Pandemic Brings Racial, Economic Healthcare Disparities Into Focus

As the United States prepares for what some experts warn could be the worst week yet of the coronavirus disease 2019 (COVID-19) pandemic, national attention has been focused on the disease’s current epicenters in New York and New Jersey.

However, across the country, the pandemic is slowly seeping into the nation’s economically vulnerable populations and is already taking a toll on minority communities.

Due to a lack of CDC data on race and COVID-19 mortality, it is difficult to know the extent to which minority populations are suffering. Last week, 5 congressional Democrats wrote to HHS Secretary Alex Azar, imploring the federal government “to monitor and address racial disparities in our nation’s response to the coronavirus disease 2019 (COVID-19) public health emergency.”

Compounding the issue, official death counts are likely inaccurate because of inconsistent protocols, limited resources and personnel, and the absence of a uniform reporting system across the country.

To make up for the lack of national data, some states, counties, and municipalities, including Illinois, North Carolina, and Wisconsin, have taken it upon themselves to track the virus’ impact on minority populations. Underlying chronic medical conditions like diabetes and lung disease may exacerbate the symptoms of COVID-19 and generally lead to worse patient outcomes. Because minorities have historically high rates of chronic conditions, these populations are at a particular risk of being severely impacted by the pandemic.

Early data, published by ProPublica, shows African Americans in Milwaukee are contracting and dying from COVID-19 at an "alarming" rate. According to one analysis, African American patients with a cough and fever were less likely to receive a test for COVID-19, Kaiser Health News reports.

“In Milwaukee, simply being black means your life expectancy is 14 years shorter, on average, than someone white,” according to ProPublica. As of April 2, “19 people had died of illness related to COVID-19 in Milwaukee County. All but 4 were black… Records show that at least 11 of the deceased had diabetes, 8 had hypertension, and 15 had a mixture of chronic health conditions that included heart and lung disease.”

In addition, ProPublica reports “African Americans have gravitated to jobs in sectors viewed as reliable paths to the middle class—health care, transportation, government, food supply — which are now deemed ‘essential,' rendering them unable to stay home.”

Racial and ethnic disparities in healthcare are a persistent and critical problem facing the country. As The American Journal of Managed Care^® (AJMC^®) reported in 2018, “Low-income individuals are more likely to have chronic illnesses, and the impact of those illnesses can be more severe. People with low incomes are also disproportionately racial and ethnic minorities.”

Native Americans also are particularly at risk of experiencing devastating consequences of COVID-19. “When you look at the health disparities in Indian country—high rates of diabetes, cancer, heart disease, asthma, and then you combine that with the overcrowded housing situation where you have a lot of people in homes with an elder population who may be exposed or carriers—this could be like a wildfire on a reservation and get out of control in a heartbeat,” Kevin Allis, chief executive of the National Congress of American Indians, told The Washington Post.

Currently, “American Indians are 600 times more likely to die of tuberculosis and nearly 200 times more likely to die of diabetes than other groups.” Without the risk of COVID-19, Native Americans have, on average, a 5.5-year lower life expectancy than the all-races population, while up to one-third of homes on tribal lands across the country don’t have electricity or indoor toilets.

Largely reliant on the hospitality and casino business, the shutdown of the US economy is poised to cripple Native American populations economically, with the Cherokee Nation already reporting a loss of $40 million per month.

Individuals representing populations of American Indians and Alaskan Natives are concerned the pandemic will wipe out entire nations. This apprehension is heightened by the fact President Trump revoked the reservation status of the Mashpee Wampanoag Tribe in Massachusetts in late March, further undermining tribes’ legitimacy. The action removes over 300 acres from federal trust protection.

Americans residing outside of the contiguous United States also face unique challenges. In Puerto Rico, an island where 72 of 78 municipalities are considered medically underserved, “The main concern is whether this pandemic would be the last straw that causes the collapse of our healthcare system," said Victor Ramos, MD, president of Puerto Rico’s Physicians Association, according to NBC News. As of April 6, the island has reported close to 500 cases and 20 deaths.

Advocates fear the island will again be left behind by the United States, leaving its most vulnerable citizens to suffer, USA Today reports. “Before the coronavirus pandemic began crippling the US economy, the unemployment rate in Puerto Rico was at nearly 9% compared to the nationwide rate of 3.5%. In 2018, the poverty rate was 43% compared to the nationwide rate of 11.8%.”

In addition, the island is still recovering from Hurricane Maria, which struck in 2017 and claimed over 3000 lives. The hurricane, along with the over 1000 earthquakes that have already hit the island this year, also took a toll on the island’s infrastructure.

Transferring patients and medical supplies in the event of a severe outbreak will stretch the island’s already thin resources. Compounding the economic impact of the pandemic is a shortage of doctors and nurses who have historically left the island to seek better opportunities. Strict enforcements have been put in place across the island, including a curfew from 7 pm to 5 am, and cruise ships are restricted from docking at the island, limiting a key source of income for many residents.

Not only could the pandemic disproportionately affect racial and ethnic minorities in the United States, but lower-income individuals of all races throughout the country may fare worse in the long run. Pockets of the rural South are predicted to face surges of cases in the coming weeks. “Without the resources of major cities, these areas are poised to see disproportionate suffering, economic hardship, and death when cases peak,” Politico reports.

Ebony Hilton, MD, an anesthesiologist at the University of Virginia Medical Center, noted that reliance on social media to inform the public, along with the prevalence of drive-through testing sites, means individuals without access to the internet or a car may be more vulnerable.

Rural areas have less dense populations, meaning they are lower on the list when it comes to prioritizing government equipment. It has also been documented that individuals in rural areas have worse health than the general population. “The reason for this disparity is that rural populations experience geographic isolation, have a lower socioeconomic status, have limited job opportunities, and tend to be older,” AJMC^® reports.

“With many Southern states only recently implementing stay-at-home orders, hospitals and local officials fear even sparsely populated counties could soon have more cases than their health care systems can handle,” Politico reports. Recently, Florida and Mississippi enacted statewide stay-at-home orders. However, Arkansas, South Carolina, and Texas do not have similar orders in place.

Social distancing remains the standard and most effective practice to help flatten the curve of patients with COVID-19. By doing so, healthcare systems will be tasked with treating a steady flow of patients over a longer period of time, as opposed to surges that risk patients receiving suboptimal care as a result of supply and staff shortages.

“The best indicator of who is at risk,” said Nirav Shah, a senior scholar at Stanford University’s Clinical Excellence Research Center, “is how tamped down are you in terms of social distancing.”