Still Compromising: The Disparate Impact of COVID-19 in St. Louis
Episode 1: (How We Know) Who Gets Sick
By: Karishma Furtado and Alexandra Morshed
In March of 1820, the Missouri Compromise was signed and the state of Missouri was born out of an insistence on the systematic subjugation and devaluation of Black lives.
In March and April of 2020–200 years later — COVID-19 is revealing that we are still very much grappling with that original sin. The pandemic and its disproportionate effect on Black St. Louisans is pulling back the veil on our broken and inequitable systems. In this series we explore how COVID-19 has laid bare the ways we continue to compromise on our shared values and how we can use this crisis as an opportunity to catalyze Racial Equity. #StillCompromising
Though it might not feel like it, we are still in the early phase of the COVID-19 public health crisis, but some things have already become clear in St. Louis City and County. First, things are going to get worse before they get better. Second, “worse” is going to look worse if you’re Black.
As data on cases and deaths by race start to trickle in, the suspicions of many are being confirmed: Black St. Louisans are more likely to get sick with COVID-19 and, once that happens, they are more likely to die from it. There are many reasons for this, but ultimately they are less about race and more about systemic racism — which makes Black St. Louisans less able to shelter in place because they cannot afford to stay home, more likely to have underlying conditions that make the disease more serious, and less likely to have the resources to seek care. We will explore many of these root causes over the course of this series on the disparate impact of COVID-19 in St. Louis.
“If Missouri and St. Louis don’t invest in strong and equitable testing practices, we will continue to see a rise in cases and deaths, especially among our Black neighbors.”
For this first episode, we’re going to rewind the clock and take a look at how testing has happened in the state and how current patterns in disease and death are partly a result of early and ongoing systematic testing inaction and inequities. These lessons can and must inform our actions in the coming days and weeks. Our region’s leaders must apply a Racial Equity Lens to COVID-19 response planning.
The Rose-Colored Glasses of Test Rationing
In an infectious disease pandemic, testing is crucial. It’s how we shine a light into the darkness and see what we’re dealing with and know how we can respond and whether those efforts are working. COVID-19 is no different. Unfortunately, St. Louis and Missouri are lagging behind where we should be. To gauge how we’re doing, it’s important to take into consideration where we are in our disease progression and population size. Many graphics and numbers out there fail to include these factors and they tell a misleading story as a result.
“For the first three weeks of March, when the disease was taking root and building up steam, we in Missouri essentially had our eyes closed. We were testing a couple of dozen people each week.”
For the first three weeks of March, before documented widespread community transmission, when the disease was taking root and building up steam, we in Missouri essentially had our eyes closed. We were testing a couple of dozen people each week. Things didn’t seem too bad, especially, many commented, compared to Illinois. We know now that this was an illusion — the rose-colored glasses of test rationing. A more telling indicator was our positive rate, which was quite high at that point because strict statewide restrictions on testing meant that, in practice, we were only testing people that we were fairly certain had COVID-19.
The graphs in this article are interactive! Click the link to track the trends, toggle different views, or download the data.
COVID-19 Testing and Positive Rates in MO compared to IL (interactive version includes CA and NY comparisons)
As the month of March turned into April, Missouri eased those restrictions (nearly three weeks after the CDC recommended doing so) and private labs and hospitals began testing more people. Days earlier, the two biggest hospital systems in the state, Mercy and BJC, opened testing sites in Chesterfield and the Central West End. As testing ramped up, so did cases detected. Estimates show that these testing shifts caused our case detection rate (how many of the actual total cases were being detected by tests) to rise from about 5% in the middle of March to closer to 15% in the last week of March. That rapid shift in detection is why, in the last week of March, Missouri saw a 600% increase in our number of new cases, the largest jump in the country.
“Our testing capacity has grown considerably in the past weeks, but we are still rationing tests.”
Our testing capacity has grown considerably in the past weeks, but we are still rationing tests. We’re far from the widespread testing used in countries like South Korea, which discovered the virus on the same day as the U.S. and has maintained a case detection rate of 40–50% for weeks. The test positivity rate there and in many developed countries is around 2%, compared to 9–10% in Missouri. Robust testing practices in South Korea have allowed leaders to effectively manage the pandemic, as evidenced by their relatively low case and mortality rates.
Who is getting tested? And who isn’t?
Underlying the uptick in testing is another concern: who is getting access to testing? (And who, relatively, isn’t?) By our count, there are 14 testing sites in St. Louis City and St. Louis County as of April 20th, with plans for three more coming soon. After much community demand — and 19 days — two sites opened in North City. We don’t know what testing capacity and utilization look like at those or really any sites. Troublingly, while there are many more testing sites than just a few weeks ago, tests are still limited, with all sites requiring passing an eligibility screen that is still fairly stringent, largely due to inadequate testing supplies.
Stories about backlogs and shortages, especially at testing sites serving low-income Black populations, abound. One function of COVID-19 testing is as part of healthcare, as a diagnostic test to determine care. The rationing of this crucial healthcare service is concerning, given that historically, Black people are less likely to receive preventive care. For example, Black individuals are more than twice as likely to have elevated blood pressure, but are 10% less likely to be screened for high cholesterol than White individuals. There are many reasons for such trends, but they ultimately boil down to a systematic lack of awareness, a lack of means, and a resulting lack of trust. Those barriers are almost certainly keeping Black St. Louisans from being tested for COVID-19.
Historically and especially when healthcare is rationed, Black people are less likely to receive preventive care.
Inconsistent and unclear information about cost is almost certainly a major barrier for many. Fear of costs will keep St. Louisans, especially Black St. Louisans, who are more likely to be low income, from getting tested. So, too, will sites that can only be reached by car, which is a resource that Black St. Louisans are less likely to have at their disposal. We should learn from cities like New Orleans that are using mobile testing sites to access low-income populations that are underserved by drive-through sites.
On top of unclear costs, information about testing (and most things COVID-19 related) has been circulated largely online, which is problematic when we know that there are racial disparities in internet access and digital literacy. Even beyond these gaps in access, the information out there is changing rapidly. Some of it, as we learned, was wrong. We called every testing center that we mapped to verify its location and that it was in fact active — that’s how we identified a handful of sites whose administrators insisted that they were not testing locations, despite what City and County resources claimed. It took us two days, 6 hours, and some creative thinking to get answers. Not many people have that sort of time.
COVID-19 Testing Locations in St. Louis City and County (interactive)
The lack of transparent information and easy access will only contribute to historical mistrust among Black people in the medical system. Black patients are more likely to have their symptoms dismissed or downgraded by healthcare providers. Similar patterns are emerging with COVID-19.
We need to acknowledge the lack of trust and ever-changing informational landscape and craft outreach and communication plans accordingly. To start with, we need a central location for all testing site information that is updated regularly, that includes eligibility criteria and costs, and that is disseminated through more than just online channels (the on-the-ground canvassing efforts that are gearing up look like a promising way of doing this).
We Must Start Now
Beyond ensuring prompt individual care when sick with COVID-19, a lack of testing hampers public health efforts to track the disease, launch timely actions, and allocate resources to communities. If Missouri and St. Louis don’t invest in strong and equitable testing practices, we will continue to see a rise in cases and deaths, especially among our Black neighbors. The fact that Black St. Louisans are more likely to get sick and die of COVID-19 has already drawn local and national attention. An equity-focused response effort would ensure timely testing to prevent spread in Black communities before transmission spirals out of control.
Consider the cases of Jazmond Dixon and Judy Wilson-Griffith, who tested positive and passed away within days. Individuals who don’t realize they’re COVID-positive are also more likely to infect others. We’re starting to see confirmation of what many knew would be coming: case and death rates are much higher in the Black population. Maps of the disease show it concentrating in North City and County, areas with high Black population densities, poverty, and disinvestment.
COVID-19 Taking Hold: Cases per 100,000 by Race and Zip Code
According to April 20th data, some of which we manually extracted from the County’s website, COVID-19 case and death rates are nearly four times higher among Black St. Louis County residents compared to White residents. In the City, Black residents are 3.3 times more likely to test positive. The City does not yet report COVID-19 deaths by race. These differences are largely the product of systems designed to serve some at the cost of others.
COVID-19 Case and Death Rates by Race in St. Louis (interactive)
The smoldering disparities that we’ve allowed to persist for decades are bursting into flames. If the human toll of those disparities isn’t enough to motivate us, remember that this is an infectious disease, so that fire will spread. We are encouraged to be physically isolated from each other right now because viruses are excellent at leveraging just how connected we are (as evidenced by the fact that community transmission, while potentially diminished, still continues despite distancing efforts). Disparities in access to the resources needed to identify and medically respond to this disease will not stay concentrated for long. Our firewall is only as strong as its weakest point.
Widespread testing will be essential to fortify that firewall. While we are seeing an increase in testing, it is precarious and still not enough. We need to test more, faster, and equitably, especially in light of new evidence that asymptomatic and presymptomatic disease is far more common than expected (consider the Boston homeless shelter where, of the 400 guests tested, 146 tested positive and none showed any symptoms). Testing is how we will know whether pandemic suppression efforts are working and whether we will be able to relax them any time soon. If we want to leave the land of social distancing, we need to halt community transmission, which will not happen if we are systematically allowing the disease to persist among some communities. Not a single scenario for controlling COVID-19 in “phase two” (after social distancing) is possible if we don’t drastically ramp up testing, as well as investment in public health infrastructure like contact tracing. We also need to make data about this pandemic more available. Municipal, city, public health, and hospital leaders should provide updated downloadable data on testing numbers, cases, hospitalizations, and deaths by race.
“Let’s lean into the tremendous pain we’re experiencing and ask hard questions and share honest truths. Let’s make better decisions and include those most affected in the decision making.”
This crisis is once again revealing how, in building systems to benefit White communities, we have compromised those systems’ ability to serve Black communities. In that unveiling is an opportunity for action. We know what to do. Countless reports and community demands have been calling for the changes that would enable us to collectively weather this storm. There are many decisions left to make that could change the trajectory of this crisis — for better or worse. The decisions we make are a reflection of our values. Let’s value all St. Louisans. Let’s lean into the tremendous pain we’re experiencing and ask hard questions and share honest truths. Let’s make better decisions and include those most affected in the decision making. We can do better. We will all benefit from an equitable COVID-19 response. We must start now.
As the pandemic continues to unfold, our region’s best hope for fighting back is information paired with a strong commitment to Racial Equity. In the coming weeks, we will explore other dimensions of the disparate impact of COVID-19 on Black St. Louisans, always with an eye towards how we can apply a Racial Equity Lens to our response. In Episode 2 we will look at why COVID-19 is proving to be deadlier for Black St. Louisans.
Read #StillCompromising Episode 2 and sign up for our newsletter to be the first to hear about future releases.
Karishma Furtado, PhD, MPH, is the Data and Research Catalyst for Forward Through Ferguson.
Alexandra Morshed, PhD, MS, is a Postdoctoral Research Associate at the Prevention Research Center in St. Louis at the Brown School at Washington University in St. Louis.
