Racism, injustice are ‘pre-existing conditions’ that lead to racial disparity in COVID-19 cases
On April 9, 2020 the Lexington Herald-Leader published an article entitled, “COVID-19 has hit Kentucky, Lexington’s black population especially hard. Why?” While the article brought attention to the long-standing crisis of health disparities that Blacks experience, it did not adequately inform its readers of historical and contemporary structural and systemic inequities that have led to Blacks comprising 31 percent of all COVID-19 cases and 49 percent of all hospitalizations due to COVID-19 in Lexington-Fayette County, where Blacks comprise only 15 percent of the population. These figures are consistent with CDC data that indicate a disproportionate burden of COVID-19 morbidity and mortality among Blacks nationally.
A common refrain known among many Black communities is, “when white America gets a cold, Black America gets pneumonia.” In the case of COVID-19, the refrain might be “when white America gets the flu, Black America dies.” Historical evidence demonstrates time and again higher morbidity and mortality for racial/ethnic minority groups, especially during public health emergencies. Such crises reveal foundational realities of racial/ethnic inequalities in the U.S. that have existed for centuries.
As the April 9 article indicated, individuals with chronic pre-existing conditions like diabetes, obesity, respiratory illness, and cardiovascular disease have been hardest hit by COVID-19, and Blacks suffer a disproportionate share of chronic disease than their white counterparts. Less frequently addressed are fundamental root causes or social determinants that are responsible, according to many researchers, for up to 80 percent of health. Such social determinants include economic stability, neighborhood and physical environment, educational opportunities, community and social context, and the health care system. As described by the April 9 article, income, poverty, and lack of health insurance play a major role in these inequities, with Black Kentuckians having the lowest household income of all racial groups, double the poverty rate of white Kentuckians, and higher numbers of uninsured than the state average.
We cannot begin to address health inequities without acknowledging that race in America is associated with all of the social determinants of health. Centuries of injustices based on structural and institutional racism embedded within social determinants are the main culprits of the higher rates of chronic pre-existing illnesses within the Black community that increase risk for COVID-19 morbidity and mortality. For example, practices such as redlining have created predominantly Black neighborhoods. As a result, Blacks are more likely to live in more densely populated, highly polluted, and toxic neighborhoods with less access to healthy food options, green spaces, recreational facilities, lighting, and safety.
Socially-determined access to resources, professions, and healthcare also shape risk exposure. For example, Blacks represent about ¼ of all public transit users and are least likely to own a car; are over-represented in essential service sectors employment like grocery and convenience stores, transportation, trucking, warehouses, the postal service, and in lower level healthcare profession – all associated with extensive human interaction. Financial vulnerability has been established; Blacks are more vulnerable to layoffs, furloughs, and wage losses. Furthermore, Blacks are more likely to receive inequitable healthcare by a clinician due to both explicit and implicit biases.
Exposure to racism constitutes an additional socially determined risk factor, with a large body of scientific evidence revealing associations between racism and health for Blacks. Due to daily racialized micro- and macro-aggressions, Blacks are exposed to higher levels of chronic stress that weaken the immune system and lower their ability to fight off infection.
All of the noted socially-determined factors impact the environments where Blacks work, live, and play, and provide fewer opportunities for adequate physical distancing, sheltering in place, and adhering to other precautionary and protective measures to avoid contracting COVID-19 – creating a recipe for socially-determined pre-existing conditions.
While it may be expedient to point to genetic differences, individual behaviors, or other racialized myths as the cause of COVID-19 disparities, evidence-based interventions, well-reasoned actions, and broad cross-sector collaborations are needed to address upstream social and structural factors to foster much needed social justice and health equity.
Anita F. Fernander, Ph.D., is an associate professor of Behavioral Science in the College of Medicine at the University of Kentucky. Lovoria B. Williams, PhD is an associate professor in the UK College of Nursing. Nancy E. Schoenberg, Ph.D. is the Marion Pearsall Professor of Behavioral Science in the UK College of Medicine and Director of the Center for Health Equity Transformation. Ariel Arthur is the Manager of the Center for Health Equity Transformation at UK.