key: cord-0693312-ao3p6unm authors: Bhandari, Sanjay; Dawson, Aprill Z.; Walker, Rebekah J.; Egede, Leonard E. title: Elderly African Americans: The vulnerable of the vulnerable in the COVID‐19 era date: 2020-10-22 journal: Aging Med (Milton) DOI: 10.1002/agm2.12131 sha: 2e0f477a8cb2dac3c6664b901b3b233b753fc091 doc_id: 693312 cord_uid: ao3p6unm nan United States are AAs. 3 This is over 400% of the demographic fraction occupied by AAs among the elderly US population, as AAs comprise just 9% of this population. Recent data show that elderly AAs had a 3.8-fold higher rate of hospitalization due to COVID-19 compared to elderly non-Hispanic White patients; moreover, elderly AAs have a disproportionately high mortality rate due to 5 Many hypotheses exist regarding why elderly AAs and other racial/ethnic minorities remain vulnerable during the COVID-19 pandemic. One suggestion is an interplay of various social, economic, and discriminatory factors embedded within the health system. 6, 7 More recently, evidence suggests that structural racism and pathways through which racism generates and reinforces inequities among racial and ethnic groups are significantly associated with worse physical and mental health outcomes. 1, 8 Elderly minorities bear a double burden, being predisposed to poor health outcomes due to old age and race/ethnicity. 9 The aim of this perspective is to illustrate actions needed to address the increased vulnerability of elderly AAs during the COVID-19 pandemic and beyond. Historical data on pandemics (including the medieval Black Death, which decreased the European population by 30%-50%) highlight the significant role that socioeconomic status, a key social determinant of health (SDOH), plays on negative health outcomes. 10 The COVID-19 pandemic is no exception. SDOHs are conditions in environments where people are born, live, and work that impact health. Minorities living in inner cities or urban areas often face challenges implementing social distancing due to crowded or multigenerational housing environments. 7 Additionally, AAs are often overrepresented in low-paying essential-service industries, thereby increasing the risk of exposure due to the need to continue working and maintain a source of income. Data from 2016 show that the proportion of elderly AAs in the US labor force is steadily increasing, and unfortunately more low-income, elderly AAs are at risk of exposure to COVID- 19. 11 As SDOH accounts for 70%-80% of health outcomes, 12 it is important to incorporate SDOH into the care of vulnerable patients, such as elderly AAs, by using a multifaceted approach to screen for unmet social needs and leverage existing resources to fulfill these needs. 13 In addition to disseminating knowledge about COVID-19, including its etiology, transmission, and prevention, providers should begin to share information on the importance of being vaccinated once a vaccine becomes available. While there is no vaccine available currently, now is the time to prime elderly AAs, a population at higher risk for infection and complications, to make them more amenable to discussion about the need for potential vaccination. Evidence suggests that racial differences exist in perceptions of vaccination efficacy and vaccination rates. 17 Physicians should begin to address concerns around vaccines among elderly racial/ ethnic minorities, including AA elderly. First, clinicians should allocate time during in-person or telehealth visits to discuss the vaccine-development process. Second, clinicians, researchers, and community partners should work together to develop culturally appropriate messaging. Third, clinicians should use personal-level experience around COVID-19 and be proactive in thwarting misinformation regarding vaccination. 17 Although the available data suggest that COVID-19 is disproportionately impacting elderly AAs, many states do not report age-stratified racial distribution of COVID-19 cases and deaths. Furthermore, reporting COVID-19 data by race/ethnicity is not a requirement, leaving some states without race/ethnicity information. There is a need for more reporting of data on the agestratified racial distribution of cases and deaths that incorporates the community, state, and national levels, thereby offsetting the possible concerns of small sample size, missing information, and resulting issues with analysis for a broader assessment; this will be critical to elucidating the reasons for underlying disparities and to developing focused interventions for vulnerable groups, including elderly AAs. 18 In conclusion, elderly AAs are one of the most vulnerable groups in terms of morbidity and mortality. In light of the COVID-19 pandemic, the vulnerability of elderly AAs and other ethnic minorities calls for concerted efforts to address disparities in these groups to mitigate the overall aftermath of the pandemic. Understanding the impact of structural racism, addressing SDOHs, building trust, increasing awareness around vaccination, and collecting more data by race and age are some of the needed strategies that might help identify, understand, and ultimately reduce the health disparities that the COVID-19 pandemic has uncovered. What is needed is not mere equality-everyone receiving the same thing-but health equity, which "requires concerted effort to achieve more rapid improvements among those who were worse off to start, within an overall strategy to improve everyone's health." 19 This work was partially supported by NIH/NIDDK (K24DK093699, The study sponsors had no role in study design, collection, analysis, interpretation, or writing of the report. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Structural racism, social risk factors, and Covid-19: a dangerous convergence for black Americans COVID-19 and African Americans COVID-NET: a weekly summary of U.S. COVID-19 hospitalization data COVID-19): hospitalization rates per 100,000 population by age and race and ethnicity-COVID-NET Health disparities: race and Hispanic origin A new paradigm for addressing health disparities in inner-city environments: adopting a disaster zone approach This time must be different: disparities during the COVID-19 pandemic Racism as a determinant of health: a systematic review and meta-analysis Aging in minority populations: an examination of the double jeopardy hypothesis Mortality risk and survival in the aftermath of the medieval Black Death Opinion: poor, older Black Americans are an afterthought in the COVID-19 crisis. Next Avenue Preparing for COVID-19's aftermath: simple steps to address social determinants of health Screening for social determinants of health: the known and unknown More than Tuskegee: understanding mistrust about research participation It's a matter of trust: older African Americans speak about their health care encounters The role of patient-physician trust in moderating medication nonadherence due to cost pressures Planning for a COVID-19 vaccination program Achieving equity in an evolving healthcare system: opportunities and challenges Health disparities and health equity: the issue is justice Elderly African Americans: The vulnerable of the vulnerable in the COVID-19 era All authors were involved in the original concept and contributed to the writing and editing of the manuscript. https://orcid.org/0000-0003-1546-1515