People with compromised immune systems or other health challenges understandably have high rates of mortality from COVID-19. But why does COVID-19 have an unusually large impact among some racialized and ethnic groups? Studies suggest that systemic discrimination against minorities, especially Black communities, is a driving factor that leaves these populations disproportionately affected by COVID-19.
Disproportionate Effects of COVID-19
In a national survey by the United States Centres for Disease Control Black persons made up 18% of the sample population but accounted for one-third of COVID-19 hospitalizations1. COVID-19 disparities worsen in areas where racialized and ethnic minorities are concentrated: Native Americans account for 11% of the population in New Mexico, which is 5.5-times the national average; and yet Native Americans represent 37% of COVID-19 cases in the state. Similarly, in Chicago, where the Black population constitutes just under 33% of residents, they account for over 70% of COVID-19-related deaths2.
While racial issues are a focal point in American society at the moment, inequities in COVID-19 are not unique to one country. In the U.K., 3% of the population identifies as Black, but they account for 12% of COVID-19 patients in the ICU3. Rates of COVID-19-related deaths are also 4-times higher in Black and South Asian populations in the U.K., compared to Whites communities4.
A Canadian Perspective
The Canadian experience is not as stark as that painted in the U.S. and U.K., but this may simply reflect a lack of scrutiny.
Governments across Canada continue to resist calls to regularly collect race and socioeconomic data for COVID-19 on the basis that all racialized and ethnic groups are equally important5. But this claim fails to recognize the inequality that persists across the country.
In a study lead by Kate Choi from Western University, researchers assembled COVID-19 statistics using publicly available data6. The study found that a 1% increase in the Black residents of a region is associated with a doubling of COVID-19 infections and deaths.
The international imbalance in COVID-19 infection rates and mortality across racialized and ethnic groups generates a fundamentally and deceptively simple question: why do these inequities exist?
Comorbidities including cardiovascular disease, diabetes, and chronic respiratory illness increase the risk of more severe illness and mortality with COVID-19. In the U.S., Black communities have the highest incidence of hypertension and kidney disease, while Native Americans have the highest rate of diabetes. Hispanics, while not at the top of any of these comorbidities, have unusually high rates of all these comorbidities. Despite the racial differences in pre-existing illnesses, a study by Millet and associates showed that when comparing COVID-19 patients with similar comorbidities the risk for death remained 18% higher in Black patients7.
A critical factor for racial disparities in COVID-19 infection rates and outcomes is the socioeconomic imbalance that exists between racialized and ethnic groups. Studies show that impoverished communities – in which people of colour are overrepresented – are most impacted by COVID-19.
Economically disadvantaged communities are disproportionately affected by COVID-19 because of factors including overcrowding and an inability to work from home, both of which limit social distancing and increase the risk of infection3. In comparison to White communities, of whom 30% can telework, only 20% of the Black population and 16% of Hispanics can work remotely8. For some, the inability to work from home comes from the nature of the job. Black persons are over-represented in a number of service industries in positions that require on-site attendance.
Inadequate internet connectivity is more common in lower income households, impacting not only the ability for remote working, but also access to telemedicine3. The increased reliance on telemedicine during the COVID-19 pandemic means that racialized minorities are less likely to receive routine and timely care.
Healthcare workers are at high-risk for infection because of exposure to COVID-19 patients, and in some cases because of insufficient personal protective equipment.
Black employees make up 12.5% of the US healthcare population, but are 21% of the health-care workers infected with COVID-199. In the U.K., Black persons account for 27% of COVID-19-related deaths among healthcare employees, despite comprising 6% of the workforce. In total, ethnic and racialized minority healthcare workers make up 21% of the National Health Service (NHS) workforce, but more than half of COVID-19-related deaths10.
The reasons for racial differences in COVID-19-related deaths among healthcare workers is not clear. In several high-risk fields including anaesthesiology and ICU where the use of personal protective equipment is rigorously enforced, members of racialized and ethnic minorities are underrepresented. By contrast, Black workers account for 30% of personal care and home health aides, which may erroneously be considered low risk. They often lack reliable supplies of protective equipment and yet are at high risk through close personal contact.
Much of the data showing bias in COVID-19 care comes from the U.S. But racialized and ethnic-related disparities in health outcomes are not unique to COVID-19, nor are they restricted to the U.S. However, one driving element behind racial inequities in COVID-19 mortality is uniquely American: a lack of health insurance.
Members of Black communities are more likely to lack medical insurance3, and are 3-times more likely to be on Medicaid, compared to those in White communities11. The lack of adequate health insurance delays people from seeking help even if they have symptoms of COVID-194. This delay is evident by the fact that more Black patients are tested in hospital rather than in outpatient care, and that more Black persons are hospitalized and transferred to the ICU compared to White patients because of more severe illness by the time healthcare is sought12.
With the disproportionate effects of COVID-19 across racialized and ethnic groups how do we, as a society, enact change to improve healthcare outcomes?
One quick and attainable solution is to provide the resources to low-income communities to increase COVID-19 testing to identify infections early13. Earlier testing of patients will allow them to isolate sooner to decrease the spread of COVID-19, as well as to obtain treatment before the illness worsens. Early intervention is more cost effective and likely to result in better outcomes.
To reduce the racial disparities of COVID-19, paid sick leave and facilities for housing symptomatic people to reduce the spread of COVID-19 should be more widely accessible. Studies have recommended the suspension of evictions to decrease overcrowding, and implementing incentives for discounted food delivery to low-income communities.
Even though there is an abundance of data showing inequities in COVID-19 outcomes, there is a need for more information. Reports designed to gather information on racial and ethnic patterns capture basic data less than half the time14. In some countries – including Canada – these data are not routinely collected, leaving a knowledge gap that endangers those most at risk.
COVID-19 is a health issue, but the elements that contribute to its spread, outcomes, and societal impact are broad and interwoven. A better understanding of healthcare issues by the general public and healthcare workers alike demands improved data collection and widely accessible education opportunities. The socioeconomic barriers that increase the risks of infection and death must be dismantled to protect the most vulnerable.
Persistent systemic disparities will cause long-term damage: minorities will experience more financial burden, greater psychosocial stress, and increased anxiety, all of which worsen the health of individuals and society.
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- 3. Haynes N, Cooper LA, Albert MA; On Behalf of the Association of Black Cardiologists. At the Heart of the Matter: Unmasking and Addressing COVID-19’s Toll on Diverse Populations. Circulation. 4 May, 2020.
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- 6. Choi K, Denice P, Haan M, Zajacova. Studying the social determinants of COVID-19 in a data vacuum. SocArXiv. 13 May, 2020.
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- 8. Albert MA, Chin-Hong P, Haynes N, Alexander K, Cooper L, Ybarra M. At The Heart of the Matter: Unmasking the Invisibility of COVID-19 in Diverse Populations Webinar. Association of Black Cardiologists (ABC). 8 April, 2020. https://abcardio.org/covid19-webinar/.
- 9. CDC COVID-19 Response Team. Characteristics of Health Care Personnel with COVID-19 – United States, February 12-April 9, 2020. Morbidity and Mortality Weekly Report. 69: 477-481. 2020.
- 10. Cook T, Kursumovic E, Lennane S. Exclusive: deaths of NHS staff from covid-19 analysed. Health Service Journal, 22 April, 2020.
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- 12. Azar KMJ, Shen Z, Romanelli RJ, et al. Disparities In Outcomes Among COVID-19 Patients In A Large Health Care System In California. Health Aff. 21 May, 2020.
- 13. Henning-Smith C, Tuttle M, Kozhimannil KB. Unequal Distribution of COVID-19 Risk among Rural Residents by Race and Ethnicity. J Rural Health. 12 May, 2020.
- 14. Laurencin CT, McClinton A. The COVID-19 Pandemic: a Call to Action to Identify and Address Racial and Ethnic Disparities. J Racial Ethn Health Disparities. 7: 398‐402. 2020.