It's Not Unhealthy Behavior. It's Systemic Racism.

Why is COVID-19 disproportionately killing Black people and people of color?

With Estelle Williams MD and Kristen Azar RN, MSN, MPH

Even when we account for other factors that people tend to use to blame Black people and people of color for their poor health outcomes, such as lifestyle factors, socio-economic status, and other health issues such as diabetes and obesity, the discrepancy in COVID-19 cases and deaths still exists based on race alone.

It was the face-palm heard around the country. During a Senate hearing over whether to declare racism a health crisis, Ohio state senator Stephen Huffman speculated about the cause of disproportionately higher COVID-19 infection and death rates among Black communities. “Could it just be that African-Americans, or the colored population, do not wash their hands as well as other groups or wear a mask or do not socially distance themselves? Could that be the explanation of why the higher incidence?”

As absurd as this explanation sounds, many other people have speculated that the higher Coronavirus rates among Black people and people of color are due to lifestyle choices, or a disregard for health among those communities. It’s almost as if people are looking for ways to blame Black, Latinx, and indigenous people for getting sick.

As the COVID-19 pandemic rages on, one thing has become impossible to ignore: This virus is affecting Black and Latinx people disproportionately more than any other ethnic or racial group. According to recent data from the CDC, Black and Latinx people have been nearly twice as likely to die from the Coronavirus as white people, while five times as many Latinx people between 40 and 59 are being infected as white people in the same age range. But they are not, in fact, to blame for suffering more from the Coronavirus.

As states, communities, health organizations, and other groups begin to publish more specific research about what’s happening in their areas, a distinct pattern is emerging:

  • According to the Center for Medicare and Medicaid Services, Black Medicare patients with COVID-19 are nearly four times as likely to end up in the hospital, and Latinx patients are more than twice as likely as non-Latinx white patients.
  • A report by Dr. Jarvis T. Chen of The Harvard Center for Population and Development Studies shows the death rate from Coronavirus in predominantly non-white communities is six times higher than it is in non-Hispanic white communities.
  • The Navajo Nation has over 4,000 cases among its population of 173,667. With that infection rate of 2,304 per 100,000 people, it has recently surpassed New York (1,806 per 100,000) as the region in the US with the highest infection rate among its residents.
  • A study by Sutter Health system looked at data from 1,052 confirmed Coronavirus cases and found that Black patients were nearly three times more likely to be hospitalized than non-Latinx white people, with one in four going into the ICU compared with one in ten white patients. 

The Sutter Health study adjusted for age, sex, comorbidities, and income. This means that even when we account for other factors that people tend to use to blame people of color for their poor health outcomes, such as lifestyle factors, socio-economic status, and other health issues such as diabetes and obesity, the discrepancy in COVID-19 cases and deaths still exists based on race alone. But why?

As a result of systemic racism, Black people and people of color are more likely to:

  • Live in densely populated areas
  • Live in multigenerational households
  • Have language barriers that prevent them from accessing important health advisories
  • Have higher rates of diabetes, high blood pressure, and cardiovascular diseases; all of which correlate with severe outcomes

As a result of systemic racism, Black people and people of color are less likely to:

  • Have health insurance, especially high-quality insurance
  • Have access to healthcare, especially quality healthcare
  • Live near healthcare centers
  • Have access to healthy food
  • Have space to self-isolate at home
  • Have paid sick leave

As dire as these disparities look, they may be even more severe than these reports show. When a new analysis from the Brookings Institution grouped mortality numbers by age, the racial and ethnic disparities widened considerably. In other words, when not adjusted for age, the death rate is two times higher for Black people, and for Latinx and white people it’s about the same. Factor in age, and the death rate for Black people is 3.6 times higher than for white people, and for Latinx people it’s 2.5 times higher.

"Unfortunately, these patterns are nothing new," says Dr. Estell Williams, assistant professor of surgery at the University of Washington School of Medicine. “When we had the H1N1 epidemic, we saw the same disparities.” And there are several reasons why we’re seeing that pattern again now.

Employment and access to quality health insurance are linked factors. Most Americans with private health insurance get theirs through full-time employment. It’s harder to pay for health insurance if you’re paying for it yourself, especially if you are self-employed or working part-time. So, knowing that unemployment rates in the US have been two times higher for Black Americans than for white Americans for the past 60 years tells you something about this relative access to healthcare. Even Black people with college degrees are twice as likely to be unemployed.

“Healthcare is tied to our employment within this country,” says Dr. Williams. “So if you don't have gainful employment, you don't have good health insurance. Those are the sorts of intersections that people fail to realize. This is systemic racism.” Don’t believe racial discrimination is at play in hiring? Dr. Williams notes that Black job applicants are twice as likely to get an interview when they have white-sounding names. And layoffs in the wake of the pandemic have hit Latinx and Black employees harder than white workers.

Being an essential worker puts you at a greater risk for COVID-19

If you are employed, the type of work you do is hugely important to your level of risk. Black and Latinx people are more likely to work as essential workers in on-site jobs, which exposes them more to the virus. People of color comprise about 33% of the population nationwide, but they make up 43% of all essential workers. Move to the epicenter of the pandemic, New York City, and we see that people of color comprise 75% of the city’s essential workforce.

Break essential workers into specific occupations, and the numbers get more dire: 60% of warehouse workers and 74% of janitors are people of color. Of New York City’s transit workers, 45% are Black and 24% are Latinx. Over 3,000 transit workers have tested positive for COVID-19 and 83 have died of the virus.

The meatpacking industry was declared “critical infrastructure” under the Defense Production Act by executive order after the chairman of Tyson Foods sounded alarms over a possible meat shortage. This is an industry that’s been hit especially hard with COVID-19 cases and where people of color do the majority of the labor: 44.4% of meatpacking workers are Latinx and 25.2% are Black. But there was no food chain disruption. Instead, American meat companies shipped record amounts of pork to China. Meanwhile, some 24,715 meatpacking workers in the US have tested positive for the Coronavirus and 89 people working at these plants have died. At Tyson plants in Arkansas, some 481 workers out of 3,700 tested have become infected (as of June 19), with nearly half of those coming from a single plant in Springdale.

All of these factors add up to a perfect storm leading to higher rates of infection and much worse outcomes from COVID-19 for people of color. But they don’t really get to the root of the problem. We need to dig deeper and ask ourselves: Why do these factors exist in the first place?

Making the connection between systemic racism and health

There is an intersectional relationship between systemic racism and health. It explains why people of color have jobs that put them at higher risk and why Black and Latinx people live in more dense communities where there’s less access to healthy food and where healthcare centers are further away or are under resourced.

In yet another study of racial and ethnic differences in death rates from Coronavirus, MIT Sloan School of Management economist Chris Knittel accounted for income, health insurance coverage, rates of smoking, diabetes and obesity, and public transit use. Still, the health disparities persisted. Knittel believes factors such as chronic stress and systemic discrimination are likely causes.

The Sutter study comes to a similar conclusion. It points to structural racism and unconscious bias as likely causes for the higher rates of hospitalization for the virus.

According to Kristen Azar, RN, MSN, MPH, and Sutter Health’s lead author for the study, “In terms of epidemic exposure, the disproportionate economic pressure that some groups are facing influences how and when patients seek care, and the lack of options for primary care, including the barriers and challenges to obtaining and accessing primary care. We think those are the primary contributors to what we’re seeing.”

Even the famous Dr. Anthony Fauci has admitted as much. In a congressional hearing on June 23, when Rep. Bobby Rush (D-Ill) asked about the role of racism in infection rates and outcomes, the National Institute of Allergy and Infectious Disease director and member of the White House Coronavirus task force conceded, “Obviously the African-American community has suffered from racism for a very, very long period of time, and I cannot imagine that that has not contributed to the conditions that they find themselves in economically and otherwise.”

And while doctors have largely been considered heroes in the fight against COVID-19, even they don’t always see the role of structural racism in a health crisis. “By thinking that we are somehow neutral or colorblind in treating health outcomes and chronic illness and the health disparities we see, and that it can be fixed by only talking about exercise, diet, and taking medication as prescribed by a doctor,” says Dr. Williams, “you’re actually doing a disservice to your patient. You’re not getting to the true root cause that will truly impact their health. It’s like putting a band-aid on an open wound that will never heal.”

How can we address racial and ethnic disparities around COVID-19?

The Sutter study was produced in the hopes of making an impact that will hopefully help to head off further disparities in the second wave of the virus, says Azar. 

“Because of this study, we have been actively seeking partnerships with communities in Oakland, California, which is an especially hard-hit area, to support testing and contribute to their contact tracing efforts,” she says.

The data from the study provides insights that help pinpoint communities that are hardest hit by the virus. The researchers are also re-analyzing that data and collaborating with other groups across California to find areas that need more resources, so that those needs can be addressed more effectively and efficiently. They’re also looking into partnering with private sector employers to help bring testing to essential workers, as well as offering unconscious bias training for physicians.

Dr. Williams is doing similar work. She and other medical professionals are creating antiracist programs for the medical community. Dr. Williams is helping to develop a CME for physicians to obtain healthcare disparities and anti-racism education in collaboration with the King County Medical Society. Emergency physician Dr. Uche Blackstock founded Advancing Health Equity, which provides healthcare organizations with tools to better serve their diverse patient population. Meanwhile, physicians at the University of Michigan developed the Cultural Complications Curriculum as a tool for QA/QI evaluation of systemic racism and implicit bias in medical care.

“As a Black woman, my identity represents a lot of the demographics and the disparities that we see within medicine,” says Dr. Williams. “I see a lot of those same disparities and health outcomes play out in my own family. And those were the initial driving forces behind my wanting to become a physician in the first place, in order to have an impact.” 

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