key: cord-0780674-slaykbhi
authors: Kullar, Ravina; Marcelin, Jasmine R; Swartz, Talia H; Piggott, Damani A; Macias Gil, Raul; Mathew, Trini A; Tan, Tina
title: Racial Disparity of Coronavirus Disease 2019 (COVID-19) in African American Communities
date: 2020-06-30
journal: J Infect Dis
DOI: 10.1093/infdis/jiaa372
sha: 9470ac17f1c5379a303f0829d8bc33b4f6021c99
doc_id: 780674
cord_uid: slaykbhi

The COVID-19 pandemic has unveiled unsettling disparities in the outcome of the disease among African Americans. These disparities are not new, but are rooted in structural inequities that must be addressed to adequately care for communities of color. We describe the historical context of these structural inequities, their impact on the progression of COVID-19 in the African American (Black) community, and suggest a multifaceted approach to addressing these healthcare disparities. Of note, terminology from survey data cited for this article varied from Blacks, African Americans or both; for consistency, we use African Americans throughout.

Coronavirus disease 2019 (COVID-19) has impacted > 8 million people and killed > 450,000 individuals as of June 16, 2020, sweeping through at least 200 countries. [1] The sentiment has been shared that "we are all in this together", regardless of ethnic background. However, there are profound racial disparities in those impacted in the United States; COVID-19 disproportionately infects and kills people of color.

According to the Centers for Disease Control and Prevention (CDC), an analysis of ~1,500 hospitalizations across 14 states found that African Americans comprised a third of the hospitalizations, despite accounting for only 18% of the population in the areas studied and 13% of the African American national population. [2] A Washington Post report revealed that majority-Black counties had infection rates three times the rate of majority-White counties. [3] In Louisiana, > 70% of individuals who have died from COVID-19 were African Americans, more than twice their 32% share of the state's population, and well over the 60% share of the population of New Orleans, where the outbreak is worst. [4] Further, African Americans make up 9% New York's population but 17% of deaths.

[5] It must be noted that, while the focus of this perspective highlights disparities in the African American community, there are emerging disturbing trends in the Latinx community that also require attention, and relatively little data reported on Native American communities, who are also at risk. Future assessments from this Taskforce will address disparities in those communities too. Here, we will describe the historical basis of this racial disparity and provide our recommendations for decreasing health inequality in the African American population.

A c c e p t e d M a n u s c r i p t Historical Context: Social Determinants, Structural Racism and Health Inequity

The National Academies of Sciences, Engineering and Medicine defines health equity as the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance. [6] Health inequity, in contrast, is promulgated by the unequal distribution of social, economic, environmental and other structural resources that put a substantial economic, clinical and human toll on communities and societies globally. [6, 7] Structural racism has been in existence since the founding of colonial America, translating to various health inequities that render African Americans particularly vulnerable in the face of the COVID-19 pandemic today. [8] Reskin defines structural racism as "the totality of ways in which societies foster [racial] discrimination, via mutually reinforcing [inequitable] systems… that in turn reinforce discriminatory beliefs, values, and distribution of resources." [9] Such systems historically have engendered racial disparities in income, unemployment, underemployment, housing, educational opportunity, food insecurity, transportation, incarceration and other key structural determinants that serve as fodder for the disproportionate impact of conditions such as COVID-19 on racial and ethnic minority communities today. [6, 7] These elements mediated potentially in part by fear of lost income with illness, lack of paid sick leave, inadequate housing and crowding, limited access to medically appropriate food and medication, and heightened comorbid disease, may potentiate disparities in COVID-19 exposure, acquisition, hospitalization and death. Such impact may be exacerbated further by ongoing structural barriers in access to care coupled with known disparities in the quality of care delivery for racial and A c c e p t e d M a n u s c r i p t ethnic minority groups. [7, 10] In the United States alone, the cost of health inequities among racial and ethnic minority populations even prior to the appearance of has been estimated to amount to several hundred billion dollars. [6] The challenge of social distancing, as recommended by the World Health Organization (WHO) and the CDC, provides a concrete example of how social determinants may increase the vulnerability of African Americans during this pandemic. c c e p t e d M a n u s c r i p t transportation as a means of getting to and from work. [12, 13] Due to several genetic, environmental, socioeconomic, and other factors, there is a higher incidence of underlying health conditions in these populations such as diabetes mellitus, hypertension, obesity, asthma, and cardiovascular disease with African Americans being disproportionally affected. [6] The CDC has identified a number of underlying health conditions that predispose an individual to severe COVID-19 (SARS-CoV-2) infection. These include diabetes mellitus, chronic lung disease, chronic kidney disease and those on dialysis, cardiovascular disease, immunocompromising conditions, age ≥ 65 yearsespecially those living in long-term care facilities, morbid obesity (BMI ≥ 40), and smoking. [2, 14] A significant proportion of individuals requiring hospitalization or who died from COVID-19 disease had > 1 of these underlying conditions. [2, 14] In the COVID-NET report, the catchment area demographics show that 59% of the population was White, 18% African American, and 14% Hispanic. However, among 580 hospitalized patients, African Americans made up 33% of the hospitalized patients. [2] African Americans also have suffered more than one-third of all the reported deaths (for which data exist). Based on the existing data on mortality, African Americans are 2.6 times more likely to die from COVID-19 compared to the percent of their overall population share. [2] This has been noted in multiple states; in Michigan, African Americans are 3.8 times more likely to die of COVID-19, in Illinois, they are 3.3 times more likely to die, in Wisconsin, the ratio is 2.5, and it is 2.2 in Louisiana. [15] We reviewed publicly available data from all 50 states and found that 26 states (and the District of Columbia) provided detailed information on cases, hospitalizations, or deaths A c c e p t e d M a n u s c r i p t due to COVID-19 by race/ethnicity. Of those states reporting this information, significant health disparities were observed in 20 states. The vast majority of those disparities negatively impact African American communities (Figures 1 and 2)[16, 17 ]. These differences suggest that the African American population is significantly disproportionately affected by COVID-19. This can, in part, be attributed to socioeconomic and environmental factors that were in place prior to the epidemic, which fuel the spread of the infection.

We recommend implementing a nation-wide analysis to estimate the impact of COVID-19 in the United States. All states' health departments should be required to provide data on race/ethnicity vs. outcomes on COVID-19-tested individuals.

Additionally, states should provide data on testing availability and accessibility, targeting testing in areas of vulnerable populations. There must be a long-term commitment and intentional effort to decrease healthcare disparities in minority communities through collaboration with local and federal governments by addressing structural inequities. We recommend:

 Engaging key community leaders (including faith-based leaders, thought leaders, regional or national celebrities) early on to disseminate information regarding infection transmission and prevention methods. [18] These community leaders will also be critical in getting treatment to the public and disseminating accurate information out. Community leaders should promote evidence-based best A c c e p t e d M a n u s c r i p t practices for preventing COVID-19 transmission and avoid cultural stigmatization.

 Leveraging the power of technology for optimizing communications with all healthcare providers (including integrative medicine) to provide tailored prevention messages as well as safe patient care. [19]  Making information accessible in multiple languages through all social media and messaging platforms, including simple infographics for messaging, assuring they are culturally acceptable to the community.

 Implementing programs to decrease food, financial, childcare, and job insecurities, and increase access to primary health care.

 Supporting Medicaid expansion in all states, as this expanded access to healthcare coverage can reduce some disparities related to these structural determinants of health. [20]  Encouraging African Americans to participate in research (as both researchers and subjects). As it pertains to COVID-19, as people from African American and Latinx communities are overrepresented in disease incidence, these individuals need to be recruited into clinical trials evaluating prospective treatment and preventive modalities. Furthermore, government, pharmaceutical industries, academia and medical societies need to work together to ensure we have thoughtful, evidence-based understanding and action. M a n u s c r i p t

This pandemic has unveiled longstanding disparities in the outcome of the disease among African Americans. With most cities and states not reporting race along with counts of confirmed cases and fatalities, we propose a call to action for states to disclose such information to the public. Without a vision of health equity and a universal commitment to tackle structural racism, health disparities will continue. Rising to the challenge is imperative in this pandemic to create conditions in which those traditionally left behind can survive and thrive.

Potential conflicts of interest. R.K. was a prior employee of Gilead Sciences. All other authors have no conflicts of interest to disclose. M a n u s c r i p t A c c e p t e d M a n u s c r i p t Figure 2 

Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease

The coronavirus is infecting and killing black Americans at an alarmingly high rate

Black Communities Are Hit Hardest By COVID-19 In Louisiana And Elsewhere

Communities in Action: Pathways to Health Equity

Reducing Racial Inequities in Health: Using What We Already Know to Take Action

The health of black folk: disease, class, and ideology in science

The race discrimination system

Designing and evaluating interventions to eliminate racial and ethnic disparities in health care

Structural racism and health inequities in the USA: evidence and interventions

Health disparities: gaps in access, quality and affordability of medical care

Inequalities in racial access to health care

Groups at higher risk for severe COVID-19 illness

The COVID Tracking Project

Interim Guidance for Administrators and Leaders of Community-and Faith-Based Organizations to Plan

The Tech That Could Be Our Best Hope for Fighting COVID-19-and Future Outbreaks

The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review. The Kaiser Family Foundation

The authors would like to thank the staff of the Infectious Diseases Society of America (IDSA) for their assistance with preparing this manuscript.

A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t