Summary box
COVID-19 has further exposed the strong association between race, ethnicity, culture,
socioeconomic status and health outcomes and illuminated monumental ethnoracialised
differences reflecting the ‘colour of disease’.
Racism, segregation and inequality have been invisibly and pervasively embedded in
dominant cultures and social institutions for decades.
The socioeconomic factors that negatively influence health outcomes within the underserved
minority communities must be identified and contextualised within historical, political,
social and economic remits.
Acquisition of disaggregated data will be vital in identifying gaps in the social
determinants of these health disparities and tailoring global policy responses.
Introduction
As COVID-19 continues to sweep across the globe leaving thousands of victims in its
wake, preliminary data from the USA suggest that minorities, especially black people,
have been infected and killed at a disproportionate rate across the country.1 The
most recent data released by the Center for Disease Control and Prevention suggests
that black communities are disproportionately affected (when it comes to hospitalisation
and deaths) by the coronavirus. In Illinois, 37% of the total confirmed cases and
45% of COVID-19 deaths are African Americans, although they account for only 16% of
the state population.2 There have been similar trends of infections and deaths in
Michigan, Missouri, North Carolina and South Carolina. Other evidence also revealed
an over-representation of Latinos and Asians in COVID-19 infection rates when compared
with their nationwide populations.3
Similar patterns showing disproportionate infections and deaths in various parts of
the globe including Asian countries, Nordic countries and the UK have emerged. People
belonging to black and Asian ethnic groups were found to be at a higher risk of in-hospital
COVID-19 deaths partly due to deprivation compared with white people.4 5 While blacks
are more than four times more likely to die from COVID-19, individuals of Bangladeshi,
Pakistani, Chinese and mixed ethnic groups are about 1.8 times more likely to die
from the pandemic.6 Somalians in Norway have also recorded infection rates more than
10 times the national average, representing 1586 per 100 000 compared with 140 per
100 000.7 A survey in Sweden by the Public Health Agency similarly found that immigrants
from Somalia, Syria and Iraq are disproportionately infected by COVID-19; although
Somali Swedes are about 0.5% of the national population, they form 5% of confirmed
cases.8
The idea that health disparities are massively influenced by race, ethnicity and culture
is not novel. Despite significant advances in civil rights and the narrowing of differences
in morbidity and death rates among disadvantaged communities, health disparities among
ethnic groups remain a far-reaching issue globally.4 5 The world’s poorest populations
are disproportionately affected by malaria, tuberculosis and HIV/AIDS, which are the
most fatal communicable diseases in the world.6 The impoverished and under-represented
minority populations are also not spared the burden of chronic and debilitating infections
aptly termed ‘the neglected infections of poverty’.
Ethnic and racial discrimination and socioeconomic status (SES) are strongly associated
with many health and healthcare outcomes.9 10 Racism is associated with poor health
service use outcomes with individuals who report experiencing racism two to three
times more likely to report low satisfaction and trust in health services and professionals.11
SES indicated by income, education or occupation plays an important role in health
outcomes as individuals with relatively fewer resources may be forced to accept a
minimum wage job or unsafe working conditions to maintain a family even at the risk
to their own health. With less income, access to quality healthcare can be limited,
especially in countries with limited public healthcare. Such disadvantages result
in ethnic stigma and greater poverty which further lead to psychological distress,
mental health-related disorders, drinking problems, chronic obstructive pulmonary
disease and obesity.12 13
A large body of evidence suggests that structural inequality is a key determinant
of who gets affected by disease and its socioeconomic fallout,14–16 the most affected
being those who are most vulnerable with underlying conditions and limited access
to quality care. Such persons are also more prone to occupational exposure to infectious
diseases, including COVID-19, as they tend to have employment in restaurants, food
outlets, healthcare settings and essential services where contagion is more likely
to occur.17 These individuals are also prone to high exposure as they tend to commute
to work by public transport where it may be difficult to practice physical distancing.
The COVID-19 pandemic has illuminated a disturbing and inconvenient truth: the ‘colour
of health’ and how ethnoracialised differences in health outcomes have become the
new normal across the world.16 This commentary examines how racism, segregation and
inequality, which have been for decades invisibly and pervasively embedded in dominant
cultures and social institutions, now emerge as a monumental COVID-19 challenge.
‘The colour of disease’: COVID-19 and social determinants of health
Social determinants of health are key factors that shape the conditions surrounding
how individuals are born, grow, live, work and age in specific environments.18 These
determinants are themselves influenced by the unequal distribution of resources, money
and power at the local and global levels, leading to health inequities among groups
of people.19
As the coronavirus continues to tighten its grip on many nations, states dominated
by African Americans in the USA are recording high infection and mortality rates,
as in the case of Illinois. In Michigan, 33% of individuals who tested positive and
50% of those who died were African Americans although this group accounts for only
15% of the population.10 In the UK, black and minority ethnic groups are 13% of the
country’s population but account for one-third of infected individuals who are admitted
at critical care units in hospitals.7 Persons who are socioeconomically disadvantaged,
such as those who experience multidimensional poverty, have lower education levels
and live in more dangerous neighbourhoods, also tend to have underlying health conditions
that place them at higher risk for severe COVID-19.12 20–24 The additional burden
of racism which predisposes individuals to high-risk jobs and lower quality care has
precipitated high rates of infections and death from COVID-19 among ethnic minorities.25
26 In many Southeast Asian countries including Singapore, Malaysia and Thailand, millions
of stranded foreign migrant workers from Myanmar, Philippines, Cambodia and Laos are
at greater risks of COVID-19 infections, while Asian migrant workers in Gulf states
face disproportionately high rates of COVID-19 infections, fore example, accounting
for 70%–80% of all new cases in Saudi Arabia. Similarly in the state of New York,
poorer neighbourhoods in Queens are recording higher per capita rates of COVID-19
infections than richer neighbourhoods in Manhattan, while neighbourhoods with high
proportions of black American (The term black Americans and African Americans are
considered interchangeable) and Hispanic (Hispanic is a term referring to people of
(generally) Latin American origin, primarily Mexican, living in the USA) populations
are recording higher infection rates per capita.27 However, these findings point to
correlations and not causation; there may be other underlying causes of such high
number of COVID-19 cases among these minority groups.
Racism is a complex social system underpinned by unequal power relations and beliefs,
resulting in ethnic minorities often being negatively stereotyped or marginalised.10
28 29 Such ethnoracialised stereotypes lead to stress and impair decision-making processes
resulting in further anxiety and aggressive behaviours.29 Research has shown that
black Americans tend to experience lower quality perinatal and neonatal care and such
disparities are associated with behavioural, physical and neurodevelopmental impairment
that affect these individuals in later life.25 These factors contribute to the development
of chronic health conditions that increase the risk of death from COVID-19. In this
context, it is very concerning that ethnic and racial disparities also seem to be
creeping into the care of persons with COVID-19. In states like Tennessee, African
Americans with COVID-19 symptoms are reportedly less likely to be tested for the disease
than white counterparts and the testing centres are preferentially located in areas
occupied by predominantly white communities.16
Why colour-blind data exacerbates racial inequities in health
Healthcare data enable health systems to understand the pattern of diseases, develop
holistic policies and enhance health outcomes. Such data can also be used to determine
how changes in healthcare systems and diseases impact ethnic and racial minorities
differently in order to undertake timely interventions to improve quality of care.30
This means that in places where minorities are increasing in number, ethnic and racial
data will be essential to understanding and addressing the inequalities and challenges
they face with respect to healthcare.31 The need for such disaggregated data is becoming
increasingly obvious as the COVID-19 pandemic continues to progress. Disaggregated
data characteristically reveal patterns and underlying trends which become crucial
to planning appropriate and efficient responses to pandemics. In pandemics, high-quality
disaggregated data are vital to identifying the vulnerable populations and factors
which impede or promote disease transmission within communities.32 As pandemics do
not affect all populations in a similar manner, the elucidation of key indices such
as age, sex, ethnicity, education, SES and geographic location is particularly pertinent.
Countries such as UK, USA, Canada, Sweden and Singapore are technologically and scientifically
advanced in terms of healthcare. However, it is well known that ethnic and racial
minorities continue to experience disproportionate health outcomes which predate the
current COVID-19 crisis.30 These groups record poorer health outcomes and have high
prevalent rates in asthma, cancer, cardiovascular disease and HIV/AIDS.20 Ethnic and
racial minorities in the USA and UK record language barriers, poorer healthcare experiences
and higher uninsured rates, which makes it less likely to access healthcare services.33
34 Between 2010 and 2018, black Americans were 1.5 times more likely to be uninsured
while Hispanics were over 2.5 times less likely to be insured compared with the rates
of white Americans. Ethnic minorities face economic and social disadvantages over
the course of life and such inequalities result in low access and utilisation of healthcare.
In places like Singapore, immigrants from neighbouring countries live in shared dormitories
with poor working conditions.24 The current COVID-19 crisis appears to be aggravating
an already very fragile situation which is characterised by these grave inequalities.
While it is clear that the acquisition of disaggregated data will be crucial in tracking
the spread of COVID-19 transmission and tailoring global policy responses, use of
such data is not practised. Many countries may lack such detailed data, or, as in
Canada, have the data but rarely make effective disaggregated use of it in health
research.32 With respect to COVID-19, and when challenged to provide more race-disaggregated
data in Canada’s pandemic briefings, federal and several provincial health officials
pushed back arguing that ‘Canada is a colour-blind society’, or that ‘race-based data
are not necessary’ during the pandemic.35 With lack of use of quality and available
minority data, it is not only difficult for minority populations to understand the
causes and patterns of diseases and their environment, but it also limits the government
from recognising the impact of health and social policies.36 One Canadian health official,
however, notably commented that it was not the time during the pandemic to address
how ‘longstanding issues’ related to the social determinants of health were affecting
black communities during the pandemic.35
Tackling ethnic health care disparities: using the available evidence to act
To reduce or prevent further ethnoracialised health disparities revealed by the COVID-19
pandemic, it will be important to conduct an intersectional analysis of the socioeconomic
factors and social determinants of health.37 38 The socioeconomic factors that negatively
influence health outcomes within the underserved minority communities must be identified
and contextualised within historical, political, social and economic remits.5 20
COVID-19 healthcare service delivery can have a direct impact on the overall health,
quality of life and life expectancy of minority populations. But not all groups, and
certainly not ethnic minorities in the USA, Singapore and Norway have equitable access
to such care. The root cause of the differential treatment of minorities in healthcare
settings, notably but not exclusively African Americans, Asians and Hispanics, will
need to be identified and innovative policies aimed at closing access and treatment
gaps introduced in ways that will guarantee a buy-in from all relevant parties. As
many countries become more diverse, it will become increasingly vital to sustain a
diverse and culturally competent healthcare workforce.20 Healthcare providers need
to be equipped and well informed to address the health needs of the growing minority
populations, especially during outbreaks such as COVID-19.
Conclusion
Ethnic and racial health disparities continue to plague minority population across
several countries resulting in worse health outcomes as reflected in the current COVID-19
crisis. Many ethnic minorities experience low socioeconomic deprivation, poorer healthcare
experiences and low health insurance coverage which contribute to inadequate healthcare
utilisation and therefore increase in long-term illnesses. These persistent ethnic
health disparities have been well known for many decades, but often systematically
ignored. The onset of COVID-19 exposes, once more, the racial fault lines that have
been the norm in many countries’ health systems, and social and economic policies.
It is poignant that wealthy countries with technologically advanced health systems
still record poor and inequitable health outcomes for their minority populations.
As governments’ COVID-19 responses unfold, disaggregated data will be vital in identifying
gaps in the social determinants of these health disparities and guiding appropriate
prevention/response efforts.