The South May Suffer the Largest Share of Covid-19 Misery. Here’s Why.

Christine Vestal April 25, 2020

A customer enters Burnell's Lower Ninth Ward Market in New Orleans on April 14. Burnell's is the only grocery store in what is otherwise considered a "food desert." New Orleans has had the highest COVID-19 death rates in the country.

Edi­tor’s Note: This arti­cle was orig­i­nal­ly pub­lished by State­line, an ini­tia­tive of The Pew Char­i­ta­ble Trusts.

It looks increas­ing­ly like­ly the South will endure more death and eco­nom­ic loss from COVID-19 than any oth­er region in the coun­try — and not just because South­ern gov­er­nors were slow to shut down busi­ness­es and order peo­ple to stay at home.

South­ern pover­ty rates are high, social wel­fare pro­grams spot­ty and health care infra­struc­ture thread­bare. In the past decade, 120 rur­al U.S. hos­pi­tals closed their doors; 75 of them were in the South.

And emerg­ing data from some cities and states shows that black peo­ple — more than half of whom live in the South — are con­tract­ing and dying from the virus at a dis­pro­por­tion­ate­ly high rate.

Because of pover­ty and lim­it­ed access to health care, African Amer­i­cans more often have under­ly­ing health con­di­tions — such as dia­betes, heart dis­ease, hyper­ten­sion, obe­si­ty and asth­ma — that increase the risk of death from COVID-19. In addi­tion, African Amer­i­cans more often work in essen­tial front­line jobs that make social dis­tanc­ing impossible.

The South is expect­ed to be hit hard, because African Amer­i­cans are expect­ed to be hit hard,” said Dr. Har­ry Heiman, a pro­fes­sor at Geor­gia State University’s School of Pub­lic Health. There’s no get­ting around that.”

Still, he and oth­er advo­cates for low-income peo­ple say it’s not too late for elect­ed lead­ers in the South to enact poli­cies that could sub­stan­tial­ly improve the region’s chances for recovery.

Med­ic­aid Politics

Expand­ing Med­ic­aid is at the top of every advocate’s wish list. Of the 14 states that still refuse fed­er­al mon­ey to extend the low-income health plan to thou­sands of adults, nine are in the South.

Med­ic­aid expan­sion, which would pro­vide health insur­ance to hun­dreds of thou­sands of low-income peo­ple with the fed­er­al gov­ern­ment pay­ing 90% of the cost, is the best way for South­ern states to boost their bud­gets, accord­ing to a study by researchers at Har­vard Uni­ver­si­ty pub­lished last month in response to the coro­n­avirus crisis.

There is no moment in recent mem­o­ry more crit­i­cal than now to bol­ster Med­ic­aid,” they wrote. Cov­er­ing more peo­ple in Med­ic­aid is a rapid way to bring need­ed resources into the health care sys­tem and infuse fed­er­al dol­lars into state economies on the verge of a major downturn.”

At a news con­fer­ence ear­li­er this month in Mont­gomery, Demo­c­ra­t­ic U.S. Sen. Doug Jones of Alaba­ma urged state lead­ers to expand Med­ic­aid now with the promise that more fed­er­al mon­ey would be com­ing soon to pay the state’s 10% share. In the mean­time, fed­er­al stim­u­lus mon­ey could be used to pay part of the costs, he suggested.

In response, a spokes­woman for Repub­li­can Gov. Kay Ivey’s office report­ed­ly said all options are on the table,” adding that to expand Med­ic­aid, there must be a sta­ble source of rev­enue for the required state match, whether that be now or three years from now,” accord­ing to The Annis­ton Star.

Oth­er than that, South­ern gov­er­nors who have resist­ed Med­ic­aid expan­sion for more than a decade have either remained silent since the cri­sis began or reaf­firmed their oppo­si­tion to an offer of mil­lions of fed­er­al dollars.

Short of expand­ing Med­ic­aid to low-income adults, state advo­cates are urg­ing South­ern gov­er­nors to seek fed­er­al per­mis­sion to make it eas­i­er for peo­ple who do qual­i­fy for Med­ic­aid to enroll and stay enrolled and for more doc­tors and oth­er med­ical pro­fes­sion­als to pro­vide ser­vices under the program.

In addi­tion, the NAACP and oth­er advo­cates for African Amer­i­cans are call­ing on the U.S. Cen­ters for Dis­ease Con­trol and Pre­ven­tion to pub­lish more nation­al data on the num­ber of COVID-19 cas­es and deaths, by race, to inform a more tar­get­ed pub­lic health response. Some cities and states already have start­ed releas­ing more data.

Local and nation­al pub­lic health offi­cials are call­ing for increased test­ing and inten­sive pub­lic out­reach cam­paigns in rur­al and urban low-income black com­mu­ni­ties, as well as more mon­ey for face masks and oth­er per­son­al pro­tec­tive gear for front­line work­ers to tamp the spread of the virus.

His­toric Inequities

Fifty-eight per­cent of African Amer­i­cans live in South­ern states and the Dis­trict of Colum­bia. And South­ern states have the high­est per­cent­ages of black pop­u­la­tions in the country.

High rates of chron­ic dis­ease, com­bined with long-stand­ing poli­cies in most South­ern states that lim­it access to health care and oth­er social pro­grams for low-income res­i­dents, put the entire region at risk, Heiman said.

You real­ly have this trag­ic mix in the South of pop­u­la­tions who are at increased risk for acquir­ing coro­n­avirus infec­tions because of their socioe­co­nom­ic and health sta­tus, com­bined with urban neigh­bor­hoods and rur­al com­mu­ni­ties with­out the health care infra­struc­ture need­ed to pro­tect peo­ple,” Heiman said. That’s all com­bined with the high­est unin­sured rates in the country.”

In addi­tion, low-income peo­ple and African Amer­i­cans are much more like­ly to have jobs deemed essen­tial, accord­ing to new research by the Kaiser Fam­i­ly Foun­da­tion. They are bus dri­vers, gro­cery store work­ers, police and oth­er front­line ser­vice work­ers who can­not isolate.

Many also are liv­ing in over­crowd­ed, sub­stan­dard hous­ing that con­tributes to the spread of the dis­ease, the report said.

While most of the under­ly­ing con­di­tions caus­ing high­er rates of COVID-19 infec­tion and death among black and low-income pop­u­la­tions can’t be cured overnight, advo­cates insist polit­i­cal lead­ers could make a big dif­fer­ence in people’s lives as the region recov­ers from the crisis.

The ide­o­log­i­cal dis­taste for the Afford­able Care Act by many of the South’s polit­i­cal lead­ers and the Trump admin­is­tra­tion, has put them at a sig­nif­i­cant dis­ad­van­tage to respond to this cri­sis,” said Joan Alk­er, exec­u­tive direc­tor of the George­town Uni­ver­si­ty Cen­ter for Chil­dren and Fam­i­lies. This cri­sis could force that to change, she said.

Peo­ple in the South don’t just need Med­ic­aid to cov­er coro­n­avirus treat­ment, they need it to deal with high rates of chron­ic dis­ease and to keep rur­al hos­pi­tals afloat. The coro­n­avirus cri­sis is going to sub­side, but the eco­nom­ic cri­sis will be around for a while.”

In gen­er­al, South­ern gov­er­nors argue that their states can’t afford to expand Med­ic­aid, because they don’t have the mon­ey in their lim­it­ed bud­gets to pay for even 10% of the bill.

Delayed Shut­downs

The first COVID-19 cas­es in the coun­try were detect­ed in Seat­tle in late Jan­u­ary, and the out­break quick­ly spread through­out the state. New York and oth­er major U.S. cities were next to expe­ri­ence outbreaks.

With the excep­tion of New Orleans, most of the Deep South seemed to be spared ini­tial­ly. Even Atlanta, with one of the largest inter­na­tion­al air­ports in the coun­try, did not appear to suf­fer immediately.

But in late Feb­ru­ary, two funer­als in a small Geor­gia city 200 miles south of Atlanta set off a chain reac­tion that quick­ly over­whelmed local hos­pi­tals with COVID-19 patients.

Albany, Geor­gia, pop­u­la­tion 75,000, had the state’s first major out­break, rival­ing on a per capi­ta basis those in New York, Seat­tle and oth­er major cities.

Now sim­i­lar hotspots are being detect­ed through­out the South. And the virus is seep­ing into rur­al com­mu­ni­ties where many local hos­pi­tals are ill-pre­pared to treat more than a hand­ful of patients at a time.

Lee Coun­ty, Alaba­ma, on the Geor­gia bor­der, report­ed an ear­ly out­break, as did Moss Point, Mis­sis­sip­pi, a pre­dom­i­nate­ly black town on the state’s Gulf coast, among oth­er small South­ern towns.

But even as it became clear that the South would not escape the virus and the Trump admin­is­tra­tion declared the coro­n­avirus cri­sis a nation­al emer­gency March 13, some gov­er­nors wait­ed weeks to shut down busi­ness­es. And in many South­ern states, restric­tions on busi­ness­es are loos­er than in oth­er parts of the coun­try and mes­sages to the pub­lic are report­ed­ly unclear.

Ivey, the Alaba­ma gov­er­nor, wait­ed until April 4 to shut down cer­tain busi­ness­es and order res­i­dents to stay at home.

In Geor­gia, Repub­li­can Gov. Bri­an Kemp issued a lim­it­ed stay-at-home order April 2, and the next day his admin­is­tra­tion told local offi­cials who had closed their beach­es to reopen them.

In Arkansas, Repub­li­can Gov. Asa Hutchin­son is still refus­ing to issue a stay-at-home order. In an inter­view on PBS New­sHour, he explained that his state was tak­ing a tar­get­ed approach to lim­it­ing the spread of the virus. Schools and shops — includ­ing bars, restau­rants, tat­too par­lors, bar­ber shops and hair salons — are closed, but oth­er­wise the state is open for business.

We want to do things that actu­al­ly work and make a dif­fer­ence,” Hutchin­son said. And our social dis­tanc­ing, our wear­ing masks is what is work­ing in Arkansas.”

Racial Dis­par­i­ties

Hur­ri­cane Kat­ri­na and its after­math laid bare the vul­ner­a­bil­i­ty of peo­ple liv­ing in pover­ty and high­light­ed huge health dis­par­i­ties between black and white New Orlea­ni­ans dev­as­tat­ed by the 2005 storm.

The coro­n­avirus cri­sis is already spot­light­ing many of those same issues.

In the Dis­trict of Colum­bia, black res­i­dents make up 45% of the pop­u­la­tion and near­ly 60% of coro­n­avirus deaths.

In Louisiana, African Amer­i­cans are 32% of the pop­u­la­tion and more than 70% of coro­n­avirus deaths, as of April 6.

And more than a quar­ter of black peo­ple in the Unit­ed States are low-wage work­ers, com­pared to 16% of whites, accord­ing to the Kaiser Fam­i­ly Foun­da­tion. This puts them at greater risk of expo­sure to the virus and income loss.

Before the cri­sis, 23% of black peo­ple had incomes below the fed­er­al pover­ty lev­el, com­pared to 10% of white people.

Already, far more African Amer­i­cans are los­ing their jobs as a result of the cri­sis com­pared to the rest of the pop­u­la­tion, Heiman said, which will make their chances of recov­ery even more tenuous.

In many South­ern states, racial health dis­par­i­ties are stark. In Alaba­ma, where mater­nal death rates are the third-high­est in the nation, black women die at more than twice the rate of white women. And in every oth­er key indi­ca­tor of over­all health, black res­i­dents score low­er than white residents.

Nation­wide, African Amer­i­cans have high­er rates of obe­si­ty, heart dis­ease, hyper­ten­sion, dia­betes, asth­ma and oth­er chron­ic dis­eases com­pared to the rest of the pop­u­la­tion. Mak­ing mat­ters worse in the South are long-stand­ing poli­cies that pre­vent many African Amer­i­cans from get­ting access to health care.

In Alaba­ma, pover­ty and poor health are a lega­cy of decades of racist pub­lic poli­cies that have exclud­ed peo­ple of col­or from health care,” said Jim Carnes, pol­i­cy direc­tor of low-income advo­ca­cy orga­ni­za­tion Alaba­ma Arise.

We’re think­ing of COVID as a high-stakes stress test on our sys­tem,” he said. It’s reveal­ing weak­ness­es and gaps we’ve always known were there. The ques­tion is whether the light will be bright enough this time that our offi­cials will be forced to face the real­i­ty and address it.”

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