Health Disparities in COVID Outcomes

Racial Health Disparities Background

Race as a social construct

The discussion on racial disparities in COVID-19 outcomes should begin with the fundamental understanding that race is a social construct rather than a biological factor (Smedley et al, American Psychologist, 2005). The American Anthropological Association upholds that “‘race’ evolved as a worldview” from “a body of prejudgements” that came together to form a myth that today impedes “our comprehension of both biological variations and cultural behavior, implying that both are genetically determined” (see AAA statement for more details and background).

Racial Disparities in Health Outcomes before COVID

Racial disparities in access to health care, health outcomes, and collection of race-based data predate the COVID pandemic. For an in-depth discussion of racial disparities prior to COVID, please refer to the supplemental material.

Racial Disparities in COVID-Specific Outcomes

Health disparities have been known to worsen health outcomes in African American and Hispanic populations. The spread of COVID-19 in the U.S. has exacerbated these racial disparities--data released from the CDC demonstrated that African American and Hispanic patients are much more likely to contract coronavirus and die from the disease. States and counties began to release racial data pertaining to COVID-19, and a pattern emerged showing that African Americans and Latinos were overrepresented among the infected and the dead. News articles abounded, illuminating the tragedy that the most vulnerable populations in America would inevitably be hit the hardest by this pandemic. Even without all states and localities reporting outcomes by race, preliminary analyses have found a relative risk of COVID-19 associated mortality of 3.57 for Black individuals compared to their White counterparts, and 1.88 for Latinx individuals compared to White individuals.

The statistics are especially alarming in cities like Chicago and Detroit, which have predominantly African American populations. In Chicago, which is 30% African American, deaths amongst this population represent 65% of the total deaths from COVID-19 and deaths amongst the Latinx community represent 11% of COVID-19 deaths. In Michigan, which is 14% African American, the number of African American deaths constitute 39% of fatalities. Detroit, Michigan, a city with the highest percentage of African Americans compared to any other large U.S. city, has emerged as a hotspot for COVID-19. Detroit is located within Wayne County, which has 47% of Michigan's COVID-19 cases.

The numbers are also stark in New York City, which has become the epicenter of the pandemic in the U.S. African Americans in New York City make up 28% of fatalities, while only accounting for 22% of the total population. Communities of color within New York City are more affected than others, with neighborhoods such as Corona, Elmhurst, East Elmhurst, and Jackson Heights recording more than 7,260 coronavirus cases as of April 8th, out of a population of 600,000. Elmhurst, a neighborhood in Queens, has been described as the epicenter of the epicenter in New York. The preliminary death rate for Latinx people in New York City is 22 people per 100,000, and, for African Americans, the rate is 20 per 100,000. In comparison, the rate is 10 per 100,000 for white people and 8 per 100,000 for Asian people. In response to the data being released from New York, Governor Cuomo committed more testing resources to minority and low-income communities, as well as additional funding for research efforts to determine why these disparities exist.

In Boston, MA where African American residents account for 25% of the population, more than 40% of COVID infected residents were reported as black. On the other hand, the number of White and Asian residents infected with COVID-19 was lower than expected for the proportion of the population they compose. Though current aggregated data does not yet reflect a higher rate of infection among Latinos in Boston, medical providers in hospitals are reporting higher rates of hospitalization among Latinos. While Governor Baker’s administration has made race-based outcomes public, only 62% of the data has race information. As a response to these statistics and the need to protect minority populations in Boston, Mayor Martin Walsh has created the COVID-19 Health Inequities Task Force.

As more race-based data is collected and reported, as shown above, the information on many minority communities, especially American Indian/Alaska Natives, remains incredibly limited. While tribes like the Navajo Nation have been recognized in the media for having rates of COVID-19 higher than New York and New Jersey, data from smaller tribes or urban dwelling American Indian/Alaska Natives are not being captured. Several states have released COVID-19 racial demographic data, which has been instrumental in highlighting differential impacts across African American and Latino populations. However, a large proportion of these states intentionally omitted an American Indian/Alaska Native racial category and opted to label such individuals as “other” making it difficult to describe the impact COVID-19 is having on many of these communities.

Further, state and federal agencies that have disaggregated racial data are withholding access from tribal epidemiology centers which is imperative to understanding risk factors that are unique to American Indian/Alaska Natives that may be putting them at higher risk for COVID-19. As a result of this neglect, the Indian Health Services has started an initiative to centralize aggregate data on the infection rate among American Indian/Alaska Natives despite being severely underfunded. This data collection relies on volunteer release of data from various organizations, health centers, and programs across the country. The call for more accurate collection and reporting of data on the health and outcomes of minority populations during COVID-19 is being echoed by leaders in medicine, public health, and policy.

A Modern Day Gardener's Tale

Framework for race, disparities, and health

Racial disparities in health outcomes are not new to the COVID-19 pandemic, but rather are intertwined within the historical, structural, and economic disadvantages afforded to communities of color throughout U.S. history. Research shows that African Americans, Native Americans, Latinos, Native Hawaiians, Pacific Islanders, and Asian Americans have disproportionately worse outcomes compared to their White counterparts (Williams, J Health Soc Behav 2012). The relationship between race and health has been explained in various frameworks; one nationally recognized framework is Dr. Camara Jones’s Gardener’s Tale, in which three levels of racism are described: institutionalized, personally mediated, and internalized (Jones, Am J Pub Health 2000). For a more in-depth discussion of racism through the lens of the Gardener’s Tale, please see the supplemental material.

Institutional Racism

On an institutional level, African American and Hispanic people are less able to socially isolate, as they make up a large portion of the essential workforce, particularly portions of the essential workforce with less representation in management, such as grocery workers, maintenance, and housekeeping. They also face reduced access to testing, inadequate treatment upon contracting the virus, and increased risk of developing serious illness due to a higher prevalence of underlying health conditions.‌

Essential workers are more restricted in their ability to participate in social distancing. Data from the U.S Bureau of Labor Statistics in 2018 showed that less than 30% of workers in the U.S. are able to work from home, falling to lower numbers in minority populations, at 20% amongst African American and 16% amongst Hispanic workers. Many workers that have been deemed essential, including many occupations that are not in the healthcare industry, occupy front-facing roles as grocery store workers, first-responders, and public transport workers, where they are at increased risk of exposure to COVID-19. In New York City, city comptroller Scott M. Stringer noted that 75% of frontline workers, including grocery clerks, bus and train operators, janitors, and child care staff, were in minority groups. He also reported that 60% of people who worked as cleaners were Latino, and more than 40% of transit employees were African American. Many essential workers depend on their jobs financially and do not have access to paid sick leave and health insurance if they do not go to work. The risk is further compounded by insufficient personal protective equipment (PPE) amongst essential workers who are not in the healthcare system. Recently, food delivery workers have initiated strikes to protest unsafe working conditions, insufficient testing, and insufficient PPE while on the job.

Once these workers return home, they are more likely to live in crowded households due to a lack of living wage and unaffordable housing, increasing the risk of exposure to family members living in the same household (New Yorker, April 2020). As an additional example of public health inequities, an alarming example is the lack of water availability in Detroit, Michigan, where residents have had their water shut off due to inability to pay rising bills. It is difficult to promote hand-washing without access to clean, affordable water, which can increase the risk of contracting infectious diseases.

Compounding the inability to have adequate social distancing due to financial and systemic constraints, COVID-19 testing is limited in availability to minority communities. Though the Families First Coronavirus Response Act provides funding for free COVID-19 testing, tests remain limited to those deemed to have serious symptoms and, in some cases, patients have been asked to cover the cost of testing (Time, Mar 2020). In some areas of the country, testing sites have been found to be concentrated in majority White neighborhoods, with fewer testing sites operating in majority non-white neighborhoods. In addition, the stimulus package does not cover all expenses related to hospitalization for COVID-19, meaning significant financial ramifications for under- or uninsured Americans if they present for care. These factors may dissuade people from going to the hospital for testing and seeking help before symptoms worsen. Further, hospitals in historically low-income communities may become overwhelmed by the sheer volume of patients, which could result in less PPE for frontline staff, lower availability of medications and ventilators, and worse outcomes for patients presenting to these hospitals in serious condition. These institutional infrastructures increase the risk of exposure amongst minority patients, limit their access to testing, and disadvantage them when they present to care.

The CDC states that people of any age who have serious underlying conditions are at higher risk for severe illness from COVID-19 compared to people without these conditions. African American and Hispanic communities are at increased risk of developing health conditions such as hypertension, cardiovascular disease, diabetes, obesity, and lung disease due to poor access to healthcare, increased exposure to air pollution, and insufficient public health support systems. In particular, cardiovascular disease starts at earlier ages in people subjected to discrimination and economic deprivation compared to people in more privileged groups (New Yorker, April 2020).

Personally-mediated racism

Personally-mediated racism can also lead to poor COVID-19 health outcomes. African American and Hispanic patients have cited difficulty obtaining COVID-19 testing. Tests are given at the discretion of physicians, which can introduce implicit bias, unless policies are enacted and resources devoted to testing in hard-hit areas, a practice implemented at MGH Chelsea. Individual bias can also mean that some physicians may not accurately calculate the risk to minority patients in deciding whether a test is warranted. There have been cases of minority patients being turned away from testing sites and emergency rooms, only to decompensate later without receiving adequate treatment. See module 8 for more discussion of the potential for bias in rationing scarce resources and in which groups have access to experimental treatments.

Internalized Racism

Finally, internalized racism can present a challenge to battling COVID-19 in minority communities. Due to repeated examples of racism throughout history, such as the Tuskegee trials and the unpermitted use of Henrietta Lacks’ cells, African American and Hispanic patients may harbor distrust towards the healthcare system and its policies. This distrust can manifest as resistance to social distancing and reluctance to present for care due to fear of discrimination. Feeling reduced self-worth due to internalized racism could also lead to delaying or avoiding care altogether. As individuals and communities take on the negative perceptions of dominant culture that label them as “unhealthy,” they may in turn feel less inclined to seek care when they need it.

Lessons for the Future

Dr. Camara Jones proposes three principles for achieving health equity during the fight against COVID-19, which include “valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need” (Newsweek, April 2020). Dr. Jones emphasizes the importance of enabling all communities to participate in social distancing, stay-at-home orders, and frequent hand-washing, which means providing housing for the homeless, hand-washing stations, and reaching out to communities of color to emphasize the importance of social distancing. It is necessary to collect and disaggregate data on “coronavirus testing, diagnosis, treatment, and outcome by ‘race’ and ethnicity so that the impacts of these historical injustices can be recognized and addressed.” Finally, it is important to agree upon a metric of need in a particular community, such as the number of diagnosed cases or indicators of the trajectory of the epidemic, to allocate and distribute resources according to that metric of need. Dr. Valerie Montgomery Rice urges the importance of concentrating resources in communities of color, commenting that, “At a federal level, we want to see resources deployed to the hardest hit communities, and, based on the data we are seeing, these are African American communities, Hispanic communities, poor communities.” In addition to petitioning for national standards for reporting race outcomes in COVID, medical organizations such as the American Medical Association (AMA) have responded by creating a Health Equity Resource website.

The data has drawn national attention. Dr. Anthony Fauci, immunologist and director of the National Institute of Allergy and Infectious Diseases (NIAID), reflected “...sometimes when you're in the middle of a crisis, like we are now with the coronavirus, it really does, ultimately, shine a very bright light on some of the real weaknesses and foibles in our society.” The extent of the toll COVID-19 will take on American society remains unclear, but it is key that society recognize and treat racial health disparities before they claim unnecessary lives.

Emerging Equity Based Efforts

Recognizing and naming these disparities within our society and our healthcare system is only the first step. Over the course of the past several weeks, several different initiatives have emerged as a means to address some of these disparities. While there is still much to do, we believe that there is merit in learning from examples set by other groups, organizations, and individuals who have attempted to combat disparities in the moment. For a growing list of efforts see the NAACP’s Equity Implications report.

Examples of emerging efforts include:

  • Demands to release of residents from jails and prisons. See Humanity Not Cages and reporting on efforts by public defenders in Louisiana.

  • Successful implementation of similar demands to address mass incarceration in Ohio.

  • Guidance made for employers whose employees may be subject to racism.

  • Multiple cities choose to suspend evictions during the pandemic.

  • Nonprofit initiatives to feed those who may be disadvantaged by this situation.

  • ACLU sues for ICE detention centers to release residents. ACLU has ongoing initiatives to also ensure that reproductive health is open to and accessible by all.

Further Reading and Resources

Our understanding of racial disparities in COVID infection, access to quality care, and outcomes will continue to evolve over the coming months. These racial disparities are closely intertwined with other social determinants of health, such as housing, employment, and immigration status. See the final section of this module for more discussion of these issues. With the framework provided above, we hope the below articles and resources help you to assess the constantly changing situation and potential solutions to mitigate these disparities.

Thought Questions:

  • What are immediate and long term policies that are necessary to curb the devastation that COVID-19 is having on minority communities?

  • What lessons can we learn from COVID regarding disparities in health care which can help us improve outcomes of minority populations in the long run?

  • What are data points that are still lacking in the race based COVID outcome reports?

  • If you were to identify a disparity or social need mentioned above (or one you have noticed, learned about, recognized yourself), what actionable steps could you take now to help contribute to emerging efforts? Change is incremental, disparities won’t disappear overnight, but they can be combated one action at a time.