Nevada Journal of Public Health (vol 18; 2021) 18

COVID-19 and Communities of Color: on COVID-19 and communities of color, Understanding the Impact of Racism on even here in Nevada. With this Public Health understanding, the article closes with potential solutions in the areas of policy, health care and COVID-19, public health, as well as future research opportunities. While Melva Thompson-Robinson, DrPH the solutions are not all encompassing, it Center for Health Disparities Research does provide a starting point for dialogue, University of Nevada Las Vegas planning, and implementation in which to [email protected] address the multitude of health disparities and health inequities that have always Johanna Adlam, PhD, MPH existed but systematically ignored either Center for Health Disparities Research intentionally or unintentionally. Regardless University of Nevada Las Vegas of intentions, it took a pandemic to be the moving force and catalyst for enlightenment Eboni Anderson, DHEd, MA, MEd, MSW as it relates to the determinants of health and A.T. Still University School of Osteopathic racism within communities of color. Medicine in Arizona KEYWORDS: COVID-19; racism; Daryl Traylor, MS, MPH, PhD(c) structural racism; communities of color Sinclair School of Nursing University of Missouri Introduction The summer of 2020 was filled with social Carolee Dodge Francis, EdD unrest amidst a global pandemic. The news School of Human Ecology broadcasts were filled with stories of deaths University of Wisconsin-Madison of George Floyd, Breonna Taylor, and Ahmaud Arbery. At the same time, across the United States, as well as Nevada, data Abstract was starting to clearly show that the As the COVID-19 pandemic spread across COVID-19 pandemic was hitting the U.S., communities of color shared an communities of color particularly hard. uneven burden of the disease. The ability to Questions started to rise about how we got understand from a public health perspective, here. One of the answers to this question the increase and devastating health effects was racism. Not just racism that happens and morbidity consequences due to COVID- between individual people, but structural 19 is alarming, but not unexpected based and institutional racism that have served as upon structural racism. In light of the recent the foundation of our country. declarations of racism as a public health crisis, the push to address the situations that In 2014, Camara Jones, MD, PhD, MPH COVID-19 has brought to bear is an was elected as President of the American imperative. This article defines the levels of Public Health Association (APHA). As an racism that exist, distinguishing between esteemed scholar of race and health, in intrapersonal, interpersonal, institutional, 2015, Dr. Jones launched an initiative at and structural racism. Redlining in terms of APHA’s annual meeting to begin to discuss the provision of home loans is used as an the impact of race and racism on public example of structural racism and its impact health (Ford, Griffith, Bruce, and Gilbert, Nevada Journal of Public Health (vol 18; 2021) 19

2019). Her work launched a movement Throughout history, racism has been a within APHA to examine the roles of and pervasive issue in the U.S. Race relations address race and racism on public health. and racism are intimately linked to historical Since then, APHA has produced webinar trends where the sociopolitical and series, statements, a book, and other economic conditions formed, and continues resources that explore these issues. (See: to form, racial divides. Racism has always https://apha.org/topics-and-issues/health- been a feature of life in the U.S., starting equity/racism-and-health) with the enslavement and genocide of Native American tribes and the trans- Additionally, in 2020, across the U.S., Atlantic slave trade (Edmondson, 1976; racism has been declared a public health Fisher, 2017). Racism was used as a means issue by various jurisdictions across 26 to justify the white exploitation of anyone different states, including states as a whole, who was deemed different or unworthy and counties, and cities, as well as by local became a vehicle to subjugate people of health authorities. Nevada has also been a color in the U.S. The notion of racism part of this movement. In June 2020, the required that people be placed into Southern Nevada Health District declared hierarchies (Jacques, 2003). The early racism as a public health issue (See: history of the U.S. saw people being https://www.southernnevadahealthdistrict.or classified into a hierarchical structure g/news-info/racism-is-a-public-health- (Roediger, n.d.). By eventually categorizing crisis/). In August 2020, Governor Steve humans by “race,” a new hierarchy was Sisolak issued a proclamation declaring invented based on what many considered racism as a public health issue (See: science (Roediger, n.d.). However, the https://gov.nv.gov/News/Proclamations/202 thoughts, ideas, and notions of race and 0/Racism,_as_a_Public_Health_Crisis/). In racism are considerably more complex and September and November 2020, the City of furtive than this. The following section North Las Vegas and Clark County, further defines racism and the level at which respectively, issued similar proclamations. racism operates.

The purpose of the article is to provide a Levels of Racism foundation for the discussion of public Race and racism are products of one’s social health, racism, and COVID-19 in Nevada. thought and the promotion of one’s own This article will define racism and relate self-interest. Jones (2018) explained, racism to public health and COVID-19. “Racism is a system of structuring Where appropriate, Nevada specific opportunity and assigning value based on examples will be provided. The article will the social interpretation of how one looks end with potential solutions that can be (which is what we call “race”), that unfairly implemented across the public health disadvantages some individuals and spectrum. We hope that the discussions that communities, unfairly advantages other are triggered by this article will lead to individuals and communities, and saps the continued and focused efforts to eliminate strength of the whole society through the health disparities and promote health equity waste of human resources” (p. 231). This in Nevada and throughout the country. explanation asserts the fact that the power, privilege, and advantages that are inherent in The Historical Context of Racism non-communities of color, and the disadvantages associated with communities Nevada Journal of Public Health (vol 18; 2021) 20

of color, remain in existence and continually example, messages about one’s own abilities adapt over time (Griffith et al., 2007). For and intrinsic worth have the tendency to be many years, communities of color have negative in nature. Jones (1999) received several different facets of metaphorically used flower boxes, seeds, inequitable treatment due to being placed at and the gardener to explain the relationships the bottom of the proverbial racial status between the different levels of racism, and it hierarchy. Whereas, non-communities of illustrated what happens when the gardener color have experienced a myriad of social (the structural system) is not concerned with privileges, advantages, and benefits by equity. Her work also demonstrated what simply being members of the dominant race. happens when one level of racism is addressed and adequately dealt with Different levels of racism are interwoven accordingly. into U.S. society. Jones (1999) formulated a theoretical framework, which categorizes From a more practical standpoint, many the three levels of racism. They include different types of racism involve oppression, institutionalized, personally mediated, and which are based on a hierarchical level and internalized racism. Institutionalized racism include the personal and interpersonal, is defined as the manifestation of material institutional, and structural levels. Personal, conditions, structural barriers, and an or the individualized level of racism, is an unequal access to power (Jones, 1999). For issue that exists within that particular example, receiving access to appropriate individual (Felder, 2020). The individual health care or a quality education fall under holds negative perceptions about his or her the category of institutionalized racism. own, or another individual’s race, ethnicity, and/or culture, which can be an inadvertent, Conversely, personally mediated racism, unconscious bias that the individual which is defined as individual-level possesses. This perception is also known as prejudice and discrimination, whether it is xenophobia. An occurrence of racism intentional or unintentional (Jones, 1999). between two different individuals is known Prejudice means differential thoughts and as interpersonal racism (Felder, 2020). feelings about the abilities, motives, of Circumstances of this nature often involve a others based on their race. According to victim and a perpetrator. This demonstrates Jones (1999), prejudice is what most people the myth of meritocracy where some think of when they think about racism. individuals believe that if one works hard Personally mediated racism may be and makes the sacrifice, then they, too, will manifested as intentional or unintentional be successful. No consideration is given thoughts and/or actions (Jones, 1999). Some that members within communities do indeed of these actions, when directed towards work hard, yet do not achieve success other cultural or ethnic groups, may because many issues that impede a person of manifest themselves as a lack of respect, color from being successful. Racism is one suspicion, devaluation, and/or dehumanizing of the reasons for this issue. Thus, society is behaviors (Jones, 1999). apoplectic when it comes to addressing this area of racism. Also, a denial of racism Internalized racism are the types of exists. For example, when two babies are privilege-based systems and societal values, born, they both have equal potential or the which causes one to reflect on and devalue same abilities; however, they are not given one’s own sense of racial identity. For Nevada Journal of Public Health (vol 18; 2021) 21

an equal opportunity, which makes a and non-communities of color. As a result difference in those babies’ lives. of this tension, there is only marginal growth in promoting racial equity in the U.S. Institutional racism entails actions and practices that propagate racial inequity and Relating Structural and Institutional inequality (Felder, 2020). Felder (2020) Racism to Public Health posited that one example of institutional Despite the public health and healthcare racism is redlining. Housing segregation as advances that have occurred over the last a result of one’s race is known as redlining. 100 years, African Americans still face Redlining has led to densely populated disproportionate morbidity and mortality, urban areas. This particular infrastructure especially as compared to their White resulted in poor housing quality. And more counterparts. African American health importantly, the housing that is there, has a disparities start at birth and continue up to devaluation because of said redlining. the age of 65 (Cunningham et al., 2017). Oftentimes, they are multigenerational Compared to White Americans, African homes. The issue of redlining has hindered Americans up to the age of 65, have higher communities of color from accumulating levels of self-reported risk factors that lead wealth. Advantage is given to dominant to increased mortality from cardiovascular- groups at the expense of denigrating related disease and cancer, diseases that are communities of color. In essence, most common in people over the age of 65 institutional racism has greatly contributed (Cunningham et al., 2017). The health to the deculturation and disempowerment of disparities that exist between Black America significant numbers in communities of color. and White America are not normal and should not exist in 21st century America Structural racism refers to a formalized and (Weinstein et al., 2017). While tempting to unified system of entities that jointly yield ascribe the disparities in morbidity and intentional or unintentional racism; which mortality to biological differences between includes inequitable treatment based on Blacks and Whites in America, this thought power and privilege, access, and policy would be ignoring the reality that the (Felder, 2020). As the top tier of the patterns of illness and death we see between hierarchical system, structural racism Black and White America reflect structural perpetuates racial division and resists and institutionalized racism in America. If paradigm shifts as it relates to equity. we are to eliminate health disparities, the Structural racism continues to pervasively effort will need to begin with a recognition influence society. Attempting to challenge of how racism has shaped health in America. structural deficits, such as lack of affordable housing, the deinstitutionalization of the Institutional and Structural Racism U.S. healthcare system (including managed Example care), social welfare reform, and While many examples of institutional and criminalization of substance use structural racism exist, this article will use dramatically impacts communities of color. the example of redlining to examine the Although the more recent advances and impact of these particular types of racism on urgency in addressing racism at the public health. structural level has been witnessed through the social justice movement, there is still a Redlining polarization between communities of color Nevada Journal of Public Health (vol 18; 2021) 22

Redlining is the systematic denial or raising health of communities of color (Bower et of prices on mortgages and loans; this al., 2015; Rabouin, 2020; Robert & Reither, process typically was targeted at African 2004). For example, redlined Americans, Latinx, and immigrant neighborhoods tend to have homes and neighborhoods (Crossney & Bartelt, 2005; businesses that are undervalued (Perry, Gee, 2008). After the Great Depression, the Rothwell, & Harshbarger, 2018). Thus, Home Owners Loan Corporation (HOLC), a homeowners and business owners will not now defunct Federal agency, produced maps receive the same tax breaks that are of 239 U.S. cities. The maps were divided available in suburban homeowners. into four categories: (1) Hazardous, (2) Definitely Declining, (3) Still Desirable, and The undervaluing of properties has resulted (4) Best. The lowest category communities, in a lower tax based for schools in redlined hazardous, were colored red on the maps communities (Williams and Collins, 2001). and these were communities where many As such, these schools tend to have lower African Americans, Latinx, and immigrants test scores, less participation in advance resided (Crossney & Bartelt, 2005). These placement courses, less qualified teachers, redlined communities, which also tend to be limited curricula offerings, deteriorating highly segregated, are also strongly facilities, and higher dropout rates. These correlated with high poverty rates (Williams communities then have limited employment and Collins, 2001). opportunities, which results in decreased income levels and high rates of Traditionally, the impact of redlining has unemployment (Williams and Collins, been thought about in terms of lost 2001). Figure 1 shows the impact of economic opportunity; however, redlining structural racism on health and health has had a profound, negative impact on the disparities.

Figure 1. Linking redlining to health disparities and inequities

greater reliance on nutrient-poor foods that Furthermore, as a result of the deleterious contribute to obesity and diabetes (Bower et impacts of redlining on communities of al., 2015; Robert & Reither, 2004). color, grocery stores may opt not to build in these communities due to perceived lack of Here in Nevada, what is now known as the return on their investment (Shannon, 2018). Historic Westside community was Living in communities that lack access to established as a result of redlining (Kohler, healthy foods has been linked to obesity and 2018, Strott, 2020). The community started diabetes (Robert & Reither, 2004). Low primarily as an all Black community as that income communities tend to have more fast was the only place in Las Vegas where food restaurants and convenience stores that Blacks could live, stay in hotels, and sale low-quality, nutrient poor foods. As socialize, among other things. Due to such, individuals residing in these low segregation, Blacks who worked and income, redlined communities must place entertained in the casinos were relegated to Nevada Journal of Public Health (vol 18; 2021) 2

staying, dining, and thriving on the Historic example, more than 50% of COVID-19 Westside until into the 1960s when illnesses and almost 70% of COVID-19 integration was allowed. This community deaths in Chicago are among African centers on the zip code of 89106, but also Americans, many of whom have COVID-19 includes portions of 89030, 89032, 89101. related pre-existing conditions such as The residents of the zip codes are still hypertension, diabetes, or cardiovascular primarily African American and Latinx. disease. These zip codes are known for high rates of unemployment and poverty, but also with Further, the COVID-19 deaths in Chicago limited resources and high rates of disease are concentrated on the city’s South Side incidence and prevalence (Strott, 2020). For (Reyes, Husain, Gutowski, St. Clair, & Pratt, example, this community had the highest 2020). Michigan and Louisiana are seeing food insecurity rate in 2017 (Three Square similar patterns of morbidity and mortality Food Bank, 2021), and still does not have a in the African American community. About major grocery store in 2021. Many of the 33% of COVID-19 illnesses and 40% of issues faced in other redlined communities deaths in Michigan have been among around the country were and still are African Americans and in Louisiana, almost experienced in the Historic Westside 71% of COVID-19 deaths have been among community. African Americans (Deslatte, 2020; Thebault, Ba Tran, & Williams, 2020). In Health Impacts of COVID-19 on New York City, one of the nation’s hardest Communities of Color hit cities, African Americans and Latinos COVID-19-related morbidity and mortality accounted for 28% and 34% of COVID-19 has disproportionately affected African deaths in the city during the early stages of American communities across America the pandemic (New York State Department (Yancy, 2020). Originally dubbed the “great of Health, 2020). equalizer” as it was assumed that everyone would be impacted equally by the COVID- According to preliminary data from Johns 19 pandemic (Gupta, 2020). However, as the Hopkins University and the American virus has spread across America, racial Community survey, the infection rate in 131 differences in morbidity and mortality were predominantly Black U.S. counties is exposed. Early data shows that African 137.5/100,000 and the death rate is Americans are more likely to grow ill and 6.3/100,000, six times higher than that for die from COVID-19 than white Americans. counties that are predominantly white (Thebault et al., 2020). Further study is Early COVID-19 data from January 2020 necessary to further refine the data; through April 2020 regarding the U.S. however, it is clear that African Americans pandemic supports early January 2020 are getting ill and are dying of COVID-19 Chinese and Italian COVID-19 studies. Data more frequently than whites. from China and Europe suggested that individuals who are older, male, have Why are the COVID-19 disparities so hypertension, diabetes, are obese, or suffer striking between Black and White cardiovascular disease have increased communities? Unfortunately, zip code is one COVID-19-related morbidity and mortality predictor of differences in health status. The (Bonow, Fonarow, O’Gara, & Yancy, 2020; communities where many African Grasselli et al., 2020; Shi et al., 2020). For Americans reside, formed by redlining, are Nevada Journal of Public Health (vol 18; 2021) 3

low income areas characterized by high racism, and unequal access to education and crime, food insecurity, lack of access to employment opportunities, all of which healthcare, high housing density, and at contribute to the racial/ethnic disparities that times, poor environmental conditions related are seen with the current COVID-19 to the air, water, and soil (Gupta, 2020; pandemic. A legal policy which may hinder Yancy, 2020). Furthermore, the very idea of access to facilitate COVID-19 testing and social distancing conveys a level of privilege treatment is the lack of Medicaid expansion that is not available to many African in some states, particularly those states in Americans (Yancy, 2020). Having the the Southern U.S. (Graves, Hatfield, Blot, ability to maintain social distancing while Keating, & McWilliams, 2020). Addressing working from home and possibly caring for these social determinants of health within children is an issue of privilege. In many Black communities requires support and African American communities, these buy-in from key community stakeholders privileges are not accessible. For example, before community engagement can begin according to the Brookings Institute, some (Dean & Fenton, 2010). 15% of households with children in high cost metropolitan areas are overcrowded Nevada has not been immune to the impact (Schuetz, 2020). African Americans in these of COVID-19 on selected communities. metropolitan areas tend to live in crowded With COVID-19, these trends have housing at higher rates than whites (Perry et continued in 2021. With a focus again on the al., 2020). Social distancing and/or zip codes that make up the Historic quarantining in a multigenerational home Westside and selected other zip codes in Las where one or more members works as an Vegas, in examining maps put together by essential worker is often not feasible. the Nevada Independent, the following can be seen in Table 1. COVID-19 infection Additionally, many African American rates in the Historic Westside, while not the communities affected by chronic disease and highest in the Las Vegas, are about two COVID-19 are also disproportionately times higher than among the lowest rates in affected by political policies that are rooted Clark County in historical policies that promote poverty,

Table 1. COVID-19 Case Rates in Selected Zip Codes in Las Vegas Zip Code Part of the Las Vegas Valley COVID-19 Rates per 10,000 Residents

89106 Historic Westside 960

89032 Historic Westside 1,193

89030 Historic Westside 1,297

89101 Historic Westside 1,139

89005 Boulder City 552

89142 Sunrise Manor/East Las Vegas 1369 (Messerly, 2021) Nevada Journal of Public Health (vol 18; 2021) 1

In February 2021, Governor Sisolak up the Historic Westside and selected other announced an initiative to establish equity in zip codes in the Las Vegas Valley. The the distribution of COVID-19 vaccines in vaccination rates in just these two zip codes Clark County. Based on maps put together are nearly 2 to 4 plus times the vaccination by the Nevada Independent, Table 2 shows rates of the zip codes for the Historic the vaccine rates for the zip codes that make Westside.

Table 2. COVID-19 Case Rates in Selected Zip Codes in Las Vegas Zip Code Part of the Las Vegas Valley COVID-19 Vaccines per 10,000 Residents

89106 Historic Westside 293

89032 Historic Westside 395

89030 Historic Westside 212

89101 Historic Westside 193

89135 Summerlin 1226

89123 Silverado Ranch 762 (Messerly, 2021)

Health Equity in Light of Structural what he or she needs in order to level the Racism playing field (George Washington As public health professionals, a focus has University, 2020). The reality is, some to be on identifying the impact of structural people have an exorbitant amount of health racism on health and promoting health resources while some cannot even get one equity for all to be healthy. Health equity is basic health resource. They start off with assurance of the conditions for optimal nothing at all. Life circumstances do not health for all people (Gee & Ford, 2011). always provide equitable and fair treatment Achieving health equity requires valuing all in health care due to race and racism. The individuals and populations equally, while bottom line is health disparities will be also recognizing and rectifying historical eliminated once health equity is achieved. injustices. Health equity provides resources according to need. Communities of color Barriers to Achieving Health Equity have called for more equitable treatment, as Very little focus has been placed on fully opposed to equal treatment. Equality refers understanding that communities of color to all individuals having the same access to experience a multitude of barriers to care and resources, where everyone needs achieving health equity. The systemic and the same exact thing (George Washington structural level of racism is seen as invisible University, 2020). or irrelevant (Gee & Ford, 2011). Further, a limited sense of interdependence exists. For However, communities of color are not a instance, it is important for individuals to monolith, and individually speaking, know that what impacts one community will communities all need different things. indeed impact other communities. The Health means providing individuals with limited sense of collective efficacy inhibits Nevada Journal of Public Health (vol 18; 2021) 2

growth as a community (Gee & Ford, 2011). determinants of health, which results in If all communities of color were headed in physical and physiological harm to the the same direction, then they could get to communities impacted (Yearby, Lewis, where they want to go much faster in terms Gilbert, & Banks, 2020). When racism is of achieving health equity. All in all, these defined as a system, it transcends the current factors are structural barriers that are not limited understanding of racism within the taken very seriously. Some individuals social determinants of health framework and seem to think issues surrounding health requires that solutions designed to end equity are irrelevant or that it does not exist racism change the system (Yearby et al., anymore due to health policy advancements, 2020). Thus, a race-conscious approach to like the Patient Protection and Affordable public health includes examining how Care Act (PPACA) (Gee & Ford, 2011). racism influences individual, institutional, Still, other individuals believe that these and societal levels to impact health barriers have never existed when, in fact, outcomes (Jee-Lyn García & Sharif, 2015). they do. Furthermore, during the COVID-19 Potential Solutions pandemic, Black and Latinx people's This article outlines a brief origin of racism economic conditions have deteriorated and its impact on public health, which disproportionately compared to White contributes to profound health disparities in people (Yearby et al., 2020). As a result of COVID-19 treatment and outcomes for the equal opportunities that racism limits for people of color in Nevada and across the wealth, education, employment, and housing U.S. In this section, the authors discuss over multiple generations, the damages from potential policy, research, public health, and racism cannot be adequately addressed and healthcare and COVID-19-related solutions rectified without providing material, in an effort to help public health institutional, and social support to affected practitioners combat racial health inequities communities (Yearby et al., 2020). when addressing this public health crisis. Moreover, to effectively anticipate and mitigate any racially disproportionate harms, Policy Solutions governments should utilize racial equity Policy plays a significant role in the health tools in their decision-making processes and well-being of individuals and society at (Yearby et al., 2020). These vital tools can large (Dawes, 2020). Racism permeates be implemented to evaluate if and how individual attitudes or interpersonal proposed policies disproportionately affect exchanges and pervades structural factors different racial and ethnic minorities such as institutional policies and societal (Yearby et al., 2020). Political systems norms (Jee-Lyn García & Sharif, 2015). As across all levels should understand that their such, public health professionals and the citizens' lives are all linked, whereas when larger society must recognize racism as a one community is negatively affected, others dominant and structural force that impedes will also experience deleterious impacts optimal health achievement for all (Jee-Lyn (Dawes, 2020). García & Sharif, 2015). Governments interested in enacting laws and policies that Research Solutions declare racism a public health crisis should Research is another essential mechanism to ensure that they identify racism as a system address racism in public health that causes racial inequalities in the social meaningfully. However, research on racial Nevada Journal of Public Health (vol 18; 2021) 3

health inequities must be performed in a through a systematic process to conduct self- more informed manner. As such, the way reflexive, race-conscious research into the that race is traditionally conceptualized and root cause of health inequities" (Ford, 2016, operationalized in public health research is p. 484). The goal of both CRT and PHCR is not a sufficient proxy measure for racism to move beyond just documenting health (Jee-Lyn García & Sharif, 2015). Race is disparities and gain a comprehensive usually only included as a research question, understanding and challenge the power variable, or topic in most health studies, structures that bolster them (Ford & although race and racism are equally crucial Airhihenbuwa, 2010b). Public health is to health. Controlling for race is a standard advanced through PHCR with an improved statistical technique employed in public understanding of how to measure racism and health research, but this type of analysis its effects on health, awareness that public does not advance understanding of racism's health's conventions may unintentionally impact on health (Jee-Lyn García & Sharif, reinforce disparities, and acknowledgment 2015). Therefore, public health researchers of the profound contributions of must increase their efforts to discern the racial/ethnic minorities in the study of health mechanisms that potentially link racism to disparities (Ford & Airhihenbuwa, 2010b). racialized health disparities (Jee-Lyn García As such, CRT and PHCRP can extend & Sharif, 2015). beyond academic institutions to help public health professionals on the front lines to Additionally, the long-standing theoretical identify and monitor potential racism-related and methodological procedures used in inequities in organizational culture, program public health fails to address the planning, and program evaluation or other complexities of structural racism and its forms of applied research (Ford & Jeffers, impacts on health and the production of 2019). knowledge concerning populations, health, and health disparities (Ford & Researchers in various disciplines within Airhihenbuwa, 2010a). Ford and public health studying racial health Airhihenbuwa (2010a) introduced Critical inequities must also grapple with better Race Theory (CRT), a race equity ways to move science forward in their areas. methodology created in legal studies, to the For example, Epidemiologists of the 21st public health community. The race equity century should convey the profound impact and social justice principles included in CRT of racial injustice on disease, disability, and foster the expansion of solutions addressing death on an individual and population level gaps in health, housing, employment, and (Krieger, 2019). Epidemiologists must also other social determinants of health. consider the impacts of racism in their work Furthermore, Ford and Airhihenbuwa to avoid harm and conduct better science (2010b) developed the Public Health Critical regarding health inequities and population Race Praxis (PHCRP) to improve CRT's health (Krieger, 2019). utilization and fidelity for public health researchers to conduct health equity As a result, Epidemiologists will gain research. fundamental knowledge as well as critical thinking skills when they learn to position The Public Health Critical Race Praxis is an their research in a historical, societal, and "iterative, semi-structured research ecological context. This process is essential methodology that guides investigators when analyzing processes that connect racial Nevada Journal of Public Health (vol 18; 2021) 4

injustice to current and evolving population it may reduce the historical trauma distributions of health and health inequities associated with researcher misconduct in the (Krieger, 2019). Additionally, racism and past and increase their willingness to health inequities may be considered from a participate in studies addressing health life course perspective, which focuses on the disparities and the social determinants of relationship between individuals and social health (Goodman & Thompson, 2019). As a institutions and how experiences of racism result, researchers have developed may vary across the life course and educational tools (Simon et al., 2021) as accumulate over time (Gee, Walsemann, & well as training programs (Coats, Stafford, Brondolo, 2012). Thus, efforts to eradicate Sanders Thompson, Johnson Javois, & health inequities must consider how racism's Goodman, 2015; Nebeker & López-Arenas, variation in time and exposure can lead to 2016) to increase research literacy in racial inequities in life expectancy and other underserved populations. Public health health outcomes across the life course and researchers are responsible for translating many generations (Gee et al., 2012). findings from racism-related research into understandable formats that community Moreover, to improve the conceptualization health stakeholders can use to address and development of research on racial health significant structural barriers or develop inequities, it is crucial to include policies, programs, and initiatives to address communities of color in the research process issues revealed in research (Goodman & to address the complex challenges in public Thompson, 2019). Thus, academic health related to how race and racism institutions, which have the infrastructure influence health outcomes (Goodman & and capacity to develop research literacy Thompson, 2019). Engaging community curriculums, should implement training health stakeholders is critical to increasing programs for non-academic community communities of color and other vulnerable partners (Goodman & Thompson, 2019). populations in the research experience. Community members with a lived To standardize the aforementioned critical experience with the research topic can considerations for researching racial health produce an immense amount of information inequities, authors Boyd, Lindo, Weeks, and to help the research team to understand the McLemore (2020) have proposed numerous critical issues facing communities of color publishing standards on racial health and other vulnerable populations (Goodman inequities intended for researchers, journals, & Thompson, 2019). Community partners and peer reviewers. However, for this need to have basic research literacy to article, we will focus on standards for effectively participate in community- researchers. When publishing on racial engaged and community-based research health inequities, Boyd et al. (2020) suggest (Goodman & Thompson, 2019). that researchers should: (1) define race when designing the study and indicate the reason Research literacy is defined as the "ability to for its use; (2) name racism, identify the understand and critically appraise scientific form, describe the mechanism by which it research including basic knowledge of may be operating, and discuss other research methodology, study design, and intersecting forms of oppression that may research terminology" (Goodman & exacerbate its effects; (3) do not offer Thompson, 2019, p. 274). When genetic interpretations of race as those communities of color have research literacy, beliefs are not grounded in science; (4) Nevada Journal of Public Health (vol 18; 2021) 5

obtain patient input as this will ensure that community advocacy. Public health research outcomes reflect the priorities of professionals must support their community the target population; (5) identify the partners in advocating for relevant policies implications for broader public policy and that improve health in communities of color clinical practice, and (6) cite the experts, and encourage local, state, and federal such as the scholars of color whose work initiatives that advance social justice (Jee- creates the foundation of public health's Lyn García & Sharif, 2015). knowledge on racism and its effects (Boyd et al., 2020). To adequately address racism and its impacts on health, the public health Public Health Solutions workforce should be trained accordingly. Racism is expressed at several levels, and The integration of race-conscious curricula thus, public health needs a more in public health programs can be comprehensive understanding of its health implemented with models, theories, and consequences and a plan for mitigating those methodologies that distinguish racial consequences (Smedley, 2019). Also, injustice as a threat to health (Jee-Lyn racism's pervasive presence in American life García & Sharif, 2015). When this approach demands a coordinated response designed to is taken to training, it fundamentally tackle multiple levels, namely intrapersonal, establishes public health as antiracist work, interpersonal, and intergroup levels which has implications for the future public (Smedley, 2019). Therefore, theory, health workforce (Jee-Lyn García & Sharif, research, and policy analysis must also 2015). adopt this approach, thereby requiring interdisciplinary and inter-sectoral Lastly, white public health practitioners collaboration as well as robust community have a central role in serving as allies to leadership and engagement (Smedley, those populations impacted by racism, as 2019). challenging racism will address a significant determinant of health equity (Margaret & Moreover, racism is a hierarchy and power Came, 2019). The work of allies is system, and individuals with power buttressed by acknowledging and advocating consistently make decisions that harm those for the agency, authority, and ability of without power, particularly racial and ethnic minority and indigenous people to make minorities (Yearby et al., 2020). Thus, to decisions for themselves and outline their effectively address systemic racism, paths forward (Margaret & Came, 2019). In collaboration with marginalized addition, the work of allies encompasses the communities is necessary (Jee-Lyn García & understanding of how racism works to Sharif, 2015; Yearby et al., 2020). privilege white ways and distinguishes Furthermore, laws and policies addressing racism in their practices and systems, as it is racism as a public health crisis must involve a "white-made problem" (Margaret & Came, community members for shared decision 2019). Furthermore, racism will not be making, creating alliances, and community addressed without engaging in the healing engagement to ensure that laws, policies, process for communities impacted by past and practices address community needs and wounds; only this will lead to remedy past harms (Yearby et al., 2020). transformational and sustainable change Public health professionals should augment (Yearby et al., 2020). their professional responsibility by including Nevada Journal of Public Health (vol 18; 2021) 6

Healthcare and COVID-19 Solutions retain towards the U.S. healthcare system Many disparities in health status and results from their ongoing mistreatment and healthcare exist among underserved is not the cause of it (Boyd et al., 2020). populations (Dawes, 2020). Structural Furthermore, a series of listening sessions racism is evident in healthcare, where care is organized by a nonprofit organization primarily provided to a patient based on aiming to advance the work of the Food and their ability to pay rather than on their Drug Administration (FDA) highlighted medical needs (Yearby et al., 2020). Racial concerns about the COVID-19 vaccine and ethnic minorities are usually among people of color (Wamsley, 2020). disproportionately poor and thus, have less Some of these concerns included the access to affordable healthcare and health quickness of the process, distrust of insurance (Yearby et al., 2020). As such, government and its agencies, skepticism of these populations experience higher the healthcare system, and concern that mortality rates and earlier onset of diseases politics and economics will be a priority (Dawes, 2020), since they cannot afford the over science (Wamsley, 2020). full cost of healthcare and tend to sacrifice necessary treatment (Yearby et al., 2020). People of color also expressed doubts that the vaccine will not work for minority Racial and ethnic biases left unexamined populations and a fear based on past contribute to further healthcare disparities experiences such as the Tuskegee (Dovidio & Fiske, 2012). One way to reduce experiment (Wamsley, 2020). Therefore, this bias is to increase the diversity of the public health researchers can develop healthcare workforce. However, it is quantitative and qualitative assessments to important to note that minority health care acknowledge and amplify the voices of providers are also victimized by people of color and their adverse discrimination in the workplace (Dovidio & experiences with the healthcare system in an Fiske, 2012). Also, the bias in healthcare can effort to understand their present concerns be reduced by educating providers on the with the COVID-19 vaccine. Subsequently, complex nature of existing bias and the in concert with these communities of color, varying degrees of stereotyping. As a result, researchers and providers can interactively providers may be better prepared to provide discuss systematic ways to address their higher-quality care in a more equitable concerns and increase vaccine uptake in a fashion (Dovidio & Fiske, 2012). Lastly, race-conscious manner. providers can develop new mental habits through training that includes developing Additionally, an effective rollout of policy culturally competent skills and direct initiatives that could address COVID-19 experiences to promote effective self- disparities would require a more in-depth regulation to circumvent subtle healthcare look at the social determinants of health data biases (Dovidio & Fiske, 2012). stratified by zip code or neighborhood (Heath, 2020) across the U.S. Researchers Moreover, claims that patient mistrust leads currently do not have access to this vital to disparities obfuscates the etiologies of information that can help public health racial health inequities and implicitly blames professionals, as well as local, state, and affected patients for their disproportionate federal governments, make informed health outcomes (Boyd et al., 2020). decisions about public health measures and Notably, any mistrust that Black patients equitable healthcare access. Thus, it is Nevada Journal of Public Health (vol 18; 2021) 7

imperative for healthcare systems across the Andreasen, N. C. (1994). Changing concepts U.S. to collect, track, and disseminate more of schizophrenia and the ahistorical comprehensive COVID-19 data by race and fallacy. American Journal of ethnicity to develop race-conscious solutions Psychiatry, 277, 1405–1407. for this public health crisis. https://doi.org/10.1176/ajp.151.10.14 05 Discussion and Conclusion Bartosz, G., & Wohar, M. E. (2013). The social unrest of the Summer 2020 and International herding: Does it differ COVID-19 exposed the inequalities that across sectors? Journal of exist throughout the U.S. and Nevada. International Financial Markets, Communities of color are being exposed as Institutions and Money, 23, 55-84. being sicker and under resourced. As the https://doi.org/10.1016/j.intfin.2012. fight against COVID-19 turns towards 09.003 vaccines, these communities of color tend to Bonilla-Silva, E. (1997). Rethinking racism: be hesitant to take the vaccine. As seen in Toward a structural interpretation. Clark County, vaccine distribution may not American Sociological Review, be done in an equitable manner (Strott, 62(3), 465-480. 2021). https://doi.org/10.2307/2657316 Bonow, R.O., Fonarow, G.C., O’Gara, P.T., As progress is made on the elimination of & Yancy, C.W. (2020). Association COVID-19, it should be remembered that of coronavirus disease 2019 the health of the community is only as (COVID-19) with myocardial injury strong as its weakest links. In other words, and mortality. JAMA Cardiology. the entire health of the state will only be as https://doi.org/10.1001/jamacardio.2 healthy as the sickest communities. In this 020.0950 case, the sickest communities tend to be Bower, K.M., Thorpe Jr., R.J., Yenokyan, communities of color, whether it is COVID- G., McGinty, E.E.E., Dubay, L., & 19, HIV, or other chronic or infectious Gaskin, D.J. (2015). Racial diseases. residential segregation and disparities in obesity among women. Moving forward, public health needs to Journal of Urban Health, 92(5), 843- understand how structural racism impacts 852. https://doi.org/10.1007/s11524- the social determinants of health and the 015-9974-z health of communities of color. Addressing Boyd, R. W., Lindo, E. G., Weeks, L. D., & social determinants of health without McLemore, M. R. (2020). On considering the impact of racism, Racism: A New Standard For particularly structural racism, will have Publishing On Racial Health limited results. To truly make improvements Inequities. Retrieved from in the health of all communities, advancing https://www.healthaffairs.org/do/10. health equity must be the focus. Thus, the 1377/hblog20200630.939347/full/?ut strategies outlined in this article can inform m_medium=social&utm_source=twi as well as enhance the antiracist work of tter&utm_campaign=blog&utm_cont public health professionals across the U.S. ent=Boyd&%20*=& and in Nevada. Carmichael, S., & Hamilton, C.V. (1967). Black power: Politics of liberation. References New York, NY: Vintage. Nevada Journal of Public Health (vol 18; 2021) 8

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Appendix: Resources

Title Author Organization Surviving & Thriving: COVID-19 Pandemic Survival Guide Linda Goler Blount, Tammy Boyd, Black Women’s Health For Black Women and Their Families 2021-2022 Kimberly Rodgers, and Steven Owens Imperative

Covid, Race, and the Revolution PolicyLink

Brandi Collins-Dexter on COVID-19 Misinformation and Brandi Collins-Dexter, Quinta Jurecic, Brookings Institution, Black Communities and Evelyn Douek TechStream; Color of Change

How racism in US health system hinders care and costs Tamika C.B. Zapolski and Ukamaka M. The Conversation lives of African Americans Oruche

Rebuilding the House That Anti-Blackness Built in Our Economic Policy Institute COVID Response

Social Distancing Is a Privilege Charles M. Blow The NY Times

Danyelle Solomon and Darrick Hamilton Center for American Progress; The Coronavirus Pandemic and the Racial Wealth Gap Kirwan Institute

To Protect Public Health, Don’t Police It Anand Subramanian and Angela Glover PolicyLink Blackwell

Under the Blacklight: The Intersectional Failures That Kimberlé Crenshaw The African American Policy COVID Lays Bare Forum

Podcast: Racism and COVID-19: The historical, political, Catherine Ceniza Choy, Ian Haney López, Othering & Belonging and social foundations and Osagie K. Obasogie with Marc Abizeid Institute

Women of Color Will Save Us All Erin Trent Johnson

Felice León The Root

Your Racism Is Showing: Coronavirus and the Racist History of Pandemics

An Epidemic of Inequities: Structural Racism and COVID- S. Bechteler, K. Kane-Willis, K. Butler, and Chicago Urban League 19 in the Black Community I. Espinosa-Ravi

Black Communities Are on the 'Frontline' of the COVID-19 Anne Branigin The Root Pandemic. Here's Why

COVID-19 Puts Structural Racism On Full Display — Will Stephen F. Gray Next City We Finally Do Something to Correct It?

How Testing for Coronavirus Became a Rorschach Test for Hilary Beard Colorlines Racism

Race Forward Statement on the Coronavirus Emergency, Race Forward Official Response and its Impacts on Communities of Color

COVID-19 – Racial Equity and Social Justice Resources Racial Equity Tools

Resources & Tools Regarding Racism & Anti/Blackness & Tatum Dorrell, Matt Herndon, and Jourdan How to be a Better Ally Dorrell