- Researchers have observed higher COVID-19-related hospitalization and mortality rates among racially minoritized groups and people with lower incomes.
- A recent review describes how high poverty rates and racial discrimination led to these disparities in COVID-19-related health outcomes.
- Preexisting medical conditions are more prevalent in individuals with a lower income and those who belong to historically marginalized groups, making them more susceptible to the negative health effects of COVID-19.
- Factors associated with high poverty rates and racial discrimination, such as limited access to healthcare, residential segregation, overcrowding, poor housing conditions, and high risk work conditions, have also contributed to the disparities in COVID-19-related health outcomes.
The health effects of COVID-19 have disproportionately affected individuals belonging to low income and racially or ethnically minoritized groups. Studies have shown a higher number of COVID-19 cases, hospitalizations, and deaths among individuals belonging to Indigenous, Black, and Hispanic communities. Similarly, evidence suggests a higher risk of severe disease and mortality among individuals with lower incomes.
Early in the pandemic, the factors associated with the higher rates of hospitalization and mortality among these groups were not well-understood. In other words, it was unclear whether comorbidities, social determinants, or both contributed to these worse COVID-19-related health outcomes.
One study, for example, which researchers conducted early in the pandemic, found that both comorbidities and social factors likely contributed to the higher mortality in the Black patient populations.
Dr. Ladan Golestaneh, professor of medicine at the Albert Einstein College of Medicine in New York City and the study’s lead author, told Medical News Today:
“Our study did a careful analysis of the population of the Bronx who receives their care at our health system — a health system that has invested heavily in programs that serve our community of patients.[…]. We were able to show that despite adjustment for multiple comorbidities and risk factors — including area-level poverty and use of public transportation — hospitalized Black patients died at disproportionately higher rates than did white patients.”
Noting the role of social determinants, as the study suggests, Dr. Golestaneh said, “The worse severity of illness and mortality outcomes seen in racial/ethnic minorities have to do with low socioeconomic status, barriers to adequate high quality healthcare, and residential racial segregation, the latter resulting from a deliberate historical act by the U.S. government to separate residential communities by race and disinvest from Black residential communities.”
A recent review in The Lancet Regional Health — Americas now summarizes evidence delineating the underlying factors responsible for the more profound health consequences of COVID-19 in people belonging to lower income households or racially or ethnically minoritized groups.
Intersection of race and poverty
Poverty levels were relatively high in the United States before the pandemic. Various factors, such as weak labor protections and an inadequate welfare state, enabled these high poverty rates.
Moreover, racial and economic inequalities tend to be interlinked and can be difficult to disentangle. Racial discrimination has had a significant impact on social welfare policies and labor laws in the U.S. Racial discrimination also influences educational and employment outcomes.
Thus, the systemic nature of racism has resulted in higher poverty rates for the targeted individuals. The 2019 Supplemental Poverty Measure published by the Census Bureau reported that the poverty rates among Black and Hispanic residents were more than 18% in the United States, whereas 8.2% of non-Hispanic white residents met the criteria for living in poverty.
Given the close association between race and poverty, the authors of the present review considered how these interconnected factors increased vulnerability to COVID-19-related health consequences.
Comorbid diseases and access to healthcare
Preexisting health conditions, such as cardiovascular disease, diabetes, cancer, and HIV, are more prevalent among individuals belonging to historically marginalized groups and those with low socioeconomic status. These preexisting conditions can worsen the effects of a SARS-CoV-2 infection, resulting in a higher number of hospitalizations and deaths.
Another closely related reason for the worse outcomes is limited access to healthcare.
Individuals belonging to low income and historically marginalized communities are less likely to have health insurance than higher income and white populations, respectively.
A 2020 study reported that 18.2 million individuals at high risk of COVID-19 due to older age and underlying conditions were uninsured or lacked adequate insurance. Notably, the study found that people with lower incomes and racially minoritized individuals were more likely to belong to this group of high risk uninsured or underinsured individuals.
State policy decisions have also contributed to the high number of underinsured individuals. For instance, 12 states have refused the expansion of Medicaid, which would extend coverage to individuals with incomes of up to 138% of the Federal Poverty Level. This has especially influenced the ability of low income marginalized groups to access healthcare.
Besides the high cost of healthcare, other obstacles hindering access to healthcare for these groups include the “earned” mistrust of healthcare institutions and clinicians, language barriers, and biases in the healthcare system.
These factors have also contributed to the low rate of vaccination in marginalized communities, especially during the initial period of the vaccine rollout. Distrust of the healthcare system due to historical reasons and recent experiences of racial discrimination in healthcare settings have led to vaccine hesitancy.
Healthcare professionals can play a vital role as trustworthy sources of information on vaccinations. However, the lack of adequate health insurance has limited access to these professionals, thus contributing to lower vaccination rates.
Housing conditions
Residential segregation by race and socioeconomic status remains prevalent in the U.S. and is associated with racial disparities in health outcomes.
Studies suggest a similar impact of residential segregation on COVID-19 outcomes, with a higher number of COVID-19 deaths occurring in racially and socioeconomically segregated counties.
Other studies have investigated the role of housing quality in mediating the COVID-19-related health disparities.
Evidence suggests that housing quality factors, such as overcrowding and incomplete indoor plumbing, are associated with higher COVID-19 cases and death rates.
Overcrowding and multiple generations residing together are more prevalent in historically marginalized and low income households.
These housing quality factors facilitating the rapid spread of SARS-CoV-2 have contributed to the disproportionate impact of COVID-19 on low income and racially minoritized groups.
These individuals are also more likely to rent than own a home. The eviction of renters during the pandemic also resulted in a surge in COVID-19 cases among those displaced.
Residential location can also influence access to COVID-19 testing and vaccination and, subsequently, vulnerability to COVID-related health consequences. For instance, states with a larger Black population and higher poverty rates had lower SARS-CoV-2 testing rates.
Similarly, a study covering 94 counties found that Black individuals were more likely to have to travel more than 10 miles to the vaccination site than their white counterparts. Lack of transportation or access to the internet to schedule a vaccination appointment may also have contributed to the lower vaccination rates.
High risk employment
Another reason for the higher levels of severe COVID-19 cases among people with a lower income and racially and ethnically minoritized individuals includes employment in occupations associated with a high risk of SARS-CoV-2 infection.
Individuals from low income households constitute a significant proportion of essential workers, who are involved in vital sectors, such as healthcare, retail, education, food production, and transportation. Individuals earning less than twice the federal poverty levels constitute nearly 25% of essential workers.
Similarly, individuals belonging to historically marginalized groups often make up a substantial share of workers in essential occupations. For example, 3 in 4 frontline workers in New York City belong to these groups.
The contagiousness of SARS-CoV-2 and the inability to work remotely meant that essential workers were at increased risk of contracting COVID-19. Moreover, the lack of adequate safety and health measures, such as the limited availability of personal protective equipment and difficulty enforcing physical distancing regulations at the workplace, further increased the risk of exposure to SARS-CoV-2.
The lack of access to paid leave or unemployment benefits also contributed to the increased vulnerability of essential workers to a SARS-CoV-2 infection.
Another contributing factor was lower vaccination rates, potentially due in part to a lack of flexibility in work schedules and unavailability of paid leave during the early phase of the vaccine rollout.
Future research
The studies that the review summarizes show how racial discrimination and high poverty rates have resulted in the disparities in the health consequences of COVID-19. Describing the impact of these structural inequities, Dr. Cary Gross, professor of medicine and epidemiology at Yale University, noted to MNT: “The COVID-19 pandemic has laid bare a hard truth about American society at large and the healthcare system in particular.”
“We see large health inequities across race and ethnic groups not because of a single shock to the system (COVID-19) but because of the very nature of the system itself — it is working exactly as designed. There is an entrenched hierarchy in which racism leads not only to differential wealth, but also differential power, prestige, and freedom. So differences across race groups in wealth and poverty are vital, but they don’t tell the whole story.”
– Dr. Gross
The review authors noted that research on the effects of COVID-19 on individuals with disabilities, members of LGBTQIA+ communities, and American Indian and Alaska Native individuals remains limited. These individuals are also often socioeconomically disadvantaged and thus may be at increased risk of negative health effects associated with COVID-19.
Although the median household income of Asian American households is higher than that of all U.S. households, there are considerable disparities in income levels within the Asian American community. For instance, individuals in the top 10% of earners in the Asian community have 10.7 times the income of those in the bottom 10% of earners.
Hence, more research is necessary to investigate whether vulnerability to COVID-19-related health consequences was more pronounced in Asian Americans with a low income.
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