key: cord-0992938-4x3dkgk9
authors: Willems, Sara S.J.; Castells, Mariana C.; Baptist, Alan P.
title: The Magnification of Health Disparities During the COVID-19 Pandemic
date: 2022-02-04
journal: J Allergy Clin Immunol Pract
DOI: 10.1016/j.jaip.2022.01.032
sha: ef00792c1a6c09a3fae73b641ea0015e1dafe6af
doc_id: 992938
cord_uid: 4x3dkgk9

Covid-19 has created and amplified racial health disparities. This has been particularly noticeable in populations with asthma. There is no one simple reason for this occurrence, but rather a complex interaction of biological, structural, and socioeconomic factors. This article will highlight reasons why the COVID-19 pandemic has been particularly impactful among minority populations throughout the world and will also offer potential solutions to help overcome health disparities.

abaptist@med.umich.edu 28 number of people tested and the way numbers are reported, the wide range of these figures can be

The identified racial disparities in prevalence, hospitalizations, and mortality ratio from COVID-19 109 could be attributed to several reasons, including biological, structural, and socioeconomic, and there is 110 growing evidence for the relationship between ethnicity and the already known risk factors for poor 111 clinical outcomes in COVID-19. Although there was initial significant concern that asthma was a 112 significant risk factor for mortality from COVID-19, this generally not been observed in studies. 15,16 113 However, in a study comparing COVID-19 outcomes, the percent of African American asthma 114 patients with COVID was significantly higher than the percent of African American non-asthma 115 patients with COVID (35.5% vs 21.4%), 17 and African American patients overall were more likely to 116 require hospitalization. Additionally, in another study of 1,827 patients with asthma, those who 117 required hospitalization were more likely to be African American than those who did not require 118 hospitalization (19.1% vs 15.0%). 18 119

To better understand the possible contributing factors of COVID-19 as an exacerbating factor of 120 asthma health disparities, as well as to quantify the impact of the pandemic on asthmatic patients, a 121 survey was conducted among 1,171 asthma patients and 225 physicians from April -May 2020. 19 Of 122 the asthma survey respondents, a total of 10% of the subjects were considered minority individuals 123 (Black or Hispanic). The results of the survey helped to delineate the unequal impact of COVID-19 124 and possible causes. 125 Table 1 summarizes how COVID-19 has worsened or magnified existing health inequities. 126

Firstly, racial minority populations experience disproportionately higher rates of underlying health 127 conditions, of which it is known that they are associated with an increased vulnerability to COVID-128 19. 20 For example, Native American populations have disproportionately higher heart disease and 129 diabetes levels, which make them particularly at risk of complications from COVID-19. 21 And in the 130 most impoverished neighborhoods, Black people and Hispanic people are at greater risk for 131 J o u r n a l P r e -p r o o f respectively hypertension and diabetes compared with White neighbors, resulting in greater risk of 132 death from a COVID-19 infection than their White counterparts. 22 The reasons for increased 133 comorbidities are complex and include social and structural determinants of health, racism (the belief 134 that personality, behavior and morals can be traced back to race, and the belief that one race is superior 135 to another), discrimination (acting upon racist thoughts), economic and educational disadvantages, 136 health care access and quality, individual behavior, and biology. Minority patients with asthma are 137 more likely to have medical comorbidities than White individuals, observed in both adult and pediatric 138 populations. 23,24 These comorbidities include cardiac disease, diabetes, and obesity. The presence of 139 medical comorbidities presented a particular impetus for worsening asthma disparities. Patients with 140 medical comorbidities have worse outcomes on most asthma metrics than those without. 25 Medical 141 comorbidities (such as obesity and congestive heart failure) are a major risk factor for morbidity and 142 mortality due to COVID-19. 26 The additive effects of medical comorbidities during the pandemic 143 amplify health disparities present for individuals with asthma. 144

Secondly, the disproportionate impact of COVID-19 on ethnic minority communities might be 145 attributable to higher exposure to the virus leading to an increased infection rate amongst these 146 communities. 10,21,22,27-30 Such factors were seen in the survey of asthma patients as well, where 147 minority individuals with asthma were more likely to have been diagnosed with COVID-19, were 148 more likely to have become unemployed due to COVID-19, were more likely to have difficulties 149 obtaining asthma medications during COVID-19, and were more likely to live in communities with 150 high number of COVID-19 cases. 23 As sustained close contact with someone who is infected with 151 SARS-CoV-2 drives the majority of new infections, the virus is much more efficiently spread in 152 enclosed and crowded environments. In addition, individuals from ethnic minority communities are 153 more likely to live in larger household sizes comprised of multiple generations. 8 Compared to their 154

White counterparts they are also more likely to experience various deprivations in their daily lives, 155 such as poor health, lack of education, inadequate living standards, disempowerment, poor quality of 156 work, the threat of violence, among others ("multidimensional poverty"). 28 They also more often live 157 in overcrowded households or accommodations with shared facilities or communal areas. 10 Ethnic 158 J o u r n a l P r e -p r o o f minorities disproportionally make up "essential workers" such as retail grocery workers, public transit 159 employees, healthcare workers, and custodial staff are more exposed to the public and at higher risk of 160 getting infected. 22, 29, 30 As it pertains to employment, social distancing is a privilege that requires the 161 opportunity and digital access to work from home, and this is not distributed equally in society. 162

Thirdly, one of the most effective tools against serious complications and death from COVID-19 is 163

vaccination, but unfortunately this again is a significant contributor to health disparities as minorities Additionally, minority individuals face language and cultural barriers limiting their access to accurate 173 information on prevention and mitigation, compelling them to rely on social media or advice from 174 friends that may be erroneous. 29, 33 175 Similar to vaccine hesitancy, minority patients who contract COVID-19 are less likely to accept 176 monoclonal antibody therapy. 34 In that study, patients who did not consent to monoclonal antibody 177 therapy were significantly more likely to subsequently require hospitalization. Additionally, a large 178 study of over 12,000 COVID-19 patients found that minority patients were far less likely to receive 179 monoclonal antibody therapy, though whether this was related to patient hesitancy or lack of access is 180 unclear. 35 There is no current data regarding COVID vaccine and/or monoclonal antibody hesitancy 181 rates among those with asthma, and additional research is needed to determine if disparities in uptake 182 are present in this population. 183

Together with the increased exposure, these healthcare-related variables are found to underlie COVID-Fourthly, also health care system characteristics play a significant role in COVID-19 related 186 disparities. Barriers in health care contribute to higher rates of comorbidities that increase the risk of 187 getting a COVID-19 infection and higher rates of bad COVID-19 outcomes. 7, 29 Despite ethnic 188 minorities being at increased risk of exposure to the virus, they also experience increased barriers to 189 testing such as the lack of transportation and co-payments. As a result, the only recourse for many 190 ethnic minority patients is to seek testing in an emergency room. 36,37 Individuals from ethnic minority 191 groups also experience barriers in health care once they become ill with COVID-19. Sometimes 192 healthcare is even not available. For example, in NYC, the borough of Bronx, with 58% of the 193 population at or below "NYCgov Poverty threshold," has half the rate of ICU beds per 100,000 194 population of adults 60 years of age and older, compared with the borough of Manhattan with 31% of 195 the population at or below the poverty threshold. 22 Among asthma patients, minority individuals are 196 more likely to seek care for an exacerbation at an emergency department rather than at a PCP office. 38 197

Not only do racial minority groups have less access to care, but they are also more likely to receive the 198 inappropriate diagnosis, treatment, or referrals compared to White people. 20 In Europe, the PRICOV-199 19 study examines how primary care practices in 37 European countries and Israel organized care 200 during the COVID-19 pandemic. Results show that practices actively reached out to patients. 201

However, this was significantly more the case for patients with chronic conditions such as diabetes, 202 than for socially vulnerable patients such as patients known as at risk for domestic violence or patients 203 with limited social resources. 39 Hence, health care services and systems are not always offered on the 204 basis of healthcare need, which is often highest in materially disadvantaged groups or ethnic minority 205 groups. And together with the increased exposure, these healthcare-related variables are found to 206 underlie COVID-19-related disparities even more than susceptibility (that is, comorbid conditions). 8 207

The US National Academy of Medicine notes that unconscious bias, stereotyping, and prejudice may 208 play an important role in persisting healthcare disparities. 40 For example, Black people are less likely 209 to be detected with pressure ulcers. 20 One of the root causes can be found in the medical training and 210 in medical science: darker skin tones are significantly underrepresented and lighter skin tones is one example of institutional (or systemic) racism: "the collective failure of an organization to 213 provide an appropriate and professional service to people because of their color, culture or ethnic 214 origin." It does not necessarily have to be deliberate or overt, but rather manifest itself through 215 unwitting prejudice, ignorance, thoughtlessness, and racist stereotyping. 42 216

Institutional and structural racism are related and interconnected. While institutional racism relates to 217 entities such as education and healthcare systems, structural racism refers to wider political and social 218 disadvantages within society, such as higher rates of poverty for indigenous people or higher COVID- Physicians also noted potential effects of structural racism, as nearly 30% of providers noted they 225 encountered more obstacles when providing asthma care for black patients than for white patients, and 226 approximately 25% of physicians felt that during COVID-19, it was more challenging to care for 227 black patients. 23 Although not explored in that study, institutional racism and individual physician 228 Table 2 gives an overview of the areas that can be identified to start assessing and correcting 240 disparities during and after the pandemic. 47 241

There is also a pressing need to decrease systemic racism throughout the medical establishment. Collecting data on disparities and report success and failures of interventions is necessary to 257 understand the true magnitude of the problem. While we start to understand the impact of the 258 pandemic there is a need to maintain essential health services for all. 259 260

The evidence from the COVID-19 pandemic shows the impact of social determinants in the incidence 262 of cases and in mortality. These inequities must be addressed to improve both overall health outcomes 263 as well as COVID-19 related outcomes. The factors that predispose to these disparities include ones 264 J o u r n a l P r e -p r o o f that are easier to address as well as ones that are achievable but will require significantly more effort 265

As Mude et al. 8 

A pneumonia outbreak associated 270 with a new coronavirus of probable bat origin

A Novel Coronavirus from Patients with 273 Pneumonia in China

World Health Organization. WHO Director-General's opening remarks at the media briefing 276 on COVID-19 -11

World Health Organization. WHO Coronavirus (COVID-19) Dashboard

Explaining among-country variation in COVID-19 case fatality 282 rate

The impact of ethnicity on 293 clinical outcomes in COVID-19: A systematic review

Ethnicity and clinical outcomes in 296 COVID-19: A systematic review and meta-analysis

COVID-19 is affecting Black, Indigenous, Latinx, and other people of color 300 the most

COVID-19 and African Americans

Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities

Disparities in COVID-19 Incidence by Age, Sex, and Period Among Persons Aged <25 Years -307

Letter to the Editor: Risk factors for 319 hospitalization, intensive care, and mortality among patients with asthma and COVID-19

During the COVID-19 Pandemic: A Survey of Patients and Physicians

Social disparities in patient safety in 325 primary care: a systematic review

COVID-19 exacerbating inequalities in the US

Prevalence of Comorbidities and Risks Associated with COVID-19 Among Black and 330

Hispanic Populations in New York City: an Examination of the

Race and Asthma Outcomes in Older Adults: Results from the 334 National Asthma Survey

Association Between Ethnicity and Severe COVID-19 Disease

Systematic Review and Meta-analysis. J Racial Ethn Health Disparities

Five Evils: Multidimensional Poverty and Race in America

The Brookings Institution

Health equity and 350 COVID-19: global perspectives

New York City's Frontline Workers

COVID-19 vaccine 354 hesitancy: Race/ethnicity, trust, and fear

African Americans and their distrust of the health care 357 system: healthcare for diverse populations

Disparities in Coronavirus

Knowledge, and Behavior Among US Adults

Challenges posed by the COVID-19 pandemic in the health of women, children, and 396 adolescents in Latin America and the Caribbean

Latin American and the Caribbean Policy Documents Series 398 19

Structural racism and health 400 inequities in the USA: evidence and interventions

Interventions designed to reduce implicit 403 prejudices and implicit stereotypes in real world contexts: a systematic review

Organization for Economic Co-operation and Development. Strengthening the frontline: How 406 primary health care helps health systems adapt during the COVID-19 pandemic

Areas to address regarding disparities during and after the pandemic 1. Identify populations at risk and provide a forum in the news, TV, social media for their voices 2. Develop and provide accessible and vetted information targeting underserved populations

Incentivize vaccinations in local neighborhoods, targeting community leaders, churches and organizations imbedded in the fabric of the underserved populations

Develop culturally responsive, gender and race sensitive targeted interventions in partnership with trusted leaders and community-based organizations within communities

Monitor and collect data on gender/race/ethnicity disparities and accurate reporting of success and failure of interventions

Determine the interactions between asthma and race on outcomes related to COVID-19

Increase awareness about existing inequities the medical community and implement implicit bias training for health care providers at all levels, including those in training