In the heart of Atlanta, steps from the birthplace of Martin Luther King Jr., infection preventionist Crystal Wright spent weeks fighting to keep her patients safe as the novel coronavirus spread through the nation’s nursing homes.
Before the coronavirus pandemic, the 37-year-old nurse at Legacy Transitional Care and Rehabilitation danced to the sounds of Luther Vandross during lively parties for the home’s elderly residents. But as the threat of the virus loomed in March, Wright spent most of her time strategizing with nursing home staff and monitoring residents and staff for signs of illness.
In the end, it wasn’t enough.
In late April, the nursing home that has been a fixture in Atlanta’s Sweet Auburn historic district for more than two decades found itself in the throes of a full-blown coronavirus outbreak.
Nearly everyone who lives at the 186-bed facility is Black. And as the virus spread, nearly everyone felt its impact. More than 120 residents and staff fell ill, including Wright, who was among the first to test positive and spent more than a month in quarantine.
Day after day, she said, she fretted about the men and women she had left behind.
“Just having to sit home, not being able to come to work, was the worst part,” said Wright, a licensed practical nurse who earned her infection preventionist certification only months before the outbreak. “It felt bad doing nothing.”
Nationwide, the coronavirus has taken a heavy toll on African Americans, a disparity that continues to alarm health researchers, lawmakers and community leaders as the country charts a path toward reopening. Experts say they are particularly concerned about majority-Black nursing homes, where a confluence of factors — an elderly population living in close quarters, often with shortages of staff and protective gear — have left African Americans already at increased risk of infection even more vulnerable.
It is difficult to know for sure whether rates of infection and death are higher among Black nursing home residents because the federal government doesn’t track such demographic data.
A Washington Post analysis of data from more than two dozen states, however, found that the death rate was more than 20% higher in majority-Black facilities compared with majority-white facilities. The analysis, which used demographic data compiled by Brown University and included about 11,000 nursing homes — nearly three-quarters of all facilities in the United States — also found that death rates increased as the proportion of Black residents increased.
Homes where at least 7 in 10 residents were Black saw a death rate that was about 40% higher than homes with majority-white populations. At these 250 predominantly Black homes, more than 2,200 residents have died, with a death rate of 6 residents per 100 beds — similar to the death rate at Legacy.
On a historic street once home to so many Black-owned businesses that Fortune magazine in the 1950s called it the “richest Negro street in the world,” the nursing home is a case study of the devastating impact of the coronavirus on Black residents and their caregivers.
About 70% of the residents at Legacy were infected with the virus, and so far 12 have died. Twenty-one employees were also infected in what became one of the largest nursing home outbreaks in Georgia.
The death rate in recent weeks has slowed, but as much of the neighborhood tries to move on, patients and staff inside the home are still struggling with the lingering effects of widespread illness, loss and isolation from a community that has been a proud and essential part of Black America for decades.
Those who study the influence of race and class bias say the disparate impact of the coronavirus on Black and brown communities should come as no surprise.
“These are tragic and preventable inequities,” said Courtney Boen, a University of Pennsylvania sociology professor who examines patterns of racial inequality in population health. “Sadly, they’re also predictable ones.”
African Americans suffer from a higher rate of chronic health conditions, but Boen and other experts also attribute the disparity to other long-standing imbalances, including a lack of access to quality health care, educational opportunities and a stable income.
“These are not natural or inevitable, biological consequences,” she said. “Any disparity that we’re seeing in terms of race in the pandemic is socially and politically constructed. These disparities are due to racism.”
In recent months, lawmakers have called on the federal government to better track the impact of the virus on Black residents in nursing homes. In July, Sens. Robert Casey Jr., D-Pa., Elizabeth Warren, D-Mass., Ron Wyden, D-Ore., and Patty Murray, D-Wash., wrote a letter to the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services (CMS) calling for more thorough data collection.
“There’s no way you can respond to the problem unless you have the data,” Casey told The Washington Post. “I’m going to continue to put a bright spotlight on the fact that Black Americans are suffering disproportionately.”
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The four-story Legacy is surrounded by reminders of the civil rights movement.
Not far from the home’s front doors, King and other civil rights leaders mobilized at the Southern Christian Leadership Conference headquarters to promote civil rights and fight the Jim Crow laws that had long segregated schools, buses, restaurants and restrooms. The neighborhood had traditionally been the center of Black life, faith and entertainment in Atlanta’s Sweet Auburn district, housing the city’s first Black-owned insurance firm, daily newspaper and radio station.
“There was an entrepreneurial spirit and independence born out of the Jim Crow era,” said LeJuano Varnell, who leads a local nonprofit, Sweet Auburn Works, focused on neighborhood preservation. “They got it done because they had to do for themselves.”
Legacy has been part of Sweet Auburn for more than two decades. Before the pandemic, residents dressed in their Sunday best to attend services just down the street at Ebenezer Baptist Church, where King was once a pastor, or eat lunches provided by volunteers in the courtyard of the nearby King Center for Nonviolent Social Change.
But in the spring, coronavirus cases soared in Fulton County, where more than 40% of residents are Black. The threat forced Legacy, like other U.S. nursing homes, to shut its doors, closing off residents from visitors and the neighborhood they knew well.
Looking back, Wright said she is still not entirely sure how the coronavirus infiltrated the home. Several staff members and residents grew ill, and by May, more than 100 were infected.
Natasha Hollins-Weaver said she was so concerned about passing the infection to her elderly patients that she quit her job as a licensed practical nurse. Hollins-Weaver had spent two years at Legacy, driving 40 miles to get there and often toting a bag filled with Dum Dums lollipops and hot sauce for an elderly resident she had come to know. He later died of COVID-19, the disease caused by the coronavirus.
“I felt survivor’s guilt,” she said. “Why did all of these people get sick, but I didn’t?”
The mother of seven said she decided to return to work at the home last month.
Reports of widespread illness at Legacy soon reached Michael Julian Bond, an Atlanta City Council member whose aunt died of COVID-19 in another majority-Black long-term care facility nearby.
Bond wanted more information, but the Fulton County Board of Health does not report coronavirus case counts by race in nursing homes. Bond said he worried that without good data, homes such as Legacy were flying under the radar.
“It’s just not front of mind,” Bond said. “People had glossed over the impact that it was having on minority communities. I think people are trying to hope and pray that it will go away before a presidential election.”
Sheena Haynes, communications director for the board of health, said in a statement that Black residents in Fulton County have been “most negatively” impacted by the coronavirus. Though county epidemiologists collect data on the race of nursing home residents with the coronavirus, the health department does not collect demographic information on those who are not infected, she said.
“Currently, we have no plans to collect such data on all residents of every nursing home in Fulton County since that is not part of our mandate,” she said.
The Georgia Department of Public Health collects demographic data through coronavirus test reports for all residents in the state, but does not have data for specific nursing homes, spokeswoman Nancy Nydam said.
The lack of information has frustrated some local leaders.
“I have no doubt that there is a disparity,” said Tony Marshall, president of the Georgia Health Care Association, which represents the state’s long-term care providers. “I just don’t have the information to be able to support [that] one way or the other. That’s the limitation of the data that’s made available.”
Democratic State Rep. Karen Bennett, chairwoman of the Georgia Legislative Black Caucus, said she has urged the state to collect and release demographic data on coronavirus cases in nursing homes.
“The health and protection of our constituents, that’s number one,” she said. “We just want to continue to have some equitable solution for protection.”
In their July 15 letter to CMS and the CDC, Warren, Casey, Murray and Wyden urged the federal government to begin to collect and release demographic data, including for race, ethnicity, age, sex, primary language and disability status, on nursing home residents and employees sickened by the virus.
“Such information is necessary to accurately understand and mitigate the impact of this crisis and appropriately direct resources,” the lawmakers wrote. “The COVID-19 pandemic has had a deadly impact on nursing homes and other long-term care facilities, and all evidence indicates that that impact has been disproportionately borne by people of color.”
The letter cited findings by University of Chicago researcher R. Tamara Konetzka, who told the Senate Special Committee on Aging in May that there was a “strong and consistent” relationship between race and the likelihood of coronavirus cases and deaths in nursing homes.
Konetzka originally looked at 12 states, determining the relationship between outbreaks and such factors as nursing home quality. Among other things, Konetzka found that nursing homes with the highest percentage of nonwhite residents were twice as likely to have coronavirus cases and deaths. In a subsequent national analysis, she said she found that race was highly correlated with where the virus was circulating.
“All of those effects were just dwarfed by the race effect in our analysis because race is a good proxy for where the virus is circulating,” Konetzka told The Washington Post.
As the United States pushes to reopen schools and businesses, Georgia Council on Aging Executive Director Kathy Floyd said she is concerned about how Black communities whose elderly residents have been particularly affected by the coronavirus will be able to move forward.
Floyd said she hopes the Black Lives Matter movement and ongoing conversations about race and justice will prod Fulton County and state officials to take a closer look at how the coronavirus continues to impact majority-Black nursing homes.
“It’s not just young Black men,” she said. “It’s old Black people, too.”
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Just months before the coronavirus struck the country, Wright completed online training through the CDC and earned her certification as an infection-control nurse.
At Legacy, where Wright had worked since 2017, she soon became the go-to source on how to prevent and control the spread of infection and other communicable diseases, from flu to urinary tract infections.
As reports of the coronavirus surfaced among nursing homes, Wright said she spent hours working with nursing home staff to come up with protocols to keep patients healthy. In April, before the outbreak at Legacy erupted, Wright began to suffer from cold-like symptoms that she at first attributed to allergies.
Days later, she decided to take a coronavirus test at Georgia State University. The results were positive.
“It was pretty devastating,” she said. “It seemed like such a big deal and I didn’t know where I got sick from.”
An administrator at Legacy declined to comment, saying caregivers who work directly with residents were in the best position to describe events at the home.
Wright said she immediately went home to quarantine and did not return to Legacy for more than a month. As she nursed herself back to health, she repeatedly called her best friend, another nurse at Legacy, to check on the status of residents and staff.
In April, the National Guard conducted a deep cleaning at the home and tested residents and staff.
In late May, Wright was finally able to return. She found a nursing home different from the one she had left behind.
Nurses and staff were scrambling to help patients recover from the virus. Caregivers and residents who had watched colleagues and roommates fall ill were feeling anxious and depressed.
“Honestly, I don’t think anyone got to say goodbye,” Wright said. “It really took a toll.”
The home remains closed to visitors and the isolation has been difficult, she said. Staff members play board games or read with recovering residents while maintaining social distance. Administrators facilitate video calls with relatives and allow families to visit through windows.
This summer, residents watched from behind their windows as Black Lives Matter protesters marched down historic Auburn Avenue to protest police brutality. The procession for Rayshard Brooks, the 27-year-old Black man who was shot and killed by a White Atlanta police officer after a DUI stop outside a Wendy’s in June, passed nearby, en route to Ebenezer Baptist Church.
Wright said the sounds of chanting outside helped make residents feel part of the movement. But more than anything, she said, the people of Legacy just want to feel normal again.
“I knew that we were going to face a lot of challenges,” Wright said. “But everything has changed.”
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How we did the analysis
The Washington Post analysis of racial disparities in nursing homes during the coronavirus pandemic included data from 28 states that release cumulative COVID-19 death counts by facility. In all, these states are home to roughly 11,000 facilities — nearly three-quarters of all Medicare-certified nursing homes in the country.
The following states were included: Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, Nevada, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas and Virginia.
Data is current as of the beginning of September. Only Medicare-certified nursing homes were included in this analysis.
To determine the racial demographics of nursing homes, The Post used data from 2017 collected by the federal government and maintained by the Shaping Long-Term Care in America Project at Brown University, which is funded in part by the National Institute on Aging.