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COVID-19 Reinforces Racial Disparities in Healthcare

November 12, 2020
Study confirms that systemic and structural issues, not racial susceptibility to the virus, are responsible for higher COVID hospitalization rates among Black Americans.

One of the first patterns to emerge in the initial chaos of the SARS-CoV-2 pandemic was the prevalence of racial disparities in both confirmed cases and deaths.1 Writing in The Lancet this fall, editor-in-chief Richard Horton argued that COVID-19 is not a pandemic, but rather a “syndemic” – a deadly confluence of epidemics that interact and worsen the effects of one another.

Indeed, COVID-19 has emerged in a world of existing epidemics of non-communicable diseases, such as diabetes, hypertension, obesity, cardiovascular disease, and chronic respiratory disease. All of these are worsened by societal factors, including educational and economic inequalities that impact individual access to healthcare.2 As the COVID-19 pandemic has unfolded and more data has been gathered, researchers are now looking into the details behind these disparities.

A team at the Medical College of Wisconsin designed a study to analyze COVID-19 outcomes by race, while controlling for age, sex, socioeconomic status, and comorbid conditions. Here’s a summary.

In the sample population of the presented study, the rate of testing as well as the rate of COVID-19 infection were both substantially higher among Black patients than among patients of other races. (iStock)

Methods

The cross-sectional study included a total of 2,595 adults who were tested for COVID-19 between March 12 and March 31, 2020.3  Both inpatients and outpatients were tested, and if necessary treated, at Froedtert Health and Medical College in Milwaukee. The data, collected from EMRs, included sex, race, age, presenting symptoms, comorbidities, and details about insurance status, as well as dates of hospital and/or ICU admission and discharge, whether or not the patient was given mechanical ventilation, and whether the patient was discharged home, to another facility, or died. Patients who were admitted were followed until discharge or death. Outpatients were followed for as long as 14 days.

Race was determined by self-reported data in the electronic record. Because health records contain no information about income, the researchers used insurance status as a proxy. Lack of insurance or enrollment in Medicaid were used as indicators of poverty. The zipcodes of the patients’ residences were used to determine which patients lived in socially disadvantaged areas.

Results

In the sample population, the rate of testing as well as the rate of infection were both substantially higher among Black patients than among patients of other races. Although race was strongly associated with positivity and hospital admission, it was not significantly associated with the risk of ICU admission, mechanical ventilation, or death. Poverty, on the other hand, was independently associated with hospitalization and ICU admission, but not mechanical ventilation or death.

These findings indicate that the poorer outcomes and higher mortality among Blacks early in the pandemic were likely due greater incidence among this patient population, not worse survival rates once hospitalized. The researchers pointed out that these findings are in agreement with other published studies to date. They speculated that the reasons for the disparities may be tied to difficulties faced by this population in adhering to social distancing recommendations. For example, Blacks make up a substantial portion of the essential workforce and are more likely to be dependent on public transportation.

Other aspects of structural racism are likely involved as well. The researchers cited 2019 census data showing that 44% of Blacks owned their own homes compared to 74% of non-Hispanic Whites. Disparities in mortgage lending, the authors wrote, “may lead to greater housing density among African American residents, in turn leading to less social distancing.”3 Indeed, the study found that zipcode explained 79%of variance in positivity, suggesting that where a patient lived was an important  factor in risk of testing positive.

The Wisconsin team speculated that the reason for higher hospitalization and ICU admissions among poor patients, regardless of race, was because poor people are more likely to wait longer after symptoms emerge to seek care. They also noted that factors not measured in this study – such as a higher level of viral load or other physical or immunological factors – could be responsible. Unsurprisingly, both obesity and a history of smoking were associated with a higher likelihood of need for ventilation. High BMI was independently associated with death.

Practical Takeaways

The potential good news from this study is that there does not seem to be a racial susceptibility to poor COVID outcomes. “Racial disparities associated with COVID-19 should not be used to propagate myths related to racial biology,” the researchers wrote.3 The challenge is that reducing the rate of infection will require attention to existing public health measures as well as the development of new and better public health methods for assuring the health of vulnerable populations.

Johnathan Goree, director of the Chronic Pain Division and Associate Professor of Anesthesiology at University of Arkansas for Medical Sciences, points out that these measures must include addressing disparities in social determinants of health, such as access to high quality food, access to gyms, the ability to work from home, and access to internet – all things that can reduce one’s susceptibility to contracting COVID-19.

“For me [the pandemic] has, in so many ways, illuminated how many kinds of disparities there are between ethnic groups and especially different class groups,” says Dr. Goree. The answer, he emphasizes, is access to basic health care and preventive measures. In addition, he says the pandemic has shown the need for connectivity, another thing poor communities often lack.

“I have some patients who don’t have home broadband, who don’t have computers or internet or smart phones, who now have less access to healthcare because there are so many restrictions on coming into the hospital.” he adds.

Listen to Dr. Goree discuss racial disparities in chronic pain management in our recent Side Chat.

 

Last updated on: November 16, 2020
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