How COVID-19 Has Unveiled a Tale of Two Americas

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MAY 08, 2020 — A recent commentary described the higher rates of COVID-19 infection and mortality in the black American community as a “sentinel event,” or an “unexpected occurrence that leads to serious physical or psychological injury.” Reports of the disproportionate toll that SARS-CoV-2, the novel coronavirus causing COVID-19, is taking on black and Hispanic Americans have become ubiquitous, as has the dismay of many, surprised by the growing disparity in infections and deaths.

Clinicians, researchers, and policymakers alike have scratched their heads wondering why as many as 70% of COVID-19–related deaths are of black people in large cities throughout the United States, from Milwaukee to Detroit, New York City to New Orleans. As black physicians and health equity researchers who understand the plight of the underserved, we argue that this pandemic is unfolding exactly as we might have imagined, and that the unfortunate element of surprise that the response to this disease has enjoyed belies a deeply entrenched failure to recognize the scourge of systemic racism.

As early data from China noted, hypertension, diabetes, asthma, and other chronic heart and lung diseases portend worse outcomes in the setting of COVID-19. Decades of research have demonstrated that these diseases are more common in black Americans. Over 40% of black persons carry a diagnosis of hypertension, are 60% more likely to have diabetes, and are nearly three times more likely to die from asthma than are their white counterparts. Cardiovascular disease remains the leading cause of death in the United States, and black Americans are far more likely to not only die from heart disease but also to die prematurely.

This baseline prevalence of comorbidity placed blacks at higher risk from the outset of the COVID-19 pandemic in the United States. Yet, communities of color have not been a focus of intensive prevention and mitigation strategies, even today. Why?

Many of the health disparities in the United States are attributed to differential access to healthcare. Even as health insurance rates improve across the nation due to Affordable Care Act–promoted measures like the health insurance marketplace and Medicaid expansion, 27 million Americans remain uninsured. Disturbingly, black and Hispanic Americans continue to have the highest uninsured rates in the country. This insurance gap results in disparate access to primary care and, therefore, preventive medicine.

Black Americans are less likely to be referred to a medical specialist, and even when referred, are less likely to receive advanced medical therapies. Decades of residential segregation and redlining have resulted in fewer hospitals in black communities, which further restrict access to healthcare, a pressing need amid a pandemic.

While healthcare access affords many the opportunity to receive support in managing disease, it is myopic to attribute the disparities in COVID-19 to clinical factors alone. The legacy of systemic racism in our nation has placed blacks at a higher risk for COVID-19 infection and death. Discriminatory housing policies have driven blacks into crowded urban neighborhoods with limited access to transportation, healthy food, clean water, and pollution-free air. Employment and wealth disparities have been well documented, as blacks are more likely to work in low-wage jobs, many of which are now deemed essential in the pandemic.

Furthermore, there remains a disproportionate number of black Americans who are homeless or incarcerated, with limited ability for social mobility, much less social distancing. Nevertheless, despite this preponderance of structural factors, many remain shocked at the COVID-19–related disparities data, a shock that has crippled the American healthcare system into inaction for far too long.

If data regarding disparities have been so prevalent for so many years, why has COVID-19 been afforded the element of surprise today? The answers are multifactorial but are rooted in a pervasive empathy gap. The highest earners and most well-to-do in our country generally cannot comprehend what life is like for the underserved.

Moreover, a bootstraps mentality has led many to place blame on individuals for their current circumstances rather than recognizing the intentional structures that have been erected in the United States to widen the gap between the haves and the have-nots. Unfortunately, our fellow colleagues in medicine are not immune. Medicine is plagued with implicit bias that contributes to lapses in care and a deep distrust that we must also overcome to move forward.

The lessons we must take from the COVID-19 era are clear.

First, we must continue to advocate for comprehensive and complete race and ethnicity data at the county, state, and federal level. This will help us ensure that testing, infection, and mortality rates are equitable.

Second, given that our most powerful tool is risk mitigation, we must create a comprehensive plan that assesses the factors that limit one’s ability to mitigate (eg, socially distance and remain 6 feet apart from others) and develop plans to address those at highest risk in this regard.

Third, resources must be deployed to ensure universal testing for every American, particularly those residing in high-risk, urban communities, with a plan for if there is a spike in cases within this population. Similarly, we must ensure that everyone has access to high-quality critical and end-of-life care during this crisis, with plans for transfer to better-equipped hospitals if needed.

Fourth, policymakers must quickly develop legislature that enhances the social safety net and ensures food, housing, and financial support to the most vulnerable Americans.

Finally, the time is now to diversify medical and public health leadership at all levels, as life-and-death decisions are being made for Americans with limited advocacy and trust in the healthcare system.

This unprecedented global crisis must serve as a moment of introspection for our nation. We live in two Americas: one where access, wealth, and power act as a shield to communicable diseases like COVID-19, and another in which lack of these resources serves as a vector for infection, particularly in communities of color. The novel coronavirus has benefited from the element of surprise to wreak havoc on the latter. It cannot any longer. We must act boldly. We must act deliberately. And we must act now to save the lives of our most vulnerable.

Utibe R. Essien, MD, MPH, is a board-certified internist and health disparities researcher at the University of Pittsburgh School of Medicine.

Quentin R. Youmans, MD, is board certified in internal medicine and a current fellow in cardiology at Northwestern University Feinberg School of Medicine.