Explaining the Covid-19 disparities disparity.

Black and Hispanic people suffered huge early losses. Then the paths diverged.

As I wrote several days ago, new research my colleagues and I published in the Centers for Disease Control and Prevention’s medical journal Morbidity and Mortality Weekly Report included an unexpected finding regarding racial disparities during the Covid-19 pandemic. While Black and Hispanic people over the age of 25 suffered the greatest relative increase in deaths during the first six months of the pandemic, in the late fall and early winter, something changed. The magnitude of excess deaths—that is, the increase in deaths of all causes above normal rates in any given period of time—rose for all groups; but the disproportionate effects recorded among Black people during the previous two major waves disappeared. By the end of 2020 and early 2021, Hispanic people were still the most disproportionately affected group. But along with White people, mortality among Black people was now the closest to seasonal norms of any race. In other words, the effect of Covid-19 continued to disproportionately affect Hispanic people, but not Black people. The animation created for Inside Medicine below shows this playing out.

Since I first noticed this finding, I’ve spent a lot of time thinking about some of the potential reasons behind it. I reached out to six physicians of color with relevant expertise for their insights and analyses. In our emails and phone conversations, some themes emerged.

Mitigation worked in the Black Community.

Dr. Jerome Adams, who served as the 20th Surgeon General of the United States: “I do feel in my personal life that I see far greater percentages of the Black community embracing mitigation versus other races. Many of them stayed home/hunkered down as instructed. My intuition is that, interestingly, Black people were much more able to access government supports that were designed to facilitate social distancing than many Hispanic/Latino people were. Anecdotally I’ve also seen many more Black people wearing masks in public than other racial groups- both white and Hispanic.”

Dr. Rhea Boyd, pediatrician, public health advocate and scholar, and the Director of Equity and Justice for The California Children’s Trust: “Speaking in churches over the past 7 months, I heard from folks who lost multiple family members, attended funeral after funeral for beloved neighbors and friends, and as a result, changed many of their daily routines (like staying home all year and having groceries brought by a friend), began projects to look out for neighbors and bring them food or take them to doctors’ appointments, or worked to get other community members vaccinated."

Geography, affluence, and local policy.

Adams: “You have to look at demographics and spread patterns. The virus hit big cities first. In the big cities you tend to have affluent (i.e. healthier and with greater opportunities to protect themselves) White people, but you also have less affluent (and often less healthy) minorities, and in more crowded living conditions. This spread pattern really amplified the impacts of disparities in the social determinants of health. Further, in New York City, many White people just plain left the city when Covid-19 got bad, while most minorities had no choice but to ride it out. As the virus then spread to suburbs and rural areas, it found fewer Black and Hispanic people, but increasing numbers of less affluent and less healthy White people."

Dr. George Alba, an Intensive Care Unit physician at Massachusetts General Hospital/Harvard Medical School, Associate Director of its Coronavirus Recovery (CORE) clinic: “States where the largest proportion of Hispanic people live (like Texas and Florida, which have a comparatively lower proportion of Black people) failed to implement policies to mitigate the spread of COVID-19 placing Hispanic people at ongoing increased risk of exposure, illness, hospitalization, and mortality.”

Hispanic/Latino people have been less able to avoid high-risk exposures.

Dr. Andrew Marshall, an emergency physician at Brigham and Women’s Hospital/Harvard Medical School, with expertise in bioinformatics (and a co-author of the CDC study): “Front line workers. I hate to generalize so grossly – but a lot of our immigrant population works with their hands. Contractors, cleaners, food services. Long hours, hard work, with not a lot of pay. I know I ran into many patients that told me they could not afford to take the two weeks off work to isolate [after an exposure or infection]. Also, household/living situations–living with parents, siblings, cousins, shared childcare, shared transport—is really common, with multiple families in one household or a single car per household.”

Media coverage has been uneven.

Covid-19 disparities received media attention starting in the spring and summer of 2020. But data suggest that media coverage more frequently covered disparities in the Black population than those among Hispanic/Latino populations, which were often as bad or worse.

Adams: “I still remain concerned that there are few to no prominent Hispanic, African American, or Native American physicians being featured by the White House via their national platform and opportunities (e.g. speaking on behalf of the Administration at press conferences, and on primetime or Sunday morning shows), but I’ve also always believed the best engagement is local.”

Alba: "There is a relative dearth of prominent Hispanic academics, researchers, policymakers, etc on television. In comparison, the Black community was able to mobilize prominent voices to speak to the inequities impacting their communities."

Dr. Cedric Dark, an emergency physician at Baylor College of Medicine in Texas, and a health policy expert: “Correlation isn’t causation, but I first heard about the atrocious disparities from COVID listening to Uché Blackstock on NPR driving into the hospital in the middle of the first wave. After that, there were so many Black voices amplifying those facts.”

Language barriers are information barriers.

Marshall: “Language barriers. This goes beyond just day-to-day communication. Sources of information/news in the Hispanic/Latinx community might be completely different than in English speaking communities. Translating public health information also is often an afterthought. I think this leads to delays in getting the message through.”

Alba: “I would also add that populations with proficiency in languages other than English face additional barriers to equitable care, something experienced by Hispanic populations. Effectively communicating with non-English-speaking populations is already challenging at the point-of-care in our current system (inability to access sufficient numbers of interpreters in medical settings, paucity of language-concordant clinicians, etc.), and it is even more challenging when the media ecosystem in the US is majority English-speaking. We need more Hispanic voices on TV (beyond Univision), on the radio, and out in the community to counter misinformation.”

Access matters.

Marshall: “Interactions with the Healthcare system. I think the same mistrust of the medical system exists in the Latinx/Hispanic community as in the general American population. I think this can be perpetuated by the language barrier, spiritual beliefs, and a layer that American-born citizens don’t generally have to deal with—concerns about legal status/insurance. Pretty low rates of primary care utilization, high rate of emergency room utilization only after symptoms have been going on for a while and are severe.”

Alba: “Most importantly, we need more Hispanic doctors providing language concordant care and advocating for patients. We need to strengthen the pipeline of BIPOC physicians, nurses, etc.”

Boyd: This is also a population that is eligible for Medicare. Did having access to health insurance change the likelihood that Black people sought care for COVID or other ailments in a way that is distinct from the other age cohorts?"

(note: To Dr. Boyd's point, it is well-documented that White people are most likely to have a primary care physician. Meanwhile, Black people are less likely and Hispanic people are the least likely to have a primary care physician).

Summary

Dr. Carlos del Rio, an infectious diseases expert at Emory University School of Medicine and Professor of Epidemiology at the Rollins School of Public Health: “How did this happen? What can we learn about the Black community? Why did excess mortality drop so precipitously among them? Also, what happened in Hispanic populations? Could it be that Hispanic people included many undocumented workers who were not eligible for financial support from the government and thus had to continue working? Could it be an issue of language and inability to understand the public health messages in English?"

Boyd: “Structural racism shapes who has to disproportionately weather and survive economic downturns, evictions, food insecurity, health care inaccessibility, and the harms of discrimination and white supremacist violence, and who does not. During the pandemic, all of these forces converged with a deadly infectious disease to place Black folks, predictably, at higher risk for death. But looking at the graphs, the fundamental question is not simply what caused the excess mortality, but more directly, how do Black folks survive? How did the summer of protests foster spaces for Black folks to develop collective survival strategies, advocate for eviction moratoriums, changes to policing policies, more access to health care, and sharing material resources? These collective actions for justice resulted in material changes in people's lives nearly immediately, because of their community advocacy. To summarize all these things, I attribute the lower mortality spikes in subsequent waves to Black people's work to survive, not as individuals but as a collective (as families, as neighbors, as friends) in the face of death all around them, despite the odds."

What do you think explains these changes? What can we learn from the Black population’s turnaround? What can we do to improve systemic disparities during and after the Covid-19 pandemic? Leave your comments below.

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Special thanks to Dr. Kristen Panthagani for data visualization created for this Inside Medicine article, to Dr. Lauren Rossen of the National Center for Health Statistics at the CDC (my primary co-author on the CDC manuscript), my colleagues at Harvard Medical School/Brigham and Women’s Hospital, and my collaborators at the Yale School of Medicine’s Center for Outcomes Research and Evaluation, led by Dr. Harlan Krumholz. I am also grateful to the experts who participated in this roundtable.

References and further reading:

My team's paper in the CDC's Morbidity and Mortality Weekly Report: https://www.cdc.gov/mmwr/volumes/70/wr/mm7033a2.htm

Media coverage of Covid-19 disparities in the Hispanic/Latino population was low: https://salud-america.org/data-latinos-make-up-less-than-2-of-covid-19-media-coverage/

White people in the United States are more likely to have primary care physicians than other races: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2757495