DHM COVID-19 Clinical Dispatch

Bite-sized, weekly clinical updates

Issue #9: Racial Disparities in COVID-19

Welcome to the 9th COVID Clinical dispatch! This week we tackle an incredibly important but often overlooked topic: how racism and systematic oppression manifest in racial disparities in the COVID-19 pandemic.

First, we dive into a recent community-led study with UCSF investigating racial disparities in COVID cases in the Mission District. We then look regionally and nationally at data showing Black Americans are disproportionately affected by COVID-19.

Finally, we address potential explanations as to why minority communities are so disproportionately affected by this pandemic and suggest some local solutions to begin addressing these disparities.

For more information on racial disparities in COVID-19 please check out:
National: COVID Racial Tracker, CDC
State: NPR disparities by state
County Data: San Francisco, Alameda

- COVID Clinical Working Group

At Our Door - Racial Disparities in our Community

In the Bay Area, early data suggests that Latinx populations are at higher risk for COVID-19 infection while Black Americans are at higher risk for death. In San Francisco, the COVID-19 Mission Screening Study has been very influential in the national conversation on racial and ethnic disparities within COVID-19. For this study, researchers offered voluntary testing in the Mission District census tract 022901, regardless of symptom status. Out of nearly 4,160 people tested, nearly 1 in 50 were COVID-19 positive. Though the tested population included only 44% Latinx individuals - strikingly - 95% of those who tested positive were Latinx.

Regionally, counties in the Bay Area are also seeing racial disparities (COVID data, Census Data), detailed below:

Case Positivity

San Francisco county: 2,809 COVID-19 cases, 50% are Latinx (just 15% of the SF population) while 5% are Black American (5.6% of the population).
Alameda County: 4,033 cases, 46.8% of patients are Latinx (22.9% of the population) (COVID Data, Census Data).

Deaths

Alameda County: 105 COVID-19 deaths, 22% were Black American (10% of the population).
California State: Black Americans account for 10% of COVID-19 deaths despite only being 6% of the state’s population.

The Larger Issue - National Disparities

Nationally, a similar pattern has emerged, though race and ethnic data are still lacking in many parts of the US. Latinx people test positive for coronavirus at disproportionate rates in almost every state.

Black Americans, on the other hand, are testing positive and dying at much higher rates than would be expected from their representation in the population. The graphic below, from the COVID racial tracker, shows Black Americans dying at a rate nearly 2x higher than their population share nationally.

Looking at this national number only underestimates the problem Black Americans face in may states, as COVID disparities vary widely across the country. The figure below highlights four states in which the Black community has been impacted in a dramatic fashion.

The “Why” of COVID-19 Race Disparities

Why might Black and Latinx be more susceptible to COVID-19 infection and its adverse outcomes?

The outsized impact of COVID-19 on communities of color, detailed above, has been attributed to a range of causes rooted in systemic racism and structural inequality. As a result, minority populations are unwittingly on the front lines of the pandemic in the US and around the world.

Minorities are more likely to become infected due to:

Living Conditions: Minority communities are more likely to live in neighborhoods with higher poverty rates and overcrowding through a well-documented legacy of residential housing segregation and the practice of red-lining.
Racial and ethnic minority groups may also be more likely to live in multi-generational households and are over-represented in congregate living settings including prisons and homeless shelters, areas which are especially susceptible to the spread of COVID-19.
Working Conditions: Minority groups are more likely to work in the low-wage essential workforce including public-facing occupations such as food services, transportation and healthcare.
Unable to social distance: Together, these living and working conditions significantly impede social distancing – a privilege that relies not only on being able to isolate in a safe home, but also on being able to work remotely and sustain an income.
- Haynes et al report in Circulation that 16% of Hispanic/LatinX and 20% of Black workers can work remotely, compared to 30% of White and 37% of Asian workers.

More likely to suffer adverse outcomes from infection due to:

Comorbidities: Rooted in many of the same structural inequalities highlighted above, minority populations experience a disproportionate burden of hypertension, cardiovascular disease, diabetes, and kidney disease - each of which are, in turn, independent risk factors for poor outcomes from COVID-19.
Access to care: Access to both testing and treatment is more limited for minority communities. This may be influenced by physical distance to care, language or financial barriers, under-insurance and hard-earned historical mistrust in the medical system.
Insurance: According to the CDC and the Kaiser Family Foundation, compared to white Americans, Blacks are twice as likely and Hispanics are almost three times as likely to be uninsured.
Racism and racial biases: Minority patients have historically received inferior care to white patients, and this racial bias continues to be prevalent among healthcare providers. The CDC explicitly advised healthcare providers caring for COVID-19 patients to identify and address biases that may hinder patient-provider interactions.
Chronic Stress: Racism and structural inequalities have also been found to increase chronic stress and inflammation, which contribute to poor outcomes among minority groups.
Unemployment: Outside of the devastating clinical impact of COVID-19, the economic impact is likely to disproportionately affect members of marginalized communities.

What can we do as providers to help reduce COVID-19 racial inequity?
This is a huge issue that warrants its own dispatch. But to start, we can work to address a few key factors for our patients:

Speak early with SW and CM to secure safe discharge options where patients can isolate. And check out this awesome list of SF community resources compiled by folks at ZSFGH.
Ensure our communications to patients are clear, frequent, and in their native language. Use interpreter services! COVID-19 Fact check, a patient-centered site by UCSF Med students is available in multiple languages.
Work to be anti-racist. (see a list of resources to learn about racism and what it means to work towards anti-racism)
Ensure racial and ethnic minority groups are linked to healthcare services outside the hospital
Use this COVID equity checklist developed by Dr. Sneha Daya when you admit COVID patients!
Check out Strategies for Reducing Healthcare Disparities at the CDC

Spaced Learning Corner: Quiz Yourself!

In the Ni et al study reviewed last week, which of the following was found in recovered COVID-19 patients?
a)    The majority of patients developed only an antibody response to viral proteins
b)   The majority of patients developed only a T-cell response to viral proteins
c)    The majority of patients developed both antibody and T-cell responses to viral proteins
d)   There was no correlation between neutralizing antibody response and T-cell response

Find the answers here!

What We’re Reading

Short summaries of articles our team finds interesting this week.

COVID-19 and African Americans (Yancy CW, JAMA, May 2020): This perspective piece discusses the disproportionate impact of COVID-19 on African Americans. The author highlights an estimated infection rate >3x higher and death rate >6x higher in predominantly black counties, as compared to predominantly white counties. Also, they discuss how the privilege to maintain physical distance at home and telecommute is not universal.
COVID-19 and Racial/Ethnic Disparities (Hooper et al, JAMA, May 2020): This perspective piece highlights two key factors of disparities in COVID-19: (1) "a disproportionate burden of underlying comorbidities...diabetes, cardiovascular disease, asthma, HIV, morbid obesity, liver disease, kidney disease...” and (2) living in more crowded conditions and employed in “public-facing occupations […which] prevent physical distancing.”
COVID-19 and the US Response: Accelerating Health Inequities (Okonkwo, et al., BMJ Evidence-Based Medicine, June 2020): This article synthesizes data from multiple sources regarding COVID-19 incidence and outcomes across diverse populations to define disparities and issue an evidence-based call to action. They found that marginalized and under-resourced communities face a number of inherent qualities which worsen COVID-19 outcomes, including economic and social constraints on physical distancing, pre-existing health disparities and reduced access to testing and healthcare services. They conclude that COVID-19 has further perpetuated many of the health disparities that these communities already faced prior to the current pandemic.
COVID-19 Pandemic: Exacerbating Racial/Ethnic Disparities in Long-Term Services and Supports (Shippee, et al., Journal of Aging and Social Policy, May 2020): This perspective article notes that there are long-standing disparities in where and how people of racial and ethnic minorities receive long term care (i.e. nursing home and assisted living settings). These healthcare settings experience a similar, disproportionate impact from the pandemic as do racial and ethnic minority communities, which places these individuals at higher risk for disease prevalence and adverse health outcomes from COVID-19.

Links

Questions, thoughts, insights? Share them on our Clinical Knowledge Portal!

Prior Dispatches:

Issue 1: GI symptoms in COVID
Issue 2: Predictors of Severe COVID Disease
Issue 3: Hypercoagulability in COVID-19
Issue 4: SARS-CoV-2 and the Inflammatory Response
Issue 5: Remdesivir for COVID-19
Issue 6: Convalescent Plasma
Issue 7: ARDS
Issue 8: Post-infectious Immunity