Black Americans are dying at disproportionate rates from COVID-19. In Chicago, nearly 70% of deaths involve black individuals, who comprise only 30% of the population. At a closer look, these deaths were initially concentrated in just five neighborhoods on the city’s South Side. In Louisiana, 70% of deaths involve Blacks, who represent only 32% of the state’s population. As more data is collected, the trend continues to be seen across the U.S.
Experts are pointing to systemic and structural racism for an explanation, but some would disagree and even accuse the U.S. of inappropriately racializing the pandemic. These skeptics use three arguments to support their claims:
1. White people disproportionately die in some diseases too! Is this not evidence of anti-white systemic racism?
2. Underlying biological differences can explain the disproportionate COVID-19 death rates among Black Americans, right?
3. Race isn’t a relevant, direct factor. We should instead focus on direct risk factors such as age and pre-existing conditions.
Let’s examine what’s wrong with each of these points.
The first argument notes that whites are more likely than Blacks to die from conditions such as Alzheimer’s and several types of cancer, suggesting the potential existence of anti-white systemic racism. The argument is a false equivalence, though.
You cannot compare COVID-19, an RNA-based viral infection, to conditions like cancer and neurodegeneration. It would be like comparing apples to COVID-19. Unlike those diseases, COVID-19 is wildly contagious, and its symptoms are way more acute in onset. As a result, COVID-19 complications are markedly pronounced in patients who live in neighborhoods that are medical deserts, food deserts, and air pollution hot spots — neighborhoods that tend to be majority Black.
Other less obvious phenomena can also explain disproportionate death rates among whites in certain diseases. Take Alzheimer’s disease (AD), which progressively worsens with age. White Americans have higher life expectancies than Black Americans and thus have more time to develop debilitating symptoms. Blacks are significantly less likely than whites to visit outpatient neurologists, even after accounting for confounding variables. Physicians are more likely to miss a diagnosis of dementia and AD in Black patients. These factors deflate the proportion of Blacks diagnosed with AD, leading to a relative underreporting of Blacks who die from AD.
An epidemiological literature review shows no mention of anti-white systemic racism but reveals that overall, white Americans have better access to care and higher utilization rates of health services. This is all to say that disproportionate white death rates in certain diseases says nothing about anti-Black systemic racism’s impact on disproportionate COVID-19 Black death rates.
Here’s the second argument: “Disease disparities are mysterious. For example, why are whites more likely to die from Alzheimer’s? Who knows! We don’t even know what causes Alzheimer’s!” Yes, some disparities are primarily genetic in nature. Blacks overwhelmingly die from sickle cell disease because they carry and pass on the β-globin gene mutation. Yes, some disparities are mysterious due to unknown causes. But neither of these situations applies to COVID-19.
We know what causes COVID-19. Moreover, it’s incredibly unlikely that immunological differences between races can explain the stark disparity in COVID-19 outcomes. Here’s why.
The major determinants of viral response are our HLA genes, which code for proteins that present degraded viral peptides to our immune system. For example, HIV-infected individuals with one version of HLA, HLA-B27, show slower progression to AIDS. HLA-B27 carriers exhibit stronger anti-HIV immunity because HLA-B27-coded proteins can bind 15 HIV peptides, whereas other HLA-B-coded proteins cannot bind as many.
In the U.S., approximately 7.5% of whites and 1.1% of Blacks have HLA-B27. Despite this 7-fold difference in population allele frequency, the HIV case-fatality rate for both Black and white Americans was approximately 80-90% before the advent of lifesaving antiretroviral therapy and approximately 2% in 2012. In other words, once you contract HIV, arguably the deadliest virus known to man, racial differences in HLA frequency have little relevance in terms of survival from a population perspective.
For COVID-19, scientists hypothesize several HLA variants may be more advantageous than others through recognizing more coronavirus peptides. It’s conceivable that white Americans could have a greater distribution of these suspected ‘advantageous’ alleles, but as we saw with our HIV example, this would be the first time in history a difference in HLA distribution alone explains such disproportionate viral death rates among a single race.
Given what we know, disproportionate COVID-19 outcomes can likely be attributed to non-biological factors, even if minimal inter-racial biological differences exist.
The third argument acknowledges there are risk factors that predispose Black Americans to worse COVID-19 outcomes such as comorbidities and poor access to quality care. The exception is that race is not a relevant, direct variable and would only become one if some new genetic factors were discovered. Again, the public health community would disagree.
More Black neighborhoods have shortages of primary care physicians than white neighborhoods. More Black neighborhoods have year-round disease-causing air pollution than white neighborhoods. More Black neighborhoods have limited access to affordable, nutritious foods but an overabundance of cheap fast food options that contribute to obesity and hypertension. These data highlight how structural racism can contribute to poorer COVID-19 outcomes.
Because race sits at the nexus of all these exacerbating structural and clinical factors, epidemiologists use race as a statistically independent and direct variable. Simply put, structural issues are medical issues. Structural issues are race issues. Race is a medical issue. Some undiscovered genetic element isn’t necessary for race to be a relevant factor.
It is evident that the three arguments above are founded on tenuous understandings of human biology. There is no disingenuous racial justice angle on the coronavirus pandemic. The data show that facets of systemic racism are contributing to the disproportionate COVID-19 death rates among Black Americans.
The U.S. has long needed a precipitating event to expose the gross inequities of our health care system. Perhaps COVID-19 could be that event.
Max Lauring is a medical student.
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