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.
With over 408,000 confirmed cases and 25,000 COVID-related deaths as of mid-July, New York State continues to represent the epicenter of the COVID-19 pandemic in the U.S. The disparate effects of COVID are particularly evident in New York City, where African Americans account for 28% of fatalities, while composing only 22% of the total population. Furthermore, significant neighborhood-level disparities have been observed in New York City during the pandemic. Communities of color within New York City are disproportionately impacted , 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.
Moreover, significant disparities have been noted in the impact of COVID within different NYC boroughs. In early April, COVID incidence was highest in Brooklyn, Queens, and the Bronx, which have higher poverty rates and a larger proportion of minorities. By mid-May, the Bronx had emerged as the leader in COVID prevalence, hospitalization, and mortality. When compared to Manhattan, the Bronx has more than twice the number of COVID cases and nearly two times the number of hospitalizations and deaths. The Bronx, in contrast to predominantly White and affluent Manhattan, has the lowest median household income and the smallest proportion of residents holding a bachelor’s degree of the five NYC boroughs Furthermore, the Bronx has the highest prevalence of diabetes, asthma, and other comorbidities, the result of decades of structural racism. 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.
An important aspect to take into consideration when evaluating the racial disparities in COVID-19 outcomes is the age differences in each group. The White population has a large proportion of older individuals (median age 44) compared to non-White populations (median age 31). Given the relationship between age and risk of poor COVID-related outcomes, not adjusting for age in analyses of racial disparities could lead to significant underestimates of the disparities. When age is taken into account, the disparities in COVID-19 mortality are even more stark. In one analysis, age-standardized risk ratios relative to White individuals were 3.6 for Black individuals, 2.6 for Hispanics, and 1.7 for Asian Pacific Islanders people and 1.2 for American Indian/Alaska Natives. However, when examining age groups individually, the risk ratios compared to white individuals were much higher (see image below). Thus, it appears that younger non-White populations are dying at significantly higher rates than their White counterparts.
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
Institutionalized, or structural racism, can be succinctly defined as the “differential access to goods, services and opportunities of society by race” (Jones, Am J Pub Health 2000). This form of racism has manifested in the current pandemic in a number of ways. , 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, maintenance, and housekeeping workers. 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.
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. 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. The overrepresentation of racial and ethnic minorities in the essential workforce is not a coincidence. Rather, it is the result of decades of intentional policies that confined racial and ethnic minorities to low-wage occupations, devalued agricultural, domestic and service vocations and excluded these occupations from legislation that boosted wages and improved working conditions.
Essential workers are more restricted in their ability to participate in social distancing. Most workers that have been deemed essential, including many 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. 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. This has led to 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, with increased risk of exposure to family members living in the same household (New Yorker, April 2020). While there are many sociocultural reasons why people choose to live in multigenerational housing, the increased proportion of racial and ethnic minorities living with a large number of other family members is predominantly due to economic inequality and exclusionary housing policies that prevent individuals in these populations from accessing affordable housing. These exclusionary housing policies have not only resulted in crowded housing, but are the cause of the significant residential segregation by race that exists throughout the US to this day.
Racial residential segregation is one component of systemic racism that has been a known contributor to poor health and racial health disparities for decades. It has also been linked to an increased risk of spread of infectious diseases. Lack of access to clean water, poor access to healthcare and increased exposure to air pollution are all underlying causes of racial health disparities that are deeply intertwined with residential segregation. Each of these factors has also fueled the racial disparities in COVID-19 outcomes. For instance, communities of color are known to have worse access to clean water, which has been exacerbated in recent months as some low-income 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. This problem has been particularly acute for Native American communities that have faced severe barriers to accessing clean water for many years. Additionally, it has been reported that greater chronic exposure to air pollution is associated with higher death rates of COVID-19, making communities of color who have disproportionately high exposure to toxic pollutants more likely to suffer severe consequences from the SARS-CoV2.
The CDC also 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 segregated communities. 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). Furthermore, Black people are known to have higher all-cause mortality, including mortality related to chronic cardiovascular and respiratory diseases, as well as poorer self-reported health behaviors and higher reported mental and physical stress. As indicated above, these pre-existing disparities in chronic disease prevalence arise from interconnected individual and structural forces such as poor health literacy, inadequate access to care, residential segregation, and overrepresentation in essential industries without paid sick leave.
Compounding the inability to have adequate social distancing due to financial and systemic constraints, COVID-19 testing is limited in availability to minority communities. Although 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.
Hospitals in historically low-income communities, often referred to as “safety-net hospitals,” predominantly serve patients who are uninsured or on Medicaid and have been hit particularly hard by the pandemic. They have been overwhelmed by the volume of patients and staffing shortages. Due to years of disinvestment in these hospitals, many were in tenuous financial situations prior to the pandemic. Moreover, they received less relief funding early in the pandemic because the initial funding allocation was based on Medicare volume, disadvantaging hospitals that service mostly Medicaid patients. The lack of funding has resulted 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 manifestations of institutional racism increase the risk of exposure amongst minority patients, limit their access to testing, and disadvantage them when they present to care.
Personally-mediated racism
Personally-mediated racism, which refers to differential assumptions about or actions toward individuals based on their race, can also lead to poor COVID-19 health outcomes. 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. African American and Hispanic patients have cited difficulty obtaining COVID-19 testing. 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, defined as “acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth,” 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 reluctance to present for care due to fear of discrimination or hesitancy to recieve a COVID-19 vaccine, as distrust is a known barrier to vaccination for other infectious diseases in communities of color. 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.
COVID-19 among Populations with Limited English Proficiency
Another group of people that has been disproportionately affected by the pandemic are those with limited English proficiency (LEP). 1 in 5 people in the US speak a language other than English at home and 1 in 12 report speaking English “less than well” (i.e. categorized as LEP). Reports from both New York and Boston in the early stages of the pandemic indicated that immigrant working class communities, in which a large proportion of people have LEP, were being hit particularly hard. At the beginning of April, officials from Massachusetts General Hospital reported that 35-40 % of the COVID-19 patients in the hospital were Latino, 40% of whom had LEP. This population is particularly vulnerable to contracting the virus and developing advanced disease due to the lack of high-quality translated information, inability to access care because of lack of insurance and immigration concerns and a high proportion of people in essential workers.
The lack of available translated materials about COVID-19 has forced people with LEP to rely on other sources of information, such as social media, that can be erroneous and misleading. For example, one article describes a man who believed he could not be infected with SARS-CoV-2 because he held his breath for 10 seconds without coughing. This myth, which had apparently circulated online in many languages, illustrates the danger of failing to disseminate public health information widely in forms that all communities can comprehend.
This problem is especially serious for the LEP population as many individuals with LEP have occupations classified as essential and, thus, are in need of reliable, accurate information about how to avoid contracting SARS-CoV-2. Hispanic populations, for example, are disproportionately represented in service and janitorial occupations and home health care occupations. This puts them at high risk not only of becoming infected, but also of suffering greatly from the financial devastation of the pandemic due to the low compensation of these positions. Moreover, as many people with LEP are immigrants with various levels of citizenship status, they often lack health insurance and are also frequently afraid to seek care for fear of the immigration-related consequences. (See section on Insecure Immigration Status)
For the LEP population that can access healthcare, they face additional barriers in both the outpatient and inpatient setting. In the outpatient setting, the shift to telemedicine has created additional hurdles for accessing care and for having high-quality interpretation services available for virtual care. In the inpatient setting, PPE shortages and the restriction of visitors and hospital personnel to the minimum necessary have created a scarcity of in-person interpretation that threatens to undermine the quality of care provided to these individuals.
As the pandemic continues and cases begin to rise in areas of the U.S. with very large LEP populations, such as Arizona, Texas, Florida and California, the vulnerability of this population remains a significant concern.
Further Reading:
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. 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.” COVID-19 has already taken a devastating toll on American society and communities of color, in particular. It is critical that society recognizes and addresses the causes of these racial health disparities before they claim more lives.
Emerging Equity Based Efforts
Recognizing these disparities as the result of racism within our society and our healthcare system is only the first step. Over the course of the past several weeks, several 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.
Racism as a Public Health Crisis
In the wake of COVID-19’s disproportionate burden on communities of color, continued acts of police violence, and countless additional injustices, the American Public Health Association has declared racism a public health crisis. Physician Assistant and advocate Leslie Gregory has long argued that racism is a public health crisis, rather than an “issue,” as it meets the four criteria of crises the CDC has previously cited:
It places a significant burden on society that is increasing
This burden is unevenly distributed throughout society (some groups are affected more than others)
Preventative strategies have the potential to reduce the burden
These strategies are not yet in place
While this crisis is not new, COVID-19 has made even more clear many of the inequities that have been harming health in communities of color for years, as discussed above. The same structures of oppression that create over-policing and violence toward communities of color result in disparities that make these communities the most susceptible to the worst COVID-19 outcomes. Acknowledgement of racism as a public health crisis pushes us to see racism, rather than race, as the risk factor for morbidity and mortality.
Cities and counties across the country have joined in this declaration, but the meaning of an official declaration remains unclear. In this national moment of focus on public health, a public health crisis may provide a useful framework for action around racial inequities. At the same time, public health itself has a racist history, and practitioners will need to remain vigilant that the voices and needs of communities of color are prioritized in future directions. While some declarations may remain symbolic with little policy or funding tied to them, others may gain support that was not previously accessible without the label of “crisis.”
While a full review of racism and antiracist education is beyond the scope of our curriculum, we feel this is something vital for future medical professionals to understand, and direct readers to resources listed at Med-Ed Portal's Antiracism Page. Please also see Module 6, Training for Clinical Roles, for additional information.
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.
The COVID Racial Data Tracker from the COVID Tracking Project
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.
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