Some media outlets and public figures have heralded the ongoing pandemic as a great equalizer, referencing the pathogen’s indiscriminate spread and disregard for national borders and tax brackets.
The sobering mortality statistics, however, dispense any notion of an equal-opportunity crisis, revealing a familiar theme among public health challenges in America: significant racial disparities exist, and communities of color are disproportionately affected.
CDC data show that blacks account for 29% of confirmed infections despite comprising 14% of the general population. An Associated Press analysis of 3,300 deaths in early April found 42% of the victims were black, and a recent study estimated the mortality rate for blacks at 2.7 times that for whites.
What explains this dramatic difference in outcomes? It is a complex question that hints at a series of economic, environmental, and health care realities, reinforced by bias, that have plagued black Americans long before the novel coronavirus emerged. This crisis is a microcosm of historical racial disparities in society, forged by decades of systemic racism and discriminatory public policy. Given this milieu of health-associated inequalities, the strikingly lopsided death rate by ethnicity is not just predictable, but inevitable.
Any discussion of health disparities must begin with economic factors, which contribute heavily to the outsized impact of the pandemic on minorities. Black families earn 71 cents of take-home income and hold 32 cents in liquid assets per dollar compared to white families, and 22% of those under the federal poverty level are black.
Given the higher poverty rate, lower-income status, and wealth deficit faced by the black community, a crippled economy can make compliance with stay-at-home orders financially unviable. Furthermore, blacks are overrepresented among low-wage and “gig” workers relative to their share of overall employment, are more often paid hourly, and infrequently benefit from sick leave policies relative to whites. While non-essential staff can “telecommute” and earn wages remotely, self-isolation is unrealistic for many essential workers, who must weigh the threat of infection against the possibility of termination.
Environmental influences further exacerbate the vulnerability of black Americans, who commonly reside in urban settings and represent a higher proportion of public housing residents.
Such areas are often overcrowded and under-funded, with major environmental hazards such as air pollution, poor water quality, lead, pests, and mold. Predictably, blacks have higher rates of chronic lung disease and die nearly thrice as often from asthma as whites.
Growing literature on COVID-19 has established that patients with underlying health conditions are subject to a higher risk of hospitalization and adverse outcomes. Additionally, the high population density in housing projects, shelters, and jails—inhabitants of which are predominately black in the U.S, a legacy of discriminatory housing practices, racist policies such as redlining, and deep-seated inequities in our criminal justice system—make social distancing virtually impossible.
Finally, inadequate access to food due to issues with location, transportation, or infrastructure further compromises health in black communities. Even before coronavirus caused mass unemployment and overwhelmed food pantries, black households were twice as likely to suffer from food insecurity versus the national average. Greater exposure to food deserts and hazardous, cramped living conditions that preclude appropriate distancing make communities of color uniquely susceptible to outbreaks like this one.
Health-wise, blacks are more likely to have chronic conditions and limited access to care. Studies show that “black patients are 40% more likely to have high blood pressure, twice as likely to have heart failure … three times more likely to have chronic kidney disease, twice as likely to be diagnosed with colon and prostate cancer.”
A CDC report found that a startling 89% of hospitalized COVID-19 patients had one or more pre-existing conditions. It is then especially troublesome that black Americans are less likely to have adequate insurance or receive employer-sponsored coverage.
The inability or unwillingness to pursue testing or evaluation portends advanced presentation, hospitalization, and poorer outcomes with infection.
While features of the economy, the built environment, individual health, and access to care render black Americans more susceptible to the novel coronavirus, bias — implicit and explicit — has long driven health disparities among minorities. Consider the curious concept of “allostatic load,” i.e., the physiological cost of chronic stress on the human body over time. Persistent activation of hormone-driven homeostatic mechanisms can overload vital organs, impair the immune system, and generate systemic pathology.
Discrimination and bias are significant stressors, and studies have linked them to higher rates of inflammation among black adults, perhaps also contributing to over-representation among confirmed coronavirus cases. Furthermore, there is robust literature suggesting that black patients are not treated equally once hospitalized, getting less pain medication, undergoing fewer procedures, receiving less explanation, and experiencing poorer quality of care compared to white patients.
One concerning study found a substantial number of white people, from laymen to residents, believe biological differences between races yield differing pain thresholds. Racism and unconscious bias have undergirded the policies and practices that allowed latent racial inequities in health care to fester, and the uneven COVID death toll reminds us as a medical community that there is a long way to go.
Rather than level the playing field, the coronavirus pandemic has exposed and intensified race-based inequities inherent in our health care system and society, fossilized over decades of neglect, de-prioritization, and otherization of communities of color. I have endeavored to highlight inextricable economic, environmental, health-related, and psychological forces that drive poorer health outcomes for black Americans overall and may provide a framework to discuss the disproportionate numbers testing positive and dying during this crisis. These factors engender higher vulnerability through increased risk of exposure and transmission, decreased immunity from stress, acute presentations due to underlying conditions and subpar access to care, and possible discrepancies in treatment upon hospitalization.
Perhaps there is a silver lining. With the pandemic throwing the differential experience of black people in terms of health and health care into sharp relief, the issue may achieve the critical mass of attention necessary to meaningfully address these deep-seated disparities. Only then can we truly dub this coronavirus a great equalizer.
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