Our country ended the first quarter of 2020 entering lockdown over COVID-19—a disease to which no one was seemingly immune, but which claims Black and Latino lives at nearly twice the rate of white lives in the U.S. As the country panicked over a growing public health crisis and an ensuing economic downturn, a third crisis reared its head. A Black man was killed in the street in broad daylight by a white police officer in Minneapolis. And this country, already simmering with two volatile crises bearing the undertones of inequality, erupted in protest.
What has occurred from the resulting movement for justice and equality is a glaring spotlight on racial disparities in America. COVID-19 presents a quintessential example of these disparities, as African Americans and Latinos are three times as likely to become infected with the virus as white Americans, according to the Centers for Disease Control and Prevention (CDC). They are also nearly twice as likely to die from COVID-19 as white people.
The question on everyone’s mind seems to be: Why? Why are Black and Latino people being infected and killed by COVID-19 at such significantly higher rates than white people in the U.S., even though they still make up a minority of the population?
To answer that, we have to understand a key fact: a virus does not discriminate. According to Dr. Brian Martin, Associate Dean for Administration at the EVMS School of Health Professions in Norfolk, “A virus just looks for opportunities to attack. But the reality is, there are factors that make a person more vulnerable to that opportunity.”
For COVID-19, these factors include comorbidities, such as cancer, chronic kidney disease, certain heart conditions and Type 2 diabetes. They also include age, as severity of illness has shown to increase with age (80% of deaths in the U.S. have been in individuals who were 65 and older, according to the CDC). But these considerations alone do not explain why Black and Latino residents are so much more likely to be infected with COVID-19 and to have a devastating outcome because of it.
To understand why this virus seems to discriminate, we must consider two key factors. One is that there are higher rates of underlying health conditions in Black and Latino Americans. And the second is what public health experts refer to as “social determinants of health,” which can contribute to worse outcomes from the disease, as well as increase the risk of being infected in the first place. These two risk factors are intimately connected, and they can have grave consequences.
According to the CDC, social determinants of health fall into five domains: neighborhood and built environment, economic stability, education, social and community context, and health care. Surprisingly, healthcare access only accounts for about 10 percent of a person’s overall health status. Roughly 30 percent is genetics. The rest is due to behavior and social determinants of health.
Take neighborhood and environment, as one example. Neighborhoods with poorer health status tend to have less stable housing, higher rates of crime, and more people living in close proximity to one another (something we have seen to augment the spread of diseases like COVID-19).
The location and safety of a neighborhood also affects residents’ health status. For example, we know that getting exercise and vitamin D is crucial to health. Thus, if your neighborhood is not safe and walkable, that can be a barrier to health. If you live in a neighborhood that does not have access to a grocery store with healthy options—or if those options are difficult to obtain for financial reasons—that is another barrier to health.
These discrepancies play out in stark ways. In Richmond, the life expectancy for those living in the Westover Hills neighborhood is 85 years. But travel 4.6 miles away to the Gilpin neighborhood, and the life expectancy is 63 years.
“This is a prime example of the old ‘other side of the tracks’ saying. Where you live can contribute to significant differences in life expectancy and health status,” Martin explains.
And where you live often correlates to race and ethnicity. Neighborhoods are not legally segregated anymore, but historically, Black neighborhoods were often literally separated from white neighborhoods by railroad tracks. And in many cities, the current infrastructure still reflects these divisions.
This is just one of myriad examples of how these social determinants of health manifest as racial disparities in health status and health outcomes.
The effects of these disparities are often insidious. But in the era of COVID-19, it is easy to see how these social determinants stack the deck against minorities. Black and Latino Americans are more likely to work essential jobs that cannot be done remotely, and therefore have a higher likelihood of coming into contact with the virus. They are also more likely to use public transportation to get to work, and to come home to more crowded residences. The list goes on.
“What we are seeing now with COVID-19 is a magnification of these disparities that we have been talking about for a long time,” says Mekbib Gemeda, Vice President for Diversity and Inclusion at EVMS.
Fortunately, Virginia’s response to the COVID-19 pandemic has taken these disparities into consideration. In March, the state established the Health Equity Working Group (HEWG), under the umbrella of Virginia’s Office of Health Equity. The group is a coalition of government agencies, community leaders and faith-based organizations, committed to applying a health equity lens to the state’s COVID-19 response.
“The reason for the disproportionate impact of COVID is unfortunately a perpetuation of preexisting health inequities,” says Sable Dyer, Acting Director of the Office of Health Equity for the Virginia Department of Health. “The Commonwealth now needs to meet this challenge and ensure that individuals regardless of race and vocation have access to healthcare.”
By leveraging epidemiological data, HEWG has been able to target communities that are most susceptible to COVID-19. With that information, they have strategically set up testing sites, dispersed personal protective equipment (PPE) and provided educational materials to the state’s most vulnerable populations.
These actions being taken to protect the health of vulnerable citizens of the Commonwealth are important. But what can be done to address the social determinants that create these disparities in the first place?
Dr. L.D. Britt, Chair of Surgery at EVMS and former president of the American College of Surgeons, says that refocusing health expenditures to mitigate social determinants is a good place to start.
“We have a $4.5 trillion healthcare industry. Our country spends more on healthcare than any other country, and yet we rank 37th in the world. We clearly aren’t getting our money’s worth” says Britt. “We don’t need more money in healthcare—we need a different strategy.”
Gemeda also advocates for a more holistic approach that considers the broader picture of health.
“You can know everything there is to know about the biomedical aspect of medicine, but it doesn’t matter much if you don’t see these other determinants. If your patient can’t actually take your advice and live in a different way, the cure is not there,” Gemeda says.
EVMS is actively working to implement this holistic approach through its educational programs, patient care and community outreach. Medical students learn about the social determinants of health on day one of their program, and it is a central aspect of the curriculum. The goal is to equip up-and-coming doctors with an understanding of the context within which their patients actually live, so they can provide meaningful care that can produce better outcomes.
“At the end of the day, the pandemic has unveiled the weaknesses of our healthcare system,” says Britt. “Our healthcare crisis is the number one issue facing this country now. We don’t have a choice now— our backs are against the wall. But this nation is at its best when its back is against the wall.”