The Impact of COVID-19 on the Well-being of African American and Latino Populations: A Liberation Psychology Perspective.

Introduction

According to the Centers for Disease Control and Prevention (CDC, 2020d), over 5.8 million cases of coronavirus disease 2019 (COVID-19) have been reported in the United States (U.S.) since January 2020.  Available data show that African Americans and Latinos have higher rates of infection and death from COVID-19 than other racial and ethnic groups (Bion, 2020; CDC, 2020a; Lardieri, 2020; Nania, 2020).  As such, health professionals (i.e., physicians, nurses, psychologists, public health educators, health researchers, etc.) must understand the factors that have placed these populations at higher risk for health disparities and inequalities, which the pandemic has exacerbated.

Laurencin and McClinton (2020) gave a call to action to understand the racial and ethnic health disparities surrounding the COVID-19 pandemic. In response to this call, we: (1) discuss the physical, financial, and emotional COVID-19 burdens in African American and Latino populations; (2) propose a liberation psychology (LP) framework (Freire, 1970; Martín-Baró, 1994; Tate et al., 2013) to interpret the factors that place African American and Latino populations at higher risk for behavioral, emotional, psychological and social consequences due to COVID-19; and (3) provide a culturally responsive, LP-driven framework for health professionals to work with these communities to alleviate the identified negative consequences. By using this framework, health professionals can begin to appropriately address the unique needs of these communities and build trusting relationships and use community and cultural resources to promote psychological healing to minimize the lasting consequences of this pandemic.

COVID-19 in African Americans and Latinos

In the United States (U.S.), half of the COVID-19 affected African Americans (19%) and Latinos (31%) (CDC, 2020a), who makes up less than one-third of the population (Census Bureau, 2019).  Similarly, African Americans and Latinos accounted for 22 percent and 17 percent of all deaths caused by COVID 19, respectively. Also, a closer look at the data showed that younger African Americans and Latinos were more likely to be disproportionally affected by COVID-19 cases and deaths than their White non-Hispanics counterparts. However, it is important to note that race and ethnicity data were only available for 49 percent of all COVID-19 cases and 82 percent of all registered deaths; thus, these data do not reflect the true picture of the numbers of cases and deaths among these groups.  Besides, data from 1,000 counties showed that African Americans and Latinos have been three times more likely to be infected with COVID-19 than Whites non-Hispanics (Oppel, et al., 2020). Moreover, since historically marginalized groups have had limited access to health care and therefore testing (Zografos & Pérez, 2014), it stands to reason these data underestimate COVID-19 cases in African Americans and Latinos.

African American and Latino populations in the U.S. are experiencing more negative physical health, mental health, and financial consequences because of COVID-19, compared to other racial/ethnic groups. Since individuals with chronic lung disease, asthma, serious heart conditions, diabetes, chronic kidney disease, and liver disease are at higher risk of contracting the disease compared to healthy individuals (CDC, 2020b), it is not surprising that African Americans and Latinos have been more affected by COVID-19 (CDC, 2020c) as these chronic illnesses are more prevalent among these groups (U.S. Department of Health and Human Services, [DHHS] 2019ab).

Structural racism and discrimination, which have shaped the health care system, and other social determinants of health (e.g.,  socioeconomic status, employment, etc.) that lead to more chronic conditions in African American and Latino populations (DHHS, 2019ab, Zografos & Pérez, 2014) mean these groups are more vulnerable overall to pandemic conditions (Hutchins et al., 2009). Thus, it is plausible that the long-term impact of COVID-19 on these communities would be greater than we have previously seen, and it falls on health professionals to respond in a manner that recognizes these disparities.

While the physical health consequences of COVID-19 are well documented, to our knowledge, there are no research studies on the mental health consequences of the disease.  Current COVID-19 preventive measures can trigger mental health problems (i.e., despair, hopelessness, anxiety, social withdrawal, etc.) (Galea et al., 2020).  Results from a survey early in the pandemic revealed that both African Americans and Latinos were more concerned about COVID-19 and its ramifications than their White counterparts. According to the Pew Research Center, Latinos (49%, 43%) and African Americans (38%, 31%) were very concerned about unknowingly spreading and contracting the virus compared to Whites (28%, 18%). Moreover, both Latinos and African Americans were more likely to report that they knew someone who has been hospitalized or died due to coronavirus than were Whites (Pew Research Center, 2020). These concerns and knowledge result in feelings of despair, hopelessness, anxiety, and fear for loved ones’ lives among members of these groups, where social connection among extended family and community is a major cultural value. Moreover, as discussed below, atop mental health concerns arising from preventative measures and concerns for personal health and family health, Latino and African American communities often have less trust in healthcare and government authorities (Boulware et al., 2003; George, et al, 2014; Rainie & Perrin, 2019). These compounding psychological issues warrant contextualized and culturally responsive action.  Several authors have also stated the need for a culturally appropriate response to the impact of COVID-19 among underrepresented populations (Brown, et al., 2020; Fortuna et al., 2020; Laurencin & McClinton, 2020)

Finally, the financial impact of COVID-19 has fallen more heavily among lower-income Americans, many of whom were feeling financial pressure well before the epidemic. Many of these individuals, especially Latinos, have reported COVID-19 related job or wage loss (Krogstad, et al., 2020ab; Parker, et al., 2020). Since African Americans and Latinos are more likely to work in service, sales, production, and related jobs, members of these communities were more likely to be on the front line of the pandemic as they could not afford to stop working to support their families (Nuñez, et al., 2020; Van Dorn, et al., 2020). Since overall African American and Latino populations’ median income is less than White families’ median income, and they are more likely to report living at the poverty levels (Pérez & Luquis, 2014b), they are more likely to be negatively affected by the financial impact of this or any pandemic. Undoubtedly, the financial consequences contribute to existing physical and mental health strains, as access to care is limited to low financial resources, thereby reinforcing disparities that lead to distrust in government and healthcare professionals.

Given the long-standing racial and ethnic disparities in health and social determinants of health, many medical, public health, and psychology scholars have proposed frameworks to address current COVID disparities. Among these calls for culturally-oriented responses, researchers and practitioners have recommended health equity-informed responses emphasizing better research on race, ethnicity, and health determinants and development of public policy-based government commissions (e.g., Abuelgasim et al., 2020; Brown et al., 2020; Laurencin & McClinton, 2020). Others have proposed trauma-informed social justice frameworks to work with minoritized communities (e.g., Fortuna et al., 2020). To our knowledge, only one group of scholars have proposed liberation psychology as a potential framework for psychologists to conceptualize racial and ethnic disparities in health (e.g., Domínguez, 2020). Here, the authors mention liberation psychology as one option of many. We agree with their recommendation and offer below a detailed justification for and recommendations from liberation psychology as a way forward.

Liberation Psychology   

Racism and discrimination, which results in lack of and/or limited access to quality health care (Bailey, et al., 2017), have caused feelings of injustice among African Americans and Latinos; this felt injustice is eroding the psychosocial wellbeing of these communities.  Liberation psychology (LP) can assist health professionals in (1) understanding how African American and Latino communities are responding to and coping with the pandemic and (2) mitigate the negative consequences of COVID-19 among these communities.  Liberation psychology (LP) is credited to Ignacio Martín-Baró, a Jesuit priest and psychologist from Spain who worked in and was murdered in El Salvador in the 1980s (Martín-Baró, 1994; Tate, et al., 2013). The principles of LP are rooted in social justice and a joining with the perspective of oppressed groups and were inspired by Liberation Theology and Freire’s work in particular (Freire, 1970; Tate, et al., 2013).

LP’s primary principles are concientización (critical consciousness), praxis, and transformation of the social scientist (Cardenas, et al., 2019; Freire, 1970; Martín-Baró, 1994). Concientización requires a focus on marginalized communities’ perspectives, including recognition that historical and contemporary narratives often marginalize oppressed groups and instead focus on individual responsibility rather than community-level responsibility, thereby maintaining oppression (Freire, 1970; Martín-Baró, 1994; Tate, et al., 2013).  Praxis and transformation of the social scientist emphasize the need to put ideas and understanding transformed by concientización into action. Thus, we may understand health inequities and responses to the present COVID-19 situation in African American and Latino communities through a concientización lens.  Further, below, we offer action-oriented recommendations in the spirit of praxis and the transformation of the social scientist.

Health professionals can use concientización to address two major themes related to race/ethnic relations and the pandemic: first, false, racialized media and public narratives (Kendi, 2020) and second, minoritized communities’ distrust of government and healthcare systems (Politico, 2020, Rose, 2021). For both themes, we must place the current pandemic and racial/ethnic inequities into a cultural context and recognize the historical recurrence of each. This critical examination will also demonstrate how the themes reinforce one another.

Laurencin and McClinton (2020) pointed out that people have racialized this pandemic from the beginning (e.g., the “Chinese virus”). Ruiz et al. (2020) found that many African Americans and Asians have been experienced racism and discrimination since the pandemic began. Similarly,  many recent public health crises have been racialized (e.g., HIV epidemic (Laurencin, et al., 2018), opioid epidemic (Santoro, et al., 2018), Hurricane Katrina (Adams, et al., 2006)) in such a way that the disease burden of African American, Latino, and other minoritized communities have been ignored or minimized. One particularly insidious theory goes beyond ignoring minoritized communities and instead suggests that African Americans are immune to COVID-19, which emergent data has shown to be markedly inaccurate (Laurencin & McClinton, 2020). This immunity narrative has two immediate consequences: first, it may have altered African Americans’ health behaviors to be less cautious of the virus, and second – and more systematically damaging – it may justify or spur inequitable policies and public sentiment. Using LP’s emphasis on understanding historical narratives, we can see that these false narratives have emerged before and led to added disease burden among minoritized communities.

Many have responded to COVID-19 health disparities with rhetoric emphasizing individual responsibility and meritocracy (Kendi, 2020), as seen in past national disasters (Adams, et al., 2006). Further, public opinion has used this individualistic rhetoric to conclude about a whole group of people, in a way that justifies the pandemic’s health disparities:

Racialized, false narratives eradicate hope of a nuanced exploration of oppression existing in COVID-19 related responses within public policy, healthcare, and community systems. Moreover, they remove the possibility of empathy and unity and provide space for racial scapegoating. As policy continues to develop, an LP framework emphasizing concientización to reexamine historical narratives and recognize community strengths and leadership is needed to assist health professionals, especially if we are faced with a second round of this pandemic. We, health professionals, can challenge both these narratives with concientización: critically examining and deconstructing the dominant culture’s historical and current narratives and recognizing the perspective of the oppressed. Thus, we have a responsibility in health practice and research to listen to these narratives and actively dismantle them to prevent widening inequities.

Once we dismantle these narratives, it becomes easier to understand the documented distrust African American and Latino communities have for the government and healthcare systems. In addition to racialized narratives around the current and past public health crises, healthcare systems and professionals historically have mistreated Latino and African American communities (e.g., the Tuskegee Syphilis Study (Northridge, 2011; Wimberly, 2012). This distrust may differ for various Latino communities, who may have varying access to healthcare systems depending on immigrant and/or undocumented or migrant status, in addition to different perspectives and concerns based on country of ancestry and language needs (Weinick et al., 2004). Moreover, past responses to public health disasters, such as Hurricane Katrina, demonstrated the government’s tendency to assist White communities over African American communities (Adams, et al., 2006) combined with reputable media sources’ documentation of the U.S. government’s failure to act on COVID-19 concerns and warnings (The New York Times, 2020) results in further distrust and hopelessness toward the government. Given the historical mistreatment of Latinos and African Americans in healthcare and ongoing health inequities (Rose, 2021), misinformation (Laurencin & McClinton, 2020), and/or be distrustful of information coming from the government (Politico, 2020) is not misguided – it is quite reasonable. In this way, we encourage public health professionals to see “resistant” or “distrustful” behaviors as adaptable, given the historical and lived experiences of oppressed communities in the U.S. Nonetheless, a recent study has found that distrust in science messaging affects whether people conform to recommended COVID-19 behavior changes, including social distancing (Plohl & Musil, 2020), making it more likely that due to distrust alone, African American and Latino communities risk for COVID-19 continues to increase. Thus, the ultimate act of concientización around the current pandemic and racial/ethnic disparities is the realization that the systems that caused the distrust are also responsible for continuing the cycle of health disparities and oppression.

Implications: Transforming the Social Scientist and Praxis (Taking Action)

Concientización without action is useless (Freire, 1970; Martín-Baró, 1994). As such, health professionals must consider culturally appropriate, holistic interventions to address the needs of these populations. Rather than lay blame at the feet of Latino and African American communities, LP encourages a fuller examination of historical events and public policy that has led us to these inequities. Health professionals have an opportunity to listen and validate the cultural values and cultural wounds suffered by these communities (Duran, et al., 2008) to establish strong working relationships with said communities, which will rebuild trust. This is especially critical as preventive and healthcare practices in the U.S. are often at odds with the cultural values of collectivism in Latino and African American communities (Diaz-Cuellar & Evans, 2014; Bavel, et al., 2020)  and may push these communities further away.

Recognize Unique Needs.

While social distancing is a public health necessity, it also promotes an individualistic approach to health. Since both the African American and Latino communities tend to value interdependence over independence, proximity, and relationships with extended families are important (familismo) (Diaz-Cuellar & Evans, 2014), which in some cases result in multi-generational families living under the same roof. Living under quarantine, therefore, triggers many of the mental health issues previously mentioned (Galea, et al., 2020).  Both Latinos and African Americans have already reported higher concerns about COVID-19 including being distress by transmitting the virus among family members, getting hospitalized, and getting access to ventilators (Pew Research Center, 2020), and, anecdotally, not being able to visit a family member in the hospital, or properly grieving a loved one who had died from it, as these preventive measures go against cultural rituals of caring for a sick member of the family or addressing the needs of the individual facing death. Thus, without culturally responsive messaging to explain social distancing and identify alternative means of social support, such measures run the risk of prioritizing western, Euro-centric values and pushing Latino and African American communities away from public health initiatives (Nuñez, et al., 2020; Plohl & Musil, 2020).

Health professionals should study and implement physical and psychological health interventions that capitalize on family and social connections. For example, public service announcements on social distancing should also include solutions for how to maintain family connections while preventing transmission. Community health professionals can work with people to obtain needed supplies to maintain connections (e.g., video chats), such as creative problem solving around access to technology, including the internet. Moreover, recommendations for social distancing and quarantine are likely more successful in interdependent cultures, rather than independent cultures, especially when such measures are tied to community (rather than individual) health (Diaz-Cuellar & Evans, 2014).  Webinars like those provided by the Migrant Clinicians Networks (2020), which provided culturally appropriate information on COVID-19, prevention strategies, risk factors for migrant workers, and how to plan to protect their families, are good examples of how to reach these underrepresented groups.

Building Relationships.

Across the healthcare system, stronger relationships between patients and health professionals yield better patient outcomes, compliance with treatment, and trust (Cameron, et al., 208; Shen et al., 2018).  Unsurprisingly, cultural competence, responsiveness, and humility affect these relationships (Hook, et al, 2017; Pérez & Luquis, 2014a; Teal & Street, 2009). For example, health professionals can recognize the distrust of healthcare messaging as a valid response to past community traumas, whereby such distrust is protective against future betrayals. As such, the inclusion of African American and Latino community leaders is imperative as part of any communication regarding preventive or healthcare services.  These community leaders are trusted sources and know-how to communicate with the intended audience (Nuñez, et al., 2020) and, in many instances, have already provided support to the community by providing needed food, masks, and other needed supplies.  Moreover, these leaders hold the social history of the community and understand the complex relations among the community and healthcare systems. By involving community leaders, health professionals convey empathy and recognition of this distrust as reasonable, which is an important step in building genuine relationships with African American and Latino communities, especially during this pandemic. It also leaves space for communities’ testimony, which is healing in itself (French, et al., 2020). This will allow health professionals to collaborate with African American and Latino communities to develop culturally responsive prevention and treatment practices during this crisis.

Create space for emotional and social healing.

As noted above, African American and Latino communities have stronger concerns about the pandemic, are experiencing more distress due to conflict between using extended familial supports and social distancing requirements, and ongoing health disparities and distrust. In addition to responding to distrust or hesitation in an empathic and validating way and identifying culturally responsive ways of implementing preventive health measures, health professionals can collaborate with these communities to capitalize on cultural strengths to process the ongoing grief and trauma of the pandemic. For example, Moane (2008) outlined how she applied LP principles to various social conditions and issues to increase concientización among oppressed groups and collaborate on actionable steps to promote change. Similar to testimony (French, et al., 2020), Wimberly (2012) discussed the importance of intergenerational storytelling as a means to process trauma and grief in communities abused by the medical community, which builds on community strengths around oral narratives.  Thus, health professionals can collaborate with African American and Latino community leaders and members of the clergy to create a community space for social and emotional healing, especially now when many of the religious institutions are again opening their doors to the community.

Moving Forward – Training in an LP Framework.

While detailed recommendations on training health professionals are beyond the scope of this perspective, we would be remiss not to encourage readers to review excellent, multicultural training approaches that align with and/or draw from LP. Most centers on the fact that health professionals should increase contact with diverse communities and focus on increased cultural competence, empathy, and communication. For example, Hook and associates’ (2016) introduce a paradigm for supervising mental health trainees in cultural humility; Teal and Street (2009) outline a cultural communication model for physicians’ professional development; and French and associates (2020) introduce an LP-influenced framework for radical healing in minoritized communities.  Finally, public health professionals must continue to incorporate concepts of cultural competency as we address health disparities during and after this pandemic end (Pérez & Luquis, 2014a).

 Conclusion

The COVID-19 pandemic provides once again a need for health professionals to tackle health disparities among African American and Latino populations.  We suggest health professionals use a  liberation psychology framework to properly understand and address the immediate and long-term behavioral, emotional, psychological, and social consequences due to COVID-19.  A culturally responsive framework provides the best option to lessen the identified negative consequences among these groups.

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