Over 162,000 deaths have been attributed to COVID-19 in the United States within the past six months. And in its wake, the inequities of our nation have risen to the surface, revealed by the light of day with an undeniable starkness. Our BIPOC (Black, Indigenous, and People of Color) communities have been dealt the biggest blow in the times of coronavirus.


Before his brutal murder sparked protests and social justice uprisings in cities around the world, George Floyd had COVID-19. And more of his fellow Black Americans have died from the virus than any other demographic in the nation in proportion to their population share.


I am not a Black American. I am Lationo, a refugee who came to the United States by boat as a four year old child from Cuba. I have had to overcome a myriad issues to be successful in America, and I support the Black Lives Matter movement. I want to offer my voice and support to the movement as a human being, a fellow American, and a primary care physician.


The truth about COVID-19: the death toll


As of August 4th, 32,702 Black Americans had died from COVID-19. This represents 23 percent of known deaths from a group that makes up 12 percent of the total population. And while White Americans have sustained the most deaths, at 73,095, this number represents 51 percent of the total number of lives lost from a group that makes up 62 percent of the population.


The Color of Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S., a project of the independent, nonpartisan APM Research Lab, is compiling data to “guide policy and community responses.” The numbers continue to reveal alarming rates of mortality within the Black and Indigenous communities. Here is the latest data:

Population Number of Deaths Per 100,000 People of Each Group

Black 80

Indigenous 67

Pacific Islander 59

Latino 46

White 36

Asian 33


And the risk of dying from COVID-19 increases exponentially with age: 



Age COVID-19 Deaths Per 100,000 Americans By Age Group


75+ 366


65-74 93


55-64 40


45-54 17


Under age 45 2


When adjusted for age, Black people are dying at a rate almost four times higher than White people in the United States as a whole with the highest disparities in mortality between White and Black residents occurring in New York, Michigan, and Connecticut. What this boils down to is this: COVID-19 is systematically killing Black Americans in 36 states and Washington, D.C. 

Indigenous Americans have also been dying at much higher rates, at three and a half times that of White Americans when accounting for age. The greatest number COVID-19 deaths among Native Americans have been found within pockets of the Navajo Nation in Arizona and New Mexico and in the Band of Choctaw Indians in Mississippi. Both groups have sustained tremendous losses.

Here is the age-adjusted data on mortality rates, representative of the number of times greater than that of the White population:

 

Population Mortality Rate Compared to White Population

Black 3.7 times greater

Indigenous 3.5 ...

Pacific Islander 3.1 ...

Latino 2.8 ...

Asian 1.4 ...



The truth about COVID-19: the sick


As of August 8th, there are over 5,000,000 U.S. COVID-19 confirmed cases. And as evidenced above, Black, Indigenous, and People of Color are overwhelmingly represented in the death toll. The Black community has sustained more deaths for their population share than any other group.


As far as the number of COVID-19 cases, however, while third in the total number of deaths by coronavirus after the White and Black populations, the Latinx community has been hit with the greatest number of COVID-19 cases for their population share. In “The Fullest Look Yet at the Racial Inequity of Coronavirus,” the New York Times reported that “Latino and African-American residents of the United States have been three times as likely to become infected as their white neighbors.”


Here are the numbers reported by the New York Times on July 5, 2020:

Population Number of Cases Per 10,000 People of Each Group

Latinx 73

Black 62

All 38

White 23

 

The data is even more disturbing when accounting for age. Five times as many Latinx people between the ages of 40-59 have been infected as White people. Of those that have died of the virus, 25 percent of Latinxs have been under the age of 60 as opposed to 6 percent of whites. The Color of Coronavirus project found the greatest disparity in Latino deaths from COVID-19 in New York and Washington D.C. when accounting for age.

The number of COVID-19 cases among Native Americans is also much higher than their population share, and though disparity was not found to be as great in Asian communities, the data still reveals Asian Americans to be more likely to become infected than their White neighbors. 

The systemic infection of Latinx communities can be found across the country in small rural midwest communities, suburban towns, and large urban centers. In one of the wealthiest communities in the country, Fairfax County, Virginia, four times as many Latinos had tested positive for the virus (as of the July 5th NYT reporting) compared to White residents, which are three times as numerous in the county. 

The NYT journalists admonish that while this federal data is more comprehensive than prior reports, it is still incomplete. It only includes data up to the end of May, and race and ethnicity information is missing from over 50 percent of the cases. The cause of infection is also missing from many reported cases.

While underlying health issues are often cited to dismiss higher mortality rates within BIPOC communities, it is important to examine the conditions to which infected BIPOC community members have been exposed. Individuals of these groups are more likely to occupy front-line jobs in high-risk settings and are more often relegated to crowded living spaces and public modes of transportation where social distancing isn’t necessarily an option. The privilege of being able to work from home has protected people with underlying health issues such as diabetes and obesity, frequently cited to explain disproportionate deaths, from getting COVID-19. Mary T. Basset, professor of the practice of health and human rights at the Harvard School of Public Health told the NY Times that ‘a big determinant of who dies is who gets sick in the first place … infections have been far more prevalent among people who can’t work from home.’

The independent Irish social justice organization, Uplift, stated in “How to Talk About COVID-19,” that

The people who are bearing the brunt of this crisis are the people who care for society, who do low-paid frontline work – and that has meant that globally, people of color [and] people who are working-class are getting sick and dying more.

 

What’s clear is that traditional power structures, along the lines of race, class, gender, migration status and disability have recreated themselves once again as we battle COVID-19. Corporations who refuse to give the people who work for them paid sick leave, protective equipment, and a living wage are framing their workers as ‘heroes’ when really we know that many people have no choice but to risk their lives by simply just going to work.

The backstory

Well-documented throughout history, the denigration, devaluing and disproportionate death of Black, Indigenous or Native American, and People of Color (BIPOC) has been happening since way before the first African slaves were said to have been brought to what is now the United States in 1619. Davidson College professor and chair of history, Michael Guasco, reported in Black Perspectives that,

From the early 1500s forward, the Portuguese, Spanish, English, French, Dutch, and others fought to control the resources of the emerging transatlantic world and worked together to facilitate the dislocation of the indigenous peoples of Africa and the Americas.

 

In fact, the killing and dislocation of Native Americans began even way before this time, and though the jury is still out on who arrived first in the Americas, evidence suggests that the Western Hemisphere has been inhabited for at least 20,000 years. Before Columbus, Cortes, and other European conquistadors left their devastating mark on the Americas, Pope Nicolas V issued the Romanus Pontifex of 1455, giving Portugal sole rights to territories of West Africa and the “right to invade, plunder and ‘reduce their persons to perpetual slavery.’” This led to the largest forced migration in the world during which time close to “12.5 million men, women and children of African descent were forced into the trans-Atlantic slave trade.”


Systemic racism has continued to negatively impact the health and life expectancy of Black, Indigenous, and People of Color in the United States for centuries, from the beginning of the slave-trade, to pre-Columbian and Columbian-era exploration and settlement, through the colonial period and westward expansion, and in the 157 years since the abolishion of slavery. The disproportionate numbers of BIPOC lives claimed by COVID-19 is yet another indication of this. Regardless of the path to these shores, the devaluing of BIPOC lives and the resulting death, brutality and murder of BIPOC individuals has been happening for centuries. And it continues. But it does not have to. 


Health disparities and access to healthcare in the United States


Despite having been born in a country 100 miles from the coast of Florida, the history of the United States is also my history. It is the history of anyone who has lived in this country. Our individual histories are not separate and isolated, rather, they influence, shape, and mold one another. 


In light of this research and the startling reality that COVID-19 is systematically infecting and killing members of BIPOC communities at rates much higher than their population share, the questions foremost in my mind are:


What impact does systemic racism have on health?

Why is Covid-19 affecting some populations more than others?

What other factors lead to health disparity?

What can primary care physicians do to be a part of the solution?



Health vs. healthcare disparity


Though intricately linked, these terms are not interchangeable. The University of Michigan defines them as such:


Health disparities are differences among population groups (that is, ethnicity, gender, income) in the incidence, prevalence and outcomes of health conditions, diseases, and related complications of diseases. 

Healthcare disparities are differences among population groups in the availability, accessibility, and quality of healthcare services aimed at prevention, treatment, and management of diseases and their complications, including screening, diagnostic, treatment, management, and rehabilitation services.

 

In short, health disparities have to do with the health of the individuals within a population group while healthcare disparities relate to the healthcare services received by members of a population group.


Key findings from the 2018 U.S. Department of Health and Human Services’ National Healthcare Quality Disparities Report show that despite a decrease in some areas, significant racial and ethnic healthcare disparities continue:


Overall, some disparities were getting smaller from 2000 through 2016-2017, but disparities persist, especially for poor and uninsured populations in all priority areas. Racial and ethnic disparities vary by group: Blacks, American Indians and Alaska Natives (AI/ANs), and Native Hawaiians/Pacific Islanders (NHPIs) received worse care than Whites for about 40% of quality measures … Hispanics received worse care than Whites for about 35% of quality measures.



Healthy People 2020 is an initiative of the Office of Disease Prevention and Health Promotion that sets 10 year objectives to improve the health of the nation. They define health disparities as a “health difference that is closely linked with social, economic, and/or environmental disadvantage.” The initiative further explains that such factors negatively affect groups of people


who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.



With regard to the factors listed above, it is clear that the job of primary care physicians is a big one. Health and healthcare disparities affect A LOT of people in this country. With this in mind, let’s turn our focus to the question of what can we do?



Increase access to primary care


Healthy People 2020 organizes the social determinants of health (SDoH) into five main areas: economic stability, education, health and healthcare, neighborhood and built environment, and social and community context. Within health and healthcare, access to primary care is identified as a key issue, “critical for improving population health and reducing health disparities.” 


Authors of a study published in the Health Services Research Journal found that “having a usual source of care is similar to having health insurance in the sense that both facilitate timely and adequate receipt of needed medical care.” In addition to providing a usual source of care, the benefits of primary care include prevention, early detection and treatment of disease, and chronic disease management. 


Healthy People 2020 reported that barriers to primary care “decrease access to services and increase the risk of poor health outcomes. ” Such barriers include:


  • lack of health insurance

  • geography and transportation

  • inability to take time off of work

  • shortage of providers

  • language barriers

  • disability



Race and ethnicity


The Institute of Medicine (IOM) conducted a study on healthcare disparities and found that  


Racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable. (Finding 1-1)


Racial and ethnic disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life. (Finding 2-1)


The IOM’s Findings and Recommendations on Health Disparities acknowledges that though a variety of sources may contribute to racial and ethnic healthcare disparities (Finding 3-1), a greater understanding of the effect of “Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers” is needed (Finding 4-1).


The IOM’s recommendations are grouped into categories: general; health system interventions; legal, regulatory, and policy interventions; patient education and empowerment; cross-cultural education; data collection and monitoring; and research. Though not couched in terms of individual provider actions, aspects of the recommendations that primary care physicians could take on personally include:


  • increase awareness of disparities and systemic causes

  • strengthen patient-provider relationships in publicly funded health plans

  • implement patient education programs to increase patients' knowledge of how to best access care and participate in treatment decisions 

  • develop cross-cultural skills and provide education for staff members on cultural competency and intercultural communication

  • increase the diversity of the healthcare profession by encouraging/mentoring aspiring primary care doctors of a wide variety of racial, ethnic, linguistic, geographic, and socioeconomic backgrounds; abilities; genders, gender identities and gender expressions; and sexual orientations


The American Medical Association (AMA) has created some tools to help primary care physicians more effectively meet the needs of racially and ethnically diverse patients. Their kit, Working Together to End Racial and Ethnic Disparities: One Physician at a Time, includes materials detailing first-hand experiences, the components of disparities (quality of care, trust and stereotyping, cultural competence, language barriers, and health literacy), and a facilitation guide for leading discussions on disparities in healthcare. The National Academies of Sciences, Engineering, and Medicine also offers a free downloadable copy of the Institute of Medicine’s consensus study report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.



People with disabilities


The American Medical Association reported in 2018 that 41 percent of older adults who qualify for Medicare and Medicaid have a disability. Citing barriers to the accessibility of healthcare facilities as one of the most significant challenges for people with disabilities, the AMA has found that “Adults with disabilities are almost twice as likely as other adults to report unmet health care needs due to problems with the accessibility of a doctor’s office or clinic.” This includes the ability to enter the facility and navigate through the entrances and hallways into exam rooms, utilize medical equipment, and access restrooms. The AMA also reports that there are higher rates of disability within the black (29 percent) and hispanic (26 percent) populations than among white adults (21 percent). 


Legislation such as Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 (ADA), and Section 1557 of the Affordable Care Act protects people with disabilities from discrimination in the pursuit of healthcare services. Under such laws, medical institutions are required to: 


  • provide equal services to individuals with disabilities

  • make reasonable modifications in policies and practices to provide equal access

  • provide auxiliary aids and services when necessary to provide effective communication



The ADA Standards for Accessible Design and the US Access Board provide leadership and guidance for healthcare practices in need of removing architectural barriers to care to bring their facilities into compliance. To ensure a compliant practice, the AMA recommends:

  • Evaluating staff training needs with regards to operating equipment, transfer and positioning patients, communicating clearly and appropriately, interacting openly and sensitively;


  • Seeking to understand the needs of patients and being prepared with needed tools, doing a health risk assessment (covered by Medicare), completing required documentation and reporting;


  • Knowing your responsibilities and financial options if your healthcare facility is in need of alterations (owner vs. tenant, altering vs. building structures) as well as tax incentives (IRS Disabled Access Credit, Architectural Barrier Removal Tax Deduction).



LGBTQ populations


Healthy People 2020 reminds us that “LGBT individuals encompass all races and ethnicities, religions, and social classes”. Furthermore, the initiative has found that, “LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights.” They stated,


Discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide. Experiences of violence and victimization are frequent for LGBT individuals, and have long-lasting effects on the individual and the community. Personal, family, and social acceptance of sexual orientation and gender identity affects the mental health and personal safety of LGBT individuals.


As such meeting the health needs of LGBT individuals “starts with understanding the history and ongoing of oppression and discrimination that these communities have faced.” 


Mental health support is an area of particular need for LGBTQ youth. The Youth Risk Behavior Survey administered to high school students across the nation found that 63 percent of LGB students experience persistent feelings of sadness or hopelessness and 48 percent seriously considered suicide. Their heterosexual peers reported 28 percent and 13 percent respectively.


Here are the social determinants required for the health and wellbeing of LGBTQ individuals:


  • laws protecting against bullying in schools;

  • legal support in access to health insurance, employment, housing, marriage, adoption, and retirement benefits;

  • social programs targeted to and/or appropriate for LGBT youth, adults, and elders;

  • increase in health care providers who are knowledgeable and culturally competent in LGBT health.

Primary care physicians can do the following to support and promote LGBTQ health equity:

  • Appropriately inquire about/be supportive of patients’ sexual orientation and gender identity to enhance the patient-provider interaction and regular use of care;

  • Seek out training to increase delivery of culturally competent care;

  • Make referrals to supportive social services as needed to reduce suicide and homelessness among youth;

  • Use effective interventions to curb human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs).

 


Support health equity legislation


From February to May of this year, close to five and a half million Americans lost their health insurance, a number which is almost 40 percent greater than that of the 2008-2009 recession. That number is predicted to rise to as much as 10 million by the end of 2020 as layoffs continue to rise due to the pandemic. This accounts for just one of the barriers to healthcare, but it is perhaps the greatest.


Legislation is needed to address the effects of systemic racism, oppression, and discrimination of community members who have experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristic or experience historically linked to discrimination and exclusion.


I would add that it is of the utmost importance to acknowledge that these factors are not simply historically linked to discrimination and exclusion, but are currently impeding and prohibiting the health and wellbeing of these community members. In fact, there has not been a secession of systemic racism and discrimination in the history of this land.


The Health Equity and Accountability Act


The Health Equity and Accountability Act (HEAA) was introduced on April 28, 2020 by Representative Jesus “Chuy” Garcia (D-IL). The bill was originally co-sponsored by the congressional tri-caucuses Congressional Asian Pacific American Caucus, the Congressional Black Caucus, and the Congressional Hispanic Caucus (CHC) among others. The Association of American Medical Colleges (AAMC) reports that the HEAA “seeks to address disparities by promoting culturally appropriate care, data collection, and reporting.” Emphasizing the urgency of the bill, Congressman Garcia remarked,


The coronavirus pandemic is exposing the deep inequities in health care--a reality my community has experienced for decades. We can all get the virus--but too many families in my community don’t have access to a doctor. The infection counts show, without a doubt, that Latin[x], African American and immigrant communities are suffering more from coronavirus than others. This is wrong, people’s health outcomes should not be determined by their zip code … Now is the time to act.


Furthermore, the AMA states that HEAA addresses “the nonmedical factors that affect health outcomes and can result in unfair, avoidable health inequities by including the Social Determinants Accelerator Act.”



We cannot “unsee”. We cannot look away.


The number of COVID-19 cases and deaths in BIPOC communities has shown a spotlight on racial inequality in the United States. This reality is not limited to, but rather embedded in the coronavirus pandemic. In the wake of George Floyd’s murder, social justice protests and uprisngs in the U.S. and around the world are highlighting that systemic racism, is a pandemic in and of itself. It is a global crisis.


The light that has been shed upon health and healthcare disparities is, in fact, so bright that we are going to have to resist the urge to shield our eyes and turn away. We must, however, keep our gaze focused unwaveringly in its direction.


"The ultimate tragedy is not the oppression and cruelty by the bad people but the silence over that by the good people."  Dr. Martin Luther King, Jr.


*Numbers of some statistics have been rounded to the nearest 10th.

*Data is representative of reporting at the time of writing and will continue to evolve and change over time.