Failing Another National Stress Test on Health Disparities

The African American daughter of one of us called from New York City in early March, worried about her Hispanic partner’s health. Did his high fevers, worsening shortness of breath, and painful cough indicate coronavirus disease 2019 (COVID-19) infection? Given his history of asthma and hypertension, was he at high risk? What should they do? Urged to seek medical attention, he resisted. The nearby affordable and accessible urgent care clinics were staffed by physicians who, based on his previous experiences, “just didn’t get it,” and he anticipated that his concerns would be dismissed. When he relented and requested a coronavirus test, he was asked about international travel, but not about their small apartment or his use of public transportation. He was told “no test,” once again confirming his impressions of an uncaring system. He decided to stay at home and tough it out. But he got worse. The fevers were unrelenting, and it was hard to breathe. He was finally cajoled to try a different clinic. There, the African American receptionist conveyed their concerns and the staff agreed to provide a COVID-19 test. The patient was handed a flyer with home care instructions, but no one asked about financial consequences of staying home and no follow-up plans were provided. And then good news—the clinic called and reported that the test was negative. Yet, a week later, the high fevers continued. They reached out to the clinic again and were reassured that “there [was] nothing to be done for coronavirus.” When they asked why the nurse was labeling him a “COVID patient” when his test was negative for coronavirus, the response was an unapologetic “Oops, you got the wrong result.” Now a month later, he is still recovering from COVID-19 and from another painful health care encounter. Why are we—a black senior educator, a white medical foundation president, and a Hispanic public health leader—coming together to share this story? This case is a personal illustration of how the long-standing systemic inequalities in the US health care system result in the tragically unequal effect of COVID-19. Many of the contributing factors—from higher rates of underlying disease risk factors, to long-standing lack of access to health care, to lack of cultural competency, to adverse social determinants of health—predict a higher incidence and worse outcomes for minorities. We are deeply disappointed, but not surprised. As of April 7, disturbing national trends are suggested, despite incomplete data capture. In New York, Hispanic and black people accounted for 34% and 28%, respectively, of deaths from COVID-19, even though they represent only 29% and 22% of the population; while white people accounted for 27% of deaths, even though they represent 32% of the population. In Chicago, black people comprise 32% of the population but thus far have accounted for 52% of nearly 5000 reported cases and approximately 70% of COVID-19 deaths. The infection rate among black people is twice their percentage of the population across Illinois. Across the state of Michigan, black individuals account for 33% of positive COVID-19 tests and 41% of deaths yet represent only 14% of the population. In Louisiana, black people comprise 32% of the population but account for 70% of the COVID-19 deaths. Black individuals comprise 35% of the residents of Charlotte, North Carolina, but more than 40% of COVID-19 cases. In Milwaukee, 26% of the residents are black but account for almost half of the COVID-19 infections and 81% of deaths. North Carolina and South Carolina report a ratio of black to white residents who have tested positive that exceeds predictions from the general population. Data are more limited for Hispanics, but similar troubling statistics are emerging. We propose that the overarching cause of these tragic statistics is decades of the effects of adverse social determinants of health. Even biological risk factors for COVID-19 like diabetes, obesity, asthma, and hypertension can reflect environmental and sociological precipitating and contributing factors, as much as racial differences in biology. A noninclusive list of confounders from the ecosystem of social determinants of health relevant to COVID-19 include struggling in poverty with limited job and social mobility; working frontline jobs with lack of adequate personal protective equipment (eg, public transportation, pharmacy, grocery, and warehouse distribution workers); living in crowded apartments where social distancing is impossible; shopping in food deserts or swamps without access to healthful foods; being underinsured and using self-rationing of health care as a strategy; relying on public transportation on crowded buses and subways; and having a public kindergarten through 12th-grade education that too often leads to functional health illiteracy. Other contributors may have reinforcing effects, including health beliefs and behavioral choices that manifest differently across cultures. Workforce diversity within health care makes a difference, especially in decision-making by minority patients. The persistent racial, ethnic, and cultural incongruity between physicians and patients, especially for African American men, reached a nadir last year after 35 years of decline. Subconscious racial bias in health care exists, as documented by differences in cardiovascular procedures and solid organ transplants. Patient choice and responsibility could be factors as well. Late self-referral because of distrust, health beliefs, and even disease fatalism may be present in some minority communities. Dangerous behavioral choices, such as attending events with large crowds or partying on spring-break A PIECE OF MY MIND