January 22, 2022
From the earliest days of the pandemic, COVID-19 has wrought a far higher toll in communities of color than in the general population – thrusting the long-standing issue of health disparities in the U.S. into the attention of public health officials and the general public.
Even though non-Hispanic white people make up 60% of the population, racial and ethnic minorities in the United States have borne significantly higher risks of COVID-19 infections than white people, as well as hospitalizations and deaths from COVID-19.
So a conversation is raging among doctors, health researchers, public health officials, policymakers and activists about how to address the social determinants of health that are driving this unequal toll on communities of color.
I am a global public health professor with expertise in multicultural health and health disparities. My teaching and research focus on the social determinants of health: the layers of policies, economic factors and social structures that affect health and quality of life, and the complicated ways they interact. I also study social justice in the context of public health, including the sociocultural context of infectious diseases.
Throughout the pandemic, American Indians and Alaska Natives as well as Hispanics and Latinos have borne more than twice the risk of white people of death from COVID-19, and Black people have been at nearly twice the risk.
Research has shown that the pandemic's unequal toll on communities of color has been driven by long-standing health inequities: injustice or unfairness in the distribution of good health and well-being in society. Public health experts and professionals call the resulting health gaps “health disparities”: the inequitable differences that exist between various groups of people in terms of disease, injury, death and other health issues.
The World Health Organization describes health inequities as differences in health status or the distribution of health resources between certain populations of people. The differences are generally caused by the varied social conditions in which people are born, grow, live and work.
In the U.S., the main drivers of health inequities are structural inequalities. They include poverty, unemployment, lack of health insurance and inability to afford health care, as well as access to healthy food, good education and transportation.
These problems can cut across race and ethnicity. Overall, however, people of color are at higher risk of poor health than non-Hispanic white Americans, whom the U.S. Census Bureau defines as being of European, Middle Eastern or North African ancestry.
For example, Black Americans are twice as likely as their white counterparts to suffer from hypertension and heart failure. Black Americans also have a diabetes rate of 13% and an obesity rate of 38.3%, compared with 8% and 30% for non-Hispanic white people in the U.S., respectively, according to data from the Centers for Disease Control and Prevention.
In a 2021 study, researchers investigated the influence of social determinants of health on COVID-19 outcomes at the county level. They found that counties with higher overall death rates had a greater proportion of Black residents. They also had higher rates of health and social inequities, including low birth weight, uninsured adults or households lacking internet.
In 2020, life expectancy declined across most ethnic or racial groups, according to the CDC. However, while the drop for the majority population of white Americans was 1.5 years, Black Americans' life expectancy dropped by 2.9 years. For people of Hispanic and Latino descent, life expectancy dropped by three years.
Not surprisingly, health inequities also affect immigrants of color. My previous work over the past four years with Hispanics, Black Africans, Burmese and other minority refugees and immigrants participating in the Iowa Migrant Education Program revealed that the health inequities they experience are largely caused by poverty, unemployment and lack of access to health care.
The U.S. population has become more racially and ethnically diverse over the past decade. Many demographers predict that by 2045, the majority of people in the U.S. will be people of color. Children of color already make up the majority of people under age 18 in many states.
But these trends don't mean that health inequities will improve on their own. Solutions will require dealing with the root causes of inequities in all sectors of society, including education, employment, income, housing, transportation, food and health care.
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Research suggests that effectively addressing social determinants of health involves an equity-focused approach. This will require providing not just equal resources and opportunities, but enough resources to reach equal health outcomes for disadvantaged populations. In action, this might look like providing disadvantaged neighborhoods with grocery stores that offer healthy food options, or improving parks and playgrounds so residents have better opportunities to exercise, play and enjoy the outdoors.
Policy makers may be starting to take this approach. For example, the city of Roanoke, Virginia, recently established an equity and empowerment advisory board. The board's tasks include reviewing all existing city policies, ordinances and regulations in order to advise its City Council on those needing change or elimination because they promote inequities.
A massive body of evidence shows that eliminating the barriers for certain groups of people will not only enable them to live to their fullest potential, but that health equity is necessary for a healthy society. Right now the U.S. infant mortality rate averages 5.8 per 1,000 live births – two points higher than in most rich countries. Among the most developed countries in the world, the U.S. ranks 33rd in life expectancy.
Research has shown that those numbers stem largely from unaddressed health disparities. It remains to be seen whether the pandemic will be the health crisis that finally spurs deep enough changes to bring about health equity and justice.