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Race-Related Disparities in Patients With COVID-19

Vikramjit Mukherjee, MD

Assistant Professor of Medicine
Division of Pulmonary, Critical Care, & Sleep Medicine
New York University School of Medicine
Director, Medical Intensive Care Unit
Bellevue Hospital
New York, New York

Vikramjit Mukherjee, MD, has no relevant conflicts of interest to report.

View ClinicalThoughts from this Author

Released: August 4, 2021

I’m an intensive care physician at Bellevue Hospital in New York, New York, where I’m also the Medical Director of our special pathogens program. As you know, New York City was an epicenter of the COVID-19 pandemic not too long ago. Here on the frontlines, we observed the much-studied, race-related disparities in patients with COVID-19 presenting to our hospitals. I’d like to discuss with you some of the newer analyses of those disparities here in the United States.

Price-Haywood and colleagues conducted a retrospective cohort study of 3481 persons who tested positive for SARS-CoV-2 in Louisiana’s Oschner Health System early in the pandemic. Among patients with confirmed COVID-19, 76.9% of the hospitalized patients and 70.6% of the patients who died from COVID-19 were Black. This is very disproportionate, as Blacks account for just 31% of the Oschner Health population. After adjusting for differences in clinical and sociodemographic features upon admission, in-hospital mortality was similar between Black and White patients.

Similarly, a larger retrospective cohort study of 570,298 patients in California, Oregon, and Washington evaluated the sociodemographic and clinical characteristics of patients with COVID-19, by race. Dai and colleagues identified major healthcare disparities, with all minority races having increased odds of testing positive for SARS-CoV-2 and being hospitalized. Disparities were most notable among Hispanics, who required excess hospitalization and mechanical ventilation and had higher odds of in-hospital mortality despite being younger. We know that older age is a big risk factor for mortality, but these increased odds were despite younger age.

A third multistate, retrospective cohort study included 11,210 patients with polymerase chain reaction–confirmed, severe COVID-19. Yehia and colleagues found that Black patients were 37.3% of those hospitalized. Of importance, mortality for those able to access hospital care did not differ between Black and White patients after adjusting for sociodemographic factors and comorbidities.

Here in New York, Ogedegbe and colleagues conducted a multicenter, retrospective cohort study of 4843 patients with confirmed COVID-19. In this analysis, Black and Hispanic patients (but not Asian patients) were more likely than White patients to test positive for SARS-CoV-2; once hospitalized, Blacks were less likely to experience critical illness or death than Whites—but only after adjustment for comorbidities and neighborhood features.

In summary, a clear theme emerges from these studies: Black or Hispanic communities have been disproportionately affected by this COVID-19 pandemic and the underlying reason is not physiological. These data suggest that the increased risk of COVID-19 illness and poorer outcomes reflect the preexisting, deep socioeconomic disparities and inequities that affect health and access to healthcare.

For example, general guidance during this pandemic is to work from home and practice isolation if one has COVID-19 infection. But in many communities of color, people do not have paid leave, cannot work from home, and do not have space enough in their homes to be able to isolate. So, when they go home infected with SARS-CoV-2, they are more likely to spread the infection to their entire families. In fact, in the intensive care unit setting, we saw entire families being admitted together.

What it also evident in these studies is that once a person with COVID-19 is admitted to the hospital and you adjust for socioeconomic factors and so on, there is no difference in outcomes. Therefore, it is not the in-hospital treatment that varies, nor the clinical course that varies—it is the prehospital phase. Access to testing, ability to isolate, and access to good care—all of these factors are what puts communities of color at an unfortunate disadvantage in a pandemic like this one. These disparities are emblematic of deep structural issues that exist in the healthcare system and that need to be addressed with urgency.

What this means, going forward, is that we need to reinvent how healthcare is accessed in this country and, more immediately, how vaccination is delivered. Current COVID-19 vaccines work very well to prevent hospitalization and deaths, even against variants of concern. Overcoming vaccine hesitancy in communities of color, through education and increased access, has to be a priority if we are to avoid further tragedy as the pandemic continues.

Your Thoughts?
How do the results of these studies on racial disparities influence your thinking about COVID-19 treatment and prevention? How are you responding to vaccine hesitancy? Answer the polling question and join the conversation by posting in the discussion section.

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