expansion program provided health insurance for
non-elderly adults with income less than 138% of the
Federal Poverty Level. As a result of the expansion pro-
gram, the uninsured rate in Louisiana fell by half –
from 22.7% to 11.4% – from 2015 to 2017 [31,32].
While Medicaid expansion was instrumental in extend-
ing access to healthcare, participants still questioned
the quality of care and health equity for African
Americans.
- “I am aware that some do not [receive the same level
of care as others]. I have private insurance. I
worked in health care. I see the bias shown to
the poor, homeless, mentally challenged, those
with addictions, overweight …” Harriet, 48,
Retired Healthcare Worker
- You get turned away when you can’t pay or you’re
sent to lower quality hospitals. Iris,34, Bartender
Some specifically felt that health inequities exist.
“I’m Black and people seem to not take my words as
seriously as others–even when I’m suffering.” Samuel,
29, Hospitality
80. “I do believe that black women have to be aggressive
about their healthcare. I have had to make sure I
bring questions with me to all my doctor visits.
Some important information is sometimes left out of
the visit. Seemingly, if I don’t ask, the doctor won’t
tell me all of the information I need.” Kay, 55,
Administrator
In summary, behavior may be predicated on an indi-
vidual’s attitude toward a behavior, social pressures,
and elements within the individual’s control to perform
the behavior [10]. The first part of this study examined
the attitudes and behaviors of African Americans in
New Orleans during the early outbreak of the corona-
virus. Many of the participants recognized the serious-
ness of the coronavirus. However, there were some
participants, primarily younger adults (ages 35 and
under), who were not compelled by the seriousness
of the virus. Furthermore, during the early stages of
the coronavirus outbreak, trust from leadership was
an important factor as people looked to their leaders
to shape attitudes about the virus. Responses from par-
ticipants reveal a measure of distrust and cynicism
toward federal political leaders. However, many trusted
local leadership as well as the health experts.
The opinions and actions of others, or subjective
norms, also affect the behavior of individuals [10]. Par-
ticipants recounted instances where they noticed others
who were not physically distancing. Nonetheless, the
majority of the participants in this research indicated
that they were taking measures to physically distance.
The ‘norm’ had been set among family and friends to
engage in this behavior.
There were some participants in this research who
81. discussed how their circumstances did not permit
them to completely self-isolate. For example, some
respondents indicated that living in mutigenerational
housing or having to continue to go to their ‘essential’
INTERNATIONAL JOURNAL OF HEALTHCARE
MANAGEMENT 307
jobs exposed them to more people. Finally, the high
rate of African American mortality from COVID-19
was concerning for participants. At a macro level, par-
ticipants offered considerable discussion regarding the
state of healthcare for African Americans and ques-
tioned whether true health equity exists in commu-
nities. In the second part of our study, we examine
specific factors influencing access to healthcare and
health equity for African Americans in New Orleans
as it relates to COVID-19 testing.
Part II: COVID-19 testing in New Orleans
Methodology
In response to evidence that COVID-19 infections and
deaths have impacted African Americans disproportio-
nately [4,33,34], our survey data captured information
on individual characteristics that may be possible dri -
vers of racial disparities in COVID-19 infections. We
measured these individual characteristics to first deter-
mine, via a rigorous least absolute shrinkage and selec-
tion operator, or LASSO [35], the best predictors of
taking a COVID-19 test among survey respondents.
LASSO is a machine-learning algorithm to identify
regressors, via induction, that best explain/predict an
82. outcome – regressand – of interest [36].
Results
Table 2 reports the results of the predictive covariate
selection from the rigorous LASSO among all the
quantitative covariates in the respondent survey. We
used the RLASSO procedure in Stata 15 [37]. In gen-
eral, RLASSO selects regressors that minimize the
mean squared prediction error, subject to a penalty
on the absolute size of coefficient estimates. The pre-
dicted outcome of interest is a binary variable indicat-
ing whether a survey respondent was tested for
COVID-19. Among the quantitative covariates, the
RLASSO selected the respondent’s age, whether he/
she is an essential worker, and the respondent’s self-
reported health status as predictors.
Given the selected predictors, Table 3 reports par-
ameter estimates across five Logit specifications to
determine how these predictors matter for the prob-
ability of an individual having had a COVID-19 test.
We report Pseudo-R2 and the xs statistic for the joint
significance of all the parameters as goodness-of-fit
measures. To inform practical versus statistical signifi -
cance, we report parameters as an odds ratio, which
indicates the quantitative impact a regressor has on
the outcome of interest. An odds ratio less(greater)
than unity indicates that having a particular
Table 2. Rigorous Lasso variable selection.
Covariate Definition Selected
Age Age of respondent in years Yes
College Binary variable equal to No
83. unity if respondent has
a baccalaureate degree
Essential Worker Binary variable equal to Yes
if respondent is an essential worker
Health Respondent’s position in Yes
health quintile distributiona
Household Size Number of people in No
in respondent’s household
Male Binary variable equal to No
if respondent is a Male
Married Binary variable equal to No
if respondent is Married
Median Income Median Income in No
Respondent’s zip codeb
Notes: aDerived from respondent’s self-reported 1–10 health-
rating, with
10 being the highest-rated measure of health. For each
respondent,
the measure was converted to a position in a distribution of
quintiles.
bSource: https://www.incomebyzipcode.com/louisiana/70119.
Table 3. Logit odds ratio parameter estimates: COVID-19
testing in Orleans Parish.
Specification (1) (2) (3) (4) (5)
Regressand: Respondent has been tested for COVID-19
84. Regressors:
Constant .467 .552 .466 .467 .466
(.706) (.775) (.613) (.577) (.317)
Age .971 .969 .971 .971 .971
(.240) (.186) (.322) (.106) (.314)
College 4.21 3.82 4.21 4.21 4.21
(.032)b (.042)b (.037)b (.042)b (.116)
Essential Worker .309 .277 .309 .309 .309
(.065)c (.040)b (.032)b (.008)a (.001)a
Health 1.64 1.74 1.64 1.64 1.64
(.124) (.101)c (.048)b (.053)c (.011)a
Standard Error Robust Zip Code Industry Household Marital
Clustering Employed Income status
Number of Observations 102 99 102 102 102
Pseudo-R2 14.49a 16.14a 11.13b 19.48a 21.65a
Ho:
∑
b i = 0 .199 .214 .199 .199 .199
(x 2 k−1)
Akaike Information Criterion 75.28 73.39 75.28 75.28 71.27
Notes: Approximate P-value in parentheses.
aSignificant at the .01 level.
bSignificant at the .05 level.
cSignificant at the .10 level.
85. 308 E. KEMP ET AL.
https://www.incomebyzipcode.com/louisiana/70119
characteristic measured by a regressor increases
(decreases) the probability of testing for COVID-19.
We also report the value of the Akaike Information
Criterion (AIC) [38] which measures the information
discrepancy between the estimated model and the
true population model. A smaller AIC suggests less dis-
crepancy between the estimated model and the true
population model.
The first column in Table 3 reports parameter
estimates with robust standard errors. The last 4 cluster
the standard errors on a respondent’s zip code, indus-
try of employment, household income, and marital
status, which may be a source assignment into the
treatment of having been tested for COVID-19. This
mitigates bias in the parameter estimates [39]. Across
the parameter estimates, being an essential worker
and position in the health quintile are always statisti -
cally significant. More specifically, essential workers
are approximately 61% less likely to have been tested
for COVID-19, and individuals in the top quintile of
self-reported good health are approximately 64%
more likely to have been tested for COVID-19.
In general, the parameter estimates in Table 3
suggest that the disproportionate COVID-19 burden
borne by African Americans is possibly driven by
race-based testing disparities. The sign and magnitude
of the estimated odds ratio suggest that, at least in New
Orleans, Louisiana, African Americans employed as
essential workers, and those who are in poor health,
![ABOUT THE AUTHOR
Keith C. Ferdinand is with the Department of Medicine, Tulane
University School of Medicine,
New Orleans, LA.
See also Benjamin, p. 542, and Rodenberg, p. 588.
“Rescue work by helicopter was slow.
That stopped at dark about 7 o’clock
. . . people began to panic. I told
Kenneth and Keith and those around
me that we may as well make the
best of it, for no one knows we are
here . . . help won’t come until
morning. The rain fell so hard that I
had to take off my glasses & hide my
head. . . . The water, still slowly rising,
had two more inches to go before it
reached the rooftop. We learned:
that communication [and] coopera-
tion are necessary factors for survival](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)