Why Are Minority Populations More at Risk for COVID-19?

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In some cities, 60% of COVID-19 cases and deaths are in people of color.
Three critical areas are driving the COVID-19 disparities among racial and ethnic minorities: clinical risk factors such as cardiovascular disease, hypertension, and diabetes; access to healthcare; and social risk factors such as homelessness, incarceration, and food insecurity.
A large portion of the 27 million black and Hispanic Americans are uninsured and have reduced access to healthcare.
Regardless of socioeconomic status, black Americans die at higher rates than white Americans do. Discrimination and bias in healthcare play a role in these disparities.
The healthcare system needs to diversify its workforce, and medical schools can help diversify the pipeline of students by enrolling more minorities.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Today I want to spend a few minutes talking about the disproportionate impact that COVID-19 has had on minority populations. To help provide insights, I've asked Dr Utibe Essien, assistant professor of medicine at the University of Pittsburgh School of Medicine, to join me. Dr Essien, in some cities, 60% of the cases of COVID-19 and 60% of the deaths are in people of color. Why are we seeing that?

Utibe R. Essien, MD, MPH: I think it's such a broad problem right now. Those of us who are health equity researchers, those of us who are physicians of color, have really been trying to drive this idea forward that, unfortunately, it's not surprising that we're seeing these disparities that you just noted.

Disparities in COVID-19 track so consistently with the disparities that we see in cardiovascular disease, in hypertension, in diabetes, in obesity—some of the common risk factors clinically that are driving the death and severe infection from COVID-19. But they also track consistently with the social factors that are really putting individuals at higher risk, whether it's homelessness, incarceration, or food insecurity. Both of these social and clinical factors are, again, consistently going along with the disparities that we're seeing in COVID-19 as well.

Whyte: Is it primarily an issue of access to care? Is it the issues of underlying conditions, as you pointed out—a greater percentage of hypertension, diabetes, obesity? Or is it the fact that in many areas, it's minority populations that are driving the buses, doing some of the cleaning services in buildings, that are in areas where there's more population density and, perhaps, greater exposure?

Essien: I think you nailed it there, where the three buckets that I have been thinking about this problem with do lie exactly in that: access to healthcare, clinical risk factors, and social risk factors. In the "access to healthcare" risk factor, one can think about who had the opportunity to "ask their doctor about their symptoms when the pandemic first began"?

We know that nearly 27 million Americans are uninsured right now, with a higher proportion of that group being from Hispanic and African American backgrounds, in turn, not able to quickly ask their primary care doctor about their symptoms.

We mentioned the clinical risk factors, as well as the social risk factors, that are putting individuals at higher risk of being "essential workers," whether it is driving the buses or the subways, as you mentioned, or those who are delivering our food and groceries for those of us who have the privilege to work from home, or those who are the custodial staff in the hospitals — environmental staff that I and my colleagues are often thought to be, actually, when we go onto the hospital floors.

So I think it's really just a crisis that put together each of these three buckets of factors, and that's what's really driving the COVID-19 disparities right now.

Whyte: Another interesting data point that I found, Dr Essien, is that sometimes people associate the prevalence in minority populations with socioeconomic status or income. It's not about being poor because there are data points that show, even in wealthy minority populations with above-average wealth and health, that they still bore an unequal share of deaths. So how do we explain that?

Essien: That exact point is the reason that I am a health disparities researcher. Back during my intern year, I saw a paper that similarly came out and showed that regardless of your income bracket, your socioeconomic status, African Americans were dying at higher rates than their white counterparts. And it made me wonder because, again, I was trained to believe in medical school that it was education, it was income, it was access to insurance that were the big drivers of racial disparities in care.

But when I came across that paper and the data that you just reported right now, it is quite clear that it's beyond that. We can think about factors such as discrimination, whether it's the microaggressions on a daily basis that influence the very cells of our bodies or it's the larger factors that we see on a day-to-day basis as well.

I think bias in care — whether you are rich or poor, especially in maternal health — really does play a role in the care that individuals of color, and specifically black Americans, receive in our country. Pushing the envelope, thinking beyond social determinants, is really important as we address the disparities of this crisis.

Whyte: Obviously, we can't ignore what's happening in the current news cycle with the killing of George Floyd. How do the protests and the desire for equity and justice play into these issues of health disparities?

Essien: I think that's a really important question. I've started to look a little bit more at history, looking back and seeing what happened in 1918 around the flu pandemic, what happened in 1968 around this other H3N2 pandemic that I'd never heard about until this weekend, and seeing just how consistently there are those times of real difficulty, both from a health standpoint and a socioeconomic standpoint, just as we're seeing today.

There happened to be protests, riots, and unrest in the same way that, unfortunately, we're seeing right now with the unfortunate death of George Floyd. I think it's come to a head. As I mentioned, there are those three buckets of clinical factors, the disproportionate toll that the COVID-19 pandemic has taken, and this idea that racism is a public health issue. It can no longer just reside in the desks of journalists and reporters. We, as physicians, have to start thinking about how this pandemic, in and of itself, is affecting the health of our patients.

Whether we're thinking about protests or thinking about how folks can safely express their views on this issue, those of us who are physicians, those of us who have an opportunity to educate the community and future trainees, really need to think about how to thoughtfully incorporate racism [discussions] into our practices and teaching.

Whyte: Let's spend a few minutes talking about this: What are potential solutions? I know none of us have a magic wand to wave over and make everything equal. But what do you see as a couple of things that we can do, both short term and long term, to address these issues of disparities?

Essien: In the short term, we really need to have access to data. Just last Thursday, the federal government offered that every state and local department would need to provide race and ethnicity data on every COVID-19 test. Making sure that everyone has access to healthcare is still a pressing issue. Like I mentioned, there are millions of Americans who remain, to this day, uninsured.

In the long term, I think we need to diversify our workforce. I trained in Boston, where we know that nearly 70% of the individuals who are COVID-19 positive in the hospital where I trained were Spanish-speaking. And we just didn't have the population of providers to literally relate the information around this severe new infection to that patient population.

So diversity in our workforce is important, at the frontline level and all the way up to leadership—and even more broadly, just reminding ourselves that, again, this is not new. We have the tools that came forth with the H1N1 crisis in 2009, where we also saw these stark racial disparities. And we need to just go back and take a look, dust off those papers, and see what we can do now to help address this current pandemic.

Whyte: Sometimes when we're in the healthcare system, our immediate reaction is that they need to have more access to healthcare and more equity in terms of how healthcare is delivered. But it's these other elements too. And I don't want to lose sight of the role of nutrition and exercise screenings. How does that all weigh into your decision-making as to what we need to do?

Essien: I think that is super-important. That's the highest level of the factors that play a role in this current crisis — the fact that there are still individuals residing in food deserts, where the closest supermarket is the bodega that doesn't have access to fresh fruits and vegetables; the fact that there are still individuals living with multiple generations in a single-family apartment building who don't have the opportunity to socially distance like we've been talking about over the past 2 or 3 months in this current crisis.

All of these social factors, as a public health researcher, are the ones that I think about far beyond the time that our patients come to us in clinic with these chronic conditions like diabetes and hypertension. What happens that actually makes them at higher risk for those conditions? We just know that they're the social factors that they're living with and residing in.

Whyte: You talked about diversifying the workforce. There are data that show that the number of black men in medical school hasn't changed much in 50 years. The number of black women has increased, but the number of black men has not changed much at all. This is a longer-term strategy. What are the two or three things that we can do in order to help more minorities enroll in medical school?

Essien: I think what we're doing right now is important. Having a conversation between the two of us, showing that black physicians do exist and are doing well in their careers, is really important. My father is a physician so I had the opportunity to see that face every day coming home, for better or worse, during stressful times in residency when I didn't think I'd ever be a physician.

But I think it means something really important to see folks who look like you in the field that you're going into. I think that's an important first step, and that can be considered a short- or long-term step. Taking a step back — and somewhere where we, as physicians, may not necessarily have the same foothold in — is thinking about the pipeline. Medical students don't get created in medical school. Medical students had to be pre-med. They had to do well in high school to get into undergrad. And even their middle school influences how they do in high school.

As physicians, we may feel that we just need to focus on our patients and our communities. But the role that we can play in helping build up the pipeline along the way is something that's important. I know that several medical schools around the country are starting to do that hard work of going deeper, beyond the pre-med solutions, to look at the downstream pipeline as well.

Whyte: What makes you hopeful?

Essien: That's a hard question. Really, honestly, it's difficult to be hopeful right now. The past 2 weeks have been really challenging and difficult. I had mentioned on social media that faith, family, and the future are the three things that are keeping me going. As a man of faith, I have hope that things can always be better and that everything happens for a reason.

My family has always been there for me through the hard parts of medical school, residency, being pre-med. Several times, I didn't think being in this position right now would be possible. And I think the future holds a lot of opportunities and possibilities.

You mentioned that for 50 years, the numbers of black physicians have not changed much. Well, 50 years ago, the cardiovascular mortality, for example, in the black community had been much higher than where it is right now. Access to care in the black community was much lower than what it is right now. So I do think that we're bending the arc toward justice, as Dr King says. And I'm hopeful that in another 50 years we'll be having a very different conversation.

Whyte: I want to thank you for providing your insights today.

Essien: Definitely. Thanks so much, Dr Whyte, for having me. I appreciate it.

Whyte: And I want to thank you for watching Coronavirus in Context.

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