Stephen Speranza / The New York Times

NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York on March 31, 2020.

June 10, 2020

Race as a Social Determinant of Health: Why Black Populations Are Disproportionately Affected by COVID-19

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As COVID-19 continues to claim over one-thousand American lives a day, Black people have been up to twice as likely as the general population to die from the disease. The reasons for the striking racial disparity are complex, but often stem from social inequities that can create an elevated risk for contracting or dying from coronavirus, researchers say.

Those social determinants of health — such as food deserts, exposure to pollution, lower quality education, increased daily stress and low-paying jobs with less financial security — all contribute to worse healthcare outcomes among Black people, explained Dr. Monika Safford, chief of general internal medicine at Weill Cornell Medical Center.

The coronavirus pandemic has only worsened and highlighted that long-existing imbalance. Because Black Americans are disproportionately burdened by those social determinants, Black communities suffer from higher rates of diabetes, hypertension, obesity, cardiovascular disease and cancer compared to White people, Safford said — all preexisting conditions that play strong a role in increasing COVID-19’s mortality.

According to Safford, the reason for this is that behaviors and social determinants have a large role in determining health outcomes — a mere 10 percent of health outcomes are determined by healthcare, whereas 40 percent are determined by individual behaviors and 20 percent by social determinants.

Moreover, because Black and Latino people disproportionately hold essential jobs that require in-person work, social distancing is much more difficult, leading to higher rates of infection.

Research has also shown that the threat of police brutality against Black people can increase racial inequities in health by causing physical injuries, psychological stress and financial strain.

“The institutionalized racism definitely plays a large role — I think it’s under-appreciated that for African American men under the age of 60, the number six cause of death is police brutality. So we’re seeing that now, in extremely sharp focus,” Safford said. “All of these things converge, leading to poorer health outcomes.”

Dr. Martin Shapiro, a professor of internal medicine at Weill, explained that racial disparities in healthcare are further perpetuated by the high cost of health insurance. According to Shapiro, whether someone has insurance, and, just as importantly, what type of insurance they have, is a major factor in determining the quality of care they receive.

Shapiro noted that although tens of millions of people are insured under Medicaid, a program available to those earning under a certain amount, many doctors do not accept patients enrolled in the program due to lower reimbursement rates. Those who are denied access to healthcare based on their insurance must, in turn, frequently rely on federally qualified health centers or public hospitals, which are often under-resourced compared to their private peers.

As a result, inaccessible or lower quality of medical care due to health insurance can significantly affect the ability of Black Americans to maintain long-term health.

“If you don’t have good insurance, you worry about going and seeking medical care. You delay, or perhaps you have responsibilities for others, and you’re trying to take care of them. So you may not … get care soon enough,” Shapiro said.

During the coronavirus pandemic, health disparities arising from social determinants and lack of  health insurance were exacerbated by a medical system often unequipped to effectively lead a rapid, coordinated response.

According to Safford, New York Health and Hospitals, the city’s public healthcare system, is structured around 11 major medical centers, as well as a network of smaller, less-funded community hospitals that disproportionately serve communities of color.

Safford explained that although New York’s large, public hospitals were able to transfer resources and patient overflow to larger facilities, like Columbia and Cornell, small, independent hospitals were left to their own limited resources and got overwhelmed. Therefore, he said, Black people were disproportionately underserved in receiving treatment for COVID-19.

According to Safford, the lack of coordination was not unique to New York City’s health system. She believes that the absence of a single-payer healthcare system — in which all essential healthcare costs are covered by a single public system — greatly impaired the country’s ability to distribute resources to where they were most needed, especially at these smaller hospitals.

“Trying to figure out what to do in a situation where people are dying left, right and center — it’s really not the time that you can organize. Then, you’re just reacting,” Safford said.

In addition to lack of healthcare access, racial disparities in COVID-19 outcomes may have been worsened by clinician bias — minorities not treated equally by medical professionals on the basis of their race.

For instance, Shapiro noted that many research studies have demonstrated scenarios in which Black and White patients present with the same symptoms, yet the appropriate treatments are more likely to be offered to White patients.

In order to explore and expose these prevalent disparities, the Cornell Center for Health Equity has been conducting research in the hopes of producing data that could eventually lead to policy changes. Safford, who is the founder and co-director of the Center, has been involved in an observational study examining the impacts of multiple social determinants on health outcomes.

“I think it is somewhat the responsibility of scientists to craft the message and to speak to, not only the scientific community, but also to the lay community, and specifically, to policymakers,” Safford said.

But despite attempts made by researchers to expose the rampant racial inequities persistent in the American healthcare system, Shapiro did not believe enough meaningful change has been produced as a result of these steps. Both Shapiro and Safford agreed that this is in part due to the lack of action taken by the government.

“I think that it would be a triumphalism to say that there has been success [in mitigating health inequity],” Shapiro said. “The problems are profound and they continue, and anyone who thinks that we’ve had meaningful success isn’t being forthright.”

Safford believes that the inability of the government to heed research and “take the pathway forward” can also be attributed to decades of deep-rooted infrastructure that has stacked the deck against Black people.

“There’s a lot of infrastructure that we have allowed to develop that really protects the interests of rich White people, and it has been laid for thirty years or more,” Safford said. “And that is going to be very difficult to counteract quickly, but that doesn’t mean we shouldn’t be doing it.”

To help educate a new generation of health professionals prepared to address inequities, Prof. Sam Beck, human ecology, teaches Practicing Medicine: Health Care Culture & Careers, a three-credit summer course that explores how race and gender affects an individual’s ability to stay healthy. Although students are no longer able to shadow clinicians, the class will continue to remotely educate students about the impact of COVID-19 on the state of medicine.

Beck said that students learning about the social determinants of health is not only important for their future as health professionals, but that they also have a responsibility to help effect change.

“As they move through their careers in medicine, they have an obligation that they fight for social justice. It is part of the practice of medicine that everyone should have access to healthcare,” Beck said.