COVID-19 in Communities of Color

Structural Racism and Social Determinants of Health

Lakisha D. Flagg, DrPH, RN, PHNA-BC; Lisa A. Campbell, DNP, RN, PHNA-BC, FAAN


Online J Issues Nurs. 2021;26(2) 

In This Article

Abstract and Introduction


Black, Indigenous, People of Color (BIPOC) communities have a disproportionally high prevalence of COVID-19 and, subsequently, a higher mortality rate. Many of the root causes, such as structural racism and the social determinants of health, account for an increased number of preexisting conditions that influence risk for poor outcomes from COVID-19 as well as other disparities in BIPOC communities. In this article we address Structural Factors that Contribute to Disparities, such as economics; access to healthcare; environment and housing concerns; occupational risks; policing and carceral systems effects; and diet and nutrition. Further, we outline strategies for nurses to address racism (the ultimate underlying condition) and the social and economic determinants of health that impact BIPOC communities.


COVID-19 places a laser beam squarely on health inequities and racial disparities that have existed for decades in communities of color. Black, Indigenous, People of Color (BIPOC) persons, as compared to White persons, are 2.7 times more likely to be diagnosed with COVID-19 (APM Research Lab, 2020); 3.7–4.1 times more likely to be hospitalized; and 2.6–2.8 times more likely to die (Centers for Disease Control & Prevention [CDC], 2021a). Between March and August 2020 there was a 20% (n = 225,530) increase in expected deaths, and 67% (n = 150,540) were attributed to COVID-19 (Woolf et al., 2020). Why do these racial disparities exist and how can nurses begin to acknowledge and confront their upstream antecedents? We address many of the key drivers of the racial disparities, structural racism, and the social and economic determinants of health that account for these disparities in communities of color. In this article we also offer a range of actionable strategies for nurses to address implicit bias and identify opportunities to advance health equity in their individual spheres of influence.

"Structural racism or racialization emphasizes the interaction of multiple institutions [macrolevel] in an ongoing process of producing racialized outcomes [microlevel consequences]" (Powell, 2008, p. 791). Structural racism "emphasizes the most influential socioecologic levels at which racism may affect racial and ethnic health inequities" (Gee & Ford, 2011, p. 3). Structural racism has created a syndemic cluster of interacting social and economic policies and environmental factors that typically disadvantage BIPOC. These conditions are not positioned amongst or created by the persons of the same race but are underpinned by structural practices that maintain the status quo (i.e., policies or practices) and systemic disinvestment (i.e., education, employment, housing, transportation, broadband) in socioeconomically disadvantaged communities.

As an example, segregation has been illegal since the 1960s. Yet, there is still residential concentration, "racialization of space" (Calmore, 1995, p. 1235), and social isolation of most African Americans in urban areas (Williams & Cooper, 2020). Sewell (2016) posited that the "ghettoization (i.e., segregation of people by ethnoracial group across residential space) is harmful to health via mesolevel political economies" (p.403). "Segregation is a predictor of economic status and predictor of variations of health" (Williams & Cooper, 2020, p. 2478). These social determinants of health (SDOH) are "the health outcomes of a group of individuals, including the distribution of such outcomes within the group, and …includes the health outcomes, patterns of health determinants, and policies and interventions that link these two" (Kindig, 2007, p. 380). Addressing SDOH requires addressing more than the individual social needs but rather requires systems level policy change to address conditions that worsen life expectancy in BIPOC.