Inequality as a risk factor for COVID-19

April 29, 2020 / By Melissa Clarke, MD

Anyone can get infected with SARS-CoV-2, the virus that causes COVID-19. However, early data from China, available since February, revealed that COVID-19 hospitalizations and deaths predominate for certain groups [i]. Those groups include individuals over 60 years old, people with immune systems weakened by HIV, cancer or autoimmune diseases like lupus, sarcoidosis and those with chronic diseases like diabetes, heart disease including high blood pressure,  chronic kidney disease, and lung diseases like asthma and COPD. This has since been corroborated the Centers for Disease Control and Prevention (CDC) [ii] and they have added obesity and chronic kidney disease to the list.

The list of these conditions that predict severe COVID-19 symptoms is closely aligned with the same conditions we find at higher rates in medically underserved communities. Significant disparities in the prevalence of these conditions exist between communities of color and white communities, regardless of socio-economic status. African Americans and other communities of color live with chronic disease at younger ages and die at higher rates than whites from heart disease, stroke, cancer, asthma, influenza and pneumonia, diabetes and HIV/AIDS [iii]. There are myriad reasons for this, ranging from the prevalence of food deserts, [iv] to epigenetics[v] to decreased access to medical care [vi]. In addition, a Drexel University report using data from the Philadelphia Department of Public Health starting April 1, 2020, showed that coronavirus testing in higher-income neighborhoods is six times greater than it is in poorer neighborhoods [vii]. The bottom line is the compromised physical health of certain American communities, especially African Americans, coupled with lower access to care, puts them in the crosshairs of the pandemic. In other words, inequality is an underlying risk factor for COVID-19.

The numbers tell the story. New York City has a 29.1 percent Latinx population, yet they make up 34 percent of the known deaths from the coronavirus [viii]. As of April 12, 31 percent of New Mexicans who have contracted COVID-19 are Native American, almost three times their percentage of the state population as a whole [ix]. African Americans far and away appear to be most affected thus far. A Washington Post analysis found that majority-black counties had infection rates three times the rate of majority-white counties [x]. A CDC analysis of nearly 1,500 hospitalizations across 14 states found that black people made up a third of the hospitalizations, despite accounting for 18 percent of the population in the areas studied [xi]. An Associated Press analysis of available death data found that black people constituted 42 percent of the victims, doubling their share of the populations of the states the analysis included [xii]. In New York, African Americans comprise 9 percent of the state population and 17 percent of the deaths [xiii].

Amidst these disturbing statistics, we know that public health messaging about testing, the importance of staying at home and the utility of face coverings has been evolving and inconsistent between national and local officials. We do know that austere shelter-in-place orders are demonstrating effect by flattening the curve and thus mitigating the overburden on healthcare resources [xiv]. Unfortunately, additional healthcare related issues are created by the shelter in place orders. People with true emergencies are afraid to go to the Emergency Department, patients with chronic diseases are missing routinely scheduled doctors’ appointments, etc. Efforts are underway to address these issues by implementing new outreach methods to identify and reach vulnerable communities. This will be the topic of the next article in this series.

Melissa E. Clarke, MD, CMQ, is a Clinical Transformation Physician Consultant with 3M Health Information Systems.

During a pandemic, healthcare information is gathered, studied, and published rapidly by scientists, epidemiologists and public health experts without the usual processes of review. Our understanding is rapidly evolving and what we understand today will change over time. Definitive studies will be published long after the fact. 3M Inside Angle bloggers share our thoughts and expertise based on currently available information.

References

[i] Wei-jie Guan, Wen-hua Liang, Yi Zhao, Heng-rui Liang, Zi-sheng Chen, et al. Comorbidity and its impact on 1,590 patients with COVID-19 in China: A Nationwide Analysis at http://medrxiv.org/content/early/2020/02/27/2020.02.25.20027664.abstract accessed April 15, 2020.

[ii] Garg S, Kim L, Whitaker M, et al.Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep.ePub:8 April 2020

[iii]Quiñones AR, Botoseneanu A, Markwardt S, Nagel CL, Newsom JT, Dorr DA, et al. (2019) Racial/ethnic differences in multimorbidity development and chronic disease accumulation for middle-aged adults. PLoS ONE 14(6): e0218462. https://doi.org/10.1371/journal.pone.0218462

[iv] Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36(1):74–81. doi: 10.1016/j.amepre.2008.09.025

[v] Vick AD, Burris HH. Epigenetics and Health Disparities. Curr Epidemiol Rep. 2017;4(1):31–37. doi:10.1007/s40471-017-0096-x

[vi] Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health Care Financ Rev. 2000;21(4):75–90.

[vii] Jones, Ayana. (2020, April 9). The Philadelphia Tribune. Racial disparities in coronavirus testing, infection grow. Retrieved from https://phillytrib.com.

[viii] How to Save Black and Hispanic Lives in a Pandemic. [Editorial] (2020, April 11). New York Times. Retrieved from  https://www.nytimes.com/2020/04/11/opinion/coronavirus-poor-black-latino.html

[ix] Childress, Marjorie. (2020, April 12). New Mexico In Depth. Native Americans make up 31% of New Mexico COVID-19 cases. New Mexico In Depth. Retrieved from http://nmindepth.com/2020/04/12/native-americans-make-up-31-of-new-mexico-covid-19-cases/

[x] Thebault, Reis, Ba Tran Andrew, and Williams Vanessa. (2020, April 7). The Washington Post. The coronavirus is infecting and killing black Americans at an alarmingly high rate.  Retrieved from https://washingtonpost.com

[xi] Garg et al

[xii] Stafford, Ky, Hoter, Meghan, and Morrison, Aaron (2020, April 8). Outcry over racial data grows as virus slams black Americans. Retrieved from https://abcnews.go.com

[xiii] How to Save Black and Hispanic Lives in a Pandemic. [Editorial] (2020, April 11). New York Times. Retrieved from  https://www.nytimes.com/2020/04/11/opinion/coronavirus-poor-black-latino.html

[xiv] Harris JE. THE CORONAVIRUS EPIDEMIC CURVE IS ALREADY FLATTENING IN NEW YORK CITY Working Paper 26917 NATIONAL BUREAU OF ECONOMIC RESEARCH. Accessed at http://www.nber.org/papers/w26917 on April 16, 2020.