COVID-19: Discrimination and inequality shape risk of severe illness and death

Reviewed by Emily Henderson, B.Sc.Apr 28 2020

Underlying conditions that increase risk of severe illness or death from COVID-19 are much more common among Black, Native American, and lower-income people in the United States.

The new coronavirus does not discriminate, but discrimination and inequality have shaped the risk of severe illness and death, according to a new Boston University School of Public Health (BUSPH) study.

The study, published in the American Journal of Preventive Medicine, finds that black, Native American, and lower-income people are much more likely to have one or more of the risk factors for severe or deadly COVID-19 illness identified by the Centers for Disease Control and Prevention (CDC), such as asthma, diabetes, or being pregnant or over 65 years old.

In many respects, COVID-19 is the latest chapter in the book about how structural disparities shape the burden of disease in America."

Mr. Matthew Raifman, a doctoral student in environmental health at BUSPH and study's lead author

"Decades of structural inequities in education, employment, housing, stress, and other factors have shaped disparities in the burden of chronic diseases by race, ethnicity, and income," says study co-author Dr. Julia Raifman, assistant professor of health law, policy & management at BUSPH (the two authors are married). "Now, these structural inequities have created a context in which people who are black, American Indian, or lower income face additional risk of death if they contract COVID-19," she says.

The researchers used 2018 data on over 330,000 people from the nationally-representative Behavioral Risk Factor Surveillance System, and looked at the prevalence of the COVID-19 risk factors. They estimated that 43 percent of American adults--approximately 97 million people--have at least one risk factor, and 18 percent--approximately 40 million people--have two or more.

Among those under 65 years old, 33 percent of black and 42 percent of Native American adults had at least one risk factor, compared to 27 percent of white adults. And 11 percent of black and 18 percent of Native American respondents had multiple risk factors, compared to 8 percent of white respondents.

For those 65 years old or older, 69 percent of Native American and 61 percent of black respondents had one or more additional risk factors beyond age, compared to 54 percent of white respondents.

The researchers found that at least 25 million people living in low-income households have at least one risk factor. Among those under 65 years old, low-income respondents were almost twice as likely to have one or more risk factors than high-income respondents, and more than twice as likely to have multiple risk factors. Low income respondents over 65 years old were also more likely to have multiple risk factors beyond age.

The authors note that the inequities that contribute to chronic conditions also make these populations more likely to work in jobs that cannot be done remotely, and to live in crowded, multi-generational homes, increasing their risk of exposure to the coronavirus.

"People who are black, American Indian, or lower income are both more likely to be exposed to COVID-19 and more likely to develop severe illness if they contract the virus," Mr. Raifman says.

"As society considers return-to-work policies and recovery efforts, it's important to recognize that risk of exposure and the severity of COVID-19 is not uniform across America," he says. "There's a real risk that the rising tide of recovery will not lift all boats equally--and, worse, that it might further exacerbate disparities in health for minorities and the least affluent among us."

Policies that reduce inequities can also help fight the coronavirus, and vice versa, Dr. Raifman says.

"Policies such as freezing evictions, rent, and mortgage payments for people affected by COVID-19 may help people stay in their homes, and expanding SNAP benefits may help people have enough to eat," she says. "As COVID-19 compounds existing health disparities, it highlights the importance of policies that support more equitable health over the long term."