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April 15, 2020

COVID-19 and African Americans

Author Affiliations
  • 1Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
JAMA. 2020;323(19):1891-1892. doi:10.1001/jama.2020.6548

Much has been published in leading medical journals about the phenomenon of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The resulting condition, coronavirus disease 2019 (COVID-19), has had a societal effect comparable only to the Spanish flu epidemic of 1918. As the flow of clinical science has better informed the contemporary narratives, more is being learned about which individuals and groups experience the most dire complications. Researchers have emphasized older age, male sex, hypertension, diabetes, obesity, concomitant cardiovascular diseases (including coronary artery disease and heart failure), and myocardial injury as important risk factors associated with worse outcomes; specifically, case-fatality rates vary over 100%.1-3 These data sourced from China and Europe have not been replicated in the US, but the US experience may nevertheless represent similarly distressing outcomes in these highest-risk phenotypes.

The concerns about these observations are appropriate and the published data are indeed actionable; those who fit the highest-risk phenotypes can be advised to assiduously adhere to safe practices including hand hygiene, use of masks in public spaces, and social distancing/physical isolation.4 These measures not only are flattening the curve but are no doubt saving lives. However, a new concern has arisen: evidence of potentially egregious health care disparities is now apparent. Persons who are African American or black are contracting SARS-CoV-2 at higher rates and are more likely to die.5 Why is this uniquely important to me? I am an academic cardiologist; I study health care disparities; and I am a black man.

What is currently known about these differences in disease risk and fatality rates? In Chicago, more than 50% of COVID-19 cases and nearly 70% of COVID-19 deaths involve black individuals, although blacks make up only 30% of the population. Moreover, these deaths are concentrated mostly in just 5 neighborhoods on the city’s South Side.6 In Louisiana, 70.5% of deaths have occurred among black persons, who represent 32.2% of the state’s population.7 In Michigan, 33% of COVID-19 cases and 40% of deaths have occurred among black individuals, who represent 14% of the population.5 If New York City has become the epicenter, this disproportionate burden is validated again in underrepresented minorities, especially blacks and now Hispanics, who have accounted for 28% and 34% of deaths, respectively (population representation: 22% and 29%, respectively).8

The Johns Hopkins University and American Community Survey indicate that to date, of 131 predominantly black counties in the US, the infection rate is 137.5/100 000 and the death rate is 6.3/100 000.5 This infection rate is more than 3-fold higher than that in predominantly white counties. Moreover, this death rate for predominantly black counties is 6-fold higher than in predominantly white counties. Even though these data are preliminary and further study is warranted, the pattern is irrefutable: underrepresented minorities are developing COVID-19 infection more frequently and dying disproportionately. Do these observations qualify as evident health care disparities?

Yes. The definition of a health care disparity is not simply a difference in health outcomes by race or ethnicity, but a disproportionate difference attributable to variables other than access to care.9 Given the known risk factors for COVID-19 complications, the confluence of hypertension, diabetes, obesity, and the higher prevalence of cardiovascular disease among black persons may be driving these early signals. Data fully adjusted for comorbidities have not been reported but it is likely that some, if not most, of these differences in disease rates and outcomes will be explained by concomitant comorbidities.

But concerns go beyond these comorbidities. Where and how black individuals live matters. If race per se enters this discussion, it is because in so many communities, race determines home. Once adverse outcomes attributable to known risks for COVID-19 complications are disaggregated from total morbidity and mortality burden due to COVID-19, the pernicious influence of adverse social determinants of health is likely to become apparent.10 The communities where many black people reside are in poor areas characterized by high housing density, high crime rates, and poor access to healthy foods. Low socioeconomic status alone is a risk factor for total mortality independent of any other risk factors. These social determinants of health must be considered in a complex equation, including known cardiovascular risk factors, which puts underrepresented minorities who live in at-risk communities at greater risk for disease, not just for cardiovascular diseases but now for COVID-19 mortality.

The most effective strategy known to reduce COVID-19 infection is social distancing, but herein lies a vexing challenge. Being able to maintain social distancing while working from home, telecommuting, and accepting a furlough from work but indulging in the plethora of virtual social events are issues of privilege. In certain communities these privileges are simply not accessible. Thus, consider the aggregate of a higher burden of at-risk comorbidities, the pernicious effects of adverse social determinants of health, and the absence of privilege that does not allow a reprieve from work without dire consequences for a person’s sustenance, does not allow safe practices, and does not even allow for 6-foot distancing. The consequent infection and death rates due to COVID-19 complications are no longer surprising; they should have been expected. These observations are rooted in the recalcitrant reality of the deeply entrenched history of health care disparities and may settle as the most painful example yet of the regressive tax of poor health. COVID-19 has become the herald event that now fully exposes the deep and chronic social wounds in US communities.

What makes this particularly egregious is that unlike the known risk factors for which physicians and others can stridently offer clear advice regarding prevention, these concerns—the burden of ill health, limited access to healthy food, housing density, the need to work or else, the inability to practice social distancing—cannot be well-articulated as clear, pithy, and easily actionable items.

What is the action plan? It is less an action plan and more of a commitment. A 6-fold increase in the rate of death for African Americans due to a now ubiquitous virus should be deemed unconscionable. This is a moment of ethical reckoning. The scourge of COVID-19 will end, but health care disparities will persist. Does the US chronicle these poor outcomes due to COVID-19 complications with the higher burden of cardiovascular disease, poorer outcomes for breast cancer, higher amputation rates for peripheral vascular disease, lower kidney transplant rates, and worse rates for maternal mortality, then safely park everything in the health care disparity domain and go back to “normal”? Or will the nation finally hear this familiar refrain, think differently, and as has been done in response to other major diseases, declare that a civil society will no longer accept disproportionate suffering?

Public health is complicated and social reengineering is complex, but change of this magnitude does not happen without a new resolve. The US has needed a trigger to fully address health care disparities; COVID-19 may be that bellwether event. Certainly, within the broad and powerful economic and legislative engines of the US, there is room to definitively address a scourge even worse than COVID-19: health care disparities. It only takes will. It is time to end the refrain.

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Article Information

Corresponding Author: Clyde W. Yancy, MD, MSc, Division of Cardiology, Northwestern University, FSM, 676 N St Clair, Chicago, IL 60611 (cyancy@nm.org).

Published Online: April 15, 2020. doi:10.1001/jama.2020.6548

Conflict of Interest Disclosures: None reported.

Additional Contributions: I thank Kristin T. Yancy and Nina M. Yancy for their review of the manuscript.

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4 Comments for this article
We Should Not Neglect the Possibility of Biologic Factors
Wm Prendergast, MD | Private practice, retired
I wholeheartedly agree with Dr. Yancy about the many unjust disparities that are suffered by our minority communities, especially in this pandemic time. However, he doesn't mention the widely reported inequalities in the gender and racial distribution of the ACE2 receptor and the possible implications of that to the morbidity and mortality (and possibly susceptibility?) to this SARS Co-V-2 virus.

To my reading, findings in this area are far from conclusive at this time, but there appears to be some strong evidence, from some of the Chinese reports and from some prior US studies on racial
difference in hypertension, that there is a tendency toward higher levels of this receptor in males and especially Asian and African American males. Not enough is certain about the pathogenesis of this disease to yet draw any firm conclusion it would seem. But I hardly think that a biological basis for the greater average severity in these groups should be written off in favor of entirely socio-economic factors.
COVID-19 and African Americans
Viraj Suvarna, MD MSc | President Medical, Eris Lifesciences Limited
While I fully understand and agree with what Dr. Yancy has shared, it is interesting that Africans in Africa have not been as badly affected by this novel Coronavirus. So could it also be the lifestyle changes that happen when people migrate? Indians too suffer from this 'Westernization' in terms of diet and physical inactivity, both in India and in the US. Agreed, the African Americans and Indians too carry their genetic traits with them, which make them more susceptible, e.g., RAAS or lipoprotein (a) respectively; there are healthcare disparities; and the luxury of physical distancing may not always be possible among the poor. But I feel the main reason for increased morbidity and mortality is the fact that they are not well controlled from a chronic underlying disease (hypertension, diabetes, chronic heart disease, CKD, etc) perspective, and hence if they get this virus, the complications of uncontrolled chronic underlying disease adds to the complications of severe COVID-19 (dysregulated inflammatory response). One of the reasons could be that they cannot afford healthcare, hence are not at goals, and are therefore susceptible to severe COVID-19.
Race can not be the problem but education may be the solution
Giuliano Ramadori, Professor of Medicine | University Clinic Göttingen,Germany
Dr Yancy mentioned "race" three times as one of the possible reasons for higher infection and death rate amongst the African American and hispanic minorities in the US. Race cannot be the reason for this situation as African-American and Hispanic people the same race as white people. Education is the most important reason for different epidemiology.
Argument Against biologic/ACE2 Receptor Relevance
Will Jaffee, DO | Baystate Medical Center-UMass Medical School, Springfield, MA
I too wonder if there are other biological factors at play here. It is curious, however, that the 2009 H1N1 virus also disproportionately affected African Americans (35% of hospitalized H1N1 patients were black compared to 16% of the 10 states' populations studied (1)). This virus had a different mechanism of cell entry, thus the difference is not clearly explained by ACE2 receptor distribution differences between those of different ethnic backgrounds.

Biological differences in ACE2 expression (or other relevant mechanisms at play) should be sought, as they could lead to helpful treatments.

This is not a zero-sum
game, however, and I think we can walk and chew gum simultaneously. No one is going to ask public health researchers to do bench research, and I wouldn't want bench researchers attempting health-disparity interviews to effect policy change.


1. https://www.cdc.gov/h1n1flu/african_americans_qa.htm