Each month, the Elsevier Atlas Award recognizes research that could significantly impact people's lives around the world. The July/August 2020 award goes to Gregorio Millett and colleagues for their July 2020 article in Annals of Epidemiology: Assessing differential impacts of COVID-19 on Black communities.
About 20 percent of counties in the United States are disproportionately Black. And, researchers reporting in Elsevier’s Annals of Epidemiology recently found that—from the early days of the pandemic—those counties had more than their fair share of COVID-19 cases and deaths. Based on publicly available data accessed in mid-April 2020, while one in five U.S. counties are predominantly Black, they accounted for more than half of all COVID-19 diagnoses and close to 60 percent of deaths.
What’s more, according to the study led by Gregorio Millett at amfAR (Foundation for AIDS Research) in Washington, DC, this pattern of health disparity wasn’t explained by underlying health conditions such as heart disease and diabetes. Rather, they found that social determinants of health such as employment and access to health insurance and healthcare were far more important for explaining the disproportionately greater impact of COVID-19.
“We found disproportionately Black counties had higher rates of those other underlying health conditions, but they did not predict COVID-19 cases or deaths,” Millett said. “We thought that was important to share because it ran counter to a large part of the media narrative at the time.”
As of April 30, 2020, more than one million cases of COVID-19 had been diagnosed in the United States, with deaths exceeding 63,000. While there was some evidence that Black communities were being hit harder in certain places, such as New York City and Milwaukee, Millett—an expert on the study of health disparities for other conditions including HIV—recognized that most of the publicly available data from the Centers for Disease Control and Prevention (CDC) hadn’t been disaggregated by race.
To get a clearer picture of the trends at the national level, he and his colleagues looked to county-level data. The goal was to compare the number of COVID-19 diagnoses and deaths in counties with higher proportions of Black people to those with lower proportions of Black people and to see if there was a notable difference in COVID-19 impacts. They also used modeling approaches to see whether any observed COVID-19 disparities were attributed to other health conditions versus social and environmental factors.
The nation-wide data showed a consistent pattern of significantly higher rates of COVID-19 diagnoses and deaths in disproportionately Black counties compared with other counties. Those same counties also had more diagnoses of diabetes along with more heart disease and cerebrovascular disease deaths. But those other underlying health conditions weren’t connected to COVID-19 in the way some people had assumed.
In addition to a higher prevalence of other health conditions, disproportionately Black counties had more individuals aged 65 years or older. They also had greater numbers of people without health insurance, more people unemployed, and more air pollution. After controlling for potential confounders, it was clear that having a higher proportion of Black residents in a county was associated with higher rates of COVID-19. In addition, higher rates of COVID-19 cases were independently associated with greater proportions of uninsured residents and more people living in crowded conditions.
The evidence showed that higher levels of unemployment was associated with fewer COVID-19 cases. The researchers explain that this is presumably because employment often increases the likelihood of COVID-19 exposure. That’s especially true in Black communities, given that just one in five Black Americans have jobs that allow them to work from home. While the Atlas-winning study focused on Black Americans, the researchers say that similar health disparities exist amongst other groups, including Latino, Native American, and other populations.
“Health disparities arise from a complex interplay of underlying social, environmental, economic, and structural inequities,” they write. “We will continue to fail to address longstanding inequities until we commit to eliminating structural racism and the systemic roots that maintain and even reinforce these injustices. Ultimately, advancing the health and well-being of all Americans relies on leveraging these and other data to effect policy change that makes equity a reality in the United States.”
A Conversation with Gregorio Millett
I talked with Gregorio Millett, first author of the Atlas-winning study, about COVID-19 and the Black community. Listen now.
We’re talking about your study on COVID-19 and where rates are higher across the country. What did you set out to do?
Gregorio Millett: My colleagues and I realized at the beginning of the pandemic that there were not a lot of data disaggregated. So, I thought perhaps we could take a look at county-level data and compare counties that are disproportionately African American to all other counties in the US. I brought in colleagues from many universities. What we found was pretty astonishing. As the number of African Americans increase, you found a commensurate increase in COVID-19 cases and deaths. We also looked at underlying health conditions, such as cardiovascular disease, diabetes and we also threw in HIV just in case. We found disproportionately Black counties had higher rates of those health conditions, but they did not predict COVID-19 cases or deaths.
At the time, the media narrative suggested that what we were seeing in terms of COVID-19 in Black communities was due to underlying health conditions. What we found is that’s actually not true. Social determinants of health such as being employed, access to health care, and others were better predictors in Black counties for disparate rates of COVID-19. We also found that HIV/AIDS was not associated with COVID-19 cases or deaths. That was very early on in pandemic when there were questions about effects on immunocompromised people.
So, the difference then is social determinants of health? Can you explain what this means a bit more?
Gregorio Millett: Absolutely. One of the things that’s axiomatic in any research on disparities is that you usually find in marginalized populations, communities of color that high rates of disease whether it’s HIV or cancer or others—there’s always another component. In fact, a National Academy of Sciences report last year said as much as 70 percent of the disease disparities we see are due to social determinants of health and health care not biological mechanisms. It really fits into a broader pattern.
Did your data show anything about other groups?
Gregorio Millett: We didn’t do that at that time, but we did follow up in another study. We looked at Latinx counties and we found essentially the same patterns, with social determinants of health predicting COVID-19. There were some differences in that, in those counties with more Black Americans, we found it didn’t matter if it was urban or rural—cases of COVID-19 were elevated anywhere there were Black Americans. For Latinx communities, it was different. Counties in mid-range cities to rural areas had higher rates of COVID-19. But, we found it was regional. There was an increase in COVID-19 diagnoses in counties that were primarily Latinx in the midwest and northeast, but there was no association in the south or the west. So, it was interesting to see this regionalization for Latinx communities that we did not see for Black Americans. This spurred a third paper to look at non-white versus white counties, and one thing we found there is that those counties that are less diverse—88 percent white or more—have fewer COVID-19 diagnoses and deaths compared to those that are more diverse. With these three studies, we’re able to see how the demographics of counties is associated with disease morbidity and mortality in the United States.
What are your thoughts about how to address these disparities?
Gregorio Millett: There needs to be a concerted effort to address disparities by making sure that innovations in health care get to those communities that need it most. As an example, a common mistake nationally was that COVID-19 tests were placed in counties or neighborhoods that were white and affluent. We found this pattern over and over again in New York, Nashville, across Texas. COVID-19 testing was primarily placed in affluent and white areas where rates were lower instead of in Black and Latinx areas where rates were higher. Thankfully that changed in July or August. But this was something that unfortunately helped the virus get out of control in some communities because we weren’t detecting it.
In the future, we need to make sure there’s access to healthcare. Right now, the Affordable Care Act is being looked at in Supreme Court and 20 million Americans could lose healthcare access. One thing that’s very clear is the ACA has brought communities of color access to healthcare and improved health outcomes. If we can further increase that access through Medicaid expansion in states that haven’t done that, we could help to reduce disparities.
I think the last thing we should consider is that there are great models out there of health equity. For example, in the U.S. military, there’s been a concerted effort to reduce disparities. Studies have found disparities in military are lower than in the general population. A study of COVID-19 including about 6,000 veterans looked at COVID-19 cases and deaths. It found that cases were greater among African American vets and Latino vets, but they found no differences by race in terms of deaths. This raises important questions as to what is taking place in the VA system of care where there is greater equity. How is that something we can bring to the general healthcare system, so we could see the same thing?
Do you have thoughts related to COVID-19 vaccines, now that they are becoming available. While this is good news, might the vaccines fuel further disparities?
Gregorio Millett: In the Black community, in addition to lower access to health care and other factors, there is a high levels of mistrust, and this is something enduring. We see this every year with flu vaccination rates with lower rates in Black compared to White communities. Something is taking place that we have to address. Several polls show African Americans are less likely to say they’d get a COVID-19 vaccine. What I’m hoping is, as time goes on, and more people are inoculated and see that adverse events are minimal that there will be greater trust. I also think it’s helpful to see someone like Kamala Harris get the vaccine, Barack Obama get the vaccine. Seeing leaders take these steps has helped in the past and I think the same will be true now.
Anything else you’d like to say?
Gregorio Millett: The only other thing I’d like to say and many others have said, too, is that COVID-19 has illuminated disparities many of us who work in this line of research have known about. Social determinants of health are associated with disparities. We see this over and over again. I’m hoping our paper and others that have brought this to light means as a society that we’ll make a concerted effort to address patterns that we’ve seen for over 100 years and to see if we can make strides to really address this.
- Coronavirus (COVID-19) (National Institutes of Health)
- Coronavirus (COVID-19) (Centers for Disease Control and Prevention)
- Combat COVID (Department of Health and Human Services)
- Coronavirus Resource Center (Johns Hopkins University & Medicine)
- Gregorio Millett (amfAR)
Annals of Epidemiology is a peer reviewed, international journal devoted to epidemiologic research and methodological development. The journal emphasizes the application of epidemiologic methods to issues that affect the distribution and determinants of human illness in diverse contexts. Its primary focus is on chronic and acute conditions of diverse etiologies and of major importance to clinical medicine, public health, and health care delivery.
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