Contextualizing Inequities in COVID Vaccination Trends Among Project REFOCUS Pilot Sites: Racism-Related Determinants of Health.

Introduction: Coronavirus disease (COVID) dashboards rarely provide insights about the racialized contexts in which vaccination inequities occur. Objective: The purpose of this study was to use the emerging Project REFOCUS dashboard to contextualize COVID vaccination patterns among 6 diverse communities. Methods: We queried the dashboard to generate descriptive statistics on vaccination trends and racism-related contextual factors among the 6 Project REFOCUS pilot sites (Albany, Georgia, Bronx, New York, Detroit, Michigan, Helena-West Helena, Arkansas, San Antonio, Texas, and Wake County, North Carolina). Results: Vaccination rates, demographic indicators, and contextual factors differed across sites. As of October 17, 2022, the proportion of people who had received at least 1 COVID vaccine dose ranged from 58.4% (Wayne County, Michigan) to 95.0% (Wake County, North Carolina). The pilot sites with the greatest percentage of Black residents (Dougherty County, Georgia, Wayne County, Michigan, and Phillips County, Arkansas) had lower proportions of fully vaccinated people. Wayne County, Michigan, had the highest level of residential segregation between Black and White residents (78.5%) and non-White and White residents (68.8%), whereas Phillips County, Arkansas, had the highest overall mortgage denial rates (38.9%). Both counties represent settings where over 75.0% of residents report Black race and over 30.0% of the population live in poverty. Discussion: The dashboard integrates racism-related factors with COVID vaccination visualizations and provides a fuller picture of the context in which COVID trends are occurring. Conclusions: Community organizers, researchers, policymakers, and practitioners can track racism-related factors and other social determinants of health as part of the contexts in which COVID-related inequities occur.

An Equity-Based Scoring System for Evaluating Surveillance-Related Harm in Public Health Crises.

Background: Although surveillance systems used to mitigate disasters serve essential public health functions, communities of color have experienced disproportionate harms (eg, criminalization) as a result of historic and enhanced surveillance. Methods: To address this, we developed and piloted a novel, equity-based scoring system to evaluate surveillance systems regarding their potential and actual risk of adverse effects on communities made vulnerable through increased exposure to policing, detention/incarceration, deportation, and disruption of access to social services or public resources. To develop the scoring system, we reviewed the literature and surveyed an expert panel on surveillance to identify specific harms (eg, increased policing) that occur through surveillance approaches. Results: Scores were based on type of information collected (individual and/or neighborhood level) and evidence of sharing information with law enforcement. Scores were 0 (no risk of harm identified), 1 (potential for risk), 2 (evidence of risk), and U (data not publicly accessible). To pilot the scoring system, 44 surveillance systems were identified between June 2020 and October 2020 through an environmental scan of systems directly related to COVID-19 (n=21), behavioral and health-related services (n=11), and racism and racism-related factors (n=12). A score of 0-2 was assigned to 91% (n=40) of the systems; 9% were scored U; 30% (n=13) scored a 0. Half scored a 1 (n=22), indicating a "potential for the types of harm of concern in this analysis." "Evidence of harm," a score of 2, was found for 12% (n=5). Conclusions: The potential for surveillance systems to compromise the health and well-being of racialized and/or vulnerable populations has been understudied. This project developed and piloted a scoring system to accomplish this equity-based imperative. The nobler pursuits of public health to improve the health for all must be reconciled with these potential harms.

Barely Tweeting and Rarely About Racism: Assessing US State Health Department Twitter Use During the COVID-19 Vaccine Rollout.

Introduction: The general public was discussing racism and potential inequities in COVID-19 vaccinations among African Americans on Twitter before the first COVID-19 vaccine received emergency use authorization, but it is unclear how US state health departments (SHDs) were using Twitter to address the inequities. This study examines the frequency, content and timing of SHD tweets during the US rollout of the first SARS Co-V2 vaccine. Methods: This was a prospective study of tweets posted from the official Twitter accounts of each of the 50 US SHDs and the DC health department from October 19, 2020 to February 28, 2021. We retrieved the content and metadata of 100% of their tweets; calculated frequencies and proportions of tweets containing key terms related to COVID-19 vaccines, equity and racism; stratified the data by region; and charted longitudinal trends. Results: Overall, SHDs tweeted infrequently, and rarely tweeted about inequities, mistrust or racism. Though 55.48% of all SHD tweets were about COVID-19, hardly any tweets contained the terms: race/ethnicity (1.20%); equity (1.09); mistrust (.59%); or racism (.06%). Similar patterns existed among vaccination-related tweets, which accounted for 24.38% of all tweets. Only 21.64% of vaccination-related tweets containing any race/ethnicity, equity, mistrust, or racism terms were posted prior to the first Emergency Use Authorization (EUA). Those about African Americans (70.45%) were posted ≥8 weeks after EUA. Conclusions: Concerns about racism and inequities in COVID-19 vaccination continue on Twitter, but SHDs rarely tweet about them. This strikes a worrisome chord of disconnection from the science linking health inequities to racism.

Integrated Methods for Applying Critical Race Theory to Qualitative COVID-19 Equity Research.

Background: Racism persists, underscoring the need to rapidly document the perspectives and experiences of Black, Indigenous and People of Color (BIPOC) groups as well as marginalized populations (eg, formerly incarcerated people) during pandemics. Objective: This methods paper offers a model for using Public Health Critical Race Praxis (PHCRP) and related critical methodologies (ie, feminist and decolonizing methods) to inform the conceptualization, methods, and dissemination of qualitative research undertaken in response to the evolving COVID-19 pandemic. Sample: Using purposive snowball sampling, we identified organizations involved with health equity and social justice advocacy among BIPOC and socially marginalized populations. Focus group participants (N=63) included community members, organizers, activists, and health workers. Design: We conducted topic-specific (eg, reproductive justice) and population-specific (eg, Asian and Pacific Islander) focus groups (N=16 focus groups) in rapid succession using Zoom software. Methods: A self-reflexive, iterative praxis guided theorization, data collection and analysis. We obtained community input on study design, the semi-structured discussion guide, ethical considerations and dissemination. Applying PHCRP, we assessed our assumptions iteratively. We transcribed each interview verbatim, de-identified the data, then used two distinct qualitative techniques to code and analyze them: thematic analysis to identify unifying concepts that recur across focus groups and narrative analysis to keep each participant's story intact. Results: The praxis facilitated relationship-building with partners and supported the iterative assessment of assumptions. Logistical constraints included difficulty ensuring the confidentiality of virtual discussions. Conclusions: These novel approaches provide an effective model for community-engaged qualitative research during a pandemic.

Race, ancestry, and genetic risk for kidney failure.

In a retrospective analysis of over 62,000 Black and non-Black participants from eight United States cohorts, Gutiérrez et al.1 examined estimated glomerular filtration rate (eGFR) equations to assess racial differences in kidney failure requiring replacement therapy and in mortality across different equations.

Using COVID-19 Surveillance Systems to Identify and Monitor Disparities: Best Practices and Recommendations.

Inadequate attention to racial health equity is a common challenge to effective, reliable monitoring and mitigation of COVID-19 disparities. Efforts to monitor and mitigate COVID-19 disparities continue to be hampered by inadequacies in how surveillance systems collect, tabulate, and report COVID-19-related outcomes. We conducted environmental scans of existing public health surveillance systems and reporting standards, literature reviews, focus groups with surveillance experts, and consultations with the Centers for Disease Control and Prevention (CDC) and an expert panel on surveillance to identify and explore strengths, weaknesses, and gaps in how existing systems monitor COVID-19 and their implications for addressing disparities in related outcomes. We present recommendations based on these reviews and propose a core minimum set of health indicators and best-practice standards for reporting these indicators by COVID-19 surveillance systems to monitor racial/ethnic and other disparities in the pandemic. These recommendations are relevant to monitoring disparities in the ongoing COVID-19 pandemic and may inform monitoring of future epidemics. This discussion is part of an effort by Project REFOCUS to develop syndemic surveillance systems for monitoring the intersecting pandemics of COVID-19 and racism.

Health inequities and the inappropriate use of race in nephrology.

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.

Use of Race in Kidney Research and Medicine: Concepts, Principles, and Practice.

Black Americans and other racially and ethnically minoritized individuals are disproportionately burdened by higher morbidity and mortality from kidney disease when compared with their White peers. Yet, kidney researchers and clinicians have struggled to fully explain or rectify causes of these inequalities. Many studies have sought to identify hypothesized genetic and/or ancestral origins of biologic or behavioral deficits as singular explanations for racial and ethnic inequalities in kidney health. However, these approaches reinforce essentialist beliefs that racial groups are inherently biologically and behaviorally different. These approaches also often conflate the complex interactions of individual-level biologic differences with aggregated population-level disparities that are due to structural racism (i.e., sociopolitical policies and practices that created and perpetuate harmful health outcomes through inequities of opportunities and resources). We review foundational misconceptions about race, racism, genetics, and ancestry that shape research and clinical practice with a focus on kidney disease and related health outcomes. We also provide recommendations on how to embed key equity-enhancing concepts, terms, and principles into research, clinical practice, and medical publishing standards.

Adequacy of Existing Surveillance Systems to Monitor Racism, Social Stigma and COVID Inequities: A Detailed Assessment and Recommendations.

The populations impacted most by COVID are also impacted by racism and related social stigma; however, traditional surveillance tools may not capture the intersectionality of these relationships. We conducted a detailed assessment of diverse surveillance systems and databases to identify characteristics, constraints and best practices that might inform the development of a novel COVID surveillance system that achieves these aims. We used subject area expertise, an expert panel and CDC guidance to generate an initial list of N > 50 existing surveillance systems as of 29 October 2020, and systematically excluded those not advancing the project aims. This yielded a final reduced group (n = 10) of COVID surveillance systems (n = 3), other public health systems (4) and systems tracking racism and/or social stigma (n = 3, which we evaluated by using CDC evaluation criteria and Critical Race Theory. Overall, the most important contribution of COVID-19 surveillance systems is their real-time (e.g., daily) or near-real-time (e.g., weekly) reporting; however, they are severely constrained by the lack of complete data on race/ethnicity, making it difficult to monitor racial/ethnic inequities. Other public health systems have validated measures of psychosocial and behavioral factors and some racism or stigma-related factors but lack the timeliness needed in a pandemic. Systems that monitor racism report historical data on, for instance, hate crimes, but do not capture current patterns, and it is unclear how representativeness the findings are. Though existing surveillance systems offer important strengths for monitoring health conditions or racism and related stigma, new surveillance strategies are needed to monitor their intersecting relationships more rigorously.

Racial Disparities in Rheumatology Through the Lens of Critical Race Theory.

According to critical race theory (CRT), racism is ubiquitous in society. In the field of medicine, systems of racism are subtly interwoven with patient care, medical education, and medical research. Public health critical race praxis (PHCRP) is a tool that allows researchers to apply CRT to research. This article discusses the application of CRT and PHCRP to 3 race-related misconceptions in rheumatology: (1) giant cell arteritis is rare in non-White populations; (2) Black patients are less likely to undergo knee replacement because of patient preference; and (3) HLA-B*5801 screening should only be performed for patients of Asian descent.

Health Implications of Housing Assignments for Incarcerated Transgender Women.

Transgender women (i.e., persons who were assigned male sex at birth but who live and identify as female) experience forms of discrimination that limit their access to stable housing and contribute to high rates of incarceration; once incarcerated, the approaches used to assign them housing within the jail or prison place them at risk for abuse, rape, and other outcomes. Yet, a paucity of studies explores the implications of carceral housing assignments for transgender women.Whether the approaches used to assign housing in jails and prisons violate the rights of incarcerated transgender persons has been argued before the US federal courts under Section 1983 of the US Constitution, which allows persons who were raped while incarcerated to claim a violation of their Eighth Amendment rights.Reforms and policy recommendations have been attempted; however, the results have been mixed and the public health implications have received limited attention.

Commentary: Just What is Critical Race Theory and What's it Doing in a Progressive Field like Public Health?

Gloria Ladson-Billings cautiously promotes the use of Critical Race Theory (CRT) to address racism's contribution to educational disparities. Nearly a decade ago, we issued a similar call to the multidisciplinary field of public health. Public health touts its progressive roots and focus on equity, but do those efforts draw on CRT? To answer this question, we define CRT, describe its origin in the field of law, and review the ways its use has grown in the field of public health. Public health interventions and policies rely heavily on evidence; therefore, we re-introduce the semi-structured research method we developed to facilitate empirical application of CRT, ie, the Public Health Critical Race Praxis (PHCRP).

Editorial: Critical Race Theory - We Are all Others.

Over the past two years, the persistence of racism in the United States has been particularly pronounced in the policies and actions of the administration of President Donald J. Trump; however, the structure of the United States has been racialized since its inception. This supplement of Ethnicity & Disease uses Critical Race Theory (CRT) to explore several implications for public health and public health research. We intend for it to spark conversations in the classroom and among researchers on how racial phenomena operate and how we as a field can address racism.