Funeral director Goulade Farrah is haunted by his clients, whose bereavement over loved ones lost to COVID-19 plays over and over in his head.
The hospital told us he was fine, and the next thing we know he’s on a ventilator.
They said go home and let us know when her oxygen level is this number, but when we went back it was too late.
We are devastated, we could not even be with him when he died.
Roughly 90% of the deaths Farrah handles at Olive Tree, the mortuary he oversees in Stanton, California, about 26 miles south of Los Angeles, are COVID-19-related. Many are Arab Americans.
Arab Americans and their advocates fear alarming rates of COVID-19 infection and deaths in their communities – but there is little data to back up these concerns because most are categorized as “white” by the federal government.
The nation’s 3.7 million Arab Americans are unable to self-identify as such on the census and other government forms. As a result, official health care data can be hard to come by, and experts and community leaders are forced to rely on patchwork, often self-compiled data.
The issue has been exacerbated by COVID-19 in a community facing numerous risk factors for the virus, including large numbers of immigrants and refugees, poverty, multigenerational households and high rates of hypertension, diabetes and heart disease.
“We are told we are white when in reality, we are deprived of proper and accurate statistical data,” Hasibe Rashid, of New York City’s planning department, said during a web panel this week on the virus’s social and economic effects on the city’s Arab immigrant and refugee populations. “We are expected to conform to something we do not agree with, and worse yet, something society does not see us as. We do not live the life of white privilege.”
Without a racial or ethnic identifier, community coronavirus infection rates are “extremely unreported,” said Madiha Tariq, deputy director of the Community Health and Research Center run by ACCESS, a Dearborn, Michigan-based social service agency serving a largely Arab American population in several surrounding counties. “This has led to a false sense of security among community members who believe this is not a disease that impacts them.”
Hasan Shanawani, a pulmonologist in Ann Arbor, Michigan, and president of American Muslim Health Professionals, a nonprofit group focused on public health, said Arab Americans’ unrecognized status consigns them and their health issues to obscurity.
“They all just check the ‘white’ box and get absorbed into the mainstream,” he said.
A growing but unseen population
Raed Al-Naser, a critical care physician at Sharp Grossmont Hospital in La Mesa, California, in east San Diego County, noticed a disproportionate number of Arab Americans coming through the intensive care unit for COVID-19-related complications during the pandemic’s first waves early last year.
As president of the National Arab American Medical Association’s San Diego chapter, he checked with colleagues in other Arab American enclaves around the country, who confirmed they saw the same thing.
By summer, Al-Naser was penning editorials in local publications, hoping to bring attention to the issue. He combed through hospital records from March through December and determined that of those admitted to Sharp Grossmont with COVID-19-related conditions, 11% were Arab American – about twice the rate of admissions he typically saw for that population.
“Nobody was noticing the impact of this disease in the community,” he said. “When it comes to Arab Americans as an ethnic minority, they’re always visible when it’s bad news, but when it’s their health, they’re invisible.”
“COVID-19 made this reality more visible and undeniable,” Al-Naser said. “And the health disparities are going to go deeper and deeper if we don’t recognize that these communities are not being served.”
More than 500,000 Americans have died from COVID-19. Federal data shows that compared with non-Hispanic whites, Blacks are nearly twice as likely to die from the virus, while death rates among Hispanics and Native Americans veer closer to two and a half times in comparison. There is no official data on Arab Americans, who are bundled into the white category.
In New York City, where immigrant and refugee families often double up to afford the city’s expensive housing, a survey conducted by the Arab-American Family Support Center found that overcrowding worsened amid the job losses of the pandemic, allowing the virus to run rampant.
“COVID-19 is spreading like wildfire because they are unable to isolate,” said Rawaa Nancy Albilal, the agency’s president and CEO. “And many of them live or work in jobs that put them at the highest risk possible.”
Front-line workers are feeling it, too. At Olive Tree, which serves greater Southern California, Farrah’s voice quivered as he recalled an Arab American physician who came out of retirement in the early days of the pandemic, only to fall victim to the effects of the virus.
“It was terrible,” said Farrah, who handled the doctor’s arrangements. “He just wanted to help.”
In January, the funeral director and community advocate oversaw the cases of two more Arab American emergency room physicians who died of COVID-19 and unnerved doctors who knew the pair had called Farrah for help in setting up their wills.
“They got the best treatment,” Farrah said, “but nothing can stop this virus. It’s all COVID. It’s become the normal now.”
Arab Americans have high-risk factors for COVID-19
The nation’s Arab American population has at least doubled since 2000, driven by the arrival of mostly Muslim immigrants and refugees, the product of multiple wars and instability in the Middle East. Coming from embattled places such as Syria, Iraq, Yemen and the Palestinian territories, they’ve joined larger populations of more established, mostly Christian Arab Americans with roots in Lebanon and Egypt, as well as Arab Chaldeans, an ethno-religious group from northern Iraq.
Southern California is home to as many as 300,000 Arab Americans, the nation’s largest concentration, but the population is highest by percentage in Michigan, primarily in Detroit and nearby areas such as Dearborn, where they comprise half of the city’s approximately 100,000 people. As of Feb. 24, Dearborn and nearby Dearborn Heights, where at least a quarter of the population is Arab American, accounted for one-fifth of Wayne County’s 64,000 COVID-19 cases outside Detroit.
For more recent arrivals, fledgling lives in the USA are often beset by poverty, lower education levels and jobs as taxi drivers or workers at restaurants, markets or cleaning services that have subjected them to health care disparities.
“They’re essential workers,” said Al-Naser of the National Arab American Medical Association. “They work in jobs where there’s no way they can do social distancing and have cultural factors that put them at high risk – big, multigenerational families living in the same home, and if someone gets sick, there’s nowhere to go. That’s why we notice significant spread of the virus in these communities.”
Many Arab Americans have avoided being screened for the virus, either unaware of available services or so worried about providing for their families that they don’t want to face a positive test result.
“The social and economic impact is costly to these communities,” Al-Naser said. “If people are sick, they can’t go to work, and if one person is supporting the family, it’s very stressful. That’s why a lot of people don’t even want to get tested. It exacerbates the whole problem.”
Many Arab Americans do not want to be classified as ‘white’
The American-Arab Anti-Discrimination Committee and Arab American Institute has fought to change the census classification of Arab Americans as white since the 1980s. As 2020 approached, confidence grew that the federal bureau would finally add a so-called MENA option, for people of Middle Eastern or North African background, to its questionnaire.
Checking the “white” box creates a certain dissonance for Arab Americans, whose experience – especially after 9/11 – hasn’t always offered the accompanying privileges of being white.
“After 9/11, we were pulled off planes left and right,” said Shanawani of the American Muslim Health Professionals. About a quarter of U.S. Muslims are Arab Americans, he said.
Shanawani said he has been stopped at an airport, “not because of how I look but because of my name.”
There’s more at stake than identity: Without a racial or ethnic identifier, Arab Americans miss out on funding for cultural- and language-specific social and health services available to other marginalized groups – services that advocates say are crucial to address issues uniquely faced by the community.
“We don’t have access to funding that other communities have because we don’t know what the community numbers are,” said Samer Khalaf, national president of the American-Arab Anti-Discrimination Committee.
What little community health data exists comes largely from academic studies in Arab American-heavy areas such as Dearborn, Southern California and New York City.
Being whitewashed from the picture hurts in other ways. Rima Meroueh, director of the Dearborn-based National Network for Arab American Communities, said that when Michigan officials assembled a commission to oversee state redistricting efforts, they based its makeup on census numbers – meaning Arab Americans, a significant part of the population, were not specifically considered for inclusion, lumped into the white category.
A Census Bureau study in 2015 found that when offered the MENA option, people from Middle Eastern and North African regions who previously self-identified as white plunged from 85% to 20%.
In 2018, Trump administration officials tabled the MENA option, saying more research was needed to decide whether the category should be considered an ethnicity rather than a race – meaning the community’s next chance to be federally recognized won’t come until 2030.
A push to educate and vaccinate Arab Americans
Advocates say the absence of reliable community data has deprived them of a major weapon as they fight to convince some Arab Americans they’re at risk of COVID-19.
“Not just at risk, but at higher risk,” Meroueh said. “Do we have a higher rate of underlying conditions like hypertension and diabetes? Yes, we know that, because we work in the community. But until we can collect that data, we’re left with only anecdotal evidence.”
The lack of data is crucial when it comes to countering skepticism, misinformation and pandemic fatigue, issues that also plague the general population, experts said.
It looms larger given the Arab American community’s risk factors – including cultural and language barriers and, for many, a distrust of government authorities fed by experiences here and elsewhere. Some feel stung by a record of post-9/11 vilification and xenophobia, while others fall prey to rumors bandied in communication networks tied to their homelands or Arabic-language sources on social media platforms such as Facebook, WhatsApp or YouTube.
“Arab Americans have been vilified by so much rhetoric that that group is not likely to trust information coming from a government entity,” Meroueh said. “It’s very difficult to access those populations. Trying to work against that tide is a really big task.”
San Diego visual artist Doris Bittar, who runs a home-based literacy program for Syrian refugees, recalled a family she’s worked with in nearby El Cajon, where as much as a quarter of the city’s 100,000 residents trace Middle Eastern roots.
Not long ago, members of the family prepared to carpool with Bittar and her husband to a community event, and “we had masks on, and they didn’t,” she said. “I felt awkward. Nobody was social distancing.”
The family assured her that they had talked with relatives in Damascus, Syria, who had gotten and survived the virus, even offering remedies.
“It was like, grind up some cloves and mix with honey and swallow it whole before you taste it,” Bittar recalled. Instead of carpooling, Bittar and her husbandasked the family to follow them in a separate car.
“And lo and behold,” she said, “Ten days later, they all had COVID.”
Advocates say some in the community struggle to socially distance because of the largely social culture.
“Arab communities are very communal,” said Jeanine Erikat a community organizer at San Diego’s Partnership for the Advancement of New Americans. “You have gatherings with your cousins and neighbors and the community at large. It’s a usual thing. It’s how you stay connected.”
Such situations can be maddening for those who deal with people who suffered the worst of the virus.
“It really upsets me that people are not taking it seriously in some sectors,” said Janet Slinkard, office manager for Orange County’s Olive Tree Mortuary, where funeral services are backlogged by at least a month. “We have been inundated. We have other funeral homes calling to ask if we can take their overflow.”
Advocates fear that the same factors fueling doubts about the virus drive skepticism about COVID-19 vaccines. Without clear data on Arab Americans, many fear officials won’t know whether Arab Americans are receiving the vaccine in proportionate numbers.
In Dearborn, Meroueh said that despite having two chemist siblings who work on virus vaccine research, she had to accompany her Lebanese mom to a clinic to ensure she went through with her first shot after a neighbor spouting sketchy information in her vastly Arab American neighborhood filled her with last-minute doubts.
In San Diego County, public health professor Wael Al-Delaimy said a small, unpublished survey of Syrian refugees conducted by his students at the University of California-San Diego found a troubling two-thirds of respondents unwilling to be vaccinated. Survey results published in December showed that barely 24% of Blacks and 34% of Latinos planned to get the vaccine, compared with 53% of whites.
Disturbed by the “wild conspiracy theories” he saw spreading on Arabic social media, Al-Delaimy created YouTube videos to urge people to get vaccinated.
“This problem is not going to go away,” Al-Delaimy said, noting the arrival of new viral strains and subsequent waves of spread as some Arab American community members continue to socialize without adequate protection. “And it’s getting worse.”