A Stark Look at Covid-19 and Racial Disparities
We knew this would happen
Life expectancy in the United States will almost certainly drop in 2020 due to Covid-19 deaths, extending a decline that frustrates economic demographers like David Bishai, MD, a professor at Johns Hopkins Bloomberg School of Public Health. After rising steadily for 50 years, U.S. life expectancy fell in 2015, 2016, and 2017. The drop wasn’t due to infectious disease or war or any biological limit to how long humans can live, but rather persistent systemic inequities and racial disparities in the health system, along with increases in deaths from opioids, alcohol, and suicide — the latter are what Bishai and other experts call “deaths of despair.”
The ultimate story of Covid-19, written through the lens of history with all the final death statistics, will undoubtedly mirror what we already know from hard data on U.S. life expectancy: On average, the haves outlive the have-nots in a country where the responsibility for health care is placed largely on the individual, and life expectancy varies dramatically based on disparities deeply rooted in geography, wealth, and race.
Globally, the United States ranks 50th in life expectancy, trailing such countries as Cuba, Chile, Slovenia, Portugal, France, and Italy. America is a full five years behind several of the leading nations.
And in America, there are notable gaps in longevity. On average, white men outlive black men by about 4.5 years, and white women outlive black women by about 2.7 years.
More glaring, life expectancy varies by a whopping 20.1 years in U.S. counties with the most favorable numbers — mostly on the coasts and scattered around a handful of other states, including Colorado — compared with counties at the bottom of the charts, which are mostly in the South or have large Native American populations. And things are not getting better for those at or near the bottom: Between 1980 and 2014, the worst counties made no progress, researchers concluded in the journal JAMA Internal Medicine.
That geographic disparity disproportionately affects minorities, the poor, people with underlying health conditions like heart disease and diabetes, and people who often have little choice about working from home or even staying home when they’re sick. Then along came Covid-19.
On average, the haves outlive the have-nots in a country where the responsibility for health care is placed largely on the individual.
Segregation of a different sort
“Most epidemics are guided missiles attacking those who are poor, disenfranchised, and have underlying health problems,” says Thomas Frieden, MD, former director of the U.S. Centers for Disease Control and Prevention.
Already, coronavirus deaths prove the point.
- While just 22% of U.S. counties are disproportionately black, they accounted for 58% of Covid-19 deaths by April 13, according to a study released May 5 by the Foundation for AIDS Research.
- Other research published in April found Covid-19 death rates among black people and Hispanics much higher (92.3 and 74.3 deaths per 100,000 population, respectively) than among whites (45.2) or Asians (34.5).
- In Chicago, nearly 70% of Covid-19 deaths have been among black people, who make up 30% of the population. Similarly lopsided statistics have come out of Michigan and Detroit.
An analysis of deaths in Massachusetts, published May 9 by the Boston Globe and based on research by Harvard scientists, finds a surge in excess deaths in the early days of Covid-19 was 40% greater in cities and towns “with higher poverty, higher household crowding, higher percentage of populations of color, and higher racialized economic segregation” compared to those with the lowest levels of those measures.
These are people who can’t afford to miss a chance to work, often don’t have paid sick leave, may not get proper protection from Covid-19 spread on the job, and tend to already have lower health status due to “persistent health inequities,” says study team member Nancy Krieger, PhD, professor of social epidemiology in the department of social and behavioral sciences at Harvard T.H. Chan School of Public Health.
“It’s been hard for Americans to understand that there are racial structural disparities in this country, that racism exists,” says Camara Jones, MD, an epidemiologist at the Morehouse School of Medicine in Atlanta. “If you asked most white people in this country today, they would be in denial that racism exists and continues to have profound impacts on opportunities and exposures, resources and risks. But Covid-19 and the statistics about black excess deaths are pulling away that deniability.”
Today’s segregation involves factors like severely limited access to healthy foods and green space, and higher exposure to environmental hazards, all contributing to higher rates of obesity, diabetes, high blood pressure, and heart disease, Jones says, echoing the views of many public health researchers.
“Prior to this pandemic and economic calamity, African Americans already lacked health insurance at a rate nearly 40% higher than white people,” says Christopher Hayes, PhD, a labor historian at Rutgers School of Management and Labor Relations. “Many of the highest rates of being uninsured are in Southern states that have not expanded Medicaid and have large black populations.”
Also, the massive unemployment caused by the 2020 global economic shutdown will only worsen the plight of U.S. minorities, putting further strain on families and their options for attending to their health. While the overall unemployment rate rose to 14.7% as of May 8, it jumped to 16.7% among black workers and 18.9% for Hispanic and Latino workers.
“Given that African Americans are disproportionately concentrated in low-wage jobs, and we live in the only rich country without universal health care, too many people only seek medical care in dire situations, and when they do, it can easily be financially ruinous,” says Hayes.
The impact of Covid-19 in the United States will almost surely prove detrimental to the longevity of African Americans and other marginalized ethnic and racial groups, the experts say.
Counting the years
Life expectancy at birth is an estimate of how long a person might be expected to live if known death rates at the time were to remain consistent throughout that person’s life. It is based on a complex calculation of age-specific mortality rates, giving more weight to the probability of death later in life than for young people. Throughout the first half of the 20th century, it spiked up and down significantly in the United States as various deadly infectious diseases swept largely unabated through the population every few years.
The spikiness began to change for many reasons, not the least being higher living standards and improved sanitation and hygiene, says Bishai, the Johns Hopkins demographer.
In 1900, tuberculosis was among America’s leading causes of death. Filthy, crowded living and workplace conditions contributed to the spread of TB bacteria. Also, contaminated food, milk, and water caused TB infections and many other foodborne illnesses, from typhoid fever to botulism. Infections began to slow with public health messages that promoted hand-washing, as well as the introduction of refrigerators and pasteurization of dairy products in the 1920s — making food safer. Along the way, several childhood vaccines were introduced, including whooping cough in 1914 and diphtheria in 1926. Smallpox was eliminated in the United States by 1949.
Vaccines for polio, measles, mumps, and rubella, introduced in the 1960s, helped keep the upward longevity trend going. In 1960, the U.S. surgeon general began recommending annual flu vaccines for pregnant women and people over 65 or with chronic diseases.
From the 1960s onward, there were “noticeable gains in life expectancy at the middle and the end of life,” Bishai says. This was helped in part by advances in heart surgery and cancer treatments. Improved insurance coverage, including Medicare, also helped, he says. But his research, published in 2018 in the journal BMC Public Health, finds that increases in life expectancy have slowed here and across the world since 1950.
Then it all came to a screeching halt.
The decline in U.S. life expectancy in 2015, 2016, and 2017 (it ticked up slightly in 2018, and 2019 figures are not out yet) reflects a stark new reality: Death rates are rising not among children or the very old, but among people age 25 to 64, especially in the economically challenged industrial Midwest and Appalachia, according to a study published last year in the journal JAMA.
“In America, that’s where the battle is — it’s in the middle of life,” Bishai says in a phone interview.
“It’s been hard for Americans to understand that there are racial structural disparities in this country, that racism exists.”
Inequalities not addressed
The federal government is well aware of the nation’s regional disparities in health and mortality. In 2011, the CDC created a Social Vulnerability Index that ranks counties by their resilience “when confronted by external stresses on human health, stresses such as natural or human-caused disasters, or disease outbreaks.” It factors things like socioeconomic status, minority status, and even access to transportation. “Reducing social vulnerability can decrease both human suffering and economic loss,” the agency states.
“Health differences between racial and ethnic groups are often due to economic and social conditions” such as living in densely populated areas, lack of access to grocery stores and medical facilities, and lack of paid sick leave, among a host of other systemic factors, the CDC states. “In public health emergencies, these conditions can also isolate people from the resources they need to prepare for and respond to outbreaks.”
Those well-known differences are driving disastrous outcomes in real time as the new coronavirus rips through low-income and poor neighborhoods. Greg Millett, MPH, director of public policy at the Foundation for AIDS Research and leader of the study out last week on the disproportionate number of deaths in predominantly black U.S. counties, ties Covid-19 directly to the known regional inequities.
Underlying health problems, including diabetes, hypertension, and heart disease, which raise the risk of death from Covid-19, “tended to be more prevalent in disproportionately black counties, but greater Covid-19 cases and deaths were still observed in those counties when adjusting for these factors,” Millett and his colleagues write.
“Many people have observed large and consistent disparities in Covid-19 cases and deaths among black Americans, but these observations have largely been anecdotal or have relied on incomplete data,” Millett says. “This analysis proves that county-level data can be used to gauge Covid-19 impact on black communities to inform immediate policy actions.”
Force for change?
Since we don’t know how many people will die in the pandemic, it’s not possible yet to predict the drop it will cause in life expectancy. But it’s a safe bet it will go down, Bishai says, adding that it would take some “miraculous” decrease in other causes of deaths to prevent a dip.
It didn’t have to be so bad. In a pandemic, a rising health tide would lift all boats. Improved overall health among the most disadvantaged, along with better access to health care and the ability for people to confidently stay at home when they are sick — all things that could change with significant governmental policy shifts — would mean fewer infections for everyone, less pressure on hospitals, and a quicker restart of the economy.
Bishai hopes one positive outcome of Covid-19 is that it helps America get past the notion that the federal government is not responsible for the nation’s health. “What makes you healthy is beyond what you choose to eat, and lifestyle, and what your doctor does for you,” he says. He’s not alone in finding it “frustrating” and “bothersome” that our political system has not addressed the dipping life expectancy curve or the gross health disparities across the country.
“The first thing the federal government could do is take charge and actually have a strategy for dealing with the pandemic,” says Hayes, the Rutgers historian. “Telling the states to handle it is not a solution and is a profound refusal to perform basic duties. Who could imagine FDR telling Hawaii to take care of Pearl Harbor or George Bush shrugging his shoulders at New York on 9/11?”
Ultimately, Hayes argues, the federal government needs to provide universal health care, greatly reduce pollution that contributes to poor heart health, and address income inequality by raising the minimum wage.
“The scourge of Covid-19 will end, but health care disparities will persist,” writes Clyde Yancy, MD, an academic cardiologist at Northwestern University, in an April 15 commentary in the journal JAMA. “The U.S. has needed a trigger to fully address health care disparities,” he writes. “Covid-19 may be that bellwether event.”