The coronavirus disease (COVID-19) pandemic has crippled the United States, halting
normal social and economic activities and overstretching the health system. As of
June 12, 2020, the United States had over 2 million cases and 113,900 deaths (1).
For historically disadvantaged populations, who experience fractured access to health
care under standard conditions (2) and who are more dependent on low-wage or hourly
paid employment (3), the pandemic has had a disproportionate impact. Reports from
state and city health departments have illuminated what many already knew: Black,
Latinx, and Native Americans test positive for and die of COVID-19 at higher proportion
than other racial and ethnic groups (Figure 1) (1). In part as a consequence of the
increased prevalence of COVID-19 in minority populations, the mortality rates among
Black, Latinx, and Native Americans far exceeds the proportion of the population that
these groups represent (1).
Figure 1.
Mortality due to coronavirus disease (COVID-19) compared with representation within
the population in states with greatest disparities for (A) Black, (B) Latinx, and
(C) Native American populations. Gray bars represent the percentage of minorities
in the state, and blue bars represent the percentage of deaths within the state across
minority groups. Data were collected from the CDC and are current through June 11,
2020.
Nearly 30% of COVID-19 cases occurred in Black Americans, who constitute only 13%
of the U.S. population (1, 4). This pattern continues to be observed at the state
level across states reporting the highest mortality from COVID-19 (1) and is paralleled
by geographic patterns, with several areas reporting prevalence gaps (i.e., differences
between the proportion of the population and the proportion of COVID-19 deaths) of
>20%. (Figure 1) (1). This disparity is equally striking across some American cities.
In Chicago, Black people represent 30% of the population but account for 45% of the
deaths from COVID-19 (5). New York City (NYC), the epicenter of COVID-19 within the
United States, has over 204,000 confirmed cases and over 21,000 deaths to date (6).
In NYC, Black people make up 22% of the population but account for 28% of COVID-19
related deaths (6).
The high rates of infection and mortality are equally distressing among Latinx Americans,
who represent 18% of the U.S. population but account for 34% of COVID-19 cases (1,
4). Similarly, in Florida, Latinx people make up 26% of the population but nearly
37% of COVID-19 cases (7). Furthermore, in San Francisco, 49% of COVID-19 cases are
among Latinx people who make up only 15% of the population (8). The same social and
structural circumstances that place Black and Latinx Americans at risk for disease
exist across Native American communities; as the pandemic unfolds, infection rates
for COVID-19 at the peak were highest in the Navajo Nation, as compared with any other
place in the United States, including NYC (9). In states with falling cases and fewer
cases overall of COVID-19, hot spots continue to disproportionately occur in communities
of color (10).
As health-disparity researchers and educators and critical care and pulmonary providers
on the front line caring for these patients, we believe it is imperative to report
on the root causes that have led to these sobering statistics. Early in the pandemic,
critical interventions to curb transmission—social distancing (11), early and widespread
surveillance (12), and isolation of confirmed cases (13)—were slow to be implemented
across the United States and were also disparately implemented and adopted across
communities of color (14, 15). This has accentuated and compounded the root causes
of disease disparities in the United States. The inequities in morbidity and mortality
from the current COVID-19 pandemic offer a lens for long-standing racial or ethnic
disparities in respiratory health (16, 17) in America. The recent deaths of George
Floyd, Ahmaud Arbery, and Breonna Taylor, all lives shortened for being Black in the
United States, highlight the important role of structural racism that has led to unequal
prevalence of disease and death from COVID-19 across Black and Brown communities.
Structural, institutional, and individual discrimination against racial and ethnic
minorities in the United States manifests through the shaping of neighborhoods, stagnant
ability to generate wealth, targeted mass incarceration of minorities, and differential
access to employment and resources. These racially based policies have been systematically
detrimental to several minority groups in the United States (18), and their generational
effects have resulted in unequal access to quality education and occupational opportunities,
thus limiting socioeconomic growth. Such is the context for the present-day root causes
and contributors to racial and ethnic health disparities in the United States, which
are further accentuated by persistent racism and ongoing implicit bias in healthcare
delivery. Notably, at the start of this pandemic, xenophobia and overtly racist labels
for the disease had negative downstream effects, including personal attacks on Asian
Americans, that likely slowed and misdirected the initial U.S. responses (19). Such
responses echo past exclusionary and racist measures, including those after Pearl
Harbor and September 11. It is neither possible nor appropriate to discuss racial
or ethnic disparities in COVID-19 outcomes without acknowledging this long history
of racial discrimination in the United States while also recognizing the resilience
of communities of color.
The social and structural determinants of health, that is, the circumstances in which
people live and the systems and structures that shape experience and access, provide
an avenue to systematically examine contributors to the marked disparities observed
with COVID-19. Applying the World Health Organization Conceptual Framework for Action
on Social Determinants of Health, we also identify potential avenues for policy action
(Figure 2) (20). This framework differentiates how the socioeconomic and political
contexts (e.g., government, policies, and cultures) manifest broadly as structural
determinants (e.g., policies, socioeconomic status [SES], and racism), which shape
exposure to intermediary social determinants (e.g., housing conditions, employment
conditions, and psychosocial stress), including healthcare access, that ultimately
create an individual’s unique social circumstances that shape behavior and risk for
disease. This approach allows us to examine the immediate circumstances of living
while also considering their broader context, allowing the identification of potential
policies for change. For this Perspective, we focus on action steps that we, as members
of the American Thoracic Society (ATS), should take to actively change the status
quo and influence policies that address root causes.
Figure 2.
Structural and social determinants of health contributing to the racial and ethnic
disparities in the coronavirus disease (COVID-19) pandemic in the United States and
proposed areas for action, as informed by the World Health Organization Conceptual
Framework for Action (26). PPE = personal protective equipment.
Specific to the COVID-19 pandemic, we describe the unique challenges that low-income
communities, non–U.S.-born communities, and communities of color face. Such challenges
increase the risk of disease and poor health outcomes and include 1) increased exposure
due to occupational and/or living circumstances that make social distancing and self-isolation
more difficult; 2) limited access to accurate, up-to-date information regarding the
health risks of COVID-19; and 3) limited and differential access to healthcare services,
including COVID-19 testing and care. These communities also have a higher burden of
chronic diseases such as uncontrolled hypertension, obesity, diabetes mellitus, heart
failure, and chronic obstructive pulmonary disease and have high rates of tobacco
smoking (partly due to targeted marketing) (21), which places them at risk for having
worse outcomes from COVID-19 (22). Moreover, the economic consequences from the pandemic
and public health measures, specifically shelter-in-place orders, exacerbate these
risk factors for disease and further transmission across vulnerable communities.
Increased Exposure
Historically disadvantaged communities have reduced capacity to adopt preventive measures.
Cell phone mobilization data demonstrates that low-SES communities adopted social-distancing
practices 3 days later than high-SES communities (14). In addition to fragmented delivery
of public health messaging, high-density living settings limit the ability to practice
social distancing. Shelters and other crowded living situations increase exposure
risk and have become an ongoing concern for outbreaks across the country (including
in San Francisco and Boston) (23). Relative to small (3%) national estimates, 16%
of individuals living in the Navajo Nation live in crowded conditions, with multiple
generations in one household because of high living costs and limited available housing
(24, 25). In NYC, 70% of the workforce providing essential services (e.g., grocery
store, delivery, and janitorial staff) are people of color (26); similar statistics
are seen nationally (27). Fearful of job loss and dependent on hourly wage income,
these workers continue to work despite limited access to protective equipment (28,
29). Furthermore, for essential workers, the need for child and elder care remains,
increasing the social networks and exposure risk for some and increasing the economic
burden for others. Fixed-income or limited-income households are also disadvantaged,
as they are less able to “stock up” or afford food-delivery options, increasing the
number of visits outside the home to obtain essential items (19). In individuals with
confirmed COVID-19 who must quarantine, these factors become accentuated. These considerations
have long-term implications, as the ability to self-isolate and rapidly readopt shelter-in-place
orders will be crucial over the next 12–18 months, as we move from the acute phase
of the pandemic to the second phase of disease containment.
Limited Access to Information
Despite greater risk for disease, minority communities with low SES and/or limited
English proficiency receive less public communication during crises and pandemics
(30, 31). Initially, COVID-19 messaging was overly complex, changing rapidly, and
fraught with mixed messages, placing significant demand on vulnerable populations
such as Latinx, Black, and Native American adults, whose health literacy is lower
than that of non-Hispanic White adults (32). Early in pandemics, widespread outreach
to improve understanding of viral transmission and knowledge of how to implement preventive
measures is crucial to slowing transmission, yet vulnerable communities are less likely
to receive these vital messages in easily interpretable language. Communication during
natural disasters systematically disadvantages nonnative English speakers by using
English-only messaging and limiting broadcasting to mainstream news outlets (30).
Vulnerable populations have less internet access and are more likely to depend on
community-targeted news sources, which limits their access to crucial information
(33–35). During the 2009 H1N1 influenza pandemic, Savoia and colleagues (31) found
home ownership to be associated with more than two and a half times the likelihood
of H1N1 symptom knowledge.
Limited Access to Care
Testing Disparities
Curbing transmission is dependent on timely access to testing and care, which is greatly
limited in low-SES and minority communities. During the pandemic, several community
health centers and federally qualified health centers, the backbone for providing
primary-care health services to the most vulnerable, have had to shutter their doors
(36, 37). This has left many communities without access to timely testing and potentially
without a lifeline for accessing care when feeling unwell. Furthermore, more resourced
centers and communities are able to use third-party services to increase screening
and testing capacity, whereas less-resourced areas are dependent on government-based
resources, which have been slower to deploy and have test results taking up to 5 days
to return (15). This is notable in San Francisco, where the University of California
at San Francisco was able to develop a telehealth screening platform within 2 weeks
of the start of the pandemic, reaching over 950 patients (38). Safety-net systems,
the health systems that provide care to the most vulnerable populations, are often
less resourced and lack sufficient funds to pivot as quickly. Moreover, such services
are only truly available to patients who have reliable high-speed internet access,
access to data and internet service plans and smart devices, and technology skills
to create accounts and log on to platforms. As health systems transfer the majority
of their care delivery to telemedicine, these gaps become more pronounced, further
widening the care-access gap for testing of COVID-19 and chronic health conditions.
Care Disparities
Capital resources and surplus funds are commodities not often afforded to health systems
and hospitals that strictly provide care to the urban poor, a group predominantly
composed of Black and Latinx Americans and immigrant populations. Before the pandemic,
debt and the proportion of uncompensated care was significantly higher in these safety-net
hospitals than in more resourced centers that provide a greater proportion of their
care to insured populations (39). These inequities across health systems have resulted
in differential access to personal protective equipment for frontline workers (40),
an inability to quickly access resources and convert space (i.e., building and equipping
ICUs, installing negative-pressure units, and having dedicated COVID-19 units), and
differential access to qualified personnel to prepare for surge and staff new units
and beds. Such conditions likely increase risk of transmission to frontline workers
(41, 42) and contribute to worse outcomes from COVID-19 (43).
What Is Our Role?
In 2013, the ATS made a commitment to health equity, diversity, and inclusion and
continues to aim to reduce those disparities that are both avoidable and unjust. Change,
extending from the individual’s role to the policy level, is imperative if the racial
and ethnic disparities in disease burden and mortality associated with COVID-19 are
to be reduced (20, 44). To move forward effectively, we outline important avenues
through which the ATS and we, as ATS members, researchers, educators, and healthcare
providers, can use our strengths for impact.
Check Our Biases and Promote Diverse Voices
The Black Lives Matter (45) movement and protests against racial injustice have led
the nation to reflect on our own personal biases and our daily contribution to racism,
overt and implicit. Over the past decade, there has been a movement in medical and
academic programs to address racial and ethnic inequity through promoting and requiring
implicit-bias training and implementing diversity, equity, and inclusion efforts.
These efforts are a start, and we ask our members to learn about their own biases
(https://implicit.harvard.edu) and reflect on their own experiences. However, as researchers,
educators, and healthcare providers, we need to be more explicit in our actions to
combat disparities. This includes applying an intentionality and holistic process
to selecting pulmonary and critical care medicine fellows, not only to promote diverse
voices but also to provide financial compensation to support these individuals and
to purposely broaden our networks (“but I needed an expert” is not a valid excuse).
Since 2013, the ATS has formed the Health Equality and Diversity Committee, required
diversity missions across all ATS committees, formed the Health Equality Fellowship
to promote early-career investigators in this area, and made an explicit effort to
ensure racial, ethnic, and gender diversity across all committees and leadership positions
in the ATS. To further promote health-disparity research, more recently, the ATS and
the American College of Chest Physicians (CHEST) have cosponsored the ATS/CHEST Foundation
Research Grant in Diversity for junior investigators.
We need to hold ourselves accountable and do more. We push for appointing diversity
champions across all committees and assemblies throughout the ATS to ensure that equity
is considered and discussed at every level. The ATS should use the trust and scientific
credibility that it has built to advocate for change on issues of systemic racism
(in the same manner we have used to tackle tobacco and air pollution). The society
should support traditionally underrepresented groups in science and in health-disparity
research, through mentoring, strategic funding initiatives, ensuring diversity in
selecting conference presenters and award recipients, and allocating investments to
interventions and implementation science that will lead to change.
Increasing Accessibility of Information and Care
Communication regarding preventive measures, testing resources, public policy changes,
and general guidance should be intentionally delivered by employing strategies for
low health literacy and using multiple languages to reach people with low English
proficiency. Working together, the ATS and CHEST organizations developed publicly
available materials on COVID-19 in English and Spanish for those with low literacy
(https://formylunghealth.com). However, as information regarding testing and care
are highly regional, it is also important for our local chapters to actively work
with local health systems and departments of public health to provide accessible information
that is both accurate and clear.
In addition to developing educational materials, the ATS should consider working together
with other medical societies to advocate for improved communication delivery by supporting
efforts and legislation for universal access to broadband internet for all Americans
(46). Closing this technological gap will allow underresourced people to access current
and relevant information, including updates on changing policies both locally and
nationally, as well as rapidly developing telehealth resources.
As healthcare providers caring for patients with COVID-19, we should consider the
impact of limited literacy or language barriers when explaining strategies to mitigate
COVID-19 exposures. Using strategies for low health literacy, such as using plain
language and accessible teach-back approaches, education should be provided on risk
factors and prevention strategies, how to access testing and care for COVID-19, and
the potential future role of vaccines in vulnerable populations. Be cognizant and
ask about potential barriers to accessing and using technology, including lack of
electronic devices, limited data storage on devices, limited internet access, and
costs of data plans. Consider use of low-tech solutions, such as telephone visits,
to ensure remote access to health care, and query patients about their preferences.
Fund, Report, and Reflect on Root Causes of Health Inequity (ATS)
Reducing disparities from COVID-19 requires awareness and understanding of the scope
of the disparities themselves and the underlying social and structural determinants
that have contributed and are primed for intervention. The CDC now mandates reporting
on race and ethnicity for all COVID-19 cases (1), but we need to go further and support
research that examines and addresses root causes. In response to the COVID-19 pandemic,
the ATS has received over $1 million (an amount that continues to grow) in philanthropic
donations. From this, the ATS is dedicating a significant portion to support junior
investigators researching COVID-19 inequities and mechanisms to decrease the disparity
gap, as well as to developing resources for low health literacy that target communities
that have been most severely affected by the outbreak.
As healthcare providers, ask about relevant COVID-19 exposures (e.g., work-, transportation-,
or housing-related) when evaluating patients from vulnerable populations with upper
respiratory symptoms. Assess structural barriers to care for minority and low-SES
patients with COVID-19, including insurance, copayments, transportation, childcare,
food insecurity, lack of housing, etc., and evaluate how these can negatively affect
the patient’s care plan. Refer patients in need to social workers, local programs,
and/or community resources. Address potential postdischarge challenges faced by minority
and low-SES patients hospitalized for COVID-19, including job loss/limited job, lack
of insurance coverage, housing problems, and care for comorbidities.
Set Standards and Practice Guidelines
Specifically regarding protections for essential workers, an especially high-risk
group, we are in dire need of standardization in safety recommendations and broad
access to personal protective equipment across all employment types (47). As the ATS,
we are in a position to continue to provide recommendations on these regulations to
governing agencies and to advocate for funding support for personal protective equipment
for high-risk jobs, including nonmedical essential workers, who regularly interact
with the public. Furthermore, asz hazard payments are actively discussed for frontline
medical workers, it is equally important to advocate for and support measures that
provide hazard pay for all essential workers in medical settings, such as medical
assistants and nutritional and environmental service workers (48).
As we continue to develop resources and recommendations on how to care for patients
with COVID-19 (https://www.thoracic.org/covid/index.php), we need to ensure that such
guidelines are designed to support equitable health outcomes across all population
groups. This includes providing guidelines on how to operate in low-resource settings,
such as safety-net settings, and how to ethically redeploy and train non-ICU healthcare
providers to provide high-quality care in surge-capacity situations.
Take a Position
Increasing access to high-quality COVID-19 care, including testing, is necessary (15).
The Coronavirus Aid, Relief, and Economic Security Act provided some of the necessary
infrastructure support for community health centers and federally qualified health
centers (49). In addition to this, expansion of the Affordable Care Act (ACA) to provide
free COVID-19 care, including emergency department visits or hospitalizations, and
access to comprehensive telehealth services would improve COVID-19 outcomes, which
are significantly worse for individuals with comorbid disease, who are disproportionately
represented in historically disadvantaged communities. The ATS believes health care
is a right (50). The ATS believes that universal access to affordable health insurance
is a necessary, but insufficient, step to close the gap on health disparities in the
United States, and this is the primary reason the ATS has been in continuous support
of the ACA. As the ACA is repeatedly challenged in the court system, the ATS has filed
multiple amicus briefs in support of the constitutionality and effectiveness of the
ACA. Because the pandemic has clearly demonstrated that social conditions shape outcomes,
we should consider working with peer societies throughout the medical and scientific
community to support policy efforts that attempt to address these important social
and structural determinants of health.
Conclusions
As stated by Franklin D. Roosevelt, “it isn’t sufficient just to want—you’ve got to
ask yourself what you are going to do to get the things you want.”
Critical care and pulmonary specialists play a major role in facing and overcoming
the COVID-19 pandemic, an event of truly historic proportions. As such, we are in
a unique position to advocate for underrepresented minority patients, who are becoming
critically ill and dying at disproportionate rates. In so doing, we should take active
measures in our own delivery of health care and support actions and policies that
improve access to information and care, while reducing exposure risk in vulnerable
populations. Targeted policy interventions that protect high-risk racial and ethnic
minority groups should reduce both ongoing health disparities in COVID-19 and long-standing
disparities in respiratory health (16, 17).