by Madison Woschkolup, WFU JD Candidate ’21
The impact of the COVID-19 pandemic on the United States is immense, but this impact has been disproportionately felt by Black communities. In thirty-three states and the District of Columbia, Black people comprise a higher proportion of COVID-19 cases relative to the percentage of the state’s population they make up.[1] In Maine, for example, Black people account for 21% of the state’s total COVID cases, even though only 1% of the state’s total population is Black.[2] In comparison, in all fifty states and the District of Columbia, the percentage of each state’s total COVID cases attributable to white people remains well below the relative percentage of white people in the state. This state-by-state trend extends nationally as well. As of June 2020, the Centers for Disease Control and Prevention (CDC) reported that 21.8% of COVID-19 cases in the United States were Black individuals, despite the fact that this group only represents 13% of the total population.
It is widely recognized that health outcomes of communities of color are objectively worse than those of white communities.[3] In addition to experiencing an increased risk of contracting the virus, Black Americans are also experiencing the highest actual COVID-19 mortality rates nationwide, more than double the mortality rate of their white counterparts.[4] As of August, 1 in 1,125 Black Americans has died from COVID-19, or 88.4 deaths per 100,000.[5] For perspective, the mortality rate for white Americans was 40.4 deaths per 100,000.[6] This gap only increases when the data are adjusted for age differences within the race groups.[7]
The pandemic has exposed and exacerbated long-standing inequalities present in the United States. This analysis aims to examine some of the structural and societal factors that contribute to Black communities’ increased risk of contracting and dying from COVID-19. A history of racial disparities in access to healthcare, employment and wages, and housing are just some of the factors that underpin this increased risk.
Access to Quality Healthcare
Black communities may face barriers in accessing quality health care in the United States, with racial disparities in health insurance coverage playing a large role.[8] Black individuals in the United States are more likely than white individuals to be without health insurance,[9] illustrated by an uninsured rate of 13.6% for Black individuals in 2019 compared to an uninsured rate of 9.8% for white individuals.[10] Health insurance makes a difference in whether people are able to seek necessary medical care, with studies showing that having health insurance is associated with improved health monitoring.[11]
Access to health insurance alone will not remove all barriers to healthcare for Black communities. Many times, Black people live in areas where medical care is either lacking or of poor quality, resulting in less effective delivery of care for COVID-19.[12] Many times, hospitals are located further away from these communities and pharmacies are subpar, leading to more obstacles to obtaining medical care and prescriptions.[13] Other factors that can interfere with access to healthcare include lack of transportation, lack of childcare, or the inability to take time off of work.[14] For example, in April, health officials in New Orleans realized that a drive-through COVID-19 testing strategy was not working.[15] After analyzing census tract data, health officials realized that a majority of hot spots for the virus were located in low-income communities of color where many residents lacked cars.[16]
Chronic Medical Conditions
A disproportionate burden of preexisting chronic medical conditions also contributes to the COVID-19 racial disparities.[17] People with certain chronic conditions, such as obesity, diabetes, and chronic obstructive pulmonary disease (COPD), are more likely to have negative health outcomes resulting from COVID-19. Black people have a disproportionately high prevalence of these comorbidities;[18] for example, Black adults are 60% more likely than white adults to have been diagnosed with diabetes,[19] and in 2016, Black individuals were 51% more likely to be obese than white individuals.[20]
This increased prevalence of chronic conditions among Black Americans is not solely biological. Social determinants of health have historically prevented minority groups from having fair opportunities to better their physical health.[21] Lower access to health insurance for Black people, as discussed above, likely exacerbates the prevalence of chronic conditions. Adults who are uninsured are over three times more likely than adults who are insured to say they have not been to a doctor in the past 12 months and are less likely to receive recommended screening tests,[22] allowing chronic conditions to go undetected or untreated. Other societal determinants discussed below, such as reduced access to healthy foods and increased air pollution in communities of color likely contribute to higher rates of chronic conditions as well.[23]
Employment
A recent study revealed that Black workers are disproportionately represented among essential workers during the pandemic.[24] While this protects some Black workers from unemployment in the short term, Black people still have a persistently higher overall rate of unemployment than white people, and Black workers are facing more severe health insecurity.[25] Working in essential industries puts these workers at an increased risk of being exposed to the virus due to their close proximity to the public or other employees, as well as the inability to work from home.[26] Many essential workers are earning low wages and have access to few benefits, which gives them little choice but to work despite these risks.[27] These high-risk working conditions are undoubtedly contributing to the disproportionate impact of COVID-19 on Black communities as a whole.
Living Conditions
Poor living conditions for many Black Americans – including high housing density, lack of healthy food options, targeted marketing, and increased pollution, to name a few — also contribute to the disproportionate impact of COVID-19. Black people, relative to white people, are more likely to live in neighborhoods such as these.[28] The high unemployment rate for Black workers discussed above may result in more sharing of housing or in homelessness. Communities that are comprised of a higher minority population typically already have a higher housing density, making it more difficult to follow COVID-19 prevention strategies such as social distancing.[29] If individuals in these communities are forced to share housing, the difficulty of implementing prevention strategies will only increase.
These living conditions likely contribute to the higher prevalence of general chronic disease seen among Black people, thus indirectly creating an increased risk for severe COVID-19 outcomes. These communities are more likely to be located within a food desert, an area lacking affordable and healthy food options.[30] As a result of decreased access to healthy foods, chronic disease management may become more difficult.[31] Marketing for unhealthy products, such as cigarettes and fast food, is also more often targeted at minority communities, resulting in unrelenting exposure to products that may exacerbate chronic medical conditions.[32] Finally, because air pollution is higher in minority communities[33] and is a cause of COPD,[34] individuals in these communities are at an increased risk of developing new or aggravating existing chronic conditions linked to a lack of clean air.
Conclusion
Other factors contributing to the disproportionate impact of COVID-19 on minority groups not discussed include poverty, criminalization, educational gaps, and racial bias in medical treatment. Many, if not all, of the factors mentioned in this analysis may be traced to a foundation of systemic racism throughout the United States.[35] For example, the substandard neighborhood conditions discussed above are a result of the history of redlining and housing segregation.[36] It is implausible that a single factor alone has produced the stark racial disparities that the pandemic has exposed. More likely, the disproportionate impact of the pandemic on Black communities is just the latest example of long-standing systemic inequities throughout the United States.
[1] COVID-19 Cases by Race/Ethnicity, Kaiser Fam. Found., https://www.kff.org/other/state-indicator/covid-19-cases-by-race-ethnicity/?currentTimeframe=0&selectedDistributions=white-percent-of-cases–white-percent-of-total-population–black-percent-of-cases–black-percent-of-total-population&selectedRows=%7B%22states%22:%7B%22all%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22White%20%25%20of%20Cases%22,%22sort%22:%22desc%22%7D (last updated Aug. 31, 2020). /
[2] Id.
[3] Prioritizing Anti-Racism in Health Policy, Policy Wisdom, http://www.policywisdom.com/dist/resources/files/Prioritizing%20Anti-Racism%20in%20Health%20Policy.pdf (last updated Aug. 2020).
[4] The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S., APM Research Lab, https://www.apmresearchlab.org/covid/deaths-by-race (last updated Aug. 19, 2020).
[5] Id.
[6] Id.
[7] Id.
[8] Access to Health Services, ODPHP, https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/access-to-health (last visited Sept. 10, 2020).
[9] Heeju Sohn, Racial and Ethnic Disparities in Health Insurance Coverage: Dynamics of Gaining and Losing Coverage over the Life-Course, 36 Pop. Res. Pol’y Rev. 181 (2016).
[10] Jennifer Ruden, Percentage of Americans Without Health Insurance by Ethnicity 2010-2019, Statista (June 29, 2020), https://www.statista.com/statistics/200970/percentage-of-americans-without-health-insurance-by-race-ethnicity/.
[11] Access to Health Services, supra note 8.
[12] Don Bambino Geno Tai et al., The Disproportionate Impact of COVID-19 on Racial and Ethnic Minorities in the United States, Clinical Infectious Diseases 1 (2020).
[12] Rashawn Ray, Why are Blacks Dying at Higher Rates from COVID-19?, Brookings (Apr. 9, 2020), https://www.brookings.edu/blog/fixgov/2020/04/09/why-are-blacks-dying-at-higher-rates-from-covid-19/.
[14] Health Equity Considerations & Racial & Ethnic Minority Groups, CDC, https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html#fn10 (last updated July 24, 2020).
[15] Maria Godoy & Daniel Wood, What do Coronavirus Racial Disparities Look Like State by State?, NPR (May 30, 2020), https://www.npr.org/sections/health-shots/2020/05/30/865413079/what-do-coronavirus-racial-disparities-look-like-state-by-state.
[16] Id.
[17] Tai et al., supra note 12.
[18] Id.
[19] Diabetes and African Americans, U.S. Dep’t Health and Hum. Serv., Office of Minority Health, https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=18 (last visited Sept. 10, 2020).
[20] Karen D. Lincoln et al., Race and Socioeconomic Differences in Obesity and Depression among Black and Non-Hispanic White Americans, 25 J. Health Care Poor Underserved 257 (2014).
[21] Health Equity Considerations, supra note 14.
[22] Rachel Garfield et al., The Uninsured and the ACA: A Primer- Key Facts about Health Insurance and the Uninsured Amidst Changes to the Affordable Care Act, Kaiser Fam. Found. (Jan. 25, 2019), https://www.kff.org/report-section/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act-how-does-lack-of-insurance-affect-access-to-care/.
[23] Health Equity Considerations, supra note 14.
[24] Elise Gould & Valerie Wilson, Black Workers Face Two of the Most Lethal Preexisting Conditions for Coronavirus- Racism and Economic Inequality, Econ. Pol’y Inst. (June 1, 2020), https://www.epi.org/publication/black-workers-covid/.
[25] Id.
[26] Health Equity Considerations, supra note 14.
[27] Abbie Langston et al., Race, Risk, and Workforce Equity in the Coronavirus Economy, PolicyLink, https://www.policylink.org/our-work/economy/national-equity-atlas/COVID-workforce (last visited Sept. 10, 2020).
[28] Ray, supra note 13.
[29] Health Equity Considerations, supra note 14.
[30] Kelly Brooks, Research Shows Food Deserts More Abundant in Minority Neighborhoods, Jons Hopkins U. (2014), https://hub.jhu.edu/magazine/2014/spring/racial-food-deserts/.
[31] Tai et al., supra note 12.
[32] Id.
[33] Disparities in the Impact of Air Pollution, Am. Lung Ass’n, https://www.lung.org/clean-air/outdoors/who-is-at-risk/disparities (last visited Sept. 10, 2020).
[34] Xu-Qin Jiang et al., Air Pollution and Chronic Airway Diseases: What Should People Know and do?, 8 J. Thoracic Disease E31, E32 (2015).
[35] Tai et al., supra note 12.
[36] See Richard Rothstein, The Color of Law: A Forgotten History of How Our Government Segregated America (2017).
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