Racial Inequalities in Covid-19—the Effect on Black Communities

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In this special article, we look at the racialized effect of COVID-19 on black communities in the United States, incorporating expert opinions and rounding up some additional evidence. The topic of how race-related health inequalities impact a variety of vulnerable people, and black communities in particular, in the United States, is very complex and has significant implications.

COVID-19 has managed only to unmask the inequities that have existed for centuries. The current climate of social unrest in the United States and the thousands of people protesting against systemic racism and in support of the Black Lives Matter movement is making these inequities even more intense, adding more political and emotional weight to the longstanding problem.

A few weeks ago, we explored some ways in which COVID-19 affects people of color and minority groups. We also interviewed Prof. Tiffany Green on how racial inequities play a part in the disparities observed during the pandemic. In this special article, we follow up by looking at the existing scientific evidence of the unequal and racialized impacts of the pandemic, as well as what other experts have to say regarding racial differences during COVID-19 and more generally in health care.

If the pandemic continues and more data becomes available, we will continue to discuss the wider problem and concentrate on the effect that COVID-19 has on different racial and ethnic groups. For the time being, much of the evidence points to a disproportionate impact on black Americans, so the remainder of this article will concentrate on this group.

 

Making sense of incomplete data

As the COVID-19 pandemic unfolds, more information is becoming available on infection rates, mortality rates, and testing, shedding light on how the crisis affects different socio-demographic groups.

However, in some countries — and perhaps most prominently in the United States, despite its high number of cases and deaths— information is becoming available in dribs and drabs, as the relevant government bodies have been reluctant to collect and disclose data organized by particular socio-demographic factors.

For example, sex-disaggregated evidence was not publicly available in the US in mid-April 2020, when the country had the highest number of COVID-19 cases in the world. Likewise, it took the federal government three months to begin monitoring the deaths and infections of COVID-19 in nursing homes, and the efforts were still inadequate, given the outcry from researchers and public health experts.

At the time, according to some reports, the race or ethnicity of people receiving 78% of diagnosis at the national level was “unknown,” and only half of the states reported COVID-19 mortality due to 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 data reporting may paint a misleading picture— one that may 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 the federal level, scientists, non-partisan study agencies, and advocacy organizations have moved forward to collect as much evidence as possible in a systematic manner.

Reports from disparate U.S. states, combined with new research, both paint a troubling picture: Black Americans are the hardest hit by the pandemic, together with Latinx groups, whereas Indigenous populations and other minority communities are still taking the brunt of COVID-19 in some states.

 

Black Americans are up to 3 times more likely to die from COVID-19

The Yale research review, which appeared as a preprint in mid-May, used more recent data, measured its accuracy, and corrected for age in its analysis. Lead study author Dr. Cary Gross and colleagues have 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 from the disease as white people are.

“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,” said the authors.

Dr. Marcella 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 is now providing national averages by ethnicity, data that was not available on its website a few weeks ago. Even so, it remains unknown whether data from all 50 states and Washington, D.C. is being used in order to reach these averages. Similar findings were identified in a study by the non-partisan American Public Media (AMP) Research Lab at the end of May.

“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 on the basis of the total number of deaths by 19 May, at which point the researchers had relevant data on 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 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.”

 

The mortality rate for black Americans doubles their population share

For black people in the U.S., the death rate of COVID-19 is astoundingly high as opposed to the population share.
Collectively, as the AMP study states, black Americans make up 13 percent of the population in all U.S. areas that have reported COVID-19 mortality but account for 25 percent 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.”

In response to the Yale study, the AMP report found big differences in individual states. These disparities are much wider than the 2.4-times higher rate in black-American mortality compared to white-American mortality.

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 the collection and dissemination of race data. 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 on how to deal with it.”

 

What explains the disparities? And how does racism play into it?

Evidence shows major inequalities and a harsh reality: COVID-19 is overwhelmingly impacting black people in the U.S., and black people are dying at an unprecedented pace as a consequence of COVID-19. But what are the reasons behind the numbers? What causes these tremendous inequities?

Experts have been saying for years that we need to tackle systemic racism and the impact on the health of colored communities. One such expert is 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.

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

Additionally, 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 “enormously” to reduce the risk of exposure to the new coronavirus, says Prof. Williams, because a lower socio-economic status means that a person is more likely to have to leave their home for work.

“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

The same sentiment is shared by Dr. Camara Phyllis Jones, an epidemiologist and fellow at the Radcliffe Institute for Advanced Study at Harvard University. “We ‘re getting more infected because we’re more and less protected,” she says.

In addition, poverty and housing problems contribute to the likelihood of the spread of 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 encouraged to explain why the number of COVID-19 cases and deaths in the United States is so high, even though the country is 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 note the “greater risk profile” of black populations and minority groups, indicating that the underlying diseases that African Americans are predisposed to lead significantly to higher deaths. His comments have drawn strong criticism and have been seen as a victim-blaming.

While comorbidities are an obvious risk factor for COVID-19 severity, it is important to question why such comorbidities occur in the first place. In his speech, Prof. Williams points out that black Americans really are more likely to have diseases such as hypertension, heart disease, and diabetes — conditions that increase the severity of COVID-19.

Research has shown, in addition, that not only do black Americans and minority groups develop these diseases at a higher rate than white Americans, they also appear to develop them at a younger age.

As to why this keeps happening, stress and racial discrimination are a major part of the answer. “Minorities are experiencing 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 adverse health consequences are not only caused by racial inequality on an interpersonal basis — Black Americans often experience this injustice when they interact with the healthcare system.

Prof. Williams and Dr. Lisa A. Cooper, epidemiologist, and professor at the Johns Hopkins University School of Medicine, Baltimore, MD, mention in a 2019 review 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 the former president of the American Public Health Association, shared similar thoughts. 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 underscored the profound harm caused by racial discrimination in healthcare. She underlined some of the particular ways in which this bias manifests itself, including the use of face masks to stigmatize black men, the disparities in Medicaid policies, and the gaps in the Affordable Care Act.

Prof. Green also talked about the value of the implementation of civil rights legislation. Prof. Williams also said COVID-19 is a magnifying glass that helps us see the racial inequalities in health. Those who are not targeted on a regular basis by racial discrimination that feels as if they are experiencing such differences for the first time, given the reality that the disparities have existed for centuries.

It could be argued that the recent demonstrations and the Black Lives Matter campaign is playing a similar role — arousing those who have been fortunate enough to overlook the injustices that have existed for hundreds of years.

It is important and necessary to use this magnified vision as an opportunity to address injustices— in healthcare and other aspects of our lives. So, it acknowledges that most of us have been completely blind to these problems.

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