Covid-19
Pharmacies, Not Local Public Officials, May Ensure Race Equity in Vaccination Rates

The release of a long-awaited report on Texas COVID-19 facilities by race-ethnicity was shocking.[1]Not because our community was unaware of race-ethnic disparities in vaccination rates but rather the large size of these disparities in Texas.  As the numbers for age-adjusted death rates per 100,000 revealed, Hispanics were nearly four times more likely to die (133.9) from the coronavirus than whites (35.2), while Blacks (72.5) were twice as likely to die as whites.  Asian death rates (33.3) were slightly lower than whites.

Texas State Rep. Shawn Thierry along with other lawmakers have been advocating for the release of this report in order to mobilize statewide efforts to target vulnerable groups like Blacks and Hispanics, although state officials have been reluctant to act more aggressively. In response to the release of this report, Rep. Thierry explained that the findings underscored the need to target resources to communities of color, especially since other data shows that white residents are getting vaccinated at higher rates than Blacks and Latinos. [2]

Given the high death rates for Latinos and Blacks, it is especially surprising that Texas state officials recently threatened to withhold vaccine doses that were allocated to Dallas County if they proceeded with a plan to target vaccinations to zip codes that included higher numbers of vulnerable Black and Latino residents.

Indeed, efforts to block targeted interventions to vulnerable communities contradicted recommendations by the National Academy of Sciences that recommended that “priority be given to ‘people who are considered to be the most disadvantaged or the worst off’ as defined by measures such as the Social Vulnerability Index created by the Centers for Disease Control and Prevention.” [3]

The announcement that the Biden administration will begin shipping vaccines to pharmacies throughout the U.S. was a major sight of relief for two reasons.  First, it minimizes the involvement of local politicians in the equitable distribution of the vaccines who have largely bungled the job in its communications, registration and distribution – resulting in higher vaccination rates of higher-income whites than lower-income Blacks and Latinos.  Texas politicians will also have less influence in threatening to withhold vaccines to jurisdictions that want to more aggressively vaccinate the more vulnerable communities of color.

Secondly, pharmacies are much easier to access for the elderly, Blacks and Latinos who encounter more barriers in registrations and obtaining vaccinations.  The Mega Centers are innovative in terms of providing a centralized location to vaccinate thousands of residents more rapidly; however, not all residents can travel to these Mega Centers or wait in line for hours during cold weather without access to restrooms or food.  The distribution of vaccines by pharmacies will not solve all the problems experienced thus far but should lead to significant improvements.

Given the gravity of the higher death rates for Texas Latinos and Blacks, it is disturbing to learn that Texas state officials are delaying any targeted interventions for these groups for several months.  Even more disturbing is that state officials threatened to withhold vaccine doses to Dallas County for attempting to follow the science by targeting the more vulnerable groups of Black and Latino zip codes.  The State of Texas deserves no praise for their callous response to the lives of its Black and Latino residents.

     

Reference Notes

[1]Morris, A.  (2021, February 2).  Report highlights disparities – but proposals targeting effects on minorities months away.  The Dallas Morning News, Accessed at: 

[2]Ibid.

[3]Cited in Warren, R.C. D.D.Sl, Dr.PH.H., M.Div., Forrow M.D., L., Hodge Sr., D.Min., Ph.D., and Truog, M.D., R.D.  (2020, November 26).  Trustworthiness before trust – COVID-19 vaccine trials and the Black community.  The New England Journal of Medicine.  Accessed at: https://www.nejm.org/doi/full/10.1056/NEJMp2030033      

Why Do Dallas-Area Public Officials Keep Fumbling the Ball on Programs Targeted to Multicultural Communities?

 Let’s give credit where credit is due. Dallas County and City of Dallas public officials have not won any accolades recently for decisions regarding programs that impact the quality of life for its multicultural community.The recent fiasco surrounding the distribution of the COVID-19 vaccine is the most recent example, but two other recent programs also come to mind – the Census 2020 Campaign and the lingering presence of food deserts in South Dallas.  As I will argue, these programs have one important thing in common that has posed a barrier to their success: the absence of quality research to guide decisions regarding public programs that are targeted to Black and Latino residents.

In 2020, I published a book entitled “The Culture of Research” that discusses the importance of conducting sound research in culturally and linguistically diverse communities and the consequences to decision making when such studies are missing or poorly conducted. Following are some insights derived from this book that should help the reader understand how sound research with multicultural communities could have produced improved outcomes in the management of the local COVID-19 vaccination program, the Census 2020 Campaign, and solving the mystery surrounding the persistence of food deserts in South Dallas.

COVID-19 Vaccine Awareness, Registration and Distribution

The local confusion and mismanagement associated with the COVID-19 vaccine distribution can be traced originally to the absence of guidance and transparency at the federal level, and the related decision by the previous administration to allow states to define their own independent strategies with a minimal financial support from the federal government.

Nonetheless, the COVID-19 vaccine distribution dilemma in Dallas County, Texas presents a good case study on decisions that public officials in urban communities should not make.   Indeed, the series of inconsistent and questionable decisions resulted in considerable public confusion and frustration with vaccine registrations, availability and distribution. Some of these missteps included the following:

  • Contradictory messages from county and city public officials;
  • Over-reliance on an Internet strategy to inform and register residents, many who lacked online access or own a computer, or were not comfortable with technology;
  • Inconsistent support in Spanish and other languages;
  • Placement of testing and vaccination sites in higher income while providing limited access in the more vulnerable areas; and  
  • Transportation barriers that prevented some residents to travel to testing or vaccination sites.
These missteps have resulted in higher numbers of white, higher-income residents getting vaccinated rather than the targeted, more vulnerable Black and Latino residents in the lower-income areas of South and Northwest Dallas. 

Figure 1:

Figure 1, published recently in The Dallas Morning News, clearly illustrates this pattern: [1]  whites comprised 62.2 percent of all persons vaccinated while representing 28.2% of the County population; Hispanics represented 19.5 percent of those vaccinated while comprising 40.8% of the population; and Blacks comprised 10.6 percent of those vaccinated although they represented 22.3% of the county population.  These disparities persist despite recent efforts by public officials to communicate more directly with civic leaders, churches and community organizations to improve vaccination rates for Blacks and Latinos in the South and Northwest part of Dallas.

The problem associated with vaccine distribution in communities of color is deeply concerning because they are the most likely to experience the more serious medical consequences from the coronavirus.  Importantly, these missteps in decision making could have been avoided with communications that were better coordinated by public officials and engagement of experts with significant experience engaging multicultural persons. 

The decision to use an Internet vehicle for the vaccination campaign is very likely the reason that white, higher income residents continue to be more successful in getting vaccinated. Although some public officials supported the idea of targeting zip codes in South Dallas that included some of the most vulnerable Black and Latino residents, the Texas State Health Department[2]immediately issued a threat to withhold vaccine doses allocated to Dallas County if the targeting was implemented.  This threat was a direct contradiction to recommendations by the National Academy of Sciences that support vaccine community intervention programs that are targeted to the most vulnerable communities. [3]  Thus, Dallas County and City of Dallas public officials learned the hard way that launching a public vaccination program in linguistically and culturally diverse communities require less reliance on technology and more reliance on outreach efforts that take the vaccines to the residents.  Ironically, while the state threatened to withhold vaccine doses if local officials employed a zip-code targeting approach in South Dallas, the use of an Internet strategy as the primary form of communication accomplished the same outcome by vaccinating higher numbers of white, higher-income residents who resided in the northern parts of Dallas County.

South Dallas Food Deserts

Why have mainstream supermarkets avoided South Dallas food deserts that are populated by lower-income Blacks and Latinos?  [4]This question inspired me to conduct a geospatial analysis using crime, demographic and supermarket expenditure data to examine the common reasons cited by supermarket executives to explain the avoidance of communities like South Dallas – such as high crime, low population density, lower household median income and insufficient food expenditures.  The study revealed that crime patterns were often inflated by previous investigators and news stories, and that the annual food-at-home expenditures in several food deserts in South Dallas were adequate to sustain the annual sales of a mainstream supermarket.  Flawed crime analyses, stereotypes of urban retail, and an apparent disdain for Black and Latino customers appeared to drive site selection decisions in South Dallas.

Over the past two decades, the City has floundered millions of taxpayer dollars on ill- conceived investments that failed to produce positive changes in the supermarket options for this community. Worst yet, a market demand study of community residents – a traditional practice to measure supermarket opportunities — has never been conducted in South Dallas. Such a study would have provided supermarket and site selection executives the statistical evidence needed for an investment decision. In the meantime, South Dallas residents will be forced to continue shopping outside of their community for healthy, affordable food or visit the less desirable dollar stores.  Once City public officials decide that the South Dallas community is deserving of a high-quality supermarket experience, a professional, high quality market demand study is the best approach for making this a reality.  If supermarket redlining practices continue in South Dallas despite solid evidence of its retail potential, it might be a good idea to recruit a supermarket chain from outside of Dallas County or Texas that reveals a greater interest in serving Black and Latino consumers in urban communities. 

The Census 2020 Campaign

In January 2020, Dallas County and the City of Dallas funded a $1.9 million Census 2020 Campaign to provide a comprehensive strategy to boost response rates in hard-to-count communities that were populated by lower-income Blacks and Latinos. The team selected to conduct the campaign submitted a report summarizing the multitude of campaign activities that they conducted from February to August of 2020 to target these HTC communities.  To monitor progress on this campaign, I produced maps on a monthly basis that illustrated the cumulative self-response rates by census tracts that were provided by the Census Bureau.  Figure 2 below shows that the final self-response rates reported by the Census Bureau were decidedly lower in the southern and northwest parts of the city where HTC Blacks and Latinos resided.  In fact, the table of Overall Self-Response Rates indicates that Dallas County ended with one of the lowest self-response rates (63.9%) compared to other large Texas counties.  Consequently, the Census Bureau was required to deploy many more field interviewers in order to minimize the potential population under-count, an especially difficult task during the pandemic.  Despite its best intentions, the Census 2020 Campaign funded by the County and City appeared to fall short of its intended goal in hard-to-count communities and will likely lead to the loss of millions of federal dollars for local programs. Although the pandemic posed a barrier to response rates during this period, the burden on Dallas County was likely similar for all other counties considered here.

                 Figure 2: Dallas County 2020 Self-Response Rates by Census Tract and City Service Area

Part of the challenge in completing the Census 2020 questionnaires can be traced to the reliance that the Census Bureau placed on using an online survey as their major data collection strategy. In past censuses, the Census Bureau relied primarily on a mail questionnaire, while data collection for the annual American Community Survey has utilized a mixed mode strategy that included mail questionnaires, telephone interviews, personal interviews and online surveys.  Not surprisingly, Black and Latino respondents to the American Community Survey have opted for telephone and personal interviews more often than whites or Asians, while online surveys were the least chosen option.

Figure 3 below presents the percentage of Dallas County households that completed the Census 2020 using an online survey.  The map presents the cumulative Internet self-response rates for the 2020 Census as of October 28, 2020.  Of the seven City Service Areas (CSAs), the Central, Southeast, South Central, Southwest and Northwest CSAs are populated primarily by lower income Blacks and Latinos. It is clear that these CSAs included census tracts (highlighted in red) with the lowest online response rates, while the numerous other census tracts (highlighted in yellow) showed modest online response rates.  The highest online return rates were realized for census tracts in the northeast and north central CSAs that were populated primarily by white, higher-income residents.


Throughout 2020, public officials in Dallas County and City of Dallas were aware of the poor performance of the Internet to encourage poor Blacks and Latinos to complete the 2020 Census.  Why then was the Internet the main vehicle used for communications related to COVID-19 vaccine awareness, registration and distribution?  Good research and multicultural expertise would have been beneficial to decision makers during this period.

Based on my past 45 years of experience in conducting surveys of multicultural populations, it is my opinion that the Census 2020 Campaign sponsored by Dallas County and City of Dallas was not guided by the best expertise regarding the strategies for successfully engaging multicultural population segments in surveys and the biennial census.  If it had been, Dallas County might have experienced a higher ranking in Census self-response rates in comparison to the many Texas counties that did not allocate any funding for a Census 2020 campaign.

Some Concluding Thoughts 

The challenges facing public officials to ensure a satisfactory quality of life for all community residents have become more complex and will require careful planning using the best expertise in understanding and engaging culturally and linguistically diverse communities.  Public officials must resist the temptation to take the path of least resistance by overlooking or dismissing the need for solid research to guide decisions that impact the quality of life of multicultural residents. Dallas County and City of Dallas public officials learned the hard way that engaging culturally and linguistically diverse residents is a complex task that requires multicultural expertise and support from community organizations. As the population of urban areas like Dallas County continues to grow and evolve demographically, the challenges to respond more effectively to important community needs and events will become more challenging.  Let’s hope that public officials will be better prepared to respond.

  

Reference Notes

[1] Garcia, N. and Jimenez, J. (2021, Jan. 28).  White Dallas residents outpace Blacks, Hispanics in registering for COVID vaccine.  Dallas Morning News, Accessed at:  https://www.dallasnews.com/news/public-health/2021/01/29/white-dallas-residents-outpace-blacks-hispanics-in-registering-for-covid-vaccine/

[2] Choi, J. (2021, Jan. 21).  Texas threatened to reduce vaccine supply to Dallas County over plan to focus on ‘vulnerable’ ZIP codes.  The Hill.   Accessed at: https://thehill.com/homenews/state-watch/535294-texas-threatened-to-reduce-vaccine-supply-to-dallas-county-over-plan-to

[3]National Academy of Sciences, Engineering and Medicine (2020). Framework for equitable allocation of COVID-19 vaccine. Washington, D.C.: National Academy Press.

[4] Rincón, E.T. and Tiwari, C. (2020, March 23). Demand metric for supermarket site selection:
 A case study. Papers in Applied Geography,  Accessed at: https://doi.org/10.1080/23754931.2020.1712555

Careless Decision Making Creates Race-Ethnic Disparities in Distribution of COVID-19 Vaccine

 

The recent story in The Dallas Morning News was clear and disturbing: 

”COVID vaccines at Fair Park aren’t going to Black, Latino residents as officials hoped” [1] 

The story chronicles the missteps in public communications efforts to schedule large-scale vaccinations to historically disenfranchised neighborhoods, which are mostly Black and Latino and below Interstate 30 – groups that have experienced a higher number of illnesses, hospitalizations and mortalities during the pandemic.  Instead, however, the thousands of residents that showed up for the vaccinations at Fair Park were mostly white North Texans from higher-income neighborhoods following mixed messages to the public – many showing up in their Mercedes, Infiniti and BMW automobiles. 

Dallas City Mayor Eric Johnson blamed County Judge Clay Jenkins for the confusion generated by the announcement to register online with the county to receive a vaccine appointment at the South Dallas Mega Center – an announcement that was apparently not coordinated with the Mayor’s office. Word of mouth spread rapidly that an appointment was not needed for residents 75 and older – which left thousands of others on a waiting list and encouraged many out-of-town residents to show up for a vaccine.  County officials pointed out that a significant number of residents who showed up were able to access an unsecured web link that allowed them to book an appointment, regardless of age or status.  Other residents who showed up also pointed to emails received from the county encouraging them to sign up for an appointment.

Interestingly, Dallas County was not prepared to release a demographic profile of those that received vaccinations, a report that would have been very useful in evaluating the extent of the exclusion of more deserving Black and Hispanic residents in the targeted community.  As an apparent after-thought to expand access to the intended Black and Hispanic residents,  Jenkins and his staff began reaching out to leaders in those communities, including elected officials, faith leaders and other organizations that work in communities where the coronavirus was most prevalent.

The vaccine distribution fiasco in Dallas County is not an isolated one as many communities throughout the U.S. are struggling to coordinate the vaccinations using a confusing set of federal guidelines that are implemented inconsistently thoughout the nation.  In a previous blogpost, I had warned about potential problems that could complicate the distribution of the vaccines once they became available.  For example:

·        The Center for Disease Control decided to exclude Blacks and Hispanics from the category of “high-risk” groups, thus reducing their priority level for intervention strategies. Why?  Because the CDC concluded that the high virus rates are not due to genetics, and they want to avoid stigmatizing these groups as “COVID carriers.” [2]

·        Race-ethnic information is missing for many of the cases, hospitalizations and mortalities recorded for COVID-19, which obscures the accurate reporting of this information for Black and Hispanic communities – a consequence of lax mandates for recording race-ethnic information. The absence of this information obscures the true picture of community spread of the virus. [3]

·        Access to testing sites in states like Texas is problematic since these sites are more commonly located in white communities than the more vulnerable Black and Hispanic communities. [4]

It is also disturbing to learn that states like Florida have relaxed the requirements for vaccine eligibility by allowing anyone over the age of 65 years to obtain a vaccine, which has encouraged many tourists and out-of-town residents to drain the vaccine supplies at the expense of more deserving local residents.

In the case of Dallas County and the City of Dallas, it was unfortunate that better coordination was not in place to implement such an important vaccine intervention program at the Fair Park Mega Center.  However, even if the communications had been better coordinated, there is still one important tactical decision that could have produced a different outcome.

In my opinion, it was a major mistake to rely primarily on a web-based strategy to encourage Black and Latino residents in the targeted communities to register for the Mega Center vaccination. From their recent experience to encourage response rates to the Census 2020, both Dallas County and City of Dallas officials were aware that Black and Latino residents, especially immigrants, were excluded in large numbers from completing the Census questionnaire which also primarily relied on the Internet.  Our past research in multicultural communities confirms that Blacks and Hispanics are more likely to respond by telephone, mail and personal contacts when completing surveys and Census questionnaires but least likely to respond by using the Internet. Lastly, a Census population pyramid easily illustrates that a much larger proportion of whites are concentrated in ages 65 and older than Hispanics or Blacks – which would provide whites a distinct advantage when using eligibility criteria based on age alone.

For damage control, Jenkins reportedly began outreach to community elected officials, faith leaders and other organizations in the targeted zip codes – an approach that should have been followed initially. Whether by intent or just careless decision-making, Mr. Johnson was correct in stating that the county was “promoting a system that gave preferential treatment” – that is, to white, higher-income residents who were not the intended target audience of the Mega Center.

With COVID-19 vaccinations, there is less room for error in the fair distribution of a life-saving solution.  Let’s hope that public officials agree to improve the coordination of public vaccination campaigns by improving their communication strategies in culturally diverse communities.

 

Reference Notes

[1]Garcia, N. and Bailey, E. (2021, January 14). COVID vaccines at Fair Park aren’t going to Black, Latino residents as hoped.  The Dallas Morning News.  Accessed at: https://www.dallasnews.com/news/public-health/2021/01/14/dallas-mayor-eric-johnson-blasts-county-after-walkups-allowed-at-covid-19-vaccine-mega-site/

[2] Rincon, E.T. (2020, July 30) CDC blunders in excluding communities of color among high risk groups for COVID-19. https://www.rinconassoc.com/cdc-blunders-in-excluding-communities-of-color-among-high-risk-groups-for-covid-19

[3] Rincon, E.T. (2020, April 16). Missing race-ethnicity data complicates COVID-19 mortality counts, but the solution is simple. Accessed at: https://www.rinconassoc.com/missing-race-ethnicity-data-complicates-covid-19-mortality-counts-but-the-solution-is-simple

[4]Fanning, R. (2020, May 29). Across Texas, black and Hispanic neighborhoods have fewer coronavirus testing sites. Texas Standard. Accessed at: https://www.texasstandard.org/stories/across-texas-black-and-hispanic-neighborhoods-have-fewer-coronavirus-testing-sites/

Texas Hispanic Construction Worker Mortalities Are Alarming: Is Anyone Listening?

The news was alarming: Hispanic construction workers represent over half (56%) of the state’s COVID-19 deaths although Hispanics currently represent 40 percent of the state’s population.  The story, reported today by The Dallas Morning News,[1]discussed the results of a research study published in the Journal of the American Medical Association (JAMA) by a team of researchers at The University of Texas at Austin. The study pointed to the increased risk faced by Hispanic construction workers and living arrangements that preclude social distancing.

The story is also concerning for the issues that were not addressed. For example, the story did not include any comments from the one organization in North Texas that would have relevant insights to contribute to our understanding of this elevated health threat to Hispanic construction workers:  The Regional Hispanic Contractors Association.  

Previous COVID-19 news reports have focused considerable attention on essential workers in healthcare, the food industry and other occupations. However, the risks faced by construction workers have received relatively little attention, especially Hispanic workers who comprise 30 percent of all construction workers. Under the current administration, OSHA (Occupational Safety and Health Administration) has relaxed their inspections of occupations to verify compliance with COVID-19 safety measures which has undoubtedly contributed to the increased risk faced by Hispanic workers who often do not wear face masks.

Of course, we have known for several months that Hispanics and Blacks have been experiencing higher levels of COVID-19 illnesses and mortalities.  As I discussed in an earlier report,[2]  these COVID-19 mortality rates are likely much higher for Blacks and Hispanics since state and federal health data are often missing information on the race or ethnicity of COVID-19 mortalities. There is a simple procedure available that can estimate the race-ethnicity of a person based on their name and zip code with 80 to 90 percent accuracy – a tool that could be used to fill in the missing data and obtain a better estimate of COVID-19 mortalities.  

Communication of these alarming health risks to the right audiences is also problematic. For example, it is not likely that the Hispanic construction workers and families that need to know about their elevated risk of death related to COVID-19 will read the report in JAMA or The Dallas Morning News.  During the pandemic period, audiences are more likely to obtain news information from television and online sources if they have Internet access. And Hispanic construction workers are more likely to use Spanish-language sources of information.  Consequently, it is imperative that Spanish-language television stations like Univision and Telemundo assume an increased responsibility to ensure that COVID-19 health alerts are regularly communicated to their audiences.  Moreover, organizations like the Regional Hispanic Construction Association are perhaps the best vehicle to deliver and reinforce the health alerts to their membership.

While the issue of increased COVID-19 exposure and deaths of Hispanic construction workers is urgent, one wonders if the study findings will be sufficient to wake up the various stakeholders to take decisive action. As the story points out, Dallas-Fort Worth is second among the country’s largest building markets in September this year with an estimated 155,000 workers in the building sector.  But as one of the study authors, professor Lauren Meyers pointed out, the study findings do not necessarily mean that construction work needs to stop. “It means that we need to go to great lengths to ensure the health and safety of workers when they do go to work.” 

In the meantime, let’s ensure that Hispanic construction workers and their families are informed about the elevated risks that they face from COVID-19 and, more importantly, that they are provided practical solutions to mitigate the risks.  Following are a few suggestions for achieving these objectives: 

  • Being the second highest building market in the nation, it seems reasonable to ask investors and builders to create a fund that is dedicated to keeping the Hispanic contractors and workforce safe and able to meet basic expenses. 

  • Create a fund to offset the costs of funeral expenses for the many Hispanic families who have lost a family member working in the construction industry.
  • Pressure OSHA to conduct more frequent checks of construction work sites to ensure that workers are following COVID-19 safety guidelines and have a sufficient supply of PPE supplies.
  • Provide funding for temporary shelter, such as trailers or hotel rooms, to provide family members the opportunity to quarantine themselves when necessary from exposed construction workers. 
  • Ensure that all construction workers are tested for the COVID-19 virus before starting their work shift.
  • Provide continuing funding to organizations such as the Regional Hispanic Contractors Association so that they are able to conduct the needed training to Hispanic contractors regarding COVID-19 safety measures and risks.
  • Lastly, ensure that all COVID-19 related communications are delivered in both English and Spanish languages.  Native-born Hispanics primarily view English-language media while foreign-born Hispanics primarily view Spanish-language media – a fact that we have confirmed from our 45 years of evaluating the media habits of Hispanics throughout the U.S.

End Notes


[1] Difurio, D. (2020, October 31).  Construction workers hit hard by virus. Dallas Morning News. Accessed at https://edition.pagesuite.com/infinity/article_popover_share.aspx?guid=6e7208df-d7f4-44e9-af63-fef33cd734fb

[2]  Rincón, E.T. (2020, April 16).  Missing race-ethnicity data complicates Covid-19 mortality counts, But the solution is simple.  https://www.rinconassoc.com/missing-race-ethnicity-data-complicates-covid-19-mortality-counts-but-the-solution-is-simple

CDC Blunders in Excluding Communities of Color Among High Risk Groups for Covid-19

It really makes little sense.  Despite the fact that Blacks, Hispanics and Native Americans are being hospitalized and dying at considerably higher rates than whites in the U.S., the Center for Disease Control recently changed its definition of Covid-19 high risk groups to exclude these groups.[i]  Why?  Because they have concluded that the high virus rates are not due to genetics, and they want to avoid stigmatizing these groups as “Covid carriers.”  By taking this action, the CDC can now remove their priority status for the delivery of health services – a disturbing action that suggests the injection of partisan politics.
 Let’s consider the fact that older persons were initially identified among the high-risk groups and remain in that category for good reasons. Indeed, one would not argue that their high-risk status should be changed because they often reside in nursing or retirement homes that have been plagued by the coronavirus. The purpose of identifying key demographic characteristics that are associated with the prevalence of a disease or virus is to target intervention strategies towards such groups as quickly as possible to mitigate the spread of the disease or illness – regardless of the circumstances that created their vulnerability – such as social determinants like comorbidities, living arrangements and working conditions.  

The CDC’s justification for re-defining the high-risk categories – to avoid stigmatizing these groups as “Covid carriers” – is specious.  Communities of color have long been stigmatized in many industries for the wrong reasons, including their skin color, language and many other attributes.  Assigning a high-risk category for Covid-19 is a health-related assessment, not a stigma, and should not be used as a basis for denying health-related services as the CDC is apparently proposing.
What seems plainly obvious is that the Trump administration has forced the hand of the CDC experts once again.  First by re-directing the reporting of Covid-19 hospitalizations from the CDC to the Dept. of Health and Human Services to the great dismay of the national health community.  Secondly, by pressuring the CDC to moderate the perceived risk of attending schools in person despite the increasing infection rates in many communities. And now by re-defining Covid-19 high risk groups with a questionable rationale.
These actions are setting the stage in the U.S. for the unfair distribution of the Covid-19 vaccine once it becomes available, a disturbing scenario that is likely to deprive the vaccine from communities of color and other groups that have been re-defined as lower risk by the CDC. By allowing this new definition of risk by the CDC to continue unchallenged, communities of color can expect a longer period of infections and mortalities from the pandemic, and more limited access to a vaccine once it becomes available.  There is a clear need for strong advocacy from civic, business and community groups that represent communities of color to challenge and correct the direction that the CDC has taken in defining high-risk groups for Covid-19.   
References

[i]Associated Press (2020, July 25). US agency vows steps to address COVID-19 inequalities.  WFAA, accessed at https://www.wfaa.com/article/news/health/coronavirus/coronavirus-inequalities-cdc/507-a770cfc8-9967-4359-b84d-12684c6aa46f
 

President Trump Launches a Civil War Against the American Public

As the November presidential election nears, there are noticeable palpitations from the Trump campaign and his supporters, which has prompted an undeclared civil war against the American public. Fueling the anxiety level throughout the Republican party is Trump’s epic failure in acknowledging and managing the Covid-19 pandemic as well as the double-digit lead by Joe Biden in several national polls. To breathe new life to his failing campaign strategy, Trump has chosen to heighten the misery index across the country with a series of actions designed to weaken the democratic electorate and keep his job for another term.   Following is a sampling of the extreme and somewhat bizarre actions that the Trump administration has directed at the American public:
Voting and Apportionment 
·       Aggressive efforts to eliminate the use of mail-in ballots despite little evidence of voter fraud and the potential exposure of voters to Covid-19 infections.  According to recent research by the Pew Research Center,  “About two-thirds of Americans say the option to vote early or absentee should be available to any voter without requiring a documented reason, while a third say early and absentee voting should only be allowed with a reason. Democrats overwhelmingly back “no excuse” early or absentee voting: 83% support it. By comparison, 55% of Republicans say a documented reason should be necessary to vote early or absentee.” [1]  
·       Attempts to include a citizenship question in the Census 2020 questionnaire designed to discourage immigrant participation in the census – later rejected by the U.S. Supreme Court.
·       Recently signing an executive order to remove counts of unauthorized immigrants from the Census computations used to define legislative districts – an action that will be legally challenged by several civil rights organizations. According to recent analysis of government data by Pew Research, the removal of these immigrants would mean that three states each could lose a U.S. House seat, while three others each could gain one.
Covid-19
·       Stating the “testing was over-rated,” Trump has delayed increasing the level of funding for Covid-19 testing and tracking despite the growing surge in infections and mortalities throughout the country.
·       A refusal to issue a federal mandate to expand the availability of personal protective equipment (PPE).
·       Trump actually recommended the use of a disinfectant like Lysol to treat Covid-19 patients.
·       Requiring hospitals to re-direct records related for Covid-19 hospitalizations from the CDC to the Department of Health and Human Services – considered by the nation’s healthcare professionals as a political attempt to obscure the true picture of Covid-19 infections and mortalities. Further evidence that the Trump administration is politicizing the data collection and analysis the pandemic data is the recent announcement by the CDC that race and ethnic minorities are no longer considered high risk or meriting higher priority for certain health services [2]. Why?  Because their Covid-19 high hospitalization, infection and mortality rates result from social determinants, not genetics, and there is a need to avoid stigmatizing and victimizing these groups.  While social determinants are indeed important factors that contribute to the higher prevalence of Covid-19 in Black and Hispanic communities, it makes little sense to use this as a basis for removing their high risk designation — indeed, they are still at high risk regardless of the circumstances that placed them at high risk.
·       The continued failure to order a national mandate for wearing face masks despite the advice of global medical experts.
·       The failure to clear up the large amount of missing race-ethnic data related to Covid-19 mortalities which greatly underestimates the mortality rates for communities of color. According to Janet Hamilton, executive director of Council of State and Territorial Epidemiologists, race and ethnicity data is missing 80% to 85% of the time, while patient address and telephone numbers are missing as much as 50% of the time.  A standard form to record such information if often not used by physicians since it is not considered a priority. [2]
·       The failure to increase OSHA inspections of employers to check compliance with CDC recommended practices related to Covid-19 employment policies. Clusters of Covid-19 infections have grown rapidly in factories and food suppliers where employees are forced to work in close proximity without the proper protective equipment.
Education
·       Pressuring schools to allow in-person instruction despite the high Covid-19 infection rates in their communities and the increased potential of exposure to students and teachers.
·       Issuing an executive order requiring foreign students in U.S. academic institutions to attend in-person classes despite Covid-19 risk — later rescinded due to many protests from U.S. academic institutions and private high-tech employers.
Abusive Actions
·       Using tear gas and injuring residents engaged in peaceful protests, as recently occurred at protests at the White House and Portland, Oregon.
·       Threatening to send Federal agents to quell peaceful protests regarding Black Lives Matter, especially in “Democratic” cities like Chicago and Albuquerque.
·       Supporting the presence of the Confederate flag, statues and similar symbolism in public places that are racially divisive.
Immigration
·       Misportraying immigrants as criminals despite substantial evidence that their crime rates are lower than native-born residents in the U.S.
·       Failure to process new DACA (i.e., Dreamer) applications despite a recent ruling by the U.S. Supreme Court to allows this process.
Coupled with the support of the Republican party, Trump’s civil war against the American public will likely diminish voter participation among Democrats during the upcoming November election, expand the spread of Covid-19 infections and mortalities, and generally deteriorate the quality of life for all U.S. residents. This level of aggression towards the American public is perplexing, especially given that our political leaders are sworn to protect U.S. residents, not harm them. 
This is not the first time, however, that Trump’s patriotism for his countrymen has been the subject of some controversy. For example, Trump has consistently praised world dictators that are known to oppress the human rights of their constituents and disparaged recognized war heroes like the late Sen. John McCain.  According to a news report, Trump avoided military service during the Vietnam conflict due to a bone spur, which earned him the title “Cadet Bone Spurs” – a term attributed by Senator Tammy Duckworth, a Purpose Heart recipient.  A story in the New York Times [3]reported that a foot doctor in Queens who rented his office from Mr. Trump’s father, Fred C. Trump, suggested that the diagnosis was granted as a courtesy to the elder Mr. Trump. In addition to avoiding military service, Mr. Trump continues to show his support for racially divisive Confederate flags and statues.
By accelerating their civil war, Cadet Bone Spurs and his Republican comrades are apparently prepared to win the November election at any cost to the health, safety and civil rights of the American public. For the upcoming November election, voters should seriously question whether Donald Trump and his fellow Republicans deserve to  represent a country whose values and quality of life they have chosen to abandon.  
References

Governor Greg Abbott Fumbles the Ball on Covid-19

As the leading quarterback in Texas, Gov. Abbott has shown a repeated tendency to fumble the ball as Covid-19 infections have surged in Texas. Instead of following the advice of the nation’s top experts on controlling the spread of Covid-19, Gov. Abbott has opted instead to place the lives of many Texans at risk by following the GOP party line of opening the Texas economy.  The governor was warned repeatedly by the commissioners in Dallas and Harris counties that Texas was not ready to re-open its businesses, but their advice was ignored and sometimes ridiculed by Abbott.  The consequences of this oversight have been devastating. Not surprisingly, the Texas Democratic Party described the governor’s strategy as “reckless.” [1]

After the governor authorized the re-opening of Texas businesses, Travis, Harris and Dallas counties experienced record high cases for two weeks, surging to 4,739 on Thursday morning (June 25th) and tripling since Memorial Day.[2] These three counties are now reviving plans for temporary hospital facilities to prepare for overwhelmed hospitals.  Gov. Abbott finally acknowledged that the opening of businesses was perhaps a bit premature and should be “paused” to ease the burden on Texas hospitals.  As a result, he issued an executive order to close all bars in Texas and reduce the restaurant capacity to 50 percent.   Unfortunately, a definitive action to mandate the use of face masks in public – considered highly effective in slowing the spread of Covid-19 — did not emerge.

As the governor recently explained: “The last thing we want to do is go backwards and close down businesses…the pause will help our state corral the spread.”  Indeed, the Covid-19 spread does not pause simply by closing business establishments but will continue to seek other victims, especially those that are unprotected by face masks, meeting or working indoors in groups, and persons with existing comorbidities. 

The Covid-19 statistics in Texas are quite grim:  137,624 reported cases; 2,324 fatalities, and 59,018 active cases.[3]  How many more lives need to be sacrificed before Governor Abbott decides to more aggressively slow the spread of Covid-19?  Interestingly, while Governor Abbott continues to fumble with his hit-or-miss strategy, other states like New York, New Jersey and Connecticut that have more successfully controlled the spread of Covid-19 are requiring a 14-day quarantine for visitors from states like Texas with big outbreaks of the virus. [4]

Impact on Communities of Color in Texas
The consequences of these poor judgements by Governor Abbott have been compounded by two other factors:  the common victims of Covid-19 and the state’s demographic composition. Various studies have confirmed that Covid-19 infections and mortalities are disproportionately impacting Blacks [5] and Hispanics [6] in communities throughout the U.S.   For example, an analysis of recent Dallas County Covid-19 cases by UT Southwestern Medical Center revealed that Hispanics comprised 60 percent of all new cases while their county population was 40 percent. [7]  
Various explanations have been proposed to explain the heightened vulnerability of Blacks and Hispanics to Covid-19, including the types of jobs held (i.e., factories, food service); living in crowded situations with less options for social distancing; lack of Covid-19 testing; and skepticism about medical doctors.

The urgency of acting more quickly in Texas is compounded by the fact that Hispanics (39.2%) and Blacks (11.7%) collectively comprise half (50.9%) of the state’s population [8] — a demographic reality suggesting that the consequences of Covid-19 for these two segments of the Texas population are likely to be more severe as a result of Abbott’s continued failure to follow the advice of health experts.

To this point, there is evidence that Blacks and Hispanics are struggling more than whites and Asians to meet important daily needs since the pandemic started. In a major effort to help the nation monitor post-Covid-19 experiences on a weekly basis, the Census Bureau along with several federal agencies began surveys with samples of residents in 15 metropolitan areas and has made the results of these surveys available to the public.[9]  The survey, provided in English and Spanish, was designed as a timely and periodic measure of the impact of coronavirus (COVID-19) on the following topics:

  •         Employment status
  •          Food security
  •          Housing security
  •          Education disruptions
  •          Physical and mental well-being

Our analysis of the 1,586 surveys completed in the Dallas/Ft. Worth metropolitan area during the week of June 11, 2020 revealed the following race-ethnic differences on three of the topical areas:
·       Food security:  Hispanics (16.9%) and Blacks (15.5%) were more likely than whites (3.3%) and Asians (3.5%) to state that they were not at all confident about their ability to afford the kinds of food that they needed for the next four weeks.  Hispanics (12.4%) were more likely than whites (5.1%), Blacks (1.9%) and Asians (5.0%) to agree that it was often true that their children were not eating enough because they could not afford enough food.  Hispanics (15.8%) and Blacks (16.0%) were more likely than whites (6.5%) and Asians (2.3%) to agree that they sometimes/often did not have enough food to eat during the past seven days.
·       Employment status:  Hispanics (65.4%) and Blacks (51.9%) were more likely than whites (43.1%) and Asians (32.9%) to state that they or someone in their household had experienced a loss of employment income since March 3, 2020. In addition, Hispanics (48.5%) and Blacks (45.4%) were more likely than whites (24.0%) and Asians (17.8%) to state that they or someone in their household expected a loss of employment income over the next four weeks.
·       Housing security:  Hispanics (27.9%) and Blacks (30.8%) were more likely than whites (9.2%) and Asians (15.8%)  to state that they had no confidence/slight confidence that their household would be able to pay their next rent or mortgage payment on time.

Absence of a Safety Net

For Blacks and Hispanics, surviving the pandemic is analogous to avoiding a torpedo that has already been launched given their history of comorbidities, the jobs that they hold, and other limitations.  Their dilemma is further amplified by the absence of a safety net for healthcare, economic and social services.  Hispanic immigrants are especially vulnerable to the consequences of Covid-19 because they are:
·       Unable to participate in Medicare or Medicaid;
·       Unable to obtain Social Security benefits despite the millions in contributions that employees make annually;
·       Not eligible to obtain food stamps;
·       Not eligible for stimulus payments due to the pandemic;
·       Not eligible for unemployment benefits; and
·       Often working in hazardous environments since their employers are infrequently inspected by OSHA for compliance with Covid-19 standards.[10]
Making matters worse, the State of Texas has joined the Trump administration in requesting that the U.S. Supreme Court end Obamacare – a cruel action that will leave many Texans without the care that they need to recover from the devastation caused by the pandemic.  
Although some reports have indicated that the Covid-19 death rates are not increasing along with increasing infection rates, we should not take any comfort with this trend because race-ethnic information is often missing from death certificates.  The actual mortality rates for Blacks and Hispanics could be much higher than currently reported. [11]

A Different Approach to Stimulating the Texas Economy

The irony in Governor Abbott’s quest to stimulate the Texas economy is not lost here.  Would it not make better sense to more aggressively stop the spread of Covid-19, give residents the opportunity to restore their health and return to jobs at businesses that have been certified as safe from Covid-19 exposure? Texas Hispanics and Blacks, for example, comprise a large segment of the state’s workforce in various industries. Moreover, aggregate household income in 2018 — $184 billion for Hispanics [12] and $73 billion for Blacks [13] – represents a substantial contribution to the Texas economy. The increasing loss of Hispanics and Blacks from the Texas workforce due to Covid-19 infections and mortalities would substantially slow down the economy and possibly negate the progress expected by Abbott in re-opening business establishments.

In the absence of a safety net, it might be a good idea for private corporations in Texas to collectively create a special fund that could be used to support vulnerable groups like Blacks and Hispanics who need financial support during this difficult period. After all, the substantial consumer spending of these two segments has contributed to the profitability of many Texas retailers and manufacturers, such as Walmart, Mission Foods, Fiesta Supermarkets, Kroger, H-E-B, Sherwin-Williams, Home Depot, and various others.  The contributed funds could be distributed to Black and Hispanic families during this difficult period with the goal of maintaining their good health; returning to work in businesses that the state has certified as safe and free of Covid-19 exposure; and continuing their consumer spending at Texas businesses.  This makes more sense – scientifically and economically.

Final Message to Governor Abbott

The following recent quote in The Washington Post accurately summarizes the failure in leadership by Governor Abbott and other leaders that are following the same Covid-19 strategy:
“A record surge in new cases is the clearest sign yet of the historic failure in the United States to control the virus – exposing a crisis in governance extending from the Oval Office to state capitals to city council.” (Page 2) [14]
It is especially perplexing that the pandemic battle in Texas has been presented in news  stories as an ongoing fight between the Governor and judges in Dallas and Harris counties – a pattern that has muted the voices of the Hispanic and Black communities where the virus is likely to have the most devastating impact. The media should assume more responsibility for including the voices of Hispanic and Black leaders in Texas who are supporting the scientific solution that has been advocated by Judge Jenkins and Judge Hidalgo. They could use some help.  
  
Governor Abbott, you have a responsibility to protect the lives of all Texans without delay, especially during a pandemic.  You should forget about party loyalty and act decisively according to the advice of the nation’s health experts.  In case you forgot, start by ordering the following:
·       Mandate the use of face masks in public and impose fines on people that refuse to obey the law;
·       Discipline public officials that refuse to comply with the law;
·       Re-institute the stay-at-home order;
·       Close dining options at restaurants and allow only take-out or delivery;
·       Prohibit the use of group meetings in public facilities (i.e., conventions) and encourage churches to conduct virtual masses instead of masses attended by their membership;
·       Allow schools to open only if they are required to use face masks and adhere to social distancing guidelines. Older or more vulnerable teachers should be assigned to teach online classes;
·       Authorize more financial resources to expand the state’s testing capabilities to avoid the long lines and waiting periods for residents who are becoming increasingly motivated to measure their Covid-19 exposure;
  •  Launch a public relations campaign that shows all public officials wearing a mask and reminding Texas residents that wearing a mask is required by law and not an option. Going forward, the campaign should avoid using the familiar phrase “Wearing a face mask is a good idea” and replace it with a clearer message like “Wearing a face mask is a life or death issue – obey the law;” and
  • Lastly, consider placing Dallas County Judge Clay Jenkins and Harris County Judge Lina Hidalgo to lead a Covid-19 commission composed of the state’s top healthcare experts to manage the state’s Covid-19 strategy going forward. Both judges have been more forceful in warning Governor Abbott against re-opening Texas businesses and showing the appropriate respect for science to protect the health of Texas residents.  Importantly, the unbiased and more objective management of the Covid-19 strategy by this commission should ensure that political considerations are removed from future decisions related to the distribution of Covid-19 treatments and vaccines as they become available.   

End Notes

[1]  Champagne, S.R. (2020 June 25). Gov. Greg Abbott pauses Texas’ reopening, bans elective surgeries in four counties to preserve bed space for coronavirus patients. Texas Tribune. Accessed at: https://www.texastribune.org/2020/06/25/texas-elective-surgeries-coronavirus-greg-abbott/
[2] Champagne, S.R. (2020 June 25). Ibid.
[3]Texas Department of State Health Services, DSHS Covid-19 Dashboard, Data reported as of June 27, 2020. Accessed at: https://txdshs.maps.arcgis.com/apps/opsdashboard/index.html#/ed483ecd702b4298ab01e8b9cafc8b83
[4]Goodman J.D. (2020 June 24). N.Y. Will Impose Quarantine on Visitors From States With Big Outbreaks,  Accessed at https://www.nytimes.com/2020/06/24/nyregion/ny-coronavirus-states-quarantine.html
[5]  Associated Press (2020 June 19). OVID-19 Is Ravaging America’s Vulnerable Latino Communities, New York Times. Accessed at:  https://www.nytimes.com/aponline/2020/06/19/us/ap-us-virus-outbreak.html
[6] Ollove, M. & Vestal, C.  (2020 May 27)  COVID-19 Is Crushing Black Communities. Some States Are Paying Attention. Accessed at: https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2020/05/27/covid-19-is-crushing-black-communities-some-states-are-paying-attention
[7] Hacker, H.K., Ambrose, S. and Keomoungkhoun, N. (2020 June 22) ‘Alarming’ trend of Dallas County COVID-19 cases could worsen by Fourth of July, UTSW experts say UT Southern Medical Center. Dallas Morning News. Accessed at: https://www.dallasnews.com/news/public-health/2020/06/22/ut-southwestern-experts-predict-surge-in-coronavirus-cases-hospitalizations-before-fourth-of-july/
[8]Census Bureau (2018).  ACS Demographic and Housing Estimates, Table DP05, 2018 5-Year Estimates. Accessed at www.data.census.gov.
[9]  U.S. Census Bureau. Measuring Household Experiences during the Coronavirus (COVID-19) Pandemic Accessed 5-29-2020 at: https://www.census.gov/householdpulsedata
[10] Held, L. (2020 June 16).  OSHA faulted for not doing more to protect workers from Covid-19. Civil Eats, accessed at https://civileats.com/2020/06/16/osha-faulted-for-not-doing-more-to-protect-workers-from-covid-19/
[11]  Rincon, E.T. (2020, April 16).  Missing Race-Ethnicity Data Complicates Covid-19 Mortality Counts, But the Solution is Simple. Accessed at: https://www.blogger.com/blogger.g?blogID=4666951909336256447#editor/target=post;postID=242538682071119357;onPublishedMenu=template;onClosedMenu=template;postNum=2;src=postname
[13] Census Bureau. Aggregate income in the past 12 months – Hispanic households. Table B19313.  Accessed at: www.data.census.gov
[14] Hawkins, D., Birnbaum, M., Kornfield, M., O’Grady, S., Copeland, K. Lati, M. and Sonmez, F. (2020 June 29). Arizona, Florida, Texas are latest coronavirus epicenters. The Washington Post. Accessed at:  http s://www.washingtonpost.com/nation/2020/06/28/coronavirus-live-updates-us/

Texas GOP Reveals Cowardice on Mail-In Ballot Issue

It was a coward’s decision – the first thought that came to my mind when I learned that the Texas Supreme Court had sided with Attorney General Paxton in denying Texas voters the right to vote by mail if they feared infection or death of Covid-19 by voting in person.  Indeed, this decision was especially disturbing given the recent news that a number of Wisconsin voters became infected from being forced to vote in person by Republican leaders and their State Supreme Court. 
This level of desperation follows previous failed efforts to limit the political clout of traditionally Democratic voters in Texas.   The dust has barely settled, for example, on recent GOP efforts to include a citizenship question in the 2020 Census; attempts to purge eligible Texans from registered voter lists;  reducing the number of polling stations in communities of color; and passing voter ID laws.
Rather than invest in a competitive strategy to win the hearts and minds of Texas voters, it appears that the Republican Party has become so desperate at the thought of losing their political stronghold in Texas that they are willing to risk the health and safety of Texas voters to maintain their status quo. The benefit to society, they argue, is the prevention of large-scale voter fraud.  In fact, numerous national studies have confirmed that evidence of voter fraud is practically non-existent in U.S. elections and contradicted by the fact that 35 states in the U.S. continue to use mail-in ballots effectively to encourage voter participation for all residents regardless of their political affiliation or other characteristics.
Interestingly, Texas Attorney General Paxton argued before the Texas Supreme Court that a physical condition must be present in order to qualify to use a mail-in ballot,  although age and military service are common exceptions.  The fear of becoming sick or dying from the coronavirus, it was argued, does not constitute a physical condition and therefore cannot be used as a basis to request a mail-in ballot. The Court, however, determined that voters can decide for themselves if they think a “physical condition” might prevent them from voting in person or harm them.  However, Attorney General Paxton warned that he plans to criminally prosecute third parties that advise voters to apply for a mail-in ballot based solely on fear of contracting COVID-19.  In other words, it is up to the voter to determine whether in-person voting will likely lead to injury due to a physical condition.
I find this argument incredulous for two reasons.  First, fear and anxiety can be both facilitating and debilitating conditions that can influence the performance of common human behavior. In many instances, fear and anxiety serve as effective survival tools for healthy living to prevent us from engaging in harmful activities, such as petting a wild animal or exposure to toxic environments.  When death is imminent or highly probable from such exposure, only a fool would knowingly risk their life if an alternative action was available. Why is the Attorney General forcing voters into the lion’s den just to exercise their right to vote?
 Secondly, various recent studies have found that Blacks, Latinos, Asians and the elderly are experiencing disproportionately higher levels of Covid-19 mortalities when compared to their representation in their communities.  Part of the explanation for this trend is that these groups have higher levels of comorbidities that increase their likelihood of dying from the coronavirus – such as diabetes, immune diseases, kidney disease, etc.  – and have living conditions and occupations that increases their exposure to the coronavirus.  Moreover, these mortality rates are likely higher than currently reported since Texas does not require the recording of race-ethnic information on Covid-19 mortalities, leading to missing data and misleading indicators.   The conclusion that it is ultimately up to the voter to determine if they will experience injury by voting in person is problematic, especially for persons with comorbidities who usually follow their doctor’s advice on their medical condition.  Should a diabetic, for example, just provide a statement from their doctor that confirms their medical condition and the danger of increased exposure to Covid-19?  Clearly, comorbidities are “physical conditions” that cannot be dismissed by Attorney General Paxton as easily as fear of the coronavirus.
 Undoubtedly, Texas Republicans are probably applauding their success on the mail-in ballot issue and may believe that their political position in Texas has been solidified by the Texas Supreme Court decision. My hope is that Texas voters with higher moral and ethical standards will prevail in the coming elections by rejecting the cowardly actions taken by Texas Republicans.  In reaching the milestone of 100,000 Covid-19 deaths in the U.S., it is hardly the time to celebrate political victories that will unnecessarily diminish the lives of our children, the elderly and communities of color.  

Missing Race-Ethnicity Data Complicates Covid-19 Mortality Counts, But the Solution is Simple

Recent news reports about mortality counts for the Coronavirus point to the potential of large under-counts due to the exclusion of deaths occurring at homes and the classification of causes of death in the frenzied environment of so many deaths occurring in communities. [i]

In addition, national reviews are showing that black mortality rates are much higher – sometimes twice as much – as their representation in the population for several communities such as Michigan, Illinois, North Carolina and South Carolina. [ii] Relatively less information has been provided in national news reports regarding mortality rates for Latinos.    
Recognizing these racial disparities, elected officials in Texas are pressing Governor Greg Abbot to form an emergency task force to evaluate racial disparities surrounding the coronavirus pandemic since several Texas cities are reporting that the disease is disproportionately affecting black residents. [iii]  Large gaps in data collection, however, exist at the county and state level, meaning that the full picture is unclear.  In response to these concerns, the Governor’s office offered no comment and continues its policy of not mandating the collection of this critical information.  As the Texas elected officials emphasized, the demographic data regarding Covid-19 mortalities is needed to guide resources to the more vulnerable communities or “hot spots” in the state.
Unfortunately, accurate estimates of Covid-19 mortality rates by race-ethnicity are systematically under-estimated because so many of the deaths are not being classified by race-ethnicity.  The absence of race-ethnic data undermines the planning of intervention strategies since it is fairly well understood that identifying clusters of infected persons can expedite a quick intervention and solution to the spread of the virus.
Thus far, the knowledge that blacks have higher Covid-19 mortality rates compared to their population in a community has been attributed to the confluence of co-morbidities like diabetes, high blood pressure, obesity, and higher prevalence of cardiovascular disease. Less attention has been devoted, however, to the influence of social determinants of health – that is, black people tend to live in poor areas that include poor access to healthy foods and healthcare providers.[iv] There could be other correlates that are equally important in explaining these high mortality rates, such as lack of knowledge about the virus, negative attitudes towards healthcare providers, religious beliefs, fear of family separation, and other psychological factors.

An Important Question to Ponder
Given the gravity of the high mortality rates among blacks and Hispanics, and the real possibility that they could be higher and likely to spread the virus more rapidly in these vulnerable communities, why have public officials not mandated the collection of race-ethnic information for Covid-19 infected persons and mortalities?   
Thus far, the explanations appear to rest on the assumption or belief that the sheer volume of mortalities does not allow sufficient time to demographically classify the corpses.  While this theory may be true, following are a few examples from my research practice that illustrate the consequences of policies that utilize inaccurate race-ethnic information or appear indifferent to its inclusion. In general, the solutions were not complicated nor time consuming.

Is Racial Profiling on the Decline?:
A recent analysis of traffic stops made by the Texas Highway Patrol revealed that racial profiling of Hispanics was on the decline, although critics suspected that the Department of Public Safety (DPS) was deliberately misclassifying Texas drivers that they stopped in order to lower the state’s racial profiling statistics. [v]  Further analysis, however, revealed that the DPS troopers were assigning the race category based on the physical characteristics of the drivers. For example, by classifying Hispanic drivers as “white,” the racial profiling statistics were systematically lowered in the State of Texas. The recommended solution was to simply ask each driver to self-identify their race or ethnicity by choosing from a card with standard race-ethnic categories that could be presented by the DPS trooper. [vi] 

Relying on Surnames:  A Legal Matter
In a Dallas County murder trial that engaged me as an expert witness, the defense attorney had requested a change of venue because he felt that a fair trial was not possible for his Hispanic client. Why? Because the share of Hispanics in the jury pool was likely to be substantially different from the Hispanic share of the county’s population. I was asked to conduct a statistical analysis to address this issue; however, the race-ethnic information recorded by the court for jury pool members was considered unreliable for the analysis because it was inconsistently recorded. A surname was the only information available to estimate the Hispanic ethnicity of jury pool members at an estimated accuracy of 75 percent.  A change of venue was justified since the estimate of Hispanics in the jury pool was not reflective of their representation in the County’s population.  Clearly, a different legal outcome might have resulted if the venue had not changed.

The Mystery Surrounding the Causes of Asian Mortalities
Information about the leading causes of mortality among Asian American subgroups have been few in epidemiological studies because (a) only seven states collected Asian subgroup information on death records before 2003, (b) coroners were more likely to make race-ethnic classification errors for Asian Americans (13%) and Hispanics (7%) and (c) national health surveys did not report data for Asian American subgroups. [vii] As a result, misleading and erroneous conclusions were often made due to the omission of Asian respondents resulting from small sample sizes, or the aggregation of data that masked important differences among the Asian subgroups. For example:
·       Asian Indians have greater coronary heart disease risk than Chinese persons when compared to non-Hispanic whites;
·       Japanese have greater risk for incident cancers while Asian Indians have the lowest risk;
·       Liver cancer mortality rates are higher for Vietnamese, Koreans and Chinese when compared to other Asian American subgroups and non-Hispanic whites.
·       Colorectal cancer rates are particularly higher for Japanese and exceed the rates for non-Hispanic whites and all other Asian subgroups.
The study investigators also discussed the results of recent pharmacogenomics studies that document how some Asian American subgroups respond differently to a variety of drug treatments, including chemotherapy, anti-coagulants, anti-platelets, and anticonvulsants. The inclusion of Asian subgroup categories in major health surveys and in the processing of medical information has greatly expanded medical knowledge and treatment related to Asian subgroups.  At least in the medical arena, the study investigators clearly illustrated that carelessness or indifference to the use of Asian subgroup identities can have significant consequences. 
Thus, it should be obvious that missing or inaccurate race-ethnic information can have serious consequences to our quality of life and should not be dismissed so easily by public officials who believe that it requires a great investment of time.

Current Technology Points to a Simple Solution for the Covid-19
In the absence of information regarding the race-ethnic background of a given population, we can take comfort in knowing that it is now possible to classify the race-ethnic background of an individual based on their first name, last name and their residential zip code.  Ethnic Technologies developed a proprietary classification system called E-Tech 2020 [viii] which has been utilized in several survey studies that I have conducted in past years.  In one national study of black, Latino and Asian consumers in the U.S., race-ethnicity information was missing and presented a major barrier to the sample design and planning of the survey.  The E-Tech tool was used to estimate a race-ethnic category in a database of 200,000 household addresses that allowed us to plan the appropriate language for the questionnaires and manage a team of telephone interviewers with the relevant language skills.  The completed surveys that we received confirmed that the accuracy of the assigned race-ethnic category using the E-Tech tool was 80-90 percent when compared to the self-reported race-ethnicity of the survey respondents.  Self-identification has usually been found to be a more valid measure of a person’s race and ethnicity, while surname and language preference have also been used although considered less valid measures. [ix]  In a more recent review and analysis using geo-coding and surnames to estimate race and ethnicity, the investigators concluded that the combined approach can yield positive predictive values of 80 percent, thereby offering a viable means for assigning race and ethnicity for the purpose of examining disparities in care until self-reported data can be systematically collected. [x] While not a perfect measure, the E-Tech tool has been shown to be quite useful in my past research experience.
What is the relevance of the E-Tech tool for the Covid-19 situation?  Simply, it can drastically reduce the amount of time needed to identify the likely race-ethnic categories for a listing of mortalities that includes their names and addresses.  Moreover, the E-Tech tool is affordable and likely to fit most public agency budgets.  By using this service, public officials could more readily identify clusters of vulnerable populations, such as blacks and Latinos, that require immediate intervention to minimize the spread of the coronavirus.  While the accuracy of the E-Tech tool in estimating a person’s race-ethnic classification is not 100 percent, it nevertheless presents a significant advantage over the current system of delays and backlogs that are typical in public agencies.  
I challenge Gov. Abbott and other public officials to mandate the classification of race-ethnicity for all Covid-19 infections and mortalities using the E-Tech tool or perhaps another service that accomplishes similar results. Indeed, this action would illustrate true leadership in our collective efforts to stop the threat of this deadly virus.

Reference Notes

[i] Gillum, J., Song, L. and Kao, J.  (2020, April 14).  There’s been a spike in people dying at home in several cities. That suggests coronavirus deaths are higher than reported.  Accessed on 4-15-20 at https://www.propublica.org/article/theres-been-a-spike-in-people-dying-at-home-in-several-cities-that-suggests-coronavirus-deaths-are-higher-than-reported
[ii] Ray, R.  (2020, April 9).    Why are Blacks dying at higher rates from COVID-19?  The Brookings Institution. Accessed on 5-15-20 at https://www.brookings.edu/blog/fixgov/2020/04/09/why-are-blacks-dying-at-higher-rates-from-covid-19/
[iii] Morris, A.  (2020, April 14).  Texas elected officials push for emergency response to racial disparities emerging in Covid-19 pandemic.  The Dallas Morning News, accessed on 4-14-20 at https://www.dallasnews.com/news/public-health/2020/04/14/texas-elected-officials-push-for-emergency-response-to-racial-disparities-emerging-in-covid-19-pandemic/
[iv] Yancy, C.W. (2020, April 15). Covid-19 and African Americans. JAMA Network. Access on 4-15-20 at https://jamanetwork.com/journals/jama/fullarticle/2764789
[v] Rincón, E. T. (2016). How DPS can improve its system of recording race/ethnicity during traffic stops.  Dallas News, Jan. 2016. Available at https://www.dallasnews.com/opinion/commentary/2016/01/27/edward-t.-rincon-how-dps-can-improve-its-system-of-recording-raceethnicity-during-traffic-stops
[vi] Ibid.
[vii] Holland, A.T. & Palaniappan, L.P. (2012, June 22). Problems in the collection and interpretation of Asian-American health data: Omission, aggregation, and extrapolation.  Ann. Epidemiol. 2(6).
[viii]Ethnic Technologies, accessed on 4-16-20 at  https://www.ethnictechnologies.com/.
[ix]Rincón, E. T. (in press).  The Culture of Research, Writers Marq, Dallas, Texas.
(x)  Fiscella, K. and Fremont, A.M. (2006).  Use of geocoding and surname analysis to estimate race and ethnicity. Health Services Research, 41-4, Part I. Access on 4-17-20 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1797082