COVID-19’s Lopsided Impact on Minorities Should ‘Ignite’ Reform, Experts Say
Better testing and culturally targeted PSAs are needed in the short term; on the other side, societal fixes will be critical.
The disproportionate burden of COVID-19 infections and fatalities among minority groups in the United States should push policy makers, the healthcare community, and citizens to do more to rectify stark healthcare disparities, experts say.
It’s no secret that minority populations have long fared worse than white patients across a host of healthcare measures in cardiology and beyond. But in the COVID-19 era, “I really think the conversation about health disparities has been ignited because the pain point is so great,” Clyde Yancy, MD (Northwestern University, Feinberg School of Medicine, Chicago, IL), told TCTMD.
“These disparities have been described for several decades and are a part of the fabric of the way that we provide care and the way we experience health and disease in this country,” he continued. “Many efforts have been explored to reduce health disparities, many descriptions of disparities are present and searchable, and a few endeavors have actually resorted in a narrowing of the gap—but along comes COVID-19. And what I mean by the pain point is that the burden is so disproportionate and the consequences are so grave that one cannot look the other way.”
Yancy authored a viewpoint on how the pandemic is affecting African-Americans, published last week in JAMA, detailing how African-Americans specifically are not only at greater risk for catching COVID-19 but also are more likely to die from it. For example, a survey of the 131 predominantly black counties in the United States shows an infection rate of 137.5/100,000 and a death rate of 6.3/100,000, which are more than threefold and sixfold higher, respectively, compared with predominantly white counties.
“Even though these data are preliminary and further study is warranted, the pattern is irrefutable: underrepresented minorities are developing COVID-19 infection more frequently and dying disproportionately,” he writes. “Do these observations qualify as evident healthcare disparities? Yes. The definition of a healthcare disparity is not simply a difference in health outcomes by race or ethnicity, but a disproportionate difference attributable to variables other than access to care.”
Similarly, in another JAMA viewpoint last week, William Owen Jr, MD (Ross University School of Medicine, Hollywood, FL), and colleagues highlight how the built-in disparities of the national healthcare system have also made it harder for minority populations to receive tests for COVID-19 and, if positive, also proper treatment. Citing similar statistics to Yancy, the authors write “the overarching cause of these tragic statistics is decades of the effects of adverse social determinants of health. Even biological risk factors for COVID-19 like diabetes, obesity, asthma, and hypertension can reflect environmental and sociological precipitating and contributing factors, as much as racial differences in biology.”
Owen and colleagues also list the following confounders from the ecosystem of social determinants of health relevant to COVID-19 that more often affect minority populations: “struggling in poverty with limited job and social mobility; working frontline jobs with lack of adequate personal protective equipment (eg, public transportation, pharmacy, grocery, and warehouse distribution workers); living in crowded apartments where social distancing is impossible; shopping in food deserts or swamps without access to healthful foods; being underinsured and using self-rationing of healthcare as a strategy; relying on public transportation on crowded buses and subways; and having a public kindergarten through 12th-grade education that too often leads to functional health illiteracy.”
Yancy agreed. “You begin to realize that this duality of risk of both the infection and less-good outcomes intersects with the black population, and that's the point of concern,” he said.
Short and Long-term Solutions?
Yancy acknowledged that there are no easy fixes. “Realize that when you're dealing with issues as deeply interwoven as the social determinants of health, . . . there is no singular trigger that recalibrates the social determinants of health. So the ‘what we do about it’ is really to incite a commitment to change. It really is saying whatever the reasons for this are, we as a civil society just cannot sit back and see one group of the population at a sixfold higher risk for anything.”
The first step is addressing the built environment and living circumstances—"whether it's as basic as education and housing [or] access to fresh fruits and vegetables”—and realizing that generational changes have to occur, he said. “There won't be one cascade event that will change everything, but there has to be a cascade moment where collectively we say we have a commitment and we believe in our country with this plurality now. And [given] the necessity for all hands on deck as our new economic engine emerges, we really do have to think about all the people who are in the workforce and what we can do to have the healthiest workforce.”
Specifically, when the economy begins to rev up again and budget cuts are considered, it’s imperative that health and human services are not reduced, Yancy stressed. “In fact, that should be the last place where we extract resources,” he said. “That's really part of how we got into this disproportionate health outcome circumstance to begin with. So, these will be interesting times to further unravel why we're seeing these disparities. They are real. This is not imaginary. And then to really process what we, as a global ‘we’ not just physicians like me, can do to revisit this definitively.”
Owen and colleagues also suggest two immediate interventions. “First, mandate that the collection and reporting of COVID-19 cases and outcomes be stratified by race/ethnicity, sex, socioeconomic status, and community health status in all states. This will allow targeting of resources and development of culturally relevant interventions that are accepted by the highest-risk groups,” they write.
“Second, begin multilingual targeted public service announcements (PSAs) for minority communities that emphasize the unequal risk and the importance of empowered solutions like social distancing and how to access testing and healthcare services,” Owen and colleagues say. “Messages of early self-referral, reassurances of compassionate and culturally sensitive care that is not dependent on insurance and wealth, and a pithy reminder to ‘Be Kool, Stay Home’ could be delivered by well-recognized and influential people, including the minority bedrock faith community.”
A joint letter to the Secretary of the US Department of Health and Human Services last week from the American Hospital Association, American Medical Association, and American Nurses Association seconds many of these suggestions and calls on the federal government to enact them.
“This has been a difficult moment for me and senior physicians because we've seen such heartache, not just in African-Americans but across the board,” Yancy said. “But what gives me really robust hope is that in the span of about 36 hours I have seen so many initiatives stand up, so many statements emerging, so many people stepping forward and staying, ‘I get it. This is unacceptable. We need to deal with this as a collective.’ And I think that's probably been one of the things missing in the past. We didn't have that rallying cry. We didn't have that tip of the spear moment to say, ‘No, unacceptable, we've got to do something different.’”
He said he hopes these initiatives are sustainable going forward. “It won't be a singular thing that we do in response to this, but it will be a collective effort that will address this,” Yancy concluded. “I don't want to live in a world where we let this happen ever again.”
Owen and colleagues conclude with a similar outlook. “The next stress test of the health system could have a different outcome if we learn from the tragic racial and ethnic disparities of the current pandemic and make changes in the US clinical care delivery and public health policy,” they write. “Ensuring access to culturally competent healthcare and creating policies and programs that address the social determinants of health are key to moving toward health equity. Public health policies must be tailored to the needs of all communities and reflect that health equity can only be achieved if interventions are made with an understanding of the differing and unequal life realities of minority populations. Addressing the contribution of historical and social racism must be pillars for the future and in place before the next pandemic occurs.”
Yancy CW. COVID-19 and African Americans. JAMA. 2020;Epub ahead of print.
Owen WF, Carmona R, Pomeroy C. Failing another national stress test on health disparities. JAMA. 2020;Epub ahead of print.
- Yancy and Owen report no relevant conflicts of interest.