Population data by race/ethnicity in each U.S. state and in the entire United States were collected from the U.S. Census Bureau's (2019) 2018 American Community Survey (ACS). We collected the frequency of COVID-19 total deaths in addition to death counts by race/ethnicity from state health department websites (please see the References section for those citations marked as [dataset] references). Most states (n = 35; 70%) and the District of Columbia (DC) had available COVID-19 death data by race/ethnicity at the time of data collection; the exceptions were Alaska, Delaware, Hawaii, Iowa, Maine, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, West Virginia, and Wyoming, which were excluded from our study. We aggregated the individual death data from all available states and DC to create an overall death prevalence. For New York state, population and COVID-19 data were collected from the CDC's National Vital Statistics System (CDC, 2020b) due to the limited availability of data from the New York State Department of Health.
Using the reported total number of COVID-19 deaths in each state, we calculated the percentage of deaths in each racial/ethnic group. All COVID-19 death data were up to date as of April 9 to April 24, 2020, depending on the state. We obtained current occupational statistics by race/ethnicity and state from the 2019 Annual Social and Economic supplement to the Current Population Survey (CPS; U.S. Census Bureau, 2019b) and linked COVID-19 death data to the CPS by race/ ethnicity and state.
In all analyses, we defined race/ethnicity groups as NH White, NH Black, Hispanic, NH Asian (including Native Hawaiians and Pacific Islanders), and NH Other (including American Indians/Alaska Natives and multiracial individuals). COVID-19 deaths included both confirmed and probable deaths. A confirmed death was defined as that of an individual with a positive COVID-19 laboratory test. A probable death was defined as that of an individual without a known positive COVID-19 laboratory test whose death certificate gave the cause of death as "COVID-19" or an equivalent. Individuals who before death displayed symptoms characteristic of COVID-19 infection were therefore counted as COVID-19 deaths using clinical judgment.
We examined 22 CPS occupational categories: (i) management operations; (ii) business and financial operations; (iii) computer and mathematical science; (iv) architecture and engineering; (v) life, physical, and social science; (vi) community and social service; (vii) legal; (viii) education, training, and library; (ix) arts, design, entertainment, sports, and media; (x) health care practitioner and technical; (xi) health care support; (xii) protective service; (xiii) food preparation and serving; (xiv) building and grounds cleaning and maintenance; (xv) personal care and service; (xvi) sales; (xvii) office and administrative support; (xviii) farming, fishing, and forestry; (xix) construction and extraction; (xx) installation, maintenance, and repair; (xxi) production; and (xxii) transportation and material moving. We excluded the armed forces due to extremely limited sample size.
We weighted CPS data according to survey methodology (Cheng, 2012) . Using CPS data, we calculated the weighted prevalence of each occupation within each racial/ethnic group and examined the difference in prevalence between NH Whites and NH Blacks for each occupation. The percentage of NH Black COVID-19 deaths were divided by the percentage of NH Black population in each state, DC, and all states combined. Using Spearman rank-order correlations, we examined the correlation between the prevalence of COVID-19 deaths and the prevalence of each occupation across racial/ethnic groups and states. All data and statistical analyses were conducted using SAS 9.4 (SAS Institute, Cary, NC) at a significance level of 0.05.
Overall, among combined states, the prevalence of NH Black deaths from COVID-19 (20.76%) was disproportionately higher than the NH Black unweighted U.S. population (12.14%; Table 1 ). This trend was also seen within 26 states and DC, with the discrepancy between mortality and population highest in Wisconsin and Kansas. In particular, whereas NH Blacks comprised 6.17% of Wisconsin's population, they comprised 36.49% of the state's COVID-19 deaths. In Michigan and New York, NH Blacks comprised 40.00% and 14.90%, respectively, of COVID-19 deaths while representing 13.53% and 8.80%, respectively, of the state's population.
The CPS data revealed differences in occupation prevalence within each racial/ ethnic group ( Table 2) . Compared with NH Whites, NH Blacks were more likely to work in jobs considered essential during the COVID-19 pandemic. Among all 35 states and DC, the five occupations with the highest disparities in the proportion of NH White and NH Black workers were transportation and material moving, health-care support, food preparation and serving, building and grounds cleaning and maintenance, and personal care and service. In particular, 10.58% of NH Blacks worked in transportation and material moving, compared with 5.33% of NH Whites; 5.46% of NH Blacks worked in health-care support, compared with 1.76% of NH Whites. 
Within each state, we found mostly consistent patterns, with more substantial contrasts seen in states with denser NH Black populations (Supplemental Table 1 ). Most notably, in New York, more NH Blacks (10.02%) than NH Whites (1.73%) worked in health-care support. In Texas, 13.97% of NH Blacks worked in transportation and material moving versus 5.61% of NH Whites. In DC, 6.50% of NH Blacks versus 0.58% of NH Whites worked in protective services. In South Carolina, NH Blacks outnumbered NH Whites working in cleaning and maintenance of building and grounds (7.88% vs. 1.98%). In Michigan, NH Blacks (13.06%) were more likely than NH Whites (7.01%) to work in production occupations. In Maryland, more NH Blacks (8.44%) than NH Whites (2.48%) worked in food preparation and serving. Finally, in Mississippi, more NH Blacks (5.50%) than NH Whites (1.88%) worked in personal care and service.
All occupational categories were significantly positively correlated with the percentage of COVID-19 deaths across all states and racial/ethnic groups (all p < .0001; Table 3 ). Spearman correlation coefficients ranged from a minimum of 0.52 in farming, fishing, and forestry occupations to a maximum of 0.90 in protective-service occupations. Other occupations with strong correlations to COVID-19 deaths included healthcare support (ρ = 0.87) and transportation and material moving (ρ = 0.87). By contrast, both computer and mathematical science occupations (ρ = 0.62) and life, physical, and social science occupations (ρ = 0.65) saw weaker correlations with COVID-19 deaths. 
In one of the first descriptive studies to examine racial disparities in COVID-19 mortality among essential workers in the United States, we identified a disproportionate number of deaths among NH Blacks relative to their distribution in state populations. For example, NH Blacks comprised 36.49% of COVID-19 deaths in Wisconsin despite making up only 6.17% of the state's population. With similar trends observed nationwide, our findings contribute to the existing knowledge base concerning health status and outcome inequalities in the United States for NH Blacks compared with NH Whites (Farmer & Ferraro, 2005; Hatzenbuehler, Phelan, & Link, 2013) .
NH Blacks were more likely than NH Whites to hold occupations considered essential (e.g., in transportation, health care, food preparation, and cleaning services). NH Blacks disproportionately occupied the top nine occupations that placed them at high risk for contracting COVID-19 and for potentially infecting their households. In March 2020, disaggregated occupational data from Amazon emerged that corroborate our findings, revealing that workers at 10 Amazon warehouses nationwide tested positive for COVID-19 (Greene, 2020) . December 2019 workforce data showed that 26.5% of Amazon workers identified as NH Black and 18.5% as Hispanic (About Amazon Staff, 2019). This compares with an overall representation in the U.S. population of 13.4% for NH Blacks and 18.3% for Hispanics (U.S. Census Bureau, 2019d).
Our findings confirmed our central hypothesis that COVID-19 mortality was highest among NH Blacks compared with NH Whites due to NH Blacks holding more essential-worker positions. Although our findings revealed state-specific occupational differences in states with denser NH Black populations, they consistently showed that disparities in NH Black-White mortality were high not only in COVID-19 hotspots but also nearly everywhere across the United States.
Chambers (2020) and Schumaker (2020) report that varied COVID-19 exposure and transmission levels in communities of color stem from a lack of personal protective equipment (PPE) and inability to fully practice social distancing. Nearly half of all urban NH Blacks in the United States live under conditions of hypersegregation and concentrated poverty (Massey, 2004) . NH Black essential workers living in high-density housing may be unable to practice social distancing at home, rendering those they live with disproportionately vulnerable to COVID-19 exposure.
We found that NH Blacks residing in the Midwest-specifically, Wisconsin, Kansas, Missouri, Michigan, and Illinois-have been the hardest hit by COVID-19, with mortality rates ranging from nearly three to six times higher than those of NH Whites. While many Midwestern cities are often designated among the "best places to live" in America (Mishkin, Bhardwaj, Raimonde, & Wilt, 2019; US News & World Report, 2020) , for NH Blacks they are among the worst places to call home due to well-documented racial disparities in education, incarceration, employment, income, health, medical care, homeownership, voting access, wages, and numerous other socioeconomic factors (Boen, 2016; Council on Ethical and Judicial Affairs, 1990; Geruso, 2012; Stebbins & Comen, 2018; Williams & Jackson, 2005) .
Despite historical pandemics such as HIV and H1N1 serving as potential guides for early intervention and improved response (Andrulis, Siddiqui, Purtle, & Cooper, 2012; Denning & DiNenno, 2010; Quinn et al., 2011) , our findings reveal a lack of progress toward health equity in pandemic response efforts in the United States. The 1985 Heckler report highlighted how NH Black Americans experienced significantly worse health outcomes than their NH White counterparts (Nickens, 1986) . Over three decades later, our study magnifies how occupational disparities contribute to the persistence of racialized health inequities. Existing structural injustices will continue to shape racial disparities in this pandemic if essential workers are treated as expendable, and unless companies and governmental leaders prioritize workplace safety and protection as a matter of public health.
A central moral dilemma of the COVID-19 pandemic revolves around "restarting America" to save the economy. We suggest that policymakers must first recognize the economic harms that structural racism has caused for NH Black families across the country. Historical evidence confirms that reallocating medical expenditures to social programs and public health interventions can be of greater benefit to the nation's economy and health than cutting public health budgets (Correia, Luck, & Verner, 2020; Masters, Anwar, Collins, Cookson, & Capewell, 2017; Tran, Zimmerman, & Fielding, 2017) . Delays in implementing pandemic mitigation interventions (e.g., stay-at-home orders, ramp-up of domestic PPE production) interacting with structural racism may explain the high COVID-19 mortality among NH Blacks in the Midwest, but ethical questions surrounding structural inequities in the health-care system require additional interrogation as data on racial disparities in cases and deaths continue to emerge.
While it is evident that COVID-19 does not discriminate, the same cannot be said about the U.S. health-care system. Although we were unable to confirm this for the current study due to a lack of COVID-19-specific provider-level data, overwhelming evidence exists that racial/ethnic minority patients continue to receive worse health care than NH White patients (Agency for Healthcare Research and Quality, 2020; Satcher et al., 2005; Smedley, Stith, & Nelson, 2003) . Moreover, when accounting for patient-level factors, health-care providers have been found to exhibit significant implicit bias against NH Blacks (Maina, Belton, Ginzberg, Singh, & Johnson, 2018) . The need for policy addressing mandatory provider implicit bias training married to rapid progress toward universal health coverage has been amplified due to COVID-19. Future research should consider modeling the cost-effectiveness role of universal health coverage and public health interventions in overcoming COVID-19.
We conclude from our study that structural disparities, not biology, continue to increase COVID-19-related racial inequalities. In agreement with the findings of Laster Pirtle (2020) and Milam et al. (2020) , our study reveals the need for interventions to address social inequality among groups most at risk for unfair or unequal treatment. The racial disparities among essential workers in the United States that we highlight are a byproduct of longstanding systemic racism and structural inequalities, combined with a lack of public policy aimed at protecting the lives of essential workers who risk their lives daily to protect and/or provide for others. Complementing recommendations by Gross et al. (2020) , increased vigilance around policy development and comprehensive strategies requiring the timely collection and public dispersal of state-and county-level data disaggregated by race and ethnicity are critical to enable timely adjustments to response practices during public health crises.
This investigation is not without limitations. First, we used unweighted population distributions of racial/ethnic groups without adjusting for regional or county-level geographical differences in race/ethnicity. Accordingly, disproportionate trends in reported COVID-19 mortality among NH Blacks may not reflect local differences in race/ethnicity. However, we employed this technique explicitly to examine state-level disparities in COVID-19 mortality by race/ethnicity. Next, COVID-19 deaths in the United States are undercounted and incomplete due to lengthy national data-gathering strategies and inconsistent counting methods between states. We did not account for these complex coding discrepancies as doing so may have biased our findings. Third, this study was purely descriptive, as we did not directly test for the causal association between increased essential occupations among NH Blacks and their increased COVID-19 mortality. Yet, it was beyond the scope of this study to account for or investigate the connections between race/ethnicity and other health conditions and how these associations may interact with the impact of occupation on COVID-19 mortality. Fourth, although the CDC provided guidance in April 2020 for certifying deaths due to COVID-19 (National Center for Health Statistics, 2020), many states and the CDC recently confirmed they conflated the results of two different types of test (viral and antibody) for coronavirus. Although testing of active cases was not the focus of our investigation, this compromising practice limits the ability of the United States to precisely determine how testing for this infectious disease has improved, and the COVID-19 incidence we report from the CDC in our introduction should be digested with caution. Last, the impact of COVID-19 on different states at different times results from the rapid evolution of the novel virus as well as from states adopting different social distancing policies at various times. Although success in "flattening the curve" was not necessary for the aim of this study, future research should determine the effects of physical distancing policies on COVID-19 mortality.
Tiana N. Rogers, PhD, MA, MA, is passionate about connecting research to