The issue of how race-related health inequalities are affecting several disadvantaged groups, and black communities in particular, in the U.S. is very complex and has wide ramifications. COVID-19 has only served to unmask inequities that have existed for hundreds of years.
The current climate of social unrest in the U.S. and the thousands of people protesting against systemic racism and in support of the Black Lives Matter movement is bringing these inequities into even sharper focus, adding more political and emotional weight to a longstanding issue.
A few articles on the matter can only begin to scratch the surface — but the complexity of an issue should not deter us from tackling it.
A couple of weeks ago, Medical News Today dove into some ways in which COVID-19 is affecting people of color and minority groups. We also interviewed Prof. Tiffany Green about how racial inequities play into the disparities observed during the pandemic.
In this Special Feature, we follow up by looking at the available scientific evidence of the uneven and racialized impacts of the pandemic, as well as what other experts have to say about racial disparities during COVID-19 and in healthcare more broadly.
As the pandemic persists and more data become available, MNT will continue to address the broader issue and focus on the impact that COVID-19 is having on specific racial and ethnic groups.
For now, much of the evidence points to a disproportionate impact on black Americans, so the rest of this article will focus on this group.
Making sense of incomplete data
As the COVID-19 pandemic unfolds, more data are becoming available regarding infection rates, mortality rates, and testing, shedding light on the ways in which the crisis is affecting different sociodemographic groups.
However, in some countries — and perhaps most notably in the U.S., considering its high numbers of cases and deaths — the information is becoming available in dribs and drabs, as the relevant government bodies have been reluctant to gather and reveal data organized by specific sociodemographic factors.
For instance, sex-disaggregated data was not publicly available in the U.S. in mid-April 2020, when the country had the highest number of COVID-19 cases in the world.
Similarly, it took the federal government 3 months to start tracking COVID-19 deaths and infections in nursing homes, and even then the efforts were incomplete, despite outcry from researchers and public health experts.
Race- and ethnicity-related data have been no exception. In mid-April, almost 3 months after the start of the pandemic in the U.S., the Centers for Disease Control and Prevention (CDC) were breaking down only 35% of their data according to race and ethnicity.
At the time, according to some studies, the race or ethnicity of people receiving 78% of the diagnoses on a national level was “unknown,” and only half of the states were reporting COVID-19 mortality by race and ethnicity.
Researchers have pointed out that while, “1 in 5 counties, nationally, is disproportionately black and only represent 35% of the U.S. population […] these counties accounted for nearly half of COVID-19 cases and 58% of COVID-19 deaths.”
Inaccurate or incomplete reports of data can paint a misleading picture — one that can misinform public health policies.
A study that has yet to be peer-reviewed — led by researchers at Yale University, in New Haven, CT — noted in mid-May that “The CDC data suggests that white patients represent a higher proportion of COVID-19 diagnoses than their representation in the general population.”
“Yet data derived from specific regions that report race and ethnicity of COVID-19 decedents show that black patients are dying at a much higher rate than their population share.”
In the absence of a clear picture at a federal level, scientists, nonpartisan research groups, and advocacy groups have stepped in to gather as much data as possible in a systematic way.
Reports from disparate U.S. states, coupled with emerging studies, are all painting a worrying picture: Black Americans are being hit the hardest by the pandemic, along with Latinx communities, while Indigenous populations and other minority communities are also taking the brunt of COVID-19 in some states.
Black Americans up to 3 times more likely to die of COVID-19
The study led by Yale researchers, which appeared as a preprint in mid-May, used more recent data, assessed its quality, and adjusted for age in their analysis.
Lead study author Dr. Cary Gross and colleagues found that black Americans are 3.5 times more likely to die of COVID-19 than white Americans. In addition, the team found that Latinx people are almost twice as likely to die of the disease, compared with white people.
“We also found that the magnitude of these COVID-19 disparities varied substantially across states. While some states do not have demonstrable disparities, [black and Latinx populations] in other states face 5- or 10-fold or higher risk of death than their white counterparts,” say the authors.
Dr. Marcela Nunez-Smith, a professor of internal medicine at Yale and senior author of the study, comments, “We need high-quality data and a consensus on the metrics we use to direct resources and tackle staggering health inequities.”
It is worth noting that the CDC are now showing national averages by race, data that was not visible on its website a few weeks ago. However, it remains unclear whether they are using data from all 50 states and Washington, D.C. to reach these averages.
A report issued by the nonpartisan American Public Media (AMP) Research Lab at the end of May found similar results.
“The latest overall COVID-19 mortality rate for black Americans is 2.4 times as high as the rate for whites and 2.2 times as high as the rate for Asians and Latinos.”
The AMP report calculated these rates based on the total number of deaths up to May 19, at which point the scientists had information about the races and ethnicities of 89% of the people who had died of COVID-19. The information came from 40 of the 50 states and from the District of Columbia.
“While we have an incomplete picture of the toll of COVID-19,” the authors write, “the existing data reveals deep inequities by race, most dramatically for black Americans.”
Death rate for black Americans doubles their population share
For black people in the U.S., the death rate of COVID-19 is staggeringly high, compared with the population share.
As the AMP report notes, collectively, black Americans make up 13% of the population in all U.S. areas that released COVID-19 mortality data, but they account for 25% of the deaths.
“In other words, they are dying of the virus at a rate of roughly double their population share, among all American deaths where race and ethnicity is known.”
By comparison, “Across all 41 reporting jurisdictions combined, whites are considerably less likely to die from COVID-19 than expected, given their share of the population. They represent 61.7% of the combined population, but have experienced 49.7% of deaths in America where race and ethnicity is known.”
Echoing the Yale study, the AMP report found huge disparities in individual states. These disparities are much broader than the 2.4-times higher rate of mortality among black Americans, compared with white Americans.
For example, “In Kansas, black residents are 7 times more likely to have died than white residents, while in Washington, D.C., the rate among blacks is 6 times as high as it is for whites. In Missouri and Wisconsin, it is 5 times greater.”
The authors of the AMP report also deplored the mishandling of this crisis by the U.S. federal government, in terms of the gathering and disseminating of data on race.
Andi Egbert, a senior researcher at APM Research Lab, said, “I won’t speculate about motive, but I can’t believe in a modern economy that we don’t have a mandated, uniform way of reporting the data across states.”
“We are in the midst of this tremendous crisis, and data is the best way of knowing who is suffering and how.”
– Andi Egbert
Dr. Uché Blackstock, CEO of Advancing Health Equity, also criticized the U.S. federal reaction to race-related disparities.
“The disparities are continuing to be reflected in the data, yet we still have a complete lack of guidance from the federal government about how to mitigate these divisions. There is no real plan how to deal with it.”
What explains the disparities? And how does racism play into it?
The evidence reveals enormous disparities and a bitter reality: COVID-19 is disproportionately affecting black people in the U.S., and black people are dying as a result of COVID-19 at an alarming rate. But what are the reasons behind the numbers? What explains these huge inequities?
Experts have been saying for years that we need to tackle systemic racism and the toll that it takes on the health of communities of color.
Prof. David R. Williams, chair of the Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health and professor of African and African American Studies and Sociology at Harvard University, is one such expert.
In a teleconference organized by the Robert Wood Johnson Foundation, a public health philanthropic organization based in Princeton, NJ, Prof. Williams points out: “Racial inequities exist not only for COVID-19, but for almost every disease.”
The new coronavirus, he says, only serves as a “magnifying glass that helps us to see some long-standing shortfalls in health” that have existed for centuries.
“For over 100 years, research has documented that black people in America and Native Americans live sicker and shorter lives than the average American.”
– Prof. David R. Williams
The impact of wealth and income disparities
“What are the reasons for this?” the researcher goes on to ask. “One is the low socioeconomic status.” Gaps in income and wealth distribution are a huge contributing factor.
“For example, national data for the U.S. in 2015 reveals that for every dollar of household income white households receive, black households receive 59 cents, Latino households 79 cents, and Native American households 60 cents,” Prof. Williams says.
“What is stunning for the 59 cents figure for African Americans is that it is identical to the racial [black-white] gap in income in 1978. I did not misspeak, you heard me correctly — 1978, the peak year of the economic gain for black households, as a result of the war on poverty and the civil rights policies of the 1960s and 1970s.”
– Prof. David R. Williams
Furthermore, Prof. Williams points out, according to “Federal reserve board data for 2016, for every dollar of wealth that white households have in the U.S., black households have 10 pennies and latino households have 12 pennies.”
Economic status matters “profoundly” for reducing the risk of exposure to the new coronavirus, says Prof. Williams, as lower socioeconomic status means that a person is more likely to have to leave their home for work.
Prof. Tiffany Green echoed this in the interview that she gave to MNT.
“For example, non-Hispanic black and Hispanic Americans are more likely to end up in occupations that we have newly deemed “essential,” including, but not limited to, retail work (e.g., grocery stores), sanitation, farming, meatpacking plants, frontline healthcare workers in nursing homes, early child care educators, etc. Each of these occupations is critical in allowing the rest of society to stay at home and ‘flatten the curve.’”
– Prof. Tiffany Green
A similar sentiment is echoed by Dr. Camara Phyllis Jones, an epidemiologist and fellow of the Radcliffe Institute for Advanced Study at Harvard University. “We’re getting infected more because we are exposed more and less protected,” she says.
In addition, issues surrounding poverty and housing add to the risk of spreading the virus. “In poor neighborhoods, [physical] distancing is not a viable option, when residing in high-density, often multi-generational housing units,” says Prof. Williams.
The impact of comorbidities
When prompted to explain why the numbers of COVID-19 cases and mortalities in the U.S. are so high, though the country makes up only 5% of the world’s population, Alex Azar, secretary of the Department of Health and Human Services, said, “Unfortunately, the American population is a very diverse [population].”
He went on to mention the “greater risk profile” of black communities and minority groups, suggesting that the underlying diseases that African Americans are predisposed to contribute significantly to the higher death toll.
His remarks have attracted considerable criticism and have been seen as victim-blaming.
While comorbidities are an undeniable risk factor for COVID-19 severity, it is important to ask why those comorbidities exist in the first place.
Prof. Williams mentions in his talk that black Americans are indeed more likely to have diseases such as hypertension, heart disease, and diabetes — conditions that amplify the severity of COVID-19.
In fact, research has shown that not only do black Americans and minority populations develop these diseases at a greater rate than white Americans, they also tend to develop them at a younger age.
As to why this happens, stress and racial discrimination are a huge part of the answer. “Minorities experience higher levels of stress […] and greater clustering of stress,” says Prof. Williams in his webinar.
“In addition to the traditional stressors, minorities experience the stress of racial discrimination that has been shown to have negative effects on physical and mental health.”
– Prof. David R. Williams
The impact of systematic racism in healthcare
Importantly, these negative health effects do not only stem from racial discrimination on an interpersonal level — black Americans also experience this discrimination when they engage with the healthcare system.
Prof. Williams and Dr. Lisa A. Cooper, an epidemiologist and professor at the Johns Hopkins University School of Medicine, in Baltimore, MD, note in a 2019 study that a report from the National Academy of Medicine draws a chilling conclusion.
“Across virtually every type of therapeutic intervention in the U.S., ranging from high-technology procedures to the most basic forms of diagnostic and treatment interventions, blacks and other minorities receive fewer procedures and poorer quality medical care than whites.”
“Access to care is a problem [and] access to testing is a problem,” Prof. Williams says.
Dr. Jones, who is also a former president of the American Public Health Association, expressed a similar sentiment.
Speaking of racial discrimination in healthcare and its effects on COVID-19 response, she observes, “Our nation has abdicated its responsibility to do that kind of work and ask those kinds of questions.”
“By creating unequal access to resources and opportunity, racism is a fundamental cause of racial inequities in health.”
– Prof. David R. Williams and Dr. Lisa A. Cooper
In her interview with MNT, Prof. Green emphasized the profound harm of racial discrimination in healthcare.
She highlighted some specific ways in which this bias manifests, including the use of face masks to criminalize black men, disparities in Medicaid policies, and gaps in the Affordable Care Act.
Prof. Green also spoke to the importance of enforcing civil rights laws. Her interview can be read in full here.
Prof. Williams said that COVID-19 serves as a magnifying glass that helps us see racial inequalities in health. Some who are not targeted by racial prejudice on a daily basis may feel as if they are seeing these inequalities for the first time, though the disparities have existed for centuries.
It could be argued that the current protests and the Black Lives Matter movement are fulfilling a similar role — awakening many who were privileged enough to ignore injustices that have existed for hundreds of years.
Using this magnified view as an opportunity to rectify injustices — in healthcare and other areas of our lives — is crucial and urgent. So is recognizing that concerning these issues, most of us have been downright blind.