COVID-19 places a laser beam squarely on health inequities and racial disparities that have existed for decades in communities of color. COVID-19 places a laser beam squarely on health inequities and racial disparities that have existed for decades in communities of color. Black, Indigenous, People of Color (BIPOC) persons, as compared to White persons, are 2.7 times more likely to be diagnosed with COVID-19 (APM Research Lab, 2020); 3.7-4.1 times more likely to be hospitalized; and 2.6-2.8 times more likely to die (Centers for Disease Control & Prevention [CDC], 2021a). Between March and August 2020 there was a 20% (n = 225,530) increase in expected deaths, and 67% (n = 150,540) were attributed to COVID-19 (Woolf et al., 2020). Why do these racial disparities exist and how can nurses begin to acknowledge and confront their upstream antecedents? We address many of the key drivers of the racial disparities, structural racism, and the social and economic determinants of health that account for these disparities in communities of color. In this article we also offer a range of actionable strategies for nurses to address implicit bias and identify opportunities to advance health equity in their individual spheres of influence.

"Structural racism or racialization emphasizes the interaction of multiple institutions [macrolevel] in an ongoing process of producing racialized outcomes [microlevel consequences]" (Powell, 2008, p. 791). Structural racism "emphasizes the most influential socioecologic levels at which racism may affect racial and ethnic health inequities" (Gee & Ford, 2011, p. 3). Structural racism has created a syndemic cluster of interacting social and economic policies and environmental factors that typically disadvantage BIPOC. These conditions are not positioned amongst or created by the persons of the same race but are underpinned by structural practices that maintain the status quo (i.e., policies or practices) and systemic disinvestment (i.e., education, employment, housing, transportation, broadband) in socioeconomically disadvantaged communities.

As an example, segregation has been illegal since the 1960s. Yet, there is still residential concentration, "racialization of space" (Calmore, 1995, p. 1235), and social isolation of most African Americans in urban areas (Williams & Cooper, 2020). Sewell (2016) posited that the "ghettoization (i.e., segregation of people by ethnoracial group across residential space) is harmful to health via mesolevel political economies" (p.403). "Segregation is a predictor of economic status and predictor of variations of health" (Williams & Cooper, 2020, p. 2478). These social determinants of health (SDOH) are "the health outcomes of a group of individuals, including the distribution of such outcomes within the group, and …includes the health outcomes, patterns of health determinants, and policies and interventions that link these two" (Kindig, 2007, p. 380). Addressing SDOH requires addressing more than the individual social needs but rather requires systems level policy change to address conditions that worsen life expectancy in BIPOC.

Structural Factors that Contribute to Disparities

Economic Divide
Low-income minority workers represent a higher portion of essential workers and have greater exposure to SARS-Co-v-2.Upon close examination of economic status, the black-white wage gap is stark; in 2015, the majority of White workers make more than Black workers at the 10^th ($9.30 vs. $8.20), 50^th ($19.17 vs. $14.14), and 95^th ($61.12 vs. $42.07) percentiles (Wilson & Rogers, 2016). Economists have found that a college degree does not narrow the black-white wage gap. Recent estimates of the economic cost for a family of four, who do not fall below the official poverty measure (U. S. Department of Health and Human Services [U.S. DHHS], 2017), is nearly $200,000. Approximately "half of [the $200,000] is lost income from Covid-19-induced recession; the remainder is the economic loss of shorter and less healthy life" (Cutler & Summers, 2020, p. 1496). Further, the minimum wage has all but stalled over several decades, creating economic inequality and the associated consequences. Low-income minority workers represent a higher portion of essential workers and have greater exposure to SARS-Co-v-2.

Health Disparities
African Americans comprise 13.4% of the United States (US) population (U.S. Census Bureau, 2019) (see Table). Yet, as an ethnic group, they have disproportionally high rates of cardiovascular disease (46%), hypertension (44%), diabetes (16.4 %), and are 1.3 times more likely to be obese as compared to non-Hispanic Whites (CDC, 2020; Go et al., 2014; Noonan, Velasco-Mondragon, & Wagner, 2016; U.S. DHHS Office of Minority Health, 2020). African Americans remain the least healthy ethnic group in the U.S. (Noonan et al., 2016). The disparate disease burden experienced by African Americans and other minorities must be examined within the context of social and economic barriers and devoid of blame. What are the chronic diseases that disproportionately affect BIPOC and compound their risk for COVID-19?

Table. Racial/Ethnic Disparities in Reporting Chronic Diseases - Comparison to the U.S. Population

Note. ^aU.S. population data for Asian and Pacific Islanders was combined to compare to those reporting 1 > chronic diseases (United States Census Bureau, 2019; Centers for Disease Control and Prevention, 2021b). Disparities amongst racial and ethnic groups exist when those reporting 1 > chronic diseases exceed the respective U.S. population.

An estimated 45% of adults who have chronic diseases...are at risk for complications from COVID-19. An estimated 45% of adults who have chronic diseases, such as cardiovascular disease, diabetes, respiratory disease, hypertension, or cancer, are at risk for complications from COVID-19. Complication rates increase with age, > 80, and varied by "race/ethnicity, health insurance status, and employment" (Adams, Katz, & Granpre, 2020, p. 1831). All BIPOC had a disproportionally higher rate of at least one of the six chronic diseases as compared to Whites (see Table). Additionally, certain pre-existing conditions in adults, such as cancer, chronic kidney disease, chronic obstructive pulmonary disease, Down syndrome, cardiovascular disease, immunocompromised state (organ transplant), obesity, severe obesity, Sickle cell disease, smoking, and type 2 diabetes mellitus increase the risk for severe illness (requiring hospitalization) from COVID-19 (CDC, 2021a). Multiple chronic diseases are associated with poor health outcomes (Sambamoorthi, Tan, & Deb, 2015).

Without dismissing individual responsibility, the risk for these conditions must also consider opportunities, or lack thereof, and living conditions of many BIPOCMany pre-existing conditions that place BIPOC at risk directly result from policies in place in the framework of structural racism (Cooper & Williams, 2020). However, individuals are still responsible to manage their own behaviors. Without dismissing individual responsibility, the risk for these conditions must also consider opportunities, or lack thereof, and living conditions of many BIPOC (Cooper & Williams, 2020). Intentional actions grounded in social justice (Buettner-Schmidt & Lobo, 2012) and a shift from the idea of cultural competency to cultural safety are necessary to achieve health equity. Cultural safety reflects safe care as defined by patients and communities, rather than providers (Curtis et al., 2019).

Access to Quality Healthcare

Insurance status and other neighborhood characteristics may account for disproportionally higher out-of-hospital deaths due to COVID-19 in Black and Hispanic communitiesInsurance status and other neighborhood characteristics may account for disproportionally higher out-of-hospital deaths due to COVID-19 in Black and Hispanic communities (Ogedegbe et al., 2020). Before implementation of the Affordable Care Act (ACA), low-income adults with Medicaid or private insurance reported greater access and quality of care than the uninsured (Nguyen & Sommers, 2016). In 2016, the number of uninsured had decreased to 28.6 million. As a result of Medicaid expansion (ACA), access to care has increased for low-income people and people of color. There has also been a decrease in cardiovascular deaths among middle-aged adults and end stage renal disease and diabetes in individuals with healthcare coverage post-ACA (Musonge-Effoe, Alema-Mensah, effoe, Akinnawo, & Caplan, 2020). Attempts to reverse some ACA provisions after the 2016 election have resulted in lower enrollment and, as a result, lower costs to the federal government (Blumenthal, Collins, & Fowler, 2020). The lower marketplace premiums and lower growth in healthcare costs have accounted for the lower federal costs, $128 billion in 2019 compared to the $172 projected.

Those with limited or no insurance face barriers to access healthcare and are at greater risk of COVID-19-related death. Within the context of COVID-19, one study found that Black individuals who had public insurance (i.e., Medicaid or Medicare), were more likely to be hospitalized (Price-Haywood, Burton, Fort, & Seoane, 2020). In 2019, the majority of nonelderly with Medicaid were BIPOC (58.9%) as compared to 41.1% who were White (Kaiser Family Foundation, 2021a). Provisions in the ACA required states to provide preventive services to newly eligible nonelderly adults enrolled in Medicaid (Gates, Ranji, & Snyder, 2014; Office of the Legislative Council, 2010). The preventive services provision did not apply to nonelderly adults enrolled in or eligible for traditional Medicaid (Gates et al., 2014). Twelve states did not take the Medicaid expansion, reflecting a large percentage of the population, or 27.4 million in 2017 without insurance (Garfield & Orgera, 2019; Kaiser Family Foundation, 2021b). Those with limited or no insurance face barriers to access healthcare and are at greater risk of COVID-19-related death. These persons also lack preventive services that could improve their overall quality of life; face paying off expensive medical bills; and often choose between basic needs (i.e., food, housing) and needed medications or other treatments.

Environment and Housing
Limitations to affordable housing options have historically led to overcrowding in poor communities and relegation of Black residents to areas where physical and environmental hazards abound. Overcrowded living conditions make it difficult for residents to practice preventive measures like social distancing and increase the risk of exposure to infectious diseases like COVID-19 (Gee & Payne-Sturges, 2004; von Seidlein, Alabaster, Deen, & Knudsen, 2021). These communities are often more likely to be fraught with violence, high crime rates, reduced green space access, and low-quality housing than White communities (Sewell, 2016). Effects of exposure to violence and the accumulated burdens of economic hardship and racism increase the risk for stress-related health disorders, such as heart disease and diabetes, for children (Havard University Center for Developing Child, 2021). For older adults in these communities, cumulative exposure to chronic environmental stressors has been linked to persisting racial health inequities and poor health (Geronimus et al., 2015).

Overcrowded living conditions make it difficult for residents to practice preventive measures like social distancing...Communities of color have historically been exposed to a disproportionate amount of tobacco and alcohol marketing, increasing the likelihood of use initiation and impulse purchases of these products in low-income neighborhoods compared to White communities (Hofrichter & Bhatia, 2006; Lee, Henriksen, Rose, Moreland-Rusell, & Ribisl, 2015; Ribisl et al., 2017). We now recognize that targeted marketing has proven to adversely and disproportionately affect the health of Black residents living in concentrated areas of poverty; this social injustice is an issue reflective of long-standing structural racism (Grier & Kumanyika, 2010). Other neighborhood-level factors impacting communities of color often include limited access to affordable markets with fresh fruits and vegetables and healthcare services – both of which are fundamental to ensuring positive health outcomes.

Access to these essential health resources is further hampered by the limited number of transportation options available to residentsAccess to these essential health resources is further hampered by the limited number of transportation options available to residents (Morello-Frosch & Lopez, 2006). Constrained mobility and ongoing exposure to environments lacking vital access to health-promoting resources further exacerbate poor health outcomes for older residents of color (Garcia, Homan, Garcia, & Brown, 2020). Many minorities who live in long-term health facilities are concentrated in predominately non-white facilities with lower care quality and poor cleaning practices (Howard et al., 2002; Li, Glance, Yin, & Mukamel, 2011; Mor, Zinn, Angelelli, Teno, & Miller, 2004; Saeb, Mody, & Gibson, 2017). Consideration of environmental impacts on health is essential to understand and address health disparities, and is related to the increased risk for chronic and infectious diseases like COVID-19.

Occupational Risks
...certain workplace settings significantly increase exposure and infection risks for BIPOC...Workers in these positions typically lack the influence necessary to demand protections...Over the course of the COVID-19 pandemic, we have learned that certain workplace settings significantly increase exposure and infection risks for BIPOC. One recent study found that 75% of those employed in the United States have jobs that cannot be done from home. The majority of these are low-income roles filled by workers of color who lack a living wage, affordable housing, and subsequently live in crowded households (Krieger, 2020; U.S. Bureau of Labor Statistics, 2020). Waitstaff, grocery store workers, mass transit workers, custodians, and other service-oriented positions critical to daily business operations are often held by Black and Latinx workers. Workers in these positions typically lack the influence necessary to demand protections like personal protective equipment (PPE) that are more readily available for high-wage, White workers (Krieger, 2020; McClure, Vasudevan, Bailey, Patel, & Robinson, 2020). This phenomenon, known as the Inverse Hazard Law, has been explained by Krieger et al. (2008) as the inverse relationship between workplace hazards with power and resources.

Policing and Carceral System Effects
Overcrowded and unclean conditions within jails or prisons amplify the risks of infectious disease exposure...Environments rife with poverty and violence often fail to provide youth with the support necessary for academic success, frequently positioning them to enter what is known as the 'school-to-prison pipeline' (Rocque & Snellings, 2018). The structural racism inherent in these environments and outcomes is manifested through targeted police violence and the mass incarceration of people of color – practices which effectively segregate and isolate Black residents (Bailey, Feldman, & Bassett, 2021). Inmate populations and immigrant detainees are disproportionally comprised of Black and low-income people (Bobo & Thompson, 2006). Overcrowded and unclean conditions within jails or prisons amplify the risks of infectious disease exposure for the majority Black and minority populations who occupy them, many of whom are in poor health. These inmates thus inherently lack the ability to frequently wash hands or comply with routine hygiene and safe social-distancing practices to prevent exposure to infectious diseases like COVID-19 (Nowotny, Bailey, Omori, & Brinkley-Rubenstein, 2020).

Diet and Nutrition
Access to an affordable diet rich in fruits and vegetables and low in sugar and calorie-dense processed foods is essential to health. Such access is a condition for health that is primarily influenced by the environment in which one lives (Office of the Surgeon General, 2021). In 2019, 10.5% of U.S. households were food insecure (U.S. Department of Agriculture, 2020), with "…disruption of food intake or eating patterns due to a lack of money or other resources" (Office of Disease Prevention and Health Promotion [ODPHP], 2020, para.1). Although trends have demonstrated an overall improvement in most adult diets in the United States, research indicates that many Americans are subject to persistent or worsening nutrition disparities based on race or ethnicity, education, and income level (Rehm, Penalvo, Afshin, & Mozaffarian, 2016). These disparities are driven by persistent racism, environmental disadvantages, and economic instability that have plagued communities of color for generations (Daniel, Bornstein, & Kane, 2018).

Food insecurity is a social determinant of health. In the United States, poor diet is the leading underlying cause of death, surpassing tobacco use in related mortality (ODPHP, 2020; Office of the Surgeon General, 2021). Food insecurity is influenced by income, employment, race/ethnicity, and disability, and the duration can be long-term or temporary (Nord, Andrews, & Winicki, 2002). Barriers to accessing high-quality, nutritious food results in a higher prevalence of preventable chronic diseases such as cardiovascular disease and diabetes – conditions, associated with increased morbidity and mortality from COVID-19 in disadvantaged populations (Belanger et al., 2020).

Strategies for Nurses

Recognition that the disproportional impact of COVID-19 in communities of color is rooted in structural racism and SDOH empowers nurses to leverage individual and systems-level measures...Recognition that the disproportional impact of COVID-19 in communities of color is rooted in structural racism and SDOH empowers nurses to leverage individual and systems-level measures to improve health equity for those most vulnerable to this disease. At the individual level and in the practice setting, nurses can seek knowledge acquisition (Fitzhugh Mullan Institute, 2020; Ford, Griffith, Bruce, & Gilbert, 2019; Kendi, 2019); be open to new ideas and new ways of knowing (Cherry & Morin, 2021); engage in reflective practice (Johns, 2009); and examine their own implicit or unconscious bias (Greenwald, McGhee, & Schwartz, 1998; Project Implicit, 2011). Implicit bias affects interactions and population health outcomes, and erodes trust. Use of inclusive language by nurses engaging in crucial conversations (e.g., discussion of personal attitudes and prejudices) with individuals and communities and commitment to an antiracist reorientation (i.e., allyship) are important actions (GuidetoAllyship, n.d.; Kendi, 2019; MyPronouns.org, n.d). Conversations matter! Patter and colleagues suggested that any crucial conversation is essential to create safety, and show mutual respect (Patterson, Grenny, McMillan, & Swizler 2012).

Why is knowledge acquisition, openness, and examining implicit bias central to nursing practice? Researchers have found that implicit biases are likely to influence diagnosis and treatment decisions and impact patient outcomes (FitzGerald & Hurst, 2017). Healthcare systems are staffed by persons "who are subjects and purveyors of various social constructs and beliefs, both positive and negative. Bias and prejudice are as much a part of health care workers as in the general population" (Argrawal & Enekwechi, 2020, p. para. 10). Nurses have consistently topped the ranks as the number one most trusted profession (Saad, 2020). Trust, while important, must not automatically be assumed. Also, one must not assume that the primary issue when working with communities of color is to establish trust.

Boyd and colleagues cautioned about the "misreading of the harms of Tuskegee Syphilis Experiment, which stem from coercion & systemic exploitation, not mistrust" (Boyd, Lindo, Weeks, & McLemore, 2020, p. 4). It is therefore critical to participate in upstream policy advocacy to address social and economic determinants of health (Castrucci & Auerbach, 2019) and structural racism that are barriers to equity (American Association of Colleges of Nursing [AACN], 2021; Associate of American Medical Colleges [AAMC], 2021). To restore trust, it is incumbent upon nurses to engage in and advocate for policies that address SDOH and institutional structural racism.

Nurse educators are equipped to close the disparity gap by broadening student competencies related to activation of systems-level strategies...Nurse educators are equipped to close the disparity gap by broadening student competencies related to activation of systems-level strategies that address the full spectrum of social determinants and social risk factors. On January 7^th, 2021, the Centers for Medicare & Medicaid Services (CMS) released guidance to codify state-level changes in funding and policies to allow for the adoption of strategies that address the SDOH (CMS, 2021). This unprecedented and groundbreaking policy change was borne out of an acknowledgement that health outcomes are significantly influenced by social, economic, and environmental factors. To effectively address health disparities in our country we must begin to identify and mitigate the range of structures and conditions that perpetuate poor health outcomes in the populations we serve (Byhoff et al., 2020). By incorporating instruction about social determinants and social risk factors into curricula and providing related experiential learning opportunities, educators can better equip nurses to identify key outcome drivers and mobilize resources and relationships to create conditions for improved health equity (Thornton & Persaud, 2018). Nurse educators can extend their capacity to develop content and provide experiential opportunities through engagement of interprofessional education and collaboration around this topic (Buckley et al., 2012).

...nurse researchers can contribute to systems-level change by exploring distinctions between SDOH and social risk factor data. By virtue of their spheres of influence, nurse researchers can contribute to systems-level change by exploring distinctions between SDOH and social risk factor data. It is important to examine opportunities for nurses to employ evidence-base tactics for upstream impact to address these distinct yet equally deleterious impediments to health equity (Alderwick & Gottlieb, 2019). The Society of General Internal Medicine’s Position Statement on the Internists’ Role in Social Determinants of Health (2020) noted that, although consensus has been established around the impacts of poverty on health outcomes, “[c]urrently, many SDOH ‘solutions’ are being developed without evidence-based hypotheses or using scientific principles to identify and evaluate them. SDOH interventions and policies should be constructed with care and build upon social and behavioral scientific disciplines now confronting structural inequality” (p. 2724) participation from nurse researchers can help define the role of nurses in the work of identifying and applying strategies to collaboratively address structural racism and subsequent health disparities across the varied spectrums of healthcare delivery.

Similarly, nurse leaders who serve as decision-makers within healthcare systems can affect upstream change by steering resource support toward development of effective partnerships and implementation of targeted strategies. In 2016, leaders from 40 health systems mobilized their influence to sustainably improve the health of the communities they serve. Their efforts resulted in the creation of the Healthcare Anchor Network, a body of committed to the goal of, “reach(ing) a critical mass of health systems adopting as an institutional priority to improve community health and well-being by leveraging all their assets, including hiring, purchasing, and investment for equitable, local economic impact” (Health Anchor Network [HAN], 2021, para. 3). Collectively, hospital and health system leaders participating in the Network have demonstrated their commitment to the health of their communities by testing and scaling solutions to address economic and racial inequities that are barriers to health for both people and the whole community (HAN, 2021). Through such avenues as board appointments and executive management roles, nurses can lead organizational efforts to advance health equity and create conditions in which populations can stay healthy (Institute of Medicine, 2011).

Regardless of their sphere of influence, nurses have a responsibility to advocate for and provide the best possible care to our patients. Regardless of their sphere of influence, nurses have a responsibility to advocate for and provide the best possible care or public health services to our patients and communities. As the COVID-19 pandemic has demonstrated, the impacts of unchecked structural racism and its subsequent barriers to health, are real and many. We recognize that it is no longer sufficient to simply treat disease in poor and vulnerable communities. We must act to confront the social determinants of health inherent to systemic structural racism.

Authors

Lakisha D. Flagg, DrPH, RN, PHNA-BC
Email: Lakisha.d.flagg@ttuhsc.edu

Lakisha D. Flagg is a U.S. Army veteran and former Army Nurse Corps officer. Dr. Flagg currently serves as an adjunct faculty member at Texas Tech University Health Sciences Center and is the Strategy, Policy, and Communications program manager for the Louisiana Department of Health's Bureau of Family Health, where she leads cross-cutting policy and strategy implementation initiatives. Her expertise includes leading efforts to enhance community/clinical collaboration, strategy development, and translation of data to action.

Lisa A. Campbell, DNP, RN, PHNA-BC, FAAN
Email: Lisa.A.Campbell@ttuhsc.edu

Lisa A. Campbell is a professor and post-master's Doctor of Nursing Practice program director at Texas Tech University Health Sciences Center. She is a former public health department director of three counties in South Texas and the Chair of the Council of Public Health Nursing Organizations. Dr. Campbell's research includes the impact of incivilities on faculty and staff and strategies to create a civil workplace culture, changes in public health nursing practice and the Affordable Care Act, and WIC peer counselor support and breastfeeding.