Updated on: June 29, 2020

Racial and ethnic inequalities during COVID-19 can’t be ignored

Original story posted on: June 30, 2020

Even with a relatively low mortality rate, the U.S. had a population of 325 million that was entirely vulnerable to the novel coronavirus. The case fatality rate is skewed older. Consider this: one out of every six people over the age of 80 may ultimately succumb to COVID-19.

We do not know the true percentage of the population that has or has had COVID-19. Until we are doing random screening of large swathes of the population, most people who self-select to be tested are sick. The increase in testing is unveiling more people with active disease. Decreasing testing will not make the disease go magically away, even if it were to lower the apparent numbers.

One of the facts not being contested is that racial and ethnic minority groups are being disproportionately affected.

I was very conflicted after George Floyd’s murder. Black lives DO matter. And the uprising that ensued is a revolution whose time is long overdue. But I didn’t want it to come smack dab in the middle of a deadly global pandemic. As I watched the news cover the protests, it was glaringly obvious to me that the COVID case total and death tolls that had been prominent on the right side of my TV screen for months had vanished. I was anguished at the lack of physical distancing and mask coverage I saw, putting protesters at further peril from COVID-19. All I can think about is how many more lives are going to be lost from COVID-19, and how folks must think that the risk is worth it, to shine a light on pervasive injustice.

The systemic racism pandemic has collided with the coronavirus pandemic.

An age-adjusted analysis by Yale University and the University of Pittsburgh revealed that black people are 3.5 times more likely, and Latinx people nearly twice as likely, to die of COVID-19 than white people. The statistics vary wildly by locale. In Wisconsin, black patients are 18 times as likely to die of COVID-19 as whites.

The underlying causes of the disparity are complex, and they are inextricably linked to the fundamental roots of the Black Lives Matter (BLM) movement. Social determinants of health (SDoH), economic and educational disadvantages, healthcare access and quality, and cultural factors all contribute.

It is universally acknowledged that comorbidities portend a worse prognosis. Racial and ethnic minorities have a disproportionate disease burden of diabetes, hypertension, cardiovascular disease, asthma, morbid obesity, HIV, and liver and kidney disease. Some of these disease processes are linked to suboptimal diet, which can be compounded by living in food deserts, and relative costliness of healthy foods as compared to fast food.

Living conditions may contribute to institutional racism in the form of residential housing segregation. It is harder to practice physical distancing in densely populated areas, and there may be multi-generational households living in cramped quarters. Physical distancing may be especially challenging for the homeless and those residing in shelters. People may need to use risky public transportation to get necessities like food and medical supplies, and to get to their places of employment.

People of color may also be overrepresented as critical workers in essential industries; nearly a quarter of employed black or Hispanic workers are employed in service industries. A total of 53 percent of agricultural workers are Hispanic, and African-Americans account for 30 percent of licensed practical nurses, and that figure is probably even higher if one were to take into consideration personal aides. These workers may not have paid sick leave, causing them to choose between their livelihood and their lives. They go to work, allowing the rest of society to shelter at home and flatten the curve.

Being under- or uninsured is likely to be a barrier to seeking healthcare. According to the Centers for Disease Control and Prevention (CDC), compared to whites, Hispanics are almost three times as likely to be uninsured, and African-Americans are almost twice as likely to be uninsured. For months, one could only be tested for COVID-19 with a physician’s order. If you had no employer-based insurance, you probably had no primary care physician, and, thus, there was no way to access a test. If you don’t know you are infected, you may expose others. Perhaps the disparity in mortality is partly due to patients seeking out medical care only when the disease is more advanced. Perhaps implicit bias by practitioners negatively impacts on healthcare provision. Access to remote telemedicine may be impaired by lack of access to the Internet.

Contact tracing may also be more challenging in communities of color, where there is a legitimate distrust of authority and law enforcement. Immigration status may be a major concern and impediment.

Why did it take a pandemic to unmask racial and ethnic healthcare inequity? No one should have to say “I can’t breathe” because society has let them down.

Erica E. Remer, MD, CCDS

Erica Remer, MD, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. She was a physician advisor of a large multi-hospital system for four years before transitioning to independent consulting in July 2016. Her passion is educating CDI specialists, coders, and healthcare providers with engaging, case-based presentations on documentation, CDI, and denials management topics. She has written numerous articles and serves as the co-host of Talk Ten Tuesdays, a weekly national podcast. Dr. Remer is a member of the ICD10monitor editorial board, a former member of the ACDIS Advisory Board, and the board of directors of the American College of Physician Advisors.

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