En español | COVID-19 has affected every aspect of American life. But while each of us has felt some level of impact, one fact is inescapable: Across the country, African American and Hispanic or Latino communities have been hit harder. Much harder.
In Louisiana, for example, black people make up less than 33 percent of the population but account for 56 percent of deaths from COVID-19. Likewise, Chicago's black residents make up 30 percent of the population but account for 48.7 percent of deaths.
What's going on here?
Studies continue, but initially no research has emerged to confirm — or rule out — a genetic role in COVID-19 severity or susceptibility. “There isn't anything per se about race, as in black or African American, or ethnicity, like Hispanic or Latino, that would necessarily put one at a higher risk for infection,” says Clyde W. Yancy, M.D., chief of cardiology at Northwestern University's Feinberg School of Medicine. “It is the living circumstances in which these populations reside,” he says, that is responsible for the elevated infection and mortality rates.
While the statistics may seem shocking, those who study public health are anything but shocked. In fact, this is exactly how they figured a potential pandemic would play out.
"COVID-19 is taking the gaps we know exist in health care, from an ethnic and socioeconomic standpoint, and not just amplifying them but making them scream out,” says Panagis Galiatsatos, M.D., assistant professor of pulmonary and critical care medicine at Johns Hopkins Medicine.
The core question — why are infection and death rates so high in black and Latino communities? — has several answers. They run on a timeline, with the very first part — exposure to the virus — offering the first answer.
Why infection rates are higher
According to the Centers for Disease Control and Prevention (CDC), “the places where people live, learn, work and play affect a wide range of health risks and outcomes.”
That means the jobs, schools and housing that define an individual's life also define his or her health risk. Another issue is “health disparity,” which means the difference in access to medical care, quality foods and other aspects of a healthy lifestyle. These two factors go a long way toward explaining how the virus gets a firmer toehold in certain communities.
- Housing density. Social distance has been critical in limiting the spread of the virus, but in lower-income urban populations, a distance of 6 feet can be a luxury. “Asking people who live in very dense households or public housing to quarantine and isolate is incredibly challenging,” Galiatsatos says. “It goes against how those buildings are constructed, and goes against the nature of their family units. That's easily why this virus is spreading so vigorously in these communities."
- Employment. Bottom line: It's impossible for many black and Latino people to self-quarantine because they are often essential workers in areas like health care and public transit. And they often can't afford to stay at home and not work. Galiatsatos puts it bluntly: “Quarantine is a privilege."
- Lack of quality food. Poor diet can compromise immune system function and raise health risks across the board. The problem is twofold: First, “food deserts,” or regions that lack retailers offering healthy food; and second, people making unhealthy choices even when healthy fare is accessible.
"We have a safety net with school and senior center feeding programs,” says Karen Glanz, professor of epidemiology and nursing at the University of Pennsylvania. “But a lot of those aren't operating right now. Food security is challenging even in normal times, and much more so during this pandemic.”
Why death rates are higher
The immediate goal after a coronavirus infection is to prevent disease progression, but underlying health issues (called comorbidities) encourage the disease to worsen. That leads to more severe symptoms, plus complications specific to this disease such as a toxic immune response (the so-called cytokine storm that can cause respiratory distress), excessive blood clotting, kidney failure and heart failure.
The following factors are found at greater levels in many communities of color, and all increase one's vulnerability to COVID-19.
- Age. The triple combination of age, underlying medical conditions and an environment of poverty is deadly. “As we get older, we're less able to mount an immune response under settings of stress,” Yancy says. “This is certainly not limited to African Americans. It's ubiquitous in our population. The older person with other diseases is exactly the person we should make every effort to keep from contracting the coronavirus.”
Age is a one-two punch, Galiatsatos says. First, immunosenescence, age-related decline of the immune system, raises vulnerability. And second, the older you are, the longer you've been subjected to negative social determinants of health. “Everything gets amplified if you're carrying comorbidities into old age because you have decades of lifestyle that result in diabetes and high blood pressure.”
- Obesity. Being overweight makes people more vulnerable and harder to treat, and black and Hispanic populations have higher obesity rates in general (38.4 percent of black adults and 32.6 percent of Hispanic adults are obese compared with 28.6 percent of white adults, per the CDC)
"Obesity is a pro-inflammatory stimulus,” Yancy says, meaning that excess fat raises the level of inflammation, which is linked to type 2 diabetes and heart disease. On top of that, an obese body is a physically compromised body that has low cardiovascular fitness. Excess belly fat can even press against the diaphragm, making it harder to fill your lungs. None of that is good while a person is fighting a disease that attacks the respiratory system .
Researchers have begun connecting these dots: A study of 4,103 COVID-19 patients in New York City found that age (older than 65), obesity and high inflammation levels were the leading factors leading to hospitalization. “We can't say that obesity actually causes the complications that lead to death; that will require more research,” Yancy says. “But we can say that for those who are obese, the risk for COVID-19 complications is higher.”
- Hypertension. High blood pressure has historically been more prevalent in African Americans — 40 percent of black adults have it compared with 28 percent of white and Hispanic adults — and the condition appears to be linked to poor COVID-19 outcomes. About 57 percent of people hospitalized in the New York City area had hypertension.
"We know from literature that's already been published from Asia and Europe that there are several variables that put people at risk for the most disheartening complications,” Yancy says. Consistently, hypertension is among the strongest risk factors, along with diabetes and obesity.
- Higher blood clot risk. Research has already shown that many COVID-19 patients develop thromboembolic disease, or extreme blood clotting, particularly in the small vessels of the lungs. One marker for this is a protein called D-dimer, which appears in the blood when the body destroys clots. High D-dimer levels are associated with cardiovascular disease risk, but doctors are finding elevated levels in virus patients.
Research has shown that African Americans are at a much higher risk for elevated D-dimer levels. One study of nearly 4,200 African Americans found they had higher D-dimer levels than people of European descent. Another study showed that elevated D-dimer levels could be related to a genetic variant related to sickle cell. It's not yet known if there's a link or if someone with already-elevated D-dimer levels has a higher risk for blood clotting complications in COVID-19, Yancy says. “Yet the risk of blood clotting in COVID-19 is higher and may be of greater consequence.”
- Lack of testing. This goes back to employment. Jobs in underrepresented communities are less likely to come with health insurance; many people remain uninsured despite the Affordable Care Act. In many cases, getting tested for COVID-19 requires a primary care physician's recommendation and transportation to a testing site. The lack of these critical needs may be suppressing official case numbers in black and Hispanic communities, experts say.
"A lot of urban communities have limited access to testing,” Glanz says. “Some testing sites are drive-through, and a lot of people don't have a car.”
Galiatsatos takes it further. “If people have symptoms but aren't bad enough for hospitalization, we tell them to go for testing. Well, they can't take public transportation because that's a violation of public health policy. I can't ask them to ride with a friend because that puts the friend at risk. So what we do is ask them to keep us posted on how they're doing. If they get worse, we may have to call 911. But the testing numbers are so low for these communities because the only way they can come for testing is if they're hospitalized."
This leaves untold numbers of likely COVID-positive people unquarantined and unable to prevent the spread of the disease.
Why this conversation needs to continue
Given how the disease has devastated communities of color, will anything change?
"These outcomes are the result of decades of institutional racism,” Galiatsatos says. “Can we come together and commit to overcoming these health disparities in the future? I'm hesitant. If there is a silver lining later, we should take it, but it's going to come at a disproportionate cost of life for very specific populations.”
"If the ultimate analyses confirm that blacks are six times more likely to die, then we have reached an incredibly important pause moment,” Yancy says. “I've been looking at health care disparities for a long time. It's not frequently that we discover differences of this magnitude. This is 600 percent more likely association with death. That is a halting comment. It may be the numbers settle out at less, but even if it's twofold or greater, that will be so much more substantial than any other health difference we've seen as a function of race. We will be compelled to act.”
Mike Zimmerman is a health journalist and author of The 14-Day Anti-Inflammatory Diet.