What are the health disparities associated with COVID-19?
Over the past several weeks public health officials and the media have brought to our attention the extensive racial, ethnic, and economic disparities surrounding COVID-19. Black people and American Indians are experiencing the most disproportionate mortality rates. Across the nation, Blacks are 2.4 times more likely to die from COVID-19 as compared to non-Latino Whites and in some states the mortality rate is up to seven times higher. The Navajo Nation has been particularly devastated, as evidenced by mortality rates 5-7 times higher for the indigenous populations in Arizona and New Mexico. A close look at California's statistics reveal dismal mortality rates for Latino Americans between 35-49 years of age, who account for 74% of all COVID-19 deaths in this age group. Furthermore, data from Los Angeles County found that residents from poor neighborhoods are three times more likely to die from the virus than residents from wealthier communities.
Health disparities experts argue that systemic inequalities and discriminatory policies contribute to the unequal distribution of resources needed to maintain optimal health and obtain quality healthcare. Public health data suggests that the elderly and individuals with chronic health conditions such as diabetes, hypertension, and cardiovascular disease experience the worst COVID-19 outcomes. Racial and ethnic minorities in the US suffer from some of the highest rates of these chronic conditions, which research suggests may be, in part, a function of chronic stress (e.g., poverty, discrimination). In the current pandemic, the added stressors associated with unclear health communication, the cost and quality of healthcare, obstacles to social distancing in multigenerational households and overcrowded communities, and the day-to-day risks our essential workers experience, may further exacerbate these already existing health disparities.
What are some of the systemic factors linked to disparities in COVID-19?
The rapid development of the pandemic has led to health communications, which have unfortunately been complex, contradictory, and in some cases untrue. For example, false rumors emerged that Black Americans were immune to COVID-19. The media also showed gatherings which violated social distancing guidelines and implied that Blacks were not taking the threat seriously. Yet, a recent study found that Blacks were nearly twice as likely as Whites to view the virus as a serious threat to their health. Further, the mislabeling of COVID-19 as the "Chinese virus" has caused an increase in stigma and discrimination towards individuals and communities of Asian descent and is a mischaracterization of the threat the virus poses to other groups. Stigmatization may extend to essential workers as well. Some individuals such as the elderly, those who struggle to understand English, and those with less education may experience difficulties comprehending and filtering complex or inaccurate health communication. While misinformation, unclear health communication, and at-risk job responsibilities can be a barrier to taking appropriate self-protection measures, it can also contribute to stigmatization and undue blame.
While state and regionally mandated stay-at-home orders were implemented to protect the health of our nation, for many, staying at home is a luxury. For example, Black and Latino Americans are less likely than Asian Americans and Whites to be able to telecommute for work. Jobs in fields like food service, retail sales, and personal/home health cannot be done remotely. These workers often do not have paid sick time or health insurance and have experienced disproportionate unemployment rates. Social distancing is particularly problematic for people who rely on public transportation and for those living in overpopulated communities and multigenerational households with no alternative locations to isolate sick relatives. Thus, high-risk, low resource communities are particularly vulnerable to the effects of the pandemic.
The economic burden of medical care and health provider bias may also be factors contributing to COVID-19 disparities. Depending on case complexity, the average cost of inpatient treatment for those with employer coverage ranges from $10-20,000 but for the uninsured it is $40-70,000. While the government plans to provide some financial support to hospitals for the uninsured, the remaining cost is likely to cause extreme financial distress for those with no insurance, potentially resulting in delayed medical care and worse outcomes. Existing health disparities literature also illuminates the implications of health professional bias on the quality of healthcare, which may contribute to medical mistrust or suspicion of healthcare providers, organizations, and systems. Collectively the limitations of our healthcare system may inhibit treatment seeking for members of marginalized groups and exacerbate both short and long-term psychological and behavioral outcomes associated with COVID-19.
What are the potential outcomes for marginalized populations during this pandemic?
The mounting psychological, behavioral, and economic outcomes of COVID-19 may have a disproportionate impact on racial/ethnic minorities and individuals from a low socioeconomic status. The weight of social distancing, altered school and work routines, health and financial stressors is new for everyone, but may fall hardest on those already reporting fewer physical and mental health resources. We have little knowledge about the mental health consequences of a global health epidemic, but outcomes of disasters like Hurricane Katrina and 9/11 suggest there will be an increase in the prevalence of mood disorders. In the absence of health resources, people often turn to alcohol, tobacco, and other drugs to cope with crises. Communities that experience the hardest economic strife tend to have higher rates of death due to drug overdose and suicide.
The mental, physical, and social consequences of COVID-19 also extend to children. During this crisis, most parents are juggling to provide homeschooling, adequate supervision, and social/emotional support for their children. It is likely even more difficult for single parents and essential workers. Unsupervised children may be at a higher risk for accidents, engagement in risky behaviors (e.g., alcohol/drugs), or in more frequent contact with abusers. For children who rely on school breakfast and lunch, the consequences of food insecurity are amplified due to school closures. Research suggests that aversive childhood experiences like low parental monitoring, poverty, and drug availability are all risk factors for future mental health and substance use disorders. Thus, COVID-19 may have short- and long-term implications on mental health and substance use behaviors that have yet to unfold.
As this crisis persists, we need to be more circumspect about the mental, physical, emotional, behavioral, and economic hardships of our patients and work to build our capacity to better serve the needs of health disparate populations. We offer the following suggestions:
- Communicate clearly about risks and strategies to keep safe from the virus
- Connect your patients with community resources (e.g., food banks, health services)
- Educate yourself and other health professionals about the historical and systemic contributions to health disparities
- Check your biases and redress mislabeling and misinformation
- Participate/train in telehealth to provide continuity of care and expand our reach
- Consider offering pro bono mental health services
- APM Research Lab: COVID-19 Deaths by Race and Ethnicity (updated weekly)
- Communicating about COVID-19
- Implicit Association Test to Recognize Bias
- Telebehavioral Health Training and Technical Assistance
- Why We Stay Home: Suzie Learns About Coronavirus (free children's book written by two Loma Linda University medical students)