Disease Doesn’t Discriminate. America Does. Why COVID-19 is Killing Black People.

This guest essay is written by Ritodhi Chatterjee, a medical student at Baylor College of Medicine.

Some media outlets and public figures have heralded the 2019-2020 coronavirus pandemic as a “Great Equalizer,” referencing the pathogen’s indiscriminate spread and hypothetical disregard for national borders and tax brackets. The sobering mortality statistics, however, quickly dispense any notion of an equal-opportunity crisis, as they reveal a theme not uncommon among public health challenges in the United States: there are significant racial disparities involved and communities of color are disproportionately affected. 

After widespread calls for more granular demographic information, the CDC began including race and ethnicity as part of its reporting on confirmed coronavirus cases as of April 17, and the data show that Blacks account for 34% of all confirmed infections despite comprising around 14% of the general population. Race, however, was only known for about one-third of all reported cases. While the CDC has not released demographic detail around COVID-19 related deaths, an Associated Press analysis of 3,300 deaths across eight states and six major cities in early April found that 42% of the victims were Black, and a more recent study by the American Public Media Research Lab showed that, based on available data, the mortality rate for Blacks was 2.7 times that for Whites.

Given the clear lack of evidence that Black people are somehow underestimating the dangers of the virus—59% of Black respondents reported being “very concerned” about their health during the pandemic versus 51% of their White counterparts in a recent Pew study—what could explain this dramatic difference in actual outcomes? It is a complex question that hints at a series of economic, environmental, and health care related realities, reinforced by both unconscious and overt bias, that have plagued Black Americans long before the novel coronavirus emerged. The current crisis has served as a microcosm of existing racial disparities in society, forged by decades of systemic racism and discriminatory public policy. In the setting of this milieu of health-associated inequalities, the strikingly disproportionate death rate by ethnicity is not just predictable, but inevitable.

Any discussion of health disparities by race in the U.S., which features one of the highest levels of income inequality among developed nations, is incomplete without an assessment of economic factors, many of which contribute to the outsized impact of the pandemic on minorities. Per the JPMorgan Chase Institute, Black families earn 71 cents of take-home income and hold 32 cents in liquid assets per dollar compared to White families. Furthermore, 22% of those living under the federal poverty level identify as Black. Given the higher poverty rate, lower income status on average, and wealth deficit faced by the Black community, a crisis that cripples the economy can make adhering to stay-at-home orders financially unviable, especially since only about one in four Black Americans have a “rainy day” fund, compared to nearly half of Americans overall. This unfortunate truth becomes less avoidable when considering that Blacks are over-represented among low-wage and “gig” workers (e.g. driving for Uber) relative to their share of overall employment, are more often paid hourly than in fixed salary amounts, and infrequently benefit from sick leave policies, relative to Whites. As an example, a study from the New York City comptroller’s office estimated that minorities encompassed 75% of the frontline work force. Self-isolation and social distancing are simply not options for many of these “essential workers”—grocery clerks, public transportation employees, janitors, etc.—who must weigh the threat of contracting the virus against the chance of being laid off and, consequently, falling behind on bills. While non-essential staff can “telecommute” and continue to earn wages from the safety of their homes, African American workers face higher risks of exposure due in part to these underlying economic disparities.

Environmental influences further exacerbate the vulnerability of Black communities to the coronavirus, both in terms of incidence and mortality. Black Americans most commonly reside in urban settings according to a recent Pew study and represent a higher proportion of those living in public housing. Such residential districts are often over-crowded and under-funded, with major environmental hazards such as air pollution, poor water quality, lead, pests, and mold. Studies have found that minority households are more likely to be adjacent to incinerators and landfills, and that disproportionately many minority-majority schools are found near highways and industrial parks. Predictably, especially when exposed to these substandard conditions from childhood, Blacks are much more likely to have chronic lung conditions and die nearly three times as often from asthma as Whites. It has been well-characterized in the growing literature on COVID-19 that patients with underlying health conditions are more likely to be hospitalized and have adverse outcomes, thus inequalities in housing cannot be overstated. 

Beyond contributing to worse outcomes, the high population density in housing projects, homeless shelters, as well as jails—the inhabitants of which are predominately Black in the United States—make social distancing virtually impossible and thus expose these populations to an outsized risk of exposure. It is worth noting that residential segregation of this nature in America is in large part due to discriminatory housing practices, racist policies such as redlining, and deep-seated inequities in our criminal justice system. Finally, lack of ready access to food due to issues with location, transportation, or infrastructure leads to further deterioration of health in Black communities and requires individuals to violate public health recommendations, for instance by having to take public transportation, in order to obtain adequate nutrition and feed their families. Even before coronavirus caused an unprecedented spike in unemployment and overwhelmed local food pantries with demand, Black households were twice as likely to suffer from food insecurity relative to the national average. With greater exposure to food deserts and hazardous, cramped living conditions that preclude appropriate distancing, communities of color are uniquely susceptible to outbreaks such as the current one.  

From a health care perspective, Blacks are more likely than other ethnic groups to have underlying health conditions and to have limited access to appropriate care, which together make it more likely that Black individuals will present later in the disease course, require hospitalization, and have poorer outcomes from infection. Due in part to aforementioned economic and environmental factors, studies have shown that “compared to their White counterparts, 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, and represent 44% of the HIV positive population.”

A CDC report found that of hospitalized COVID-19 patients in the study period, a startling 89% had one or more underlying conditions. Having established that Black patients are more likely to suffer from chronic illness and that patients with chronic illness are more likely to have severe manifestations of the disease, it is then especially troublesome that Black Americans are less likely to have adequate insurance or receive employer-sponsored coverage. When coupled with lower rates of health literacy, which could imply poor understanding of sentinel symptoms or when to seek care, the story highlights a significant racial gap in access to care. If Black patients are unable or unwilling to seek out primary care on a routine basis, then existing comorbidities will worsen and new ones will emerge, or—in the context of coronavirus—if individuals cannot pursue testing or evaluation once symptoms manifest, they are likely to present to the ER at a more advanced stage. 

While features of the economy, the built environment, individual health, and access to care render Black Americans more susceptible to the novel coronavirus, bias—both implicit and explicit—has long been a driver of disparities in health outcomes among minorities, and this crisis is no different. First, there is the curious concept of “allostatic load”, which McEwan and Stellar introduced in 1993 to mean the physiological cost of chronic stress on the human body over long periods of time. They suggest that persistent activation of homeostatic mechanisms involving hormones such as catecholamines and cortisol in response to stress can permanently change brain function, overload vital organs, cripple the immune system, and contribute to systemic pathology such as hypertension. Naturally, discrimination and bias are significant stressors and studies have linked them to higher rates of inflammation among Black adults. Interestingly, some studies have suggested a link between allostatic load, poorer health, and increased mortality even in higher-income African Americans as well, which lends credence to the important notion that racial disparities exist even when controlling for socioeconomic status. Thus, though challenging to prove, the unavoidable stress of systematic racism may be further contributing to the unbalanced representation of Black Americans among confirmed coronavirus cases. 

Perhaps even more important, there is robust literature showing that Black patients are not treated equally once hospitalized, which may partially explain the disproportionate death toll within this community. Studies demonstrate that Black patients receive fewer medications for pain, undergo fewer procedures, receive less explanation, and generally experience poorer quality of care compared to White patients. One concerning paper from 2016 even found that a substantial number of White people, from laymen to medical students and residents, genuinely believe there are biological difference between Blacks and Whites that contribute to differing pain thresholds. Racism and unconscious bias have undergirded the policies and practices that allowed the present racial inequities in health care to fester, and the data on COVID deaths remind us as a medical community that there is still a long way to go. 

 Rather than level the playing field, the coronavirus pandemic has exposed and, in some ways, further intensified the race-based inequities inherent in our health care system and society, fossilized over decades of neglect, de-prioritization, and otherization of communities of color. While impossible to disentangle completely, I have endeavored to categorize and highlight the economic, environmental, health-related, and psychological forces at play that have led to poorer health outcomes for Black Americans in the past, and that may provide a framework to discuss why a disproportionate number of African Americans are becoming infected and dying during the current crisis. These factors taken together engender higher vulnerability in Black communities due to increased risk of exposure and transmission, decreased immunity due to stress, more severe presentations due to underlying health conditions and subpar access to care, and possible discrepancies in treatment upon hospitalization. The racial disparities evident in the COVID-19 statistics underscore the need for detailed racial or ethnic demographic data on testing, cases, hospitalizations, and deaths to facilitate a more data-driven approach for addressing existing inequities. 

Perhaps there is a silver lining here. 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 investigate and address some of the deep-seated disparities in a meaningful way. Only then can we truly dub this coronavirus a Great Equalizer.