The COVID-19 pandemic has exposed persistent gaps in the U.S. healthcare system: from inaccessible and unaffordable high-quality care and coverage to longstanding racial and ethnic inequities in health risks and patient outcomes.
Findings from a recent study published in Circulation further revealed the magnitude of these racial and ethnic inequities since the beginning of the pandemic. Among 7,800 patients hospitalized in the U.S. with COVID-19 between January and July of last year, 33 percent were Hispanic, 25.5 percent were Black, 6.3 percent were Asian, and 35.2 percent were white. Of these patients, overall mortality was 18.4 percent, with more than half of all deaths occurring in Black and Hispanic patients.
Additionally, hospitalized Black and Hispanic patients were a decade younger than white and Asian patients, were more likely to be uninsured, had the highest prevalence of comorbidities (obesity, hypertension and diabetes), and had the highest rates of mechanical ventilation and renal replacement therapy.
These findings are stunning, said Clyde Yancy, MD, MSc, the Magerstadt Professor, chief of Cardiology in the Department of Medicine, vice dean for Diversity and Inclusion, and a co-author of the study. More importantly, these findings reaffirm that institutions must aggressively and operationally commit to preventing underrepresented minority populations and their communities from acquiring COVID-19 in the first place, according to Yancy.
“If we don’t pay attention to what’s happening in these communities, they will lose their essence,” Yancy said. “They’re losing their parents, their grandparents, the people that own small businesses. It will make it very, very difficult for these communities to have any meaningful recovery. Suffering this pandemic disproportionality and then losing so many important community figures is cruel; it’s time to stop it.”
Read a Q&A with Yancy and Sadiya Khan, ’09 MD, ’14 MS, ’10, ’12 GME, assistant professor of Medicine in the Division of Cardiology and of Preventive Medicine in the Division of Epidemiology, offering her perspective and commentary on the publication.
What do we already know about racial and ethnic disparities in COVID-19 hospitalizations, patient outcomes and mortality in the U.S.?
This year has been a learning laboratory: what we thought we understood in March and April of last year is different from what we understand now, specifically that the burden of COVID-19 risk comes from communities characterized by self-described race or ethnicity. But that’s not the vulnerability.
The vulnerability is the life and living circumstances in these communities. This vulnerability leads to a higher infection rate — that is where the difference resides. After hospitalization, outcomes are roughly the same. The difference that we see is the number of people disproportionately being hospitalized from these communities. We know that the rate of death is about one in five for everyone hospitalized with COVID-19. That’s striking.
The overarching question that this paper really did a nice job of addressing was at the individual level: What are the characteristics that are potentially different among individuals of racial and ethnic minorities that are being hospitalized with COVID-19, and how are those differences manifesting in terms of outcomes related to the hospitalization, surviving the hospitalization, dying during the hospitalization and severity of illness.
What findings from this study particularly stood out to you?
I think one other comment that the paper really clearly identifies is not just that there is disproportionate representation in COVID-19 hospitalizations, but that hospitalized individuals who are Black or Hispanic are a lot younger. The average age among Hispanic patients who were hospitalized with COVID-19 was 12 years younger and Black patients were nine years younger. That difference of about a decade was really remarkable to see.
I think the severity of illness at a younger age is something that we’ve also seen with cardiovascular disease, and likely has to do with multiple factors in addition to social and structural factors, systemic racism, as well as the contribution of comorbidities that we know are associated with severity of illness, like obesity, diabetes and hypertension.
This community is at risk for several reasons: their life and living circumstances create vulnerability; their employment is disproportionately in essential services where they must be physically be present to support the livelihood of their families, and which necessarily means that they are exposed to human-to-human transmission.
After nearly a year, many of us are numb to the numbers. But I have always been struck by the idea that if it happens to one person, it’s a tragedy; If it happens to thousands of people, it’s a statistic. Still today, there’s a three times greater chance for Black individuals to die from COVID-19 and a two-and-a-half times greater chance for Hispanic individuals to die from COVID-19 compared to white individuals. That is much more than a statistic, it is a disparity. We are talking about people with 250 percent to 300 percent greater risk. That is almost incalculable in any biological paradigm that Dr. Khan and I are accustomed to understanding.
What public health measures must happen in order to mitigate COVID-19 risk in these communities?
It is going to the community and providing masks, it is generating public health messages of safe, physical distancing and frequent hand washing. And certainly, this community should not be last in line to receive the vaccine. But that becomes a bit of a quagmire because this is a community that traditionally has failed to trust the medical establishment, for good reason. So, their unwillingness to accept the vaccine will actually exacerbate the burden of this disease that we’re already seeing.
I don’t get a sense that there’s a sufficient urgency within our public health community. We are contemplating how best to expose these communities to the vaccine and disseminate it, but we need to think very carefully about who the people at unique risk are and why are they at risk. Now that we actually know the zip codes in Chicago where the greatest pain and, subsequently, the most likely death events have occurred, we can target those zip codes. It seems intuitive that we should have some sort of multifaceted program in those communities to make the vaccine available.
How can we better invest in and support these communities?
The root cause of all of these exposures, the life and living circumstances, is economic insecurity. The one variable that always tracks best with longevity and health is economics; having an income, having resources, having financial security, having food security and having intact housing.
We have tried many other approaches — health insurance, making medicines available in community clinics, exporting services to the communities where people live — and they all need to continue. But the one thing that has fundamentally not been explored and that is a root cause is reinvigorating the economic infrastructure in these communities. It will not change in one year, it will not change in one presidential cycle, but it can change in a generation.
The conversations we are having about social justice are so important because finally we are recognizing the extent of the disempowerment and the disenfranchisement because of repetitive longitudinal, systematic disinvestment in multiple communities, and the result of poor health and poor health outcomes. If we do not change, it is COVID-19 now, but it will be something else down the road.