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COVID-19 and African Americans

Much has been published in leading medical journals about the phenomenon of severe acute respiratory syn- drome coronavirus 2 (SARS-CoV-2) infection. The result- ing condition, coronavirus disease 2019 (COVID-19), has had a societal effect comparable only to the Spanish flu epidemic of 1918. As the flow of clinical science has bet- ter informed the contemporary narratives, more is being learned about which individuals and groups experience the most dire complications. Researchers have empha- sized older age, male sex, hypertension, diabetes, obe- sity, concomitant cardiovascular diseases (including coro- nary artery disease and heart failure), and myocardial injury as important risk factors associated with worse out- comes; specifically, case-fatality rates vary over 100%.1-3

These data sourced from China and Europe have not been replicated in the US, but the US experience may never- theless represent similarly distressing outcomes in these highest-risk phenotypes.

The concerns about these observations are appro- priate and the published data are indeed actionable; those who fit the highest-risk phenotypes can be ad- vised to assiduously adhere to safe practices including hand hygiene, use of masks in public spaces, and social distancing/physical isolation.4 These measures not only are flattening the curve but are no doubt saving lives. However, a new concern has arisen: evidence of poten- tially egregious health care disparities is now apparent. Persons who are African American or black are contract- ing SARS-CoV-2 at higher rates and are more likely to die.5

Why is this uniquely important to me? I am an aca- demic cardiologist; I study health care disparities; and I am a black man.

What is currently known about these differences in disease risk and fatality rates? In Chicago, more than 50% of COVID-19 cases and nearly 70% of COVID-19 deaths involve black individuals, although blacks make up only 30% of the population. Moreover, these deaths are concentrated mostly in just 5 neighborhoods on the city’s South Side.6 In Louisiana, 70.5% of deaths have occurred among black persons, who represent 32.2% of the state’s population.7 In Michigan, 33% of COVID-19 cases and 40% of deaths have occurred among black individuals, who represent 14% of the population.5 If New York City has become the epicen- ter, this disproportionate burden is validated again in underrepresented minorities, especially blacks and now Hispanics, who have accounted for 28% and 34% of deaths, respectively (population representation: 22% and 29%, respectively).8

The Johns Hopkins University and American Com- munity Survey indicate that to date, of 131 predomi- nantly black counties in the US, the infection rate is 137.5/ 100 000 and the death rate is 6.3/100 000.5 This infection rate is more than 3-fold higher than that in pre- dominantly white counties. Moreover, this death rate for predominantly black counties is 6-fold higher than in pre- dominantly white counties. Even though these data are preliminary and further study is warranted, the pattern is irrefutable: underrepresented minorities are devel- oping COVID-19 infection more frequently and dying dis- proportionately. Do these observations qualify as evi- dent health care disparities?

Yes. The definition of a health care disparity is not simply a difference in health outcomes by race or eth- nicity, but a disproportionate difference attributable to variables other than access to care.9 Given the known risk factors for COVID-19 complications, the conflu- ence of hypertension, diabetes, obesity, and the higher prevalence of cardiovascular disease among black per- sons may be driving these early signals. Data fully ad- justed for comorbidities have not been reported but it is likely that some, if not most, of these differences in dis- ease rates and outcomes will be explained by concomi- tant comorbidities.

But concerns go beyond these comorbidities. Where and how black individuals live matters. If race per se en- ters this discussion, it is because in so many communi- ties, race determines home. Once adverse outcomes at-

tributable to known risks for COVID-19 complications are disaggregated from total morbidity and mortality burden due to COVID-19, the pernicious influence of adverse social determinants of health is likely to become apparent.10 The commu-

nities where many black people reside are in poor areas characterized by high housing density, high crime rates, and poor access to healthy foods. Low socioeconomic sta- tus alone is a risk factor for total mortality independent of any other risk factors. These social determinants of health must be considered in a complex equation, includ- ing known cardiovascular risk factors, which puts under- represented minorities who live in at-risk communities at greater risk for disease, not just for cardiovascular dis- eases but now for COVID-19 mortality.

The most effective strategy known to reduce COVID-19 infection is social distancing, but herein lies a vexing challenge. Being able to maintain social distanc- ing while working from home, telecommuting, and accepting a furlough from work but indulging in the plethora of virtual social events are issues of privilege. In certain communities these privileges are simply not accessible. Thus, consider the aggregate of a higher burden of at-risk comorbidities, the pernicious effects of adverse social determinants of health, and the

The US has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event.

VIEWPOINT

Clyde W. Yancy, MD, MSc Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.

Related article page 1905

Corresponding Author: Clyde W. Yancy, MD, MSc, Division of Cardiology, Northwestern University, FSM, 676 N St Clair, Chicago, IL 60611 ([email protected]).

Opinion

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absence of privilege that does not allow a reprieve from work with- out dire consequences for a person’s sustenance, does not allow safe practices, and does not even allow for 6-foot distancing. The consequent infection and death rates due to COVID-19 complica- tions are no longer surprising; they should have been expected. These observations are rooted in the recalcitrant reality of the deeply entrenched history of health care disparities and may settle as the most painful example yet of the regressive tax of poor health. COVID-19 has become the herald event that now fully exposes the deep and chronic social wounds in US communities.

What makes this particularly egregious is that unlike the known risk factors for which physicians and others can stridently offer clear advice regarding prevention, these concerns—the burden of ill health, limited access to healthy food, housing density, the need to work or else, the inability to practice social distancing—cannot be well- articulated as clear, pithy, and easily actionable items.

What is the action plan? It is less an action plan and more of a com- mitment. A 6-fold increase in the rate of death for African Americans due to a now ubiquitous virus should be deemed unconscionable.

This is a moment of ethical reckoning. The scourge of COVID-19 will end, but health care disparities will persist. Does the US chronicle these poor outcomes due to COVID-19 complications with the higher burden of cardiovascular disease, poorer outcomes for breast can- cer, higher amputation rates for peripheral vascular disease, lower kidney transplant rates, and worse rates for maternal mortality, then safely park everything in the health care disparity domain and go back to “normal”? Or will the nation finally hear this familiar refrain, think differently, and as has been done in response to other major diseases, declare that a civil society will no longer accept dispropor- tionate suffering?

Public health is complicated and social reengineering is com- plex, but change of this magnitude does not happen without a new resolve. The US has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event. Certainly, within the broad and powerful economic and legislative engines of the US, there is room to definitively address a scourge even worse than COVID-19: health care disparities. It only takes will. It is time to end the refrain.

ARTICLE INFORMATION

Published Online: April 15, 2020. doi:10.1001/jama.2020.6548

Conflict of Interest Disclosures: None reported.

Additional Contributions: I thank Kristin T. Yancy and Nina M. Yancy for their review of the manuscript.

REFERENCES

1. Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hospitalized patients with COVID19 in Wuhan, China. JAMA Cardiol. Published online March 25, 2020. doi:10.1001/jamacardio.2020. 0950

2. Bonow RO, Fonarow GC, O’Gara PT, Yancy CW. Association of coronavirus disease 2019 (COVID-19) with myocardial injury and mortality. JAMA Cardiol. Published online March 27, 2020. doi:10.1001/ jamacardio.2020.1105

3. Grasselli G, Zangrillo A, Zanella A, et al; COVID-19 Lombardy ICU Network. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy

region, Italy. JAMA. Published online April 6, 2020. doi:10.1001/jama.2020.5394

4. Pan A, Liu L, Wang C, et al. Association of public health interventions with the epidemiology of the COVID-19 outbreak in Wuhan, China. JAMA. Published online April 10, 2020. doi:10.1001/jama.2020.6130

5. Thebault R, Ba Tran A, Williams V. The coronavirus is infecting and killing black Americans at an alarmingly high rate. Washington Post. April 7, 2020. https://www.washingtonpost.com/nation/ 2020/04/07/coronavirus-is-infecting-killing- black-americans-an-alarmingly-high-rate-post- analysis-shows/

6. Reyes C, Husain N, Gutowski C, St Clair S, Pratt G. Chicago’s coronavirus disparity: black Chicagoans are dying at nearly six times the rate of white residents, data show. Chicago Tribune. Published April 7, 2020. Accessed April 12, 2020. https://www.chicagotribune.com/coronavirus/ct- coronavirus-chicago-coronavirus-deaths- demographics-lightfoot-20200406- 77nlylhiavg jzb2wa4ckivh7mu-story.html

7. Deslatte M. Louisiana data: virus hits blacks, people with hypertension. US News World Report. Published April 7, 2020. Accessed April 12, 2020.

https://www.usnews.com/news/best-states/ louisiana/articles/2020-04-07/louisiana-data-virus- hits-blacks-people-with-hypertension

8. New York State Department of Health. COVID-19 fatalities. Updated April 11, 2020. Accessed April 12, 2020. https://covid19tracker.health.ny.gov/views/ NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker- Fatalities?%3Aembed=yes&%3Atoolbar=no&% 3Atabs=n

9. Gomes C, McGuire TG. Identifying the source of racial and ethnic disparities. In: Smedley B, Stith AY, Nelson AR, eds. Unequal Treatment. National Academies Press; 2003.

10. Havranek EP, Mujahid MS, Barr DA, et al; American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council. Social determinants of risks and outcomes for cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2015;132(9):873-898. doi:10.1161/CIR. 0000000000000228

Opinion Viewpoint

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