As racial and ethnic data on COVID-19 patients slowly begins to surface, it appears to confirm what public health experts expected: That poor and minority communities would be affected the most.
“There were predictions by folks in the health equity space that this was going to definitely impact the black community and other racially marginalized groups potentially—immigrants, Latinx, Native Americans,” Aletha Maybank, MD, MPH, chief health equity officer and group vice president of the Center for Health Equity at the AMA, said during a video interview with Todd Unger, the AMA’s chief experience officer.
The predictions were based on recent history where black communities were disproportionately affected by disasters like Hurricane Katrina and pandemics like the H1N1 virus.
More racial and ethnic data would provide evidence that this was indeed happening with COVID-19, Dr. Maybank said. It would also help public health experts track trends, develop strategies and direct financial resources.
“You can’t address what you don’t measure,” Dr. Maybank said, noting that the U.S. Census is a prime example of how data is used to direct how funding is distributed.
(The U.S. Census was the topic of a recent AMA Moving Medicine podcast with Dr. Maybank. Listen on Apple Podcasts, Google Play and Spotify.)
Evidence of inequities
In the video, Dr. Maybank noted how the outcry over the lack of data grew as public health experts and health equity advocates spoke out and wrote op-ed pieces emphasizing why this information was important.
This includes a column Dr. Maybank wrote for the New York Times that told how, even though fewer than a dozen states had published race and ethnic data, patterns were becoming clear:
- In Wisconsin’s Milwaukee County, only 25% of the population is black, but African Americans accounted for 45% of COVID-19 cases and 70% of the deaths.
- In Michigan, only 14% of the population is black, but black people account for 33% of COVID-19 cases and 41% of the deaths.
- In Chicago, one third of the city is black, but they accounted for half of COVID-19 cases and 70% of deaths last month. (The number is now reportedly down to 60%.)
“This data is central to understanding injustice and ensuring the optimal health of people, but it is gravely missing in this crisis—missing from health department websites, daily updates by political leaders and, until recently, news reports,” Dr. Maybank wrote.
The AMA joined the National Medical Association, National Hispanic Medical Association, Association of American Indian Physicians, National Council of Asian Pacific Islander Physicians and other physician organizations in a letter to Health and Human Services (HHS) Secretary Alex Azar urging HHS to collect, analyze, and publicly post standardized data on COVID-19 patients’ race, ethnicity, and preferred language along with their COVID-19 testing status, hospitalization, and mortality.
“It is well-documented that social and health inequities are long-standing and systemic disturbances to the wellness of marginalized, minoritized, and medically underserved communities,” the physician groups told Azar. They noted that COVID-19 did not created the circumstances that led to inequities, but it continues to exacerbate them along racial and ethnic lines that affect housing stability, employment, health care access and food security.
Dr. Maybank said in the video that a lack of consistency and standardization is an obstacle to data collecting as are the circumstances connected to hospital admission. She explained that proper way to collect race and ethnicity data is by self-report and self-identify. In other words, patients are asked explicitly about their race and ethnicity. But that information may be difficult to obtain in an emergency.
Dr. Maybank added that she recently went to a drive-up COVID-19 testing facility and was not asked her race or given the opportunity to note it herself for the record.
The CDC National Center for Health Statistics is now posting data for some states listing COVID deaths by race and ethnicity and showing how those numbers compare to a weighted distribution of those groups in the population of areas in the state affected by COVID-19. (The CDC’s weighting formula is based on demographics of the areas where COVID-19 cases are reported and excludes areas where there are no cases.)
In Louisiana, for example, non-Hispanic blacks account for 50.8% of the deaths, despite being only 36.9% of the “weighted distribution of population.”
Statistics are also showing the devasting impact of COVID-19 on Native American communities. The CDC shows that non-Hispanic American Indian or Alaskan Natives account for 28.6% of COVID-19 deaths in Arizona, but account for only 2.2% of the weighted population.
Other jurisdictions are also posting race and ethnicity data.
The New York State Department of Health posted that Hispanics make up 29% of New York City’s population, but account for 34% of the city’s COVID-19 deaths.
The CDC does not post statistics for New Mexico, but the state’s Department of Health posted that Native Americans including Alaskan Natives account for more than 41% of COVID-19 cases there but only account for 10.7% of the population, according to the National Congress of American Indians.
Addressing underlying factors
The AMA is involved in major efforts to lower the incidence of hypertension and diabetes in the U.S., which are two chronic diseases that have hit African American communities hard and put them at risk for COVID-19.
The New York State Department of Health reported that, as of April 20, there were 14,828 COVID-19 deaths in the state, with 13,197 (89%) having at least one comorbidity. This included 8,508 people with hypertension and 5,541 with diabetes.
“Underlying conditions in terms of physical health are absolutely critical to note, and black people in this country are more likely to suffer from those particular underlying conditions,” Dr. Maybank said. “But we also have to look at the underlying conditions of the communities in which they live and the reality of them having to be front-line workers and essential workers.”
Crowded urban housing is another underlying condition, she added.
“These are all underlying conditions that contribute to the severity and the experience black people are going through,” Dr. Maybank said, explaining that these conditions are the result of longstanding structures, policies and laws.
“It sounds big and it is big,” Dr. Maybank said in an interview with Oprah Winfrey on Apple TV+. “But I don't feel we can get to meaningful solutions unless we name structural racism as the fundamental cause of why these health inequities exist in the first place.”
Early data indicates that poor and minority patients will likely suffer disproportionally during the COVID-19 pandemic. The AMA is equipping physicians with tools and resources to confront these health inequities.