Early in the pandemic, it became clear that Black, Hispanic, and American Indian communities in the United States were being hit harder than Whites and Asians with disproportionately higher rates of cases, hospitalizations, and deaths. Ongoing statistics continue to confirm this troubling trend.

Data published in November from the US Centers for Disease Control and Prevention (CDC) showed that compared to non-Hispanic Whites, the age-adjusted hospitalization rates were 4.2 times higher for Hispanics, 4.1 times higher for American Indians, and 3.9 times higher for Blacks.

Despite the heavy toll the virus is taking on these communities, they remain underrepresented in clinical trials for a COVID-19 vaccine. In Pfizer’s trial in the United States, for example, only 11 percent of volunteers are Black and 8 percent Hispanic. (Blacks and Hispanics make up 13 and 18 percent of the US population, respectively.) However, the company has partnered with the Johns Hopkins Center for American Indian Health and the Navajo Nation to set up study sites in Arizona and New Mexico.

After slowing its trial to recruit more volunteers from underserved communities, Moderna is now at full participation and 37 percent of volunteers are people of color, including 20 percent Hispanic, 10 percent Black, and 7 percent American Indian and other underrepresented groups.

In an interview with CNN in August, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said the number of volunteers in COVID-19 vaccine trials from underrepresented groups should be at least double their percentage in the population.

We asked four neurologists—Charlene Gamaldo, MD, FAAN; Karlo J. Lizarraga, MD, MS; Jeffrey McClean, MD, FAAN; and Lakshmi Warrior, MD, MPH—for insights into these inequities and what people can do to remain safe. Drs. Gamaldo, Warrior, and McClean served on the American Academy of Neurology’s Special Commission on Racism, Inequity, and Social Justice. Dr. McClean and Dr. Lizarraga are editorial board members of Brain & Life and Brain & Life en Español, respectively.

Q: Are Blacks, Hispanics, and American Indians more susceptible to the virus?
Although Blacks, Hispanics, and American Indians are dying at a higher rate, they are not necessarily more susceptible to the virus, according to national health officials. However, the data suggest that these populations are negatively and disproportionately affected by various social determinants of health, which make them more susceptible to certain disease and to more devastating outcomes. 

Q: In what ways are these groups most vulnerable to complications from COVID-19?
Chronic health conditions such as high blood pressure, heart disease, obesity, lung disease, diabetes, and substance abuse disorder, which disproportionately affect these groups, are the biggest risk factors. As another example of health inequities, many communities had difficulty getting tested—initially sites were not set up in underserved communities and transportation was challenging and for those who lacked insurance, cost was an obstacle. These are a few of the challenges that resulted in delayed access, diagnosis, and care for many Blacks, Hispanics, and America Indians. In many cases, however, Blacks, Hispanics, and American Indians who died from COVID-19 attempted to seek care many times before developing symptoms so severe they required hospitalization.

In addition, American Indians and other groups in underserved and under-resourced areas in the South may have difficulty following CDC recommendations for different reasons. Lack of access to clean, running water makes strict handwashing protocols impossible. And many find social distancing challenging if they live in multigenerational households or high-density residential homes and facilities.   

Q: Are people of color more at risk occupationally?
Statistically, more Blacks and Hispanics are employed as essential workers in industries that require them to be on-site, including transit services, childcare, health care, cleaning services, and postal work. Nationally, Hispanics make up 53 percent of agricultural workers. People of color also are more likely than Whites to be in the public transportation industry in urban areas. For example, in New York City, more than 40 percent of transit workers are Black. In many of these workplaces, employees cannot practice social distancing, which puts them at higher risk of exposure to the virus. In addition, people without health insurance are more likely to work in service industries and many cannot afford to take a sick day if they start to exhibit symptoms. So simply having one essential worker in a household can put an entire multigenerational family at risk for the virus.

Q: Does using public transportation increase the risk of infection?
At the beginning of the pandemic, it may have increased risk. It may have been harder to practice social distancing on buses and subways and most people weren’t wearing masks in the early weeks. Ten months into the pandemic, public transit is considered relatively safe, especially if people wear masks, maintain a distance of six feet from others, refrain from touching surfaces, and wash their hands as soon as possible after riding buses and subways.

Q: What cultural factors may account for the higher mortality and complication rates among Hispanics?
The disproportionate impact of COVID-19 underscores the importance of understanding the interaction and impact of social determinants of health on patients. For instance, in many Hispanic communities, generations of families live in one household, and if one person—a child, for example—is infected or is an asymptomatic carrier, that person may spread the disease to more vulnerable members of the household. Based on the size of the home and number of occupants, it may be challenging to quarantine or practice social distancing. In addition, cultural norms like greeting others with hugs and kisses may make it harder to adopt social distancing guidelines. For those who are undocumented and uninsured, the fear of getting fired from their jobs and even deported may keep them away from hospitals until their condition is dire. If a patient doesn’t speak English and family members aren’t allowed to be with the patient, the language barrier can pose even more difficulties. Interpreters may not be readily available, and communication can be more challenging while wearing a mask and trying to remain socially distant. The pandemic has highlighted the need to provide more support and resources to help patients understand basic health care needs, symptoms that require attention, and available services.

Q: What measures can people of color take to protect themselves against the virus?
While public policy reform is needed to address social determinants of health that negatively and disproportionately impact marginalized communities—including income inequality and access to testing, health care, safe housing, and healthy food—there are ways people can be proactive. For example, they should seek medical attention as soon as possible after developing symptoms of COVID-19. Essential workers can do their best to practice social distancing and, if possible, request protective gear. In some areas, community organizers and health groups are handing out free masks, and in most states face coverings are required for employees and customers in places of business. Families should find a doctor they trust and keep regular appointments through telehealth or when necessary in-person visits. Those who smoke or are overweight should talk to their doctors about quitting smoking or improving their diet. Those with a chronic health condition such as high blood pressure, diabetes, or heart or lung disease should make efforts to manage it with medication or lifestyle modifications like exercise, stress reduction, and healthy eating. These conditions increase the risk of worse outcomes if infected with COVID-19. Wearing a mask is also a must.

Q: How can people of color protect their mental health, given these sobering statistics?
During these troubling times, pursuing nurturing and supportive activities is key. For some people that includes prayer, reading sacred texts, or listening to music. Places of worship around the country are providing virtual services for their congregants, which can be comforting. Others might prefer meditation or mind-body practices such as yoga or tai chi. Free mental health services are available in some areas, including programs for frontline workers. To stay connected with family and friends while remaining physically distant, people can engage in regular video conference calls. Those who find that news reports provoke anxiety, anger, or fear should limit their consumption, especially on social media where the quality and accuracy of information is inconsistent. At a minimum consider restricting the time for viewing social media and news outlets, especially close to bedtime. When possible take in nature by sitting outside or walking in parks or around your neighborhood. Both sunlight and connection with the outdoors are natural mood enhancers. It is crucial that people regularly engage in what keeps them mentally, physically, and spiritually nourished and fulfilled.

Q: Is anything being done to support the American Indian community?
The CDC has channeled more than $200 million to Indian Country—self-governing communities of American Indians—to help tribes and tribal organizations respond to the pandemic. The agency is working with tribal nations to improve access to medical and mental health care, information, and testing.

Q: How can underrepresented groups get involved with clinical trials for a COVID-19 vaccine?
Several regional organizations, such as CASA, a Hispanic advocacy group in Virginia, Pennsylvania, and Maryland, are reaching out to underserved communities to encourage them to volunteer for vaccine trials. In September, the National Institutes of Health (NIH) initiated a campaign to educate underserved communities about vaccine trials. It also contributed $12 million toward establishing community engagement teams in 11 states hit especially hard by the pandemic. As part of the NIH’s COVID-19 Prevention Network, Black pastors are also working to dispel myths and misinformation about vaccines with the hope of recruiting more volunteers from underrepresented populations.

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COVID-19 (Coronavirus) and Neurologic Disease Resource Center