The Color of Coronavirus: Large Burden of COVID-19 Borne by African Americans
The disproportionate distribution of disease is not surprising, say experts, given the historic injustices faced by people of color.
Although the COVID-19 pandemic eventually reached all 50 states, straining communities from the east coast to the west, the disease has not affected everybody equally.
As part of their summer COVID-19 education series, the American College of Cardiology is reminding physicians that the “color of coronavirus” is disproportionately Black and Brown, with experts highlighting the massive disparities in healthcare outcomes amongst the different races and ethnicities in the United States. Clyde Yancy, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who chaired the online session addressing the disproportionate burden of COVID-19 in communities of color, cited data showing that the overall COVID-19 mortality rate for Black Americans was 2.4 times higher than the rate for white Americans, and 2.2 times higher than the rate in Asian and Latino populations.
Put another way, Yancy said that if nonwhite Americans had died at the same rate as white Americans, roughly 13,000 Black Americans as well as 1,300 Latino Americans would still be alive today. “This really helps us understand the disproportionate burden of death from COVID-19 that aligns with race and ethnicity,” he said.
Race matters in COVID-19. Herman Taylor
These health disparities, said Yancy, fit within the broader picture of civil unrest rocking the United States at present. As thousands gather to protest police brutality and systemic racism following George Floyd’s death after a Minneapolis police officer kneeled on his neck for nearly 9 minutes, Yancy said it’s critical to acknowledge the injustice faced by people of color, an injustice that is intrinsically linked with poorer health.
“Not only do communities of color bear a disproportionate risk from COVID-19, but they have dealt with a lifelong burden of risk from injustice,” said Yancy.
Herman Taylor Jr, MD (Morehouse School of Medicine, Atlanta, GA, and Harvard T.H. Chan School of Public Health, Boston, MA), who led the landmark Jackson Heart Study, said the observed disparities in COVID-19 outcomes is an “unsurprising tragedy.” At this stage, to be caught off guard by the disparate burden of COVID-19 on African Americans is to be unaware of data that has shown “with mind-numbingly regularity” that they have a significantly higher risk of death than white Americans since the turn of the 20th century.
“Race matters in COVID-19,” said Taylor. “Race is a proxy for other ills that stand behind race and it is necessary to make more fundamental changes beyond what we can do at the bedside to really see a retrenchment of disparities after COVID-19.”
Social Determinants of Health
At Lenox Hill Hospital/Northwell Health in New York, NY, cardiac ICU director Robert Roswell, MD, said they have approximately 40 beds for cardiology and pulmonary critical care, but within a span of 2 weeks at the height of the surge, they had more than 100 patients admitted for the infection, including many who didn’t speak English well, or lacked health literacy. Social and economic circumstances factor into the total health of patients, he stressed.
“We know that just 20% of someone’s health outcomes are related to their access to care and the quality of that care,” said Roswell. “Another 30% is healthy behavior. As we move upstream, this is what preventive cardiology does, looking at diet and exercise and all the other things we examine and look at with patients with their social history. But we have to move further upstream, and when we move more upstream we’re talking about the social and economic factors, and also the physical environment, that account for 50% of health outcomes.”
Making dents in those social determinants of health—social and community context, economic stability, education, neighborhood/environment, and healthcare—can appear overwhelming, said Roswell, but they play an “oversized role” in the health of patients. “Once we start thinking about [the upstream factors], and contextualizing our patients within these social determinants of health, we can actually start to make change.”
We have to move further upstream, and when we move more upstream we’re talking about the social and economic factors, and also the physical environment. Robert Roswell
Johanna Martinez, MD (Zucker School of Medicine at Hofstra/Northwell, New York, NY), also acknowledged that thinking about healthcare disparities from a “macro” perspective can seem overwhelming, leading to a paralysis with respect to solutions. However, she said physicians can make a difference at the bedside. She encouraged physicians to ask about social needs and cultural preferences and to check their own assumptions, judgements, and biases. She also encouraged the use of an interpreter, if necessary, and to take the patient’s social needs into account when devising the treatment plan.
“Not only is it important to ask about their social history in a systematic way, but if we do nothing with that knowledge, you’ve done nothing to improve the care of our patients,” she said.
A Catalyst for Change
During the session, Yancy said he believes the US healthcare system needed a “trigger” to fully address healthcare disparities and the COVID-19 pandemic might very well be such a catalyst. In resetting risk across communities, Yancy highlighted key findings from various public health initiatives, noting that economically disadvantaged and at-risk communities are more vulnerable when confronted with external stresses on human health, such as disease outbreaks. For example, in downtown Chicago, the social vulnerability index is 0.089—a score of zero means low vulnerability, whereas a score 1 suggests highly vulnerable to stresses on heath—but on Chicago’s southside, just 10 miles away, the vulnerability index is 0.937.
“It’s a striking difference,” said Yancy.
Using data from the Ochsner Health System in Louisiana, Taylor presented data looking at the characteristics of 1,063 African Americans hospitalized with COVID-19. Although Black patients represent just 31% of patients routinely cared for at Ochsner Health, they represented 77% of the hospitalized COVID-19 cohort. Black patients with COVID-19 tended to be younger than their white counterparts (60.5 versus 69.2 years), were more reliant on Medicaid, and were more likely to come from low-income neighborhoods in the New Orleans metropolitan area, said Taylor. After adjusting for differences in sociodemographic and clinical characteristics at admission, however, Black race was not associated with higher in-hospital mortality compared with white/non-Hispanic race.
Taylor also cited US data showing much higher rates of COVID-19 cases among various tribal nations. For example, the case rates per 100,000 people are significantly higher for the Pueblo people of Zia and San Felipe than COVID-19 rates reported in New York City, a hotspot for infection. White Mountain Apache and members of the Navajo nation had higher rates of COVID-19 infection than rates observed in New Jersey.
“You have very distinct groups, but the common denominator is their relative marginalization, their social deprivation,” said Taylor. “Yes, there might be more comorbidities, but those comorbidities can often be traced in turn to social marginalization.” While there is speculative evidence pointing to a biological basis for disparities in COVID-19 outcomes, such as different inflammatory responses by race, there is wide genetic heterogeneity of the groups having a difficult time with the disease.
For clinicians, Taylor reminded physicians that successful discharge is not the end of the story, noting that disparities can re-emerge at home and in service-oriented workplaces. He also acknowledged the widespread protests across the US, noting that many African Americans and others may be placing themselves at risk for COVID-19.
“These individuals clearly feel that the threshold against going out and congregating has been exceeded by the compelling need to make a statement, as Dr. Yancy has alluded to, about what is more likely to kill an African American,” said Taylor. “People have made a judgement that this is a risk worth taking given the social context.”