When a Pandemic Meets an Epidemic of Disparity: A Call to Action on COVID-19 in Black Americans

“A pandemic superimposed on a historic epidemic of health and healthcare disparities.” That’s how a new commentary by a team of Cleveland clinicians and academicians describes the effect of COVID-19 on Black Americans.

The commentary, published in the Journal of the National Medical Association (2020 Aug 1 [Epub ahead of print]), identifies four factors that have contributed to the disproportionately greater impact of COVID-19 on Black U.S. residents:

• Insufficient availability of public testing for the virus that causes COVID-19
• Dramatic spikes in unemployment and/or health insurance loss among low-wage service sector workers, who are disproportionately likely to be Black
• High prevalence of preexisting chronic diseases and reduced access to preventive/primary healthcare
• Bias among individual healthcare providers and structural bias at the healthcare system level

‘More than a statistical aberrancy’

“Even in the best of times, Black Americans experience higher rates of chronic diseases such as hypertension, diabetes, coronary artery disease, kidney disease, stroke and cancer compared with white Americans,” says the commentary’s lead author, Lee Kirksey, MD, MBA, a vascular surgeon in Cleveland Clinic’s Miller Family Heart, Vascular & Thoracic Institute. “This manifests through shorter life expectancies and higher infant mortality rates among Black Americans. Data now show us that these health disparities are being exacerbated by COVID-19, in part because underlying chronic disease makes people more vulnerable to severe effects of COVID-19 but also because of larger systemic and societal issues.”

Dr. Kirksey and colleagues cite striking data demonstrating such disparities across a number of U.S. states:

• In Illinois, Blacks represent 15% of the population but 28% of confirmed COVID-19 cases and 43% of COVID-19 deaths.
• In Michigan the respective percentages are 14%, 33% and 40%.
• In Louisiana, Blacks make up 33% of the population but account for 70% of COVID-19 deaths.

The authors write that while collection of racial and ethnic data in COVID-19 tracking has been inconsistent across states and municipalities and therefore incomplete, “it is clear that the finding that COVID-19 is disproportionately afflicting and killing more African Americans is more than a statistical aberrancy.”

What can be done

Dr. Kirksey and colleagues devote a good portion of their commentary to outlining what can be done to counter these disparities.

The essential first step, they argue, is timely and accurate identification of precise numbers of tests performed, confirmed cases and COVID-19-related deaths within Black communities. This demands action and commitment at municipal, state and federal government levels — including placing requirements on private testing labs — as well as consistent and transparent public reporting.

They add that testing availability must be supplemented by efforts to ensure access to testing and promote its use by Black and other minority communities. They urge that efforts be focused on locating testing centers in underserved neighborhoods and that testing be promoted by tailored advertising campaigns to overcome historical distrust of population testing among Black citizens and to dispel potential “urban myths” around COVID-19. “Faith-based organizations, prominent community leaders and visible African American healthcare professionals can play an essential role in spreading timely and accurate information in this regard,” says Dr. Kirksey.

Mitigating implicit and explicit healthcare provider bias is another essential step in ending racial disparities around COVID-19 care and healthcare in general, the commentary authors note. In the context of COVID-19, bias can range from selective offering of testing to decisions concerning intubation and “futility”-related withdrawal of care.

“Bias can be countered by applying evidence-based protocols that lay out standardized care guidance for all patients with enough flexibility for the exercise of prudent clinical judgment,” Dr. Kirksey notes. He adds that this strategy can be bolstered by ensuring that critical decisions be made by multidisciplinary “triage teams,” including a bioethicist, to avoid forcing single physicians to carry the moral burden of such decisions on their own.

Beyond the moral imperative

The authors conclude by noting that as strong as the moral imperative is for equitable distribution of resources for testing, tracing and treating cases of COVID-19 among all populations, there are other reasons as well.

“A profound business case can be made that improving care within underserved groups will reduce emergency department visits [and] hospitalizations for advanced-stage COVID-19 presentations,” they write. They add that such an approach will help allow healthcare facilities “emerge from the COVID-19 fog” and resume more normal business. It also might help nudge the nation beyond the thicker public health fog of continuing healthcare disparities more generally.

To view the open-access commentary in full, click here.