Why Are More Black Americans Dying of COVID-19?

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. Today, we’re talking about COVID-19 and race. Black, Latinx, and Native American people are way more likely to get coronavirus, be hospitalized, and die. This suffering is layered upon a centuries-old crisis that the U.S. has been grappling with: racism against communities of color.

My guest, Dora Hughes, is going to talk about what the COVID-19 racial disparities mean and what can be done about it. And it’s important to say that we’re recording three weeks after George Floyd was killed by policemen in Minneapolis, and there have been protests across the nation, hundreds of thousands of people marching to speak out against police brutality. So in this context of a national reckoning with a centuries-old problem, it’s really important to talk about how the current pandemic is impacting us.

Dora is a professor of health policy at George Washington University and she’s an expert on health equity. Welcome to the show.

DORA HUGHES: Thank you for having me.

SHANOOR SEERVAI: So get us started, Dora, by just telling me what do we know about the disparities and COVID-19 deaths?

DORA HUGHES: Sure. We are seeing pervasive disparities, both in terms of hospitalizations as well as deaths. If we look at a recent study on Sutter Health Hospitals in California, they found that Black Americans were 2.7 times more likely to be hospitalized than white patients. So in the simplest terms, for every 10 white patients that had to be hospitalized, 27 Black Americans had to be hospitalized. And even if we look at the state level, not individual hospital health system data, when New York City released its data, it found that Black Americans were two times more likely to die from COVID than white Americans. And Latinx populations were more than 50 percent more likely to die from COVID-19.

And so, even though I focus on Black and Latinx, we’re also certainly seeing disturbing trends in Native American populations, certain immigrant groups. And so, just across the continuum, both the magnitude and the breadth of disparities it’s been quite disheartening.

SHANOOR SEERVAI: And so, of course, this is shocking and disheartening, but in some ways it just reveals inequalities and health outcomes that have existed for a long time. Correct?

DORA HUGHES: Exactly. We, whether you look on the front end in terms of access to care, whether it’s levels of insurance coverage, or are there enough hospitals or providers in the area? To the back end in terms of who’s getting sick, what types of quality of care are they receiving? Minority groups have traditionally been at the short end of the stick across all of these domains of prevention and care.

SHANOOR SEERVAI: So let’s get into that in detail though. What’s going on? Why are you more susceptible to COVID-19 if you’re Black or Latinx? Why are you more likely to be hospitalized and to die?

DORA HUGHES: Well, it’s very interesting, Shanoor. When policymakers and researchers started looking at it, at first, they focused on the individual-level factors. Like, okay, many minorities are more likely to have diabetes or high blood pressure, respiratory conditions, and that’s why their health outcomes are worse. But as people start to dive a little deeper, even in the most recent analysis by Sutter Health, they found that, oh, wait a moment, even if you correct for these underlying chronic conditions, minorities are still more likely to have adverse health outcomes. And so, what are some of the other factors that we need to think about?

And of course, that logically led people to think about, oh, why is minorities at higher risk? And that really helped to shine a light on what we call social determinants of health. And I think as one easy example is thinking about the types of jobs that minorities are more likely to have. They are more likely to work in the service industry, for example. People of color, 50 percent more likely to work in service industries. So whether that’s in retail or if that’s in grocery stores or frontline occupations such as custodial services, they are more likely to encounter, to work in situations that increase their risk of exposure to individuals who are infected with COVID-19. And so, therefore they themselves are more likely to get the virus.

And then if you think about the other social determinants of health, people think about housing, and again, that increases the risk of exposure. Minorities are more than 25 percent more likely to live with multiple generations in the same household or the same apartment. So it’s the children, the parents, the grandparents all together. And again, that makes it harder to socially isolate. Particularly it’s harder to keep children away from the grandparents who would be at higher risk because of their age. Again, it just works against some of the messaging they’re hearing that in order to minimize your risk, you should socially isolate, you should . . . Particularly if one person gets sick, they should separate themselves into another bedroom or another floor of the house.

All of that it’s impossible in many cases, if you’re multiple generations, a lot of family members are together in the same household. So those are just two examples and certainly we could discuss more.

SHANOOR SEERVAI: For so many people, they are finding themselves on the front line bagging groceries when they’ve never signed up to help the U.S. fight this pandemic in the first place.

DORA HUGHES: Exactly. Exactly. I share your same thinking. I make no secret that I have multiple sclerosis. And so, I am on an immunosuppressant and it’s very easy. I’m doing this podcast from my home. I can rely on others to bring me my groceries and to bring me any other items that I need to stay safe. But others are not so fortunate, whether it’s because of the type of job that they have or because they’re lower income so they can’t afford not to work, or they don’t have paid sick leave. That’s another issue. I know that Latinx populations are the least likely of all groups to have paid sick leave.

And so, all of those social circumstance, social determinants are at play here and very much on display in this pandemic.

SHANOOR SEERVAI: I’m also curious about how these social determinants, as you describe, intersect with those health disparities that you said we see higher incidents of chronic illnesses, but why is that the case? Like why are you more likely to have, you raised high blood pressure and diabetes as examples, why are you more likely to have those chronic conditions if you’re Black or Latinx?

DORA HUGHES: Yeah. So, and that is, you get at a very good point. Minority populations are more at risk for developing chronic conditions for a variety of reasons. One relates to access to care. So maybe you’ve been uninsured or you don’t have access to a health care provider that’s offered screenings to let you know that, oh, you have prediabetes. Here are steps that you need to take. We also know that populations that are very food insecure are more likely across the whole range of chronic conditions. If you don’t have enough food, you are more likely to develop certain chronic conditions. Or if there’s no green space or grocery stores offering certain foods. All of that can lead to chronic conditions.

But even more so, it is also the experience in this country as a person of color, whether it’s the overt racism, discrimination, that so many face, or if it’s the microaggressions, as people describe them, that collectively lead to higher levels of stress which can get to levels of toxic stress. And that plays out through increased chronic conditions, increased blood pressure, increased cortisol.

You know, there’s a lot of biological mechanisms that we don’t necessarily need to dive into here, but those are just as important, in my view, as some of the more physical factors that we talked about, whether that’s appropriate housing or green space or food.

SHANOOR SEERVAI: And so, just to sort of spell it out, what you’re saying is that the stress of being a person of color in the U.S. is actually what makes you more vulnerable to a whole host of diseases. And now, in that sense, makes you more vulnerable to COVID-19?

DORA HUGHES: Yes, all of that together. You can’t disentangle. I mean, it’s hard to say that this factor contributes 10 percent and this factor contributes 50 percent. And is, I like to say, one plus one does not always equal two. I mean, these factors are working together synergistically to elevate the risk for disease and to elevate the risk for poor outcomes.

SHANOOR SEERVAI: And that’s also sort of what we’re seeing when people are protesting, right?

DORA HUGHES: Right.

SHANOOR SEERVAI: Like where people are protesting police brutality. And there have been a series of immediate instances of police brutality that people are protesting, but they’re also protesting the fact that they’ve been protesting this for a really long time and nothing has changed. And so, in a way I feel as if people are protesting against the fact that even this global pandemic, which in some ways has reached every single corner of the country, every single corner of the world, but it is still worse for you if you are a Black American, an American of color?

DORA HUGHES: Yes. And make no mistake. When we talk about social determinants of health, although a lot of times the reports will focus on or analysis will focus on housing or food or transportation or education, another social determinant of health is community safety. And that very much reflects levels of police brutality or other violence, or the risk of violence that many people of color experience on a daily basis or regularly basis.

And so, it’s not just when these murders that we’re seeing that have really helped to galvanize the protest, but it’s also for many just being pulled over constantly by the police or having that negative presence in your community or unfair rates of incarceration or school suspensions and expulsions. I mean, it’s the whole spectrum of issues that reflect the justice systems and legal sectors that are very much a very important social determinant consideration for a lot of minority communities.

SHANOOR SEERVAI: So you make a really important point, Dora, about the stress and the risk exposure to COVID-19 at every single level for Black and Latinx communities. But what has the government done? What have policymakers done as they started learning about these disparities?

DORA HUGHES: In terms of the government, I think that some policymakers were caught a bit flat-footed in terms of the disparities. Certainly, they were not unexpected, but I think the magnitude of the disparities was shocking to many, not to those of us that have been working in this field for so long, certainly, but for many. And the first problem that we encountered was just the data wasn’t being collected for certain racial, ethnic minority groups, or it was being collected, but not reported. And so, we lost the opportunity to take a number of steps to mitigate the impact on these groups.

One is in terms of how do we target the resources? We know that even in their earliest waves of funding, some of the hospitals and health systems that were treating more minority groups did not receive as much funding support as hospitals that had a higher share of privately insured patients, for example.

So it’s being able to allocate those resources, to know where the hotspots are and to get in front of that. That opportunity was lost. Some of it was in terms of communication and messaging to different groups that maybe are not being reached by mainstream media. There are different groups, whether it’s the faith-based community or other public health allies or community health workers that may have been better positioned to liaise with certain minority groups. And that is another example.

And then there’s other just very concrete examples. I mean, how do we define essential health workers? Who is getting the PPE, the masks, the gloves, the Purell, that could help to minimize the risk or to keep populations safe? And so, we certainly focus on hospitals and health care systems. What about nursing homes? And we’re able to see that seniors and others in nursing homes and group homes were terribly impacted, of course. And there may have been other groups that we had to think about more creatively like homeless individuals would be another population. So, on the front end, there is a number of issues that had to be overcome.

SHANOOR SEERVAI: So if we think about what we should do or could do to address racial disparities, if there is a second wave or future waves, what would you recommend? What would you tell policymakers?

DORA HUGHES: That we need to both think from the individual patient perspective, but also at a community level, at a state level, how do we address some of the systems and structural drivers of inequities that we saw, that we’re continuing to see in this first wave, that we can mitigate in the fall? And there’s going to be another overlay of considerations. We’re talking about contact tracing, how is that going to play out in communities of color where there’s already a level of distrust anyway for providers and individuals that are not known?

I think I saw one story. In one housing area the national guard was sent in to do the testing and not surprisingly, the community residents were concerned about these strangers in military uniform coming and knocking on the doors. And so, it’s being mindful, how is this contact tracing, how is that going to play out in different communities?

And then also when we have the vaccine, how is that going to be distributed? And particularly in areas, again, where there are scarce or fewer health care resources, whether it’s hospitals or providers or clinics, how are we going to make sure that we are fairly providing access to the vaccine, particularly for higher-risk populations?

And so, that is going to be the additional burden that we’re going to have to face whether it’s during the second pandemic or the end of the year, that this is the time that we need to start thinking through now so we’ll be ready.

SHANOOR SEERVAI: Are you hopeful that this is something policymakers are thinking through? Do you think that they are making the disparities in the burden of COVID a priority when it comes to ideas about what the public health response will be going forward?

DORA HUGHES: Absolutely. I’m hopeful. I am seeing the medical, the public health, and social service sectors come together already to start thinking through what is it that we need to do better as part of this existing pandemic, what are we going to be doing in the rebuilding and recovery process? Could there be some type of permanent mandatory funding for a public health infrastructure fund so that we can ensure that the public health community has the resources it needs on a regular basis to try to prevent and delay onset of chronic disease? So that’s one example.

And the other example that I would offer is starting to think through if we want to empower communities, and that’s where decisions are made, policies are put in place. How can you make sure that the community voice is represented in some of these funding decisions as more resources are coming from the federal government and how do we make sure that their voice is represented across multiple sectors, trying to bring together the business community, the health community, employment, education, legal, altogether, along with the community voice to think about how do we rebuild our community? How do we innovate to try again to address social determinants of health in a sustainable fashion? And that is another area that’s being discussed by a number of different groups.

And so, I think both of those are encouraging that we’re not just thinking about how do we get back to where we were, but how do we get to where we should be, moving forward?

SHANOOR SEERVAI: And when we think about where we should be, again, in the context of these recent protests, on the one hand it’s really heartening to see so many hundreds of thousands of people marching day after day, standing up for something they believe in, but on the other it is also a little bit scary to think about this in the context of this highly contagious disease that’s spreading. Do you think the protests will help or hinder the response and the next wave of COVID-19?

DORA HUGHES: Well, certainly, I mean, that’s a tricky question. And certainly, in terms of the mass protests, it may lead to increased levels of infection because individuals are together in the streets protesting and certainly not socially distanced as their public health leaders have advised. But at the same time though, I think the combination of COVID-19 in the context also with the police brutality and the killings, I just think that it has really helped to galvanize awareness and mobilize support in ways that we, as the medical community, could never have accomplished on our own.

And I think that it has really brought so many more Americans who maybe were aware, but more on the sidelines, have really brought them into this movement, into this discussion. There seems to be a commitment to addressing this at the highest levels. And I think that was such an extraordinary level of support, not just in the U.S., but across the world, that we are at an inflection point and that we will be able to move forward. I mean, I’m optimistic, cautiously optimistic, but optimistic, nonetheless, that we have the commitment to move forward. And so, certainly the onus is on us to translate all of this energy and passion into action. But I think we can do this.

SHANOOR SEERVAI: Well, let’s end on a note of optimism then. Thank you so much for joining me today.

DORA HUGHES: Thank you. Thank you very much.