Public health faculty members discuss novel coronavirus health disparities

Authors:

Archana J. McEligot, PhD
Mojgan Sami, PhD
Portia Jackson Preston, DrPH
Tabashir Z. Nobari, PhD, MPH

4/22/20

Our commitment to equity and diversity, as an institution and as Titans, requires a call to address the novel coronavirus disease 2019 (COVID-19) health disparities and renew efforts towards health equity. Emerging COVID-19 data provide supportive evidence of vast racial and ethnic disparities in morbidity and mortality rates in the United States. A recent Morbidity and Mortality Weekly Report (MMWR), published via the Centers for Disease Control (CDC), presents data on 1,482 COVID-19 hospitalized patients admitted between March 1 – March 30, 2020 from 99 counties in 14 states (Garg 2020). The researchers show that of the 580 hospitalized COVID-19 patients with race/ethnicity data, 45% were white, 33% were African American, and 8% were Hispanic/Latinx. However, African Americans comprised only 13% of the population in the respective catchment area, suggesting disproportionate rates of hospitalization. Preliminary ongoing data collection reported on confirmed COVID-19 cases (n = 551,775) in the United States indicates that among cases in which race was specified (n=195,308), 33% were African American, yet African Americans comprise only 14% of the regions included  in the analyses (CDC 2020). States and local jurisdictions have independently confirmed these early findings.  According to data released by LA County health officials reflecting 57% of reported deaths due to COVID-19, African Americans accounted for 17% of those deaths, although they comprise only 9% of the LA County population (Fry 2020). Further, African Americans make up 45% of the total District of Columbia population, yet account for 29% of confirmed COVID-19 cases and 59% of fatalities (Artiga 2020).  Higher rates of COVID-19 have also been observed for racial/ethnic groups in Connecticut with African Americans being twice as likely, and Latinos one and a half times as likely, to contract the disease as whites. A sudden increase in COVID-19 incidence has also been reported for Native Americans.  

Established structural and systemic factors exasperate existing health disparities and pre-existing conditions, which have been linked to increased COVID-19 exposure, risk and hospitalization for vulnerable communities.  The MMWR report showed that hospitalization was higher for those 50 years of age and older (74.5%), males (54.4%), and for those with underlying medical conditions, including hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%), and cardiovascular disease (27.8%) (Garg 2020). These findings reveal that individuals with pre-existing conditions are at increased risk for COVID-19, as well as for subsequent hospitalization and death.  The long-standing inequities did not begin with COVID-19 in communities of color.  In fact, the long-standing inequitable distribution of social and economic resources in these communities (e.g., inequitable access to care; lack of high-paying jobs, good schools, grocery stores, and affordable and safe housing; lack of safe spaces to exercise), created and continues to create an inequitable burden of chronic conditions, which place these communities at greater risk of complications and hospitalization as a result of COVID-19.

Racial/ethnic minorities, particularly those who are low-income, are more likely to work in essential jobs, such as in health care facilities, nursing homes, agriculture, food processing, grocery and restaurant service, food and package delivery, janitorial service and public transportation. These “essential” services put minority populations at a higher risk of exposure to COVID-19.  Essential workers do not have the luxury to stay home, and often suffer from low wages and inadequate (un)employment protections. In New York, of the 72,000 Metropolitan Transportation Authority (MTA) workers, 1,900 have tested positive for COVID-19 and 50 have died (ABC7NY, 2020).  According to the United Food and Commercial Workers International Union, 3,000 supermarket employees have had to leave work due to symptoms or complications of COVID-19, and 30 or more have died (Brown 2020).  In addition, COVID-19 can increase insecurity for people who rely on the informal economy for their livelihoods. Those who are undocumented face additional obstacles in obtaining access to emergency benefits, and may lack options for paid or sick leave if they become infected.

Environmental racism is also a driver of the disparities we are seeing. A recent study from Harvard’s T.H. Chan School of Public Health compared fine particulate air pollution (PM_2.5) with COVID-19 deaths in 3,080 counties across the country (Wu 2020). The researchers found that a small increase in long-term exposure to particulate matter is related to a large increase in COVID-19 death rates. The burden of environmental pollution is not shared equally across racial and ethnic groups.  Many studies have reported on elevated pollution exposure via traffic, industrial plants, proximity to freeways, toxins, mining and waste dumping in African American, Latino/Latinx and other racial/ethnic groups, and its inequitable deleterious effects on the health of these communities (Fernández-Llamazares Á 2020, Ostro 2005, O’Neill 2003, Finkelstein 2003, IOA 2003, ALA 2001).  In addition, Native American communities are at a higher risk of exposure to COVID-19.  For example, the Navajo Nation, which has historically been deprived of access to safe drinking water and electricity and suffers from increased exposure to environmental toxins, is experiencing a high incidence rate of COVID-19 (NDOH 2020 ).

An additional factor contributing to increased disease burden in racial/ethnic populations is existing interpersonal and institutional racism compounded by this crisis. There are no known biological/genetic factors, nor is there a biological basis associated with disparities related to COVID-19. However, in addition to structural disparities, experiences of prior discrimination or mistreatment in the health care setting may discourage some from seeking care for symptoms (Breslow 2020). The Anti-Defamation League reports that there has been an increase in hate crimes against Asian-Americans since the start of the pandemic (ADL 2020). These incidents have affected people of all ages, even as they carry out essential work and seek care. It is imperative that we—as an institution and individuals—take an active stand against all racist acts we may witness, including micro-aggressions. It is important to emphasize that a virus knows no borders, and to discriminate against individuals based on their racial/ethnic origin is intolerable, with disastrous implications for how we will function as a society moving forward. In an unprecedented global crisis, we need to support each other, more than ever before.

In addition, COVID-19 health disparities underscore the multiple systemic failures, including lack of equitable access to healthcare, lack of affordable housing, lack of economic and social safety nets, gender discrimination and mass incarceration, to name a few. We need to address both the individual impacts and systemic causes of racial/ethnic health disparities through clinical, preventative public health and structural determinants of health strategies.  The “long-standing” history or “for as long as we can remember” inequities must be eradicated.

We must acknowledge that health disparities existed before the novel coronavirus, and that conversations on health disparities should be transitioned to a focus on equity.  COVID-19 is providing us with opportunity to challenge the systemic and structural oppression embedded in our “status quo” mentality that lead to the racial/ethnic disparities we are witnessing in COVID-19 morbidity and mortality outcomes.

We call on all academicians, researchers, institutions, organizations, policy makers, legal systems and governmental agencies to steer efforts towards health equity, not merely to survive the current pandemic, but to contribute to creating healthful communities in which everyone can thrive.