Predominantly black neighborhoods east of the Anacostia River are some of the hardest-hit by the pandemic, which has killed more black people in the city than people of any other race.
The coronavirus has already killed two of Sierra's friends. She says her sister is sick. So is her half-sister's mother, and another friend.
"I have been having panic attacks," she says. "My heart's been racing. I've been waking up in the middle of the night, sweating."
Sierra did not want to share her last name for privacy reasons. We met as she was waiting for a COVID-19 test at a newly-opened site off Benning Road in Ward 7. She was previously been turned away from two hospitals where she tried to get tested.
"They just said I had a fever, but I haven't had any other symptoms," she says.
Sierra was lucky enough to get an appointment at this site, which, unlike many others, does not require test recipients to have a note from a primary care physician.
This kind of access is a distinct shift from the way testing worked before. The new clinic, run by the Howard University Faculty Practice Plan and made possible by a $1 million dollar grant from Bank of America, is an attempt to address a massive and glaring problem: COVID-19 is killing black people in D.C. at an alarming rate.
The disparity shows up not in terms of who gets diagnosed with the virus, but in who is dying from the disease. Black people make up 47% of the confirmed cases in the city, (which tracks with their share of the population), but are 80% of the people who have died from the coronavirus.
This mirrors what is happening in cities across the country, like Milwaukee County, Wisconsin, where black people represent 26% of the population but 70% of those who died from COVID-19; and Chicago, where black people are 40% of the population but represent 70% of the dead.
The disparity in who dies from the virus isn't an anomaly — it matches disparities in myriad other health conditions. And as the death toll from the coronavirus continues to rise, many people in communities most affected are asking for a response that matches the depth of these dual crises: The one caused by COVID-19, and the health crisis in these communities that existed long before.
Sierra is black. She lives close to the Benning Road testing site, which sits at the intersection of several predominantly black Ward 7 neighborhoods. Nearby Lincoln Heights, for example, is among the neighborhoods in the city with the most confirmed cases of COVID-19. The testing effort she saw there surpassed her expectations.
"It's a godsend, because I need to know," she says. "I usually feel like they don't care about us in this neighborhood, but ... it's all organized and everything and nice and clean. So that's good to see."
She only had time to speak briefly before disappearing down the elevator. She was on the clock and was supposed to be online, teleworking from home.
The Problem Coronavirus Exposed
The rector of Christ Church in Georgetown, Rev. Timothy Cole, was diagnosed in early March as D.C.'s first official COVID-19 case. But reports suggest the virus could have been present in the city weeks earlier; a Woodley Park resident who was sick in February recently tested positive for antibodies to the virus. Over the span of about 8 weeks after the rector's diagnosis, the disease spread across the city, infecting more than 5,400 people and killing at least 277. Of those who died, at least 220 were black.
Ward 2, which includes the areas around Christ Church, now has the second-lowest number of confirmed cases in the city. Ward 3, where the other early suspected case in Woodley Park was reported, has the fewest confirmed cases. Wards 2 and 3 are the city's wealthiest wards and are about 70% white and 80% white, respectively.
Meanwhile, in Ward 8, where 92% of residents are black and the median household income is around $30,000, residents are confronting the highest per-capita number of deaths in the District.
For those familiar with the city and its inequality, this outcome was devastating but unsurprising. They say it was fated here, where neighborhoods drive health outcomes and black people who live in the poorest parts of the city die prematurely. In Ward 8, the average life expectancy is 72 years. In Ward 3, it is 87.
"The virus is not really the problem. It's actually the systems which are killing people," says an academic physician at a hospital in D.C. who declined to be named because he was not authorized to speak to reporters.
He says the majority of patients being treated for COVID-19 in the hospital are black, but black people were overrepresented in the hospital on any typical pre-pandemic day.
Data shared by health officials on Monday showed that 71% of those who died from the coronavirus in the District had hypertension, and 49% had diabetes. D.C. Health Director Dr. LaQuandra Nesbitt said a "substantial number" of those who died from the virus had more than one underlying condition.
The same is true in other big cities. An analysis of thousands of COVID-19 patients in New York City found that nearly all who were hospitalized had at least one major chronic health condition — and 88% had at least two. Nearly 60% had high blood pressure, 40% were obese. About one-third had diabetes.
These underlying conditions correlate tightly with income and race, which in turn correlate with each other. One-fifth of D.C. residents who did not graduate from high school have diabetes. Thirteen percent of black residents have type 2 diabetes, compared to only 2.5% of the city's white residents. People making less than $15,000 a year in D.C. are two-to-three times more likely to have type 2 diabetes than those making more than $50,000. The prevalence of high blood pressure, or hypertension, among black people in D.C. is 40% — more than double that for non-Hispanic white people in the city.
"Obesity, type 2 diabetes, poorly controlled hypertension, heart disease ... are much more prevalent in people of color for a variety of reasons," says Dr. Randi Abramson, medical director for Bread for the City, a nonprofit that provides food, healthcare and other services to low-income Washingtonians.
"The stress and the racism in this country, the lack of access to other resources. It's not just their health but also their access to what you need to survive. And the fact that we don't have all that equal access in the city is really driving up morbidity and mortality within this community and within people of color."
Tamara Smith is president and chief executive of the D.C. Primary Care Association. The network's 60 clinics serve 1 in 4 D.C. residents, most of them black and low-income. Smith says she is "not surprised at all by the disparity" in COVID-19 deaths in the city.
"It has always existed," Smith says. "And there are factors that are driving the disparity that are more than just access to health care. There are racially institutionalized structures and policies ... that have promoted and supported this disparity."
Race and neighborhood are some of the leading predictors of health in the city, in part because of "urban renewal" projects that decimated black neighborhoods and facilitated white flight, along with disinvestment in education, employment and amenities for black people and black neighborhoods.
"Acknowledge the issue around racism," says Mustafa Abdul-Salaam, an ANC Commissioner and leader of economic development planning in Ward 8.
"We tend not really to put a lot of focus there, but in the work that I've been doing in the community, when we talk about structural challenges that the community has no control over, it always comes back to racist policies that cause these kinds of issues," Abdul-Salaam says.
Courtesy of/District of Columbia
On May 6, the District released neighborhood-level data on COVID-19 infections.
Courtesy of/District of Columbia
Public health experts agree that only 20% of health disparities can be explained by so-called "clinical" factors, like insurance rates and access to primary care and hospitals. Instead, the bulk of what drives health disparities are social determinants of health, including housing, employment and food access.
"We're seeing the most vulnerable ... get sickest the quickest, because they can't take care of themselves," says Abramson, who last month said several of her patients had already been diagnosed with the virus. "They have no place to rest. They have no place to have somebody else help provide some services, like bringing them food and water and making sure they've got some Tylenol and that they're feeling safe and supported."
Abramson said it was her greatest fear that "people are going to get this virus and will not have the resources to really do what is the best thing for their health."
"When they say isolate, and that's impossible in your current situation," says Abramson. "If you're currently housed or not housed. If you are housed, how crowded are you? Do you have access to your own bathroom? That's unthinkable for most people. But yet those are the suggestions."
A new COVID-19 testing site opened at the Benning Road Center in Ward 7 this week.
'A Marshall Plan' For D.C.
D.C. Mayor Muriel Bowser has called attention to these disparities. Health providers and community leaders are calling for a reckoning, and for a response to match the size of the problem. It's a response they say should go well beyond this pandemic.
The city has been working to boost access to testing in black and Latino neighborhoods and at free clinics. Bowser's administration upped its messaging to residents about the coronavirus by proactively calling residents with certain underlying conditions and rolling out public service announcements voiced by Michelle Obama.
D.C. is also hiring contact tracers who will be trained to track and mitigate the virus' spread across the city. Health advocates want to make sure that corps of employees includes people with ties to the most-affected black neighborhoods in the city.
"We're in the process right now of talking to faith leaders, and we're actually going to start recruiting contact tracers," says Ambrose Lane Jr., who chairs the Ward 7-based Health Alliance Network, which advocates for health equity and the reduction of chronic disease, and also chairs a D.C. Health committee on chronic disease.
"If the mayor says that she's going to hire 900 [contact tracers], then they should be from the communities where [COVID-19] lives the most," Lane says. "Otherwise, if you have someone else from outside of the community that is trying to call people to try to do contact tracing, there's a level of trust that doesn't exist in that."
Howard University President Dr. Wayne Frederick, who is co-chairing a D.C. government committee on equity in the coronavirus response, says there are plans for more mobile testing sites in the works, and his team is also collaborating with faith leaders and trusted community messengers who can ensure contact tracing and outreach is not just focused on the virus, but also on access to what they need to stay healthy.
"You have to ask them about their ability to isolate ... their ability to get to food, healthy food," Frederick says. "The acute need we will have will be around coronavirus, but the long-term need is to have community influencers and contact tracers who can work together to bring that equity to the neighborhood."
But ultimately, Lane and Frederick agree: Testing and contact tracing alone cannot lower the death rates among D.C.'s black residents.
"That is going to require an investment by the city in communities of color, particularly black communities, sort of like a Marshall Plan after World War II," Lane says, referring to the more than $15 billion dollars of aid the U.S. provided to western Europe.
"I want to know what the future planning is so that this can never happen again," Lane says. "We must say: Never again will African-Americans be caught with so many disparities because the city is not spending the requisite resources in black communities."
The Community Health Response
Frederick says the Howard faculty practice plan is boosting its use of telehealth among black patients. "We are proactively reaching out to patients in this population to find out about how they're feeling," he says. "Going forward, we have to do more of that in these communities ... and we certainly have to invest in the long-term."
Dr. Carla Henke, chief medical officer with Community of Hope, which serves more than 10,000 mostly low-income patients out of three locations, says her team is also proactively calling patients with chronic conditions to do welfare checks — not only about disease management, but also about their overall access to essential resources. They will ask questions like: Do you have access to food? Who is in the house with you? Do you have any sick contacts?
They are also sending patients with hypertension blood pressure cuffs and teaching them how to monitor symptoms themselves.
Community health centers — small clinics that have grown in number in recent years — have been working to expand access to accessible and high-quality primary care particularly in neighborhoods with few other options — and Henke says they have a special role to play in this public health crisis.
"Community health centers are uniquely set up to address health disparities," Henke says. "It's no different in a pandemic in terms of addressing those, it's just transforming how we work to reach patients now in this new era."
But while the centers see themselves as the primary safety net before the hospital for patients who are overwhelmingly poor and black or Latino, their finances have been devastated by the pandemic.
Medical and behavioral visits are down 40 to 75%, as people are encouraged to stay home, utilize telemedicine and only visit in-person when medically necessary. Health centers are losing $1.1 million a week — and the city's largest community health centers who employ more than 500 people are not eligible for certain disaster loans and forms of federal assistance for nonprofits and businesses.
"We've spent the last 20 years building primary care infrastructure in this city," Smith says. "Everything we spent the last 20 years building is in jeopardy, because the revenue is not coming in."
The question moving forward, Smith says, is not just whether black and Latinx communities in D.C. will get equal investment — but whether they will get more.
"Equity means everybody gets to the same level," Smith says. "The communities that have higher disparities ... need more health care, they need more testing, they need more vaccines, they need more education and they need more support. In an age when there's vaccines, the communities that have higher incidence and death rates need more."
'We're Dealing With This Struggle Just Like Everyone Else'
For now, local organizers are supplementing government support with a system they call mutual aid. Samantha Davis, the executive director of Black Swan Academy who helps to lead mutual aid efforts in Wards 7 and 8, said last month that her team of neighborhood volunteers was serving 15,000 hot meals a week, supporting 400 families a week with groceries and toiletry kits and supplementing that work with up to 2,000 in-person deliveries of groceries and infant and toddler supplies per month. This is all an effort to keep people in those neighborhoods — particularly those with pre-existing conditions and little access to transportation — in their homes and less exposed to the virus.
"We are the ones that we can and should rely on," says Davis. "This very community-centered way of thinking has become true in this moment — and so that, to me, has been extremely beautiful and inspiring."
But Davis admitted that this kind of emergency, community-led response was not sustainable in the long-term, and there are going to be "years of trauma, and years of economic recovery that folk in ward 7 and ward 8 are going to have to go through," along with the rest of the city.
She worries about how the city will allocate funding now that the pandemic has forced $600 million in cuts from this year's budget.
"Most likely those budget cuts will impact the residents of Ward 7 and Ward 8 the most, and so I do see these next few years being difficult," Davis says.
And as her team organizes to deliver groceries, prescriptions and essential supplies to some of the most under-resourced residents of the city, they are also personally touched by the pandemic. Several people on Davis's team of mutual aid volunteers have had friends or family fall ill, and at least two have had close family members die from the virus.
"Part of the nature of it being mutual aid is we're dealing with this struggle just like everyone else," Davis says.
Kristi Matthews was not able to go home to North Carolina, where her grandmother died of COVID-19 earlier this spring, because of the pandemic. Instead, she remains in D.C., working as an organizer with the Legal Clinic for the Homeless and the D.C. Girls Coalition and volunteering to help mutual aid efforts in Wards 7 and 8.
"Every single day when I wake up and the numbers are up, it just reconnects me to my grandma," says Matthews. "I feel like it's keeping it very much raw for me, which is making me a better organizer."
It makes her better because she knows each death is not just a number. Her grandmother, who would have been 78 in September, raised seven children and numerous grandchildren. She lived through the 1979 Greensboro Massacre, when Nazis and KKK members shot and killed members of the Communist Workers' Party who were rallying against white supremacy. When Matthews nervously came out to her after moving to D.C., she embraced her granddaughter's sexuality and formed a close relationship with her partner.
Matthews says her grandmother was the kind of person who was always hosting large birthday parties and cooking for large gatherings, but she died alone in the hospital, her burial was limited to 10 guests and many of the people who loved her were unable to attend.
"This disease — it doesn't give you the ability to have true closure," says Matthews. "And I don't want people to go through what my family is going through."
Talk of re-openings feel incongruous with her experience.
"If this disease was killing white people at the rate it is black people, and harming white people at the rate it is black people, it would be a 100% shift in how we were responding," she says. "I feel like white America and corporate America — it's not hitting them."