What is Driving Racial/Ethnic Disparities in COVID-19 Morbidity and Mortality?
Monica L. Wang, ScD, MS
To my parents, who worked tirelessly and selflessly so I could have the best education they could provide, and to my Community Health Sciences family of faculty, staff, and students at the BU School of Public Health, who are social justice and health equity champions alongside me.
As an alumna of Boston’s Metropolitan Council for Educational Opportunity program (METCO) program (the longest continuously running voluntary school integration program in the nation), I am intimately familiar with neighborhood disparities and health. From elementary through high school, I lived in Roslindale (an ethnically diverse neighborhood of Boston) and commuted 3 hours each school day (school bus in elementary; public transit starting in 8th grade) to attend public school in Belmont, a picturesque suburb that boasts one of the top public schools in the state. One would have to be blind and deaf not to notice the stark differences in demographics, built environment, and economic and educational opportunities (or lack thereof) between the two neighborhoods, spaced less than 10 miles apart.
My Boston neighborhood friends and METCO peers knew not to frequent parks past a certain hour — ever. We witnessed theft and assault and more than occasionally experienced harassment on our long commutes to school. Our walk to and from the public transit stops were inundated with fast food outlets, liquor stores, and corner stores. Sidewalks were in need of repair but available at best; completely lacking at worst.
Most of my classmates in Belmont seemed to live in another world. Many brought colorful lunches packed with fruits and vegetables to school, participated in expensive arts and athletics programs, walked or rode bikes to school, and some even left their back doors unlocked (inconceivable for my neighborhood). It did not escape me, even in elementary school, that key differences in neighborhood characteristics, such as crime, access to healthy food, walkability, and pollution, differentially influenced children and families’ ability to engage in healthy behaviors and prioritize health, depending on one’s zip code. This experience profoundly shaped my dedication to promoting community health and working to address health inequities from a population level.
Fast forward 20 some-odd years. I have a master’s and doctoral degree from the Harvard T.H. Chan School of Public Health and am an Associate Professor at the Boston University School of Public Health and an Adjunct Associate Professor at Harvard. I have been conducting research and teaching graduate courses on the social determinants of health, including the underlying drivers of racial/ethnic health disparities, for the past decade.
The other day, one of my former students from Harvard’s Master in Health Care Management Program asked me via Twitter why U.S. cities were experiencing substantial racial disparities in COVID-19 (he knew the answer, or else I would ask him to re-take my race/ethnicity and health module). If I had to condense that lecture into a Twitter feed, this would be it. But it got me thinking beyond Population Health in the Midst of a Pandemic and ultimately writing this piece.
Health disparities or inequities refer to preventable and unjust health differences between groups of people that are closely linked with social, economic, and/or environmental disadvantage. In the U.S., racial/ethnic disparities are observed in nearly every single health outcome, with Blacks, Latinx, and Native American/Alaskan Indians suffering disproportionately higher rates of diabetes, heart disease, obesity, cancer, infectious diseases, preterm births, and higher mortality rates, to name a few. These racial/ethnic disparities are rooted in colonialism, slavery, and systemic or institutionalized racism, the latter of which continues to be perpetuated and practiced between individuals across sectors (e.g., housing, health care, policy, judicial system, education) today. To understand why we see racial disparities in COVID-19 infection and death rates, we have several mechanisms to unpack.
The first mechanism is the contribution of race and socioeconomic status (SES) on health and why both matter, particularly in the U.S. SES refers to a person’s position in a social hierarchy based on prestige and access to resources and is often measured by indicators such as income, education level, occupation, and wealth. In the U.S., race is strongly associated with SES because of institutionalized racism (e.g., Jim Crow laws, redlining), which systemically undermined social and economic opportunities for advancement among people of color.
Because of institutional, interpersonal, and internalized racism, people of color have lower income and wealth (despite equivalent levels of education), are over-represented in lower-paying, nonstandard occupations like essential workers, have less job security, and higher rates of being uninsured or under-insured, as insurance is directly tied to occupation in the U.S. This means that people of color, particularly Blacks, Latinx, and Native Americans have poorer access to socioeconomic resources and health care, as well as experience more stressors, constraints, and barriers to achieving health (e.g., lower-income individuals are less able to afford to engage in healthy behaviors, such as join a gym, buy fresh produce, take time off work to see their primary care physicians, and fill prescriptions). During a pandemic, staying at home and practicing social distancing is a privilege that is neither randomly nor equitably distributed across racial and economic lines.
The second mechanism of racial/ethnic health disparities is discrimination (the unjust, prejudicial treatment of people based on characteristics such as the color of their skin). It is well-established that discrimination occurs across multiple domains and sectors in the U.S., including the labor market, judicial system, education, health care, and housing. Studies show that Blacks who experience discrimination based on their race have higher cortisol and blood pressure levels and shorter telomeres (a marker of accelerated aging). This is to say nothing of intersectionality (the “complex, cumulative manner in which effects of different forms of discrimination” such as race, gender, and class combine, overlap, or intersect). Thus, effects of socioeconomic disadvantage and physiological impacts of experiencing discrimination accumulated over the lifecourse and across generations puts communities of color at substantial disadvantage when it comes to health.
The third mechanism is the impact of neighborhoods on health. Practices such as redlining (a racialized system of economic and social investment that denied various services by government (federal and local) and the private sector to minority (most notably Black) communities in the U.S., either directly or through selective pricing) resulted in disinvested communities of color that experience poorer access to healthy food, health care, and green space, excessive access to fast food outlets, liquor stores, targeted marketing of tobacco and alcohol, and higher exposure to pollutants, to name a few. You can check out which neighborhoods were redlined at Mapping Inequality, an interactive site that takes scores of Home Owners Loan Corporation maps and embeds them on a single map of the U.S. The poorer built environment that communities of color were forced into unsurprisingly translates into poorer overall health and higher rates of diabetes, hypertension, heart disease, and respiratory conditions among these populations — the very underlying conditions known to be associated with greater risk of COVID-19 complications, including death.
The fourth mechanism is discrimination in health care. A blinded randomized trial demonstrated that implicit bias exists among some physicians, coloring their diagnosis and treatment plans for patient profiles who presented with the same set of symptoms and demographics, save for the color of their skin. This study and others demonstrate that unconscious or conscious biases in the health care setting contribute in part to racial/ethnic disparities in medical procedures (including COVID-19 testing) and ultimately health outcomes. Discrimination in this setting is not lost on communities of color, where the mistrust of health care providers and health officials runs deep due in part to the egregious and infamous Tuskegee Study.
Let me be clear — health care is not the only setting and providers are not the only players that have the power to exacerbate or mitigate health disparities. The reason why racial/ethnic health disparities are so pervasive and persistent in the U.S. is because racism is systemic — each cog in our system (e.g., housing) operates in conjunction with the other cogs (education, judicial system, health care). By the time patients show up in the hospital or the clinic to be seen, they have already embodied the physiological, psychological, behavioral, and environmental effects of being exposed to discrimination — a chronic stressor amassed over generations and accumulated across the lifecourse. Having worked in a medical setting, working in a career that involves daily interactions with physicians and clinicians (including teaching them), and being married to a physician, I can also say that many are working tirelessly towards reducing and eliminating health disparities in their sector. To make a bigger impact, we need to coordinate such efforts across all sectors.
This is by no means an exhaustive list of the underlying drivers of racial/ethnic disparities in health, but these are some of the most critical mechanisms in my view to understand. When you combine hundreds of years of history with multiple levels of discrimination that occur across nearly every sector of influence, it comes as no surprise that we see racial/ethnic disparities in COVID-19 infection, morbidity, and mortality rates, as evidenced from early data in Boston, Chicago, Detroit, Michigan, New Orleans, and Philadelphia. Boston’s map of COVID-19 cases by neighborhood overlaps onto its historically redlined neighborhoods.
What is disgraceful is that it took a pandemic to shine a hard light onto what public health experts and communities of color have known for generations. MA Govenor Baker announced in April of 2020 that race/ethnicity data would be required for COVID-19 reporting moving forward. This is a small but crucial step to documenting health inequities, which will catalyze efforts to eliminate them, as we should always be striving towards. We will have learned nothing if we continue to let history repeat itself. We can and must do better. Now it’s time to get to work.
