Unequal Impact
The study authors note that at the time of their report: “Although many reports on COVID-19 have highlighted age- and sex-related differences in health outcomes, racial and ethnic differences in outcomes have yet to be described in depth.”
On June 11, the New England Journal of Medicine, released an accompanying audio interview editorial titled, “The Impact of Covid-19 on Minority Communities,” with Editorial Board Member Michele K. Evans, MD, Senior Investigator and Deputy Scientific Director at the National Institute on Aging. Conducting the interview was Stephen Morrissey, PhD, Executive Managing Editor of the journal. Participating in audio editorial were Editor-in-Chief Eric Rubin, MD, PhD, and Deputy Editor Lindsey Baden, MD.
Commenting on the study results, Dr. Evans, noted that although the patients’ hospital cohorts were fairly similar (about 40% of both the black and non-Hispanic white COVID-19-positive patients were hospitalized), there was greater morbidity among the black patient cohort. The study findings showed that the patient’s health at the time of admission determined the outcome, not the patient’s race.
The disparities in hospitalizations and in-hospital deaths are underpinned by “…long-standing and persistent health disparities among the poor, among minority populations, in general, and particularly for African Americans,” Dr. Michele Evans said. These disparities exist for most chronic diseases (e.g., cardiovascular disease, diabetes), for many types of cancer where African Americans have a greater incidence of mortality, and from the very start of life. African American women experience higher rates of maternal morbidity and mortality—independent of education or income.
“So, once these disparities begin at birth, if we don’t have the economic supports, the health system supports, to work against what happens at birth, we wind up with these serious, persistent health disparities,” said Dr. Evans. “This certainly ties into what Dr. Price-Haywood and colleagues found. When you look at their COVID-positive patients who were hospitalized, African American [patients] were younger than white patients, 60 compared to 69. Although this may not be statistically significant, it perhaps is a subtle sign of the accelerated aging phenotype or the weathering that’s associated with health disparities and premature mortality among African Americans.”
Challenges at Every Level
Many minority communities are also experiencing greater incidence of less severe Covid-19. Dr. Evans emphasized four main drivers of this disparity:
- Employment status. Essential worker positions and gig economy non-traditional and part-time jobs do not allow for work from home options. Many African Americans and other minority populations are employed as “essential workers” with jobs in public transportation, healthcare, food service, and other industries. “For example, about 50% or so of essential workers in food and agriculture are people of color…these workers, could not distance themselves or substantially reduce their exposure,” Dr. Evans said.
- Economic inequality. Pay gaps and lack of economic opportunity substantially impacts the development of health disparities and co-morbidities. Education does not eradicate the problem, noted Dr. Evans. “College-educated African American and Hispanic men earn maybe 80 percent of what college-educated white men [earn], and when you look at African American and Hispanic females, the pay gap is even worse.” With SARS-CoV-2, these factors put these underserved patient populations at a disadvantage. A further concern is the lack of knowledge about the long-term health effects of surviving COVID-19 infection.
- Residential segregation. There are pockets of segregation within cities and as a result ZIP codes can be “predictors of health, of school quality, of job access, of housing quality, of population density, city services, as well as the availability of high-quality food…residential segregation has substantial effect on healthcare outcomes and, in this case, on infectious disease,” Dr. Evans said.
- Healthcare access and quality. As noted above the gig economy jobs, as well as “essential worker” jobs in many industries, do not provide health insurance, resulting in unequal access to healthcare.
In terms of health disparities and inequalities being revealed by the current pandemic, the conversation turned to how much is due to long-standing issues of racism in medicine and what may be new in the context of the SAR-CoV-2 pandemic?
Dr. Rubin shared his perspective that the problem is two-fold: there is long-standing racism in the medical field and in how patients are treated, and there are racism issues in public health, “in our communities outside of our institutions.”
Dr. Evans concurred, expanding on Dr. Rubin’s comment. “I will say in medicine we have recognized health disparities. We have recognized the influence of social determinants of health,” she said. “But we have not fully marshalled our intellectual resources to prioritize this as we did with the war on cancer that Nixon funded or the quest for us to unravel the human genome led by Francis Collins. Racial discrimination as a social determinant of health causes real harm and causes real disease. There are numerous studies that link racism and discrimination to accelerated aging, to poor brain health, to chronic kidney disease, and sub-clinical atherosclerotic disease in African Americans. It’s not a political agenda. We need to be approaching it as an etiological factor in disease more commonly.”
In conclusion, Dr. Evans was asked for suggestions on what can be done immediately. Dr. Evans urged that healthcare professionals:
- Focus our efforts on attaining health equity. Healthcare is a right not a privilege.
- Protect our patients from environmental toxic racism by working to understand and trying to mitigate its wide-ranging effects on health.
- Recognize the vulnerability of African American and minority students and trainees already in the biomedicine pipeline at the undergraduate, medical school, and post graduate levels. Listen to them. Acknowledge their experience.
- Reject being a bystander by becoming an upstander so that you can advocate for your colleagues and these trainees through the education process.
- Address under-representation of African Americans not just as practicing physicians, as academics in medical institutions, and also as biomedical researchers.
- Fix the funding gap between African American and white scientists by understanding and examining how to equitably ameliorate the gap that occurs at each stage of the funding and grant review process. NIH is actively taking steps to do this, but all funding agencies need to do this.
- Expand the research resources that are allocated to understanding and ameliorating health disparities and conditions that disproportionately affect African American and minority populations.
Read the study by Dr. Price-Haywood and colleagues here and listen to the New England Journal of Medicine editorial audio interview with Dr. Michele Evans here.
