Who Gets Sickest with COVID-19 | Still Compromising Ep. 2
By Alexandra Morshed & Karishma Furtado
Last week marked the point when the number of COVID-19 deaths — as of May 7, 2020, at 74,239 — surpassed US deaths in the Vietnam War. The breakdown of deaths by race shows us that they are not borne equally across groups of Americans. The first episode of this series examined how current COVID-19 patterns are partly due to early and ongoing testing inaction and inequities.
Who is getting sickest?
In this episode, we look at what puts some people — and in our region, Black St. Louisans — at greater risk for hospitalization and death once exposed to COVID-19, and as a result, how efforts and resources should be targeted in St. Louis in order to ensure equity now and in the long term.
The Still Compromising Series: In March of 1820, the Missouri Compromise was signed and the state of Missouri was born out of an insistence on the systematic subjugation and devaluation of Black lives.
In March and April of 2020–200 years later — COVID-19 is revealing that we are still very much grappling with that original sin. The pandemic and its disproportionate effect on Black St. Louisans is pulling back the veil on our broken and inequitable systems. In this series we explore how COVID-19 has laid bare the ways we continue to compromise on our shared values and how we can use this crisis as an opportunity to catalyze Racial Equity. #StillCompromising
From descriptions of patients in New York City, Seattle, Louisiana, Italy, and Wuhan, we know that people who are older or have medical conditions like diabetes, high blood pressure, and obesity get more sick from COVID-19 and die at a higher rate. In New York City, half of hospitalized COVID-19 patients had high blood pressure, two in five had obesity, and a third had diabetes. As these risk factors tend to occur together (e.g., obesity with diabetes and high blood pressure, high blood pressure with age), 88 percent had more than one underlying condition. People who have obesity, which leads to many of the underlying conditions, are at a particularly high risk. Obesity is also very common: two in five Americans have it, a result of an increasing trend over the past two decades, with unacceptably high rates in children and teenagers
“ Narratives about the role of individual responsibility and choice in addressing diseases like diabetes, high blood pressure, and obesity distract from understanding and acting on these systems. ”
During the pandemic, a person who has an underlying condition can have a harder time seeing their doctor and managing their illness (e.g., keeping their blood sugar in check or getting dialysis). If they get a severe COVID-19 illness, they require more treatment and are more likely to walk away with lung and heart damage to their bodies. And, on top of this, patients with obesity are routinely dismissed and undertreated by their healthcare providers, which for Black patients comes on top of widespread race-based discrimination in healthcare.
A typical but flawed frame to explain diseases like diabetes, hypertension, and obesity focuses on a person choosing (or not) to eat the right foods, exercise, and take care of their health. But what decades of research demonstrate is that our choices are not made in a vacuum. Rather they are predominantly shaped by whether we are able to access and afford healthy foods, have a safe place to be active, have time and resources to cook for our families, or are free of economic stress, structural racism, and discrimination. What we also know is that the same systems that determine how resources and influence are distributed in a society determine who has a better shot at being healthy.
“ In the City of St. Louis, neighborhoods with the highest rates of these risk factors are located north of the Delmar Divide. “
Black communities hit the hardest
Considering the meaningful ways place, marginalization, and past and present opportunities shape health, it is no surprise that COVID-19 underlying conditions cluster within neighborhoods. In the City of St. Louis, neighborhoods with the highest rates of these risk factors are located north of the Delmar Divide. The long history of policies and practices of segregation can be felt to this day in these predominantly Black neighborhoods, resulting in higher poverty and lower economic opportunity, food access, access to insurance, mobility, and air quality. These neighborhoods have also seen more COVID-19 cases than other parts of the city.
The graphs in this article are interactive! Click the link to track the trends, toggle different views, or download the data.
Illness on Top of Illness: Underlying Risk Factors of COVID-19 Death in St. Louis (interactive maps!)
The same systems that concentrate underlying risk factors for COVID-19 within communities experiencing marginalization make it more difficult for their residents to protect themselves from exposure to coronavirus due to economic and social reasons (more on that in Episode 3). Together these factors contribute to the same pattern of racial disparity in COVID-19 case load and death rate in cities across the nation: in St. Louis and Chicago, about 1 in 3 people are Black, but they make up 1 out of 2 people dying from COVID-19; in Milwaukee, 4 in 10 people are Black, while making up 5 in 10 people dying from COVID-19; and in the City of New Orleans, 3 in 5 people are Black, while making up 3 out of 4 people dying from COVID-19. These tragic disparities in COVID-19 deaths are unsurprising and far from accidental — rather they reflect the health, social, and economic inequities present in our society.
COVID-19 and Being Black: Risk of Infection and Death in Cities across the Country (interactive chart!)
Ushering in a new era
A highly rational response on the part of Black communities to the high rates of COVID-19 illness and death, particularly when they see the slow and inadequate efforts to contain and mitigate the spread, has been to ask: “Are they trying to kill us?” In terms of the much slower suffering and death from underlying illnesses in our society, the answer is yes and ‘they’ are those whose profits, power, or status quo derive from systems that cause these illnesses. Yet, narratives about the role of individual responsibility and choice in addressing diseases like diabetes, high blood pressure, and obesity distract from understanding and acting on these systems. Similar discourse has at times been used to lay the blame for higher numbers of COVID-19 cases and deaths in Black communities at the feet of Black people. The absence of systems-based, structural explanations for the inequities amplified by COVID-19 ignores the reality long known to communities of color and health equity experts. More importantly, this absence provides an excuse for continuing to ignore the need in these communities for equitable and transformative solutions.
In the short term, the just answer to the injustice of a higher burden of underlying COVID-19 risk factors in Black communities is to allocate a higher amount of resources to these communities.
This means putting in place sufficient testing, surveillance, mitigation strategies, and economic and healthcare safety nets in these communities. It also means that any plans for rationing care or public health resources must not be colorblind. To avoid continuing and deepening today’s inequities, all short-term actions must explicitly incorporate a Racial Equity Lens.
In the long term, the pandemic presents an opportunity to dismantle the systems and structures that create health inequities in Black communities …
those that provide a foundation in life that is much sturdier and more protective for some than others. We must put in place and then go beyond actions that compensate for the current systems (like referrals to food banks or SNAP). It is transformative solutions like living wage policies and affordable housing that will address the cycle of disadvantage and thus root causes of disease. We know what needs to be done. Will we wait for the next crisis to ensure health equity in our communities?
Alexandra Morshed, PhD, MS, is a Postdoctoral Research Associate at the Prevention Research Center in St. Louis at the Brown School at Washington University in St. Louis.
Karishma Furtado, PhD, MPH, is the Data and Research Catalyst for Forward Through Ferguson.
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