Capstone Project Topic Selection and Approval

Social and Psychological Consequences of the Covid-19 Pandemic in African-American Communities: Lessons From Michigan

Rodlescia S. Sneed and Kent Key Michigan State University

Sarah Bailey Bridges Into the Future, Inc., Flint, Michigan

Vicki Johnson-Lawrence Michigan State University

The mental health consequences of the COVID-19 pandemic are particularly relevant in African- American communities because African-Americans have been disproportionately impacted by the disease, yet they are traditionally less engaged in mental health treatment compared with other racial groups. Using the state of Michigan as an example, we describe the social and psychological conse- quences of the pandemic on African-American communities in the United States, highlighting commu- nity members’ concerns about contracting the disease, fears of racial bias in testing and treatment, experiences of sustained grief and loss, and retraumatization of already-traumatized communities. Furthermore, we describe the multilevel, community-wide approaches that have been used thus far to mitigate adverse mental health outcomes within our local African-American communities.

Keywords: community mental health, trauma, racial disparities, coronavirus, population health

African-American communities in the state of Michigan have been disproportionately impacted by the coronavirus 2019 (COVID-19) pandemic. Despite making up only 13% of Michi- gan’s population, African Americans account for 32% of con- firmed cases and 41% of pandemic related-deaths (Michigan De- partment of Health and Human Services, 2020). In Michigan’s primarily African-American communities, more than 10% of COVID-19 cases end in death (Michigan Department of Health and Human Services, 2020). A disease that was initially thought to mostly impact older adults and the chronically infirmed has now become a national scourge, devastating African-American com- munities across the United States.

From a mental health perspective, the pandemic has heightened fear in a segment of the population that already faces significant barriers to mental health treatment. Despite having rates of mental

illness similar to Whites, African Americans experience significant disparities in mental health treatment engagement. Among those with any mental illness, only 31% of African Americans receive treatment, compared with 48% of Whites (Agency for Healthcare Research and Quality, 2016). Furthermore, when African Ameri- cans do receive treatment, it is often due to serious mental illness requiring hospitalization rather than mild or moderate illness that can be managed in an outpatient setting. African Americans are less likely than Whites to have ongoing relationships with mental health providers; rather, they are more likely to engage with the mental health care system through emergency departments and primary care visits (U.S Surgeon General, 2001). These disparities are likely due to greater stigma surrounding mental illness, lack of culturally competent mental health care providers, general distrust of the health care system, and lack of insurance/underinsurance (American Psychiatric Association, 2017). Thus, any adverse men- tal health impacts of the pandemic may be particularly devastating in African-American communities because of these preexisting disparities in engagement.

Fear of contracting the virus is high in African-American com- munities. Population-based surveys estimate that 33% of African Americans are very concerned that they will get COVID-19 and require hospitalization, compared with only 18% of Whites. Fur- thermore, African Americans are 2 times more likely than Whites to know someone who has been hospitalized or has died because of COVID-19 (Pew Research, 2020). Fear of the disease is per- vasive, even for those whose social networks have not yet been impacted because news stories produced by most local and na- tional news outlets since March have focused on COVID-19, often with photos and anecdotes featuring African Americans who have been impacted by the disease. Consequently, many African Amer- icans have begun to experience a form of vicarious trauma because

Editor’s Note. This commentary received rapid review due to the time- sensitive nature of the content. It was reviewed by the Journal Editor.—KKT

This article was published Online First June 11, 2020. X Rodlescia S. Sneed, Department of Family Medicine, and Division of

Public Health, College of Human Medicine–Flint, Michigan State Univer- sity; X Kent Key, Division of Public Health, College of Human Medicine–Flint, Michigan State University; Sarah Bailey, Bridges Into the Future, Inc., Flint, Michigan; Vicki Johnson-Lawrence, Department of Family Medicine, and Division of Public Health, Michigan State Univer- sity, College of Human Medicine–Flint, Michigan State University.

Correspondence concerning this article should be addressed to Rodlescia S. Sneed, Division of Public Health, College of Human Medicine–Flint, Michigan State University, 200 East First Street, Flint, MI 48502. E-mail: [email protected]

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Psychological Trauma: Theory, Research, Practice, and Policy

© 2020 American Psychological Association 2020, Vol. 12, No. 5, 446 – 448 ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000881

446

they repeatedly witness the pain and suffering of those who look like them. This type of trauma can lead to both emotional and physical symptoms, including symptoms of anxiety, helplessness, nausea, and headache.

In addition to fearing disease, many African-American commu- nity members fear racial bias and discrimination in disease testing and treatment. Racial bias in health care is well documented and thought to contribute to a range of racial health disparities, includ- ing higher rates of maternal mortality (Bryant, Worjoloh, Caughey, & Washington, 2010) and poor pain-related outcomes among African Americans (Meghani, Byun, & Gallagher, 2012). Both empirical and anecdotal evidence suggest that African Americans presenting with symptoms of upper respiratory infection (e.g., cough, fever) have been less likely to get tested for COVID-19 than their White counterparts (Rubix Life Sciences, 2020). Addi- tionally, there have been fewer testing centers located in African- American neighborhoods, further suggesting bias or discrimina- tion in testing. Even after testing positive, many African Americans fear that they may not receive life-saving assistance if they experience severe disease. As medical centers become over- whelmed with COVID-19 patients, some have suggested limiting advanced care protocols for patients with less chance of recovery, such as those with underlying comorbidities. Given that African Americans have greater prevalence of chronic health conditions, many fear being denied care because of discriminatory assump- tions about their likelihood of survival. In epidemiological studies, such perceived racial discrimination has been linked to numerous adverse mental health outcomes, including greater self-reported symptoms of depression, anxiety, and psychological distress (Lewis, Cogburn, & Williams, 2015). Perceived racial discrimina- tion has also been associated with greater clinical diagnosis of posttraumatic stress disorder, generalized anxiety, and major de- pressive disorder (McLaughlin, Hatzenbuehler, & Keyes, 2010).

Because of overrepresentation in the death tolls, Michigan’s African-American communities are also managing significant stress related to grief and loss. Social media sites have become online obituary sections as community members mourn the deaths of their friends and family members. Community members no longer ask, “Will someone I know die of the virus?” Instead the question has now become, “Who will die next of the virus?” Residents are not just experiencing one loss—they are experienc- ing multiple losses within a brief period, resulting in grief over- load. This type of cumulative grief is known to increase risk of pain-numbing avoidance behaviors (e.g., substance use, disordered eating) and prolonged grief disorders.

As they cope with grief and loss, community members are not able to engage in many sociocultural practices that facilitate cop- ing. For example, current social-distancing measures have halted observance of common funeral traditions. African-American fu- neral traditions play an important role in managing community grief and loss. These primarily Christian traditions celebrate death as a homegoing rather than an ending. Large floral arrangements, celebratory music, and lengthy processions to the burial site are the norm as friends and family near and far gather to comfort grieving family members and share anecdotes about the deceased. Such traditions offer honor and respect in death to those who (because of their racial or socioeconomic background) may have had little social standing in life. In this COVID-19 era, loved ones who die are buried quickly, often only in the presence of a minister and a

mortician. The loss of this tradition funeral ritual disrupts the grief process, impacting how loved ones process the reality of the death, express painful thoughts and feelings, and reconcile the meaning of life and death. This disruption of the grief process further increases risk of prolonged grief disorders and bereavement- related depression.

Finally, the pandemic has unfolded within African-African com- munities that have already experienced significant community trauma. April 25, 2020, marked the sixth anniversary of the Flint Water Crisis, a public health emergency that exposed residents to lead in the municipal water supply, devastating Flint, Michigan, a city that is 56% African American. In the aftermath of the crisis, residents experienced significant adverse mental health outcomes. In 2016 (the year when the crisis was publicly acknowledged), 23% of households reported unmet mental health needs, 29% of individuals self-reported symptoms of depression, and 33% of individuals self-reported symptoms of anxiety (Fortenberry et al., 2018). Although public health efforts since 2016 have led to improvements, residents still report poor mental health outcomes compared with the rest of the state of Michigan more than 3 years later. Even today, residents are afraid to use water from the municipal supply for drinking, cooking, or bathing. For residents, the uncertainty surrounding COVID-19 is reminiscent of the Flint Water Crisis because it similarly ignites fear and mistrust of government to protect the public against a health-related disaster. With COVID-19, Flint residents are being retraumatized while still managing the fallout from the water crisis. This experience of multiple long-lasting traumatic events can lead to extreme emotion dysregulation and a range of biological changes and stress re- sponses that can result in notable mental and physical health problems.

Effective management of the mental health sequelae of the pandemic in African-American communities requires a multilevel, community-wide approach led by culturally sensitive mental health professionals, including those specifically skilled in helping people maneuver through grief, loss, and trauma. This mental health engagement must be supported by community resources to reach those who may never seek formal care on their own. Fur- thermore, directly addressing the valid public health threat of the pandemic in African-American communities through education, testing, and treatment is crucial for ultimately improving mental health outcomes.

In Michigan, many steps have been taken to improve outcomes within African-American communities. State and local leaders have acknowledged the racial disparities in COVID-19 –related outcomes and have formed diverse multisector task forces to address issues of racial bias related to testing, diagnosis, and treatment. Weekly videoconferences and webinars sponsored by community groups and academic institutions have increased the dissemination of relevant disease-related information. The African-American faith community has been instrumental in pro- viding support to community members, conducting religious ser- vices via videoconferencing and social media sites, dispatching church leaders to conduct wellness checks for vulnerable residents, and referring residents for support services. Specific services sup- porting mental health have also been activated. Local public men- tal health providers, with additional federal funding, have devel- oped virtual crisis centers to support mental health and substance abuse screening and to mitigate treatment engagement barriers

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447AFRICAN-AMERICAN MENTAL HEALTH AND COVID-19

common in African-American communities. Local community leaders (in collaboration with academic clinical psychologists and public health professionals) are conducting virtual support groups and sessions, targeting those who may not be in crisis but who may benefit from a supportive environment to discuss their fears and stressors. Additionally, evidence-informed models for processing stress and trauma are being used in nonclinical community spaces. These include mindfulness-based stress reduction and the Com- munity Resiliency Model, a biologically based approach that teaches a set of wellness skills designed to reduce the physical sensations of stress and trauma (Grabbe & Miller-Karas, 2018; Miller-Karas, 2015). All of these supports and services are de- signed to be culturally appropriate, recognizing how African- American cultural practices and traditions may impact mental health engagement. Furthermore, they are trauma informed, with sensitivity to the notion that the pandemic itself is an ongoing traumatic event that may retrigger trauma-related memories and feelings of powerlessness. As the pandemic endures, these ap- proaches must be reviewed and refined to ensure optimal mental health and well-being within African-American communities.

References

Agency for Healthcare Research and Quality. (2016). 2015 National Healthcare Quality and Disparities Report. Retrieved from https://www .ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html

American Psychiatric Association. (2017). Mental Health Disparities: Af- rican Americans. Retrieved from https://www.psychiatry.org/File%20 Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/ Mental-Health-Facts-for-African-Americans.pdf

Bryant, A. S., Worjoloh, A., Caughey, A. B., & Washington, A. E. (2010). Racial/ethnic disparities in obstetric outcomes and care: Prevalence and determinants. American Journal of Obstetrics and Gynecology, 202, 335–343. http://dx.doi.org/10.1016/j.ajog.2009.10.864

Fortenberry, G. Z., Reynolds, P., Burrer, S. L., Johnson-Lawrence, V., Wang, A., Schnall, A., . . . Wolkin, A. (2018). Assessment of behavioral health concerns in the community affected by the Flint water crisis— Michigan (USA) 2016. Prehospital and Disaster Medicine, 33, 256 – 265. http://dx.doi.org/10.1017/S1049023X18000250

Grabbe, L., & Miller-Karas, E. (2018). The trauma resiliency model: A “bottom-up” intervention for trauma psychotherapy. Journal of the American Psychiatric Nurses Association, 24, 76 – 84.

Lewis, T. T., Cogburn, C. D., & Williams, D. R. (2015). Self-reported experiences of discrimination and health: Scientific advances, ongoing controversies, and emerging issues. Annual Review of Clinical Psychol- ogy, 11, 407– 440. http://dx.doi.org/10.1146/annurev-clinpsy-032814- 112728

McLaughlin, K. A., Hatzenbuehler, M. L., & Keyes, K. M. (2010). Re- sponses to discrimination and psychiatric disorders among Black, His- panic, female, and lesbian, gay, and bisexual individuals. American Journal of Public Health, 100, 1477–1484. http://dx.doi.org/10.2105/ AJPH.2009.181586

Meghani, S. H., Byun, E., & Gallagher, R. M. (2012). Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Medicine, 13, 150 –174. http://dx.doi .org/10.1111/j.1526-4637.2011.01310.x

Michigan Department of Health and Human Services. (2020). Michigan data: Confirmed COVID-19 cases by jurisdiction updated April 30, 2020. Retrieved from https://www.michigan.gov/coronavirus/0,9753,7- 406-98163_98173-,00.html

Miller-Karas, E. (2015). Building resilience to trauma: The trauma and community resiliency models. New York, NY: Routledge. http://dx.doi .org/10.4324/9780203134115

Pew Research. (2020). Health concerns from COVID-19 much higher among Hispanics and Blacks than Whites. Retrieved from https://www. people-press.org/2020/04/14/health-concerns-from-covid-19-much- higher-among-hispanics-and-blacks-than-whites/

Rubix Life Sciences. (2020). Covid-19 and minority health access. Re- trieved from https://rubixls.com/2020/04/01/health-data-in-the-covid- 19-crisis-how-racial-equity-is-widening-for-patients-to-gain-access-to- treatment/

U.S. Surgeon General. (2001). Mental health: Culture, races, and ethnic- ity—A supplement to mental health: A report of the Surgeon General. 2001. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK44243/

Received April 30, 2020 Revision received May 18, 2020

Accepted May 18, 2020 �

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448 SNEED, KEY, BAILEY, AND JOHNSON-LAWRENCE