Racial Disparities in COVID‐19 Mortality Among Essential Workers in the United States

Abstract

Introduction

The World Health Organization (2020) reported 3,018,952 confirmed cases and 207,973 deaths from the coronavirus disease 2019 (COVID‐19) worldwide on April 29, 2020. With 1,005,147 (33.29% of all) cases and 57,505 (27.65% of all) deaths, the United States is the epicenter of the pandemic (Centers for Disease Control and Prevention [CDC], 2020a). As national‐level data disaggregation by race continues to lag, released data and articles from states, cities, and news outlets provide glimpses into COVID‐19's disproportionate impact. As of April 6, 2020, the Alabama Department of Public Health reported disproportionate rates of infection and death between non‐Hispanic (NH) Black and NH White patients (Zanolli, 2020). On April 16, 2020, Louisiana reported that although NH Blacks comprise 33% of the state's population, they represented 60% of the state's deaths from the virus (Louisiana Department of Health, 2020). COVID‐19–specific inequities continue to surface in disease hotspots such as New York City, where NH Black residents account for 22% of the city's population but 28% of deaths, while Hispanic residents account for 29% of the population and 34% of deaths (New York State Department of Health, 2020). As death rates continue to climb, better data‐driven understanding of the disproportionate racial impact of the pandemic is warranted to enable officials to best direct state‐level mitigation, testing, treatment, and funding efforts.

It is no surprise to some that COVID‐19 is exposing health disparities in the United States, which is outranked only by Portugal and Chile on income‐based health inequities (Hero, Zaslavsky, & Blendon, 2017). The “weathering hypothesis”––defined as “chronic exposure to social and economic disadvantage [that] leads to accelerated decline in physical health outcomes and could partially explain racial disparities in a wide array of health conditions” (Forde, Crookes, Suglia, & Demmer, 2019)––provides a possible framework for better understanding these disparities (Forde et al., 2019; Geronimus, Hicken, Keene, & Bound, 2006). This phenomenon manifests in higher rates of chronic medical conditions, including asthma, chronic obstructive pulmonary disease, heart disease, and diabetes among people of color compared with NH Whites (CDC, 2018; Maxwell, 2020). Critics have argued that the weathering hypothesis fails to consider allostatic load—that is, the wear and tear the body experiences as it strives to achieve stability in disruptive environments (Thomas, 2006). Nonetheless, the disproportionate health effects of the COVID‐19 pandemic are consistent with the unequal presentation of chronic medical conditions among communities of color that result from a historical legacy of structural inequities.

Strong ties among health insurance coverage, care, and outcomes are well established in the literature (Committee on the Consequences of Uninsurance, 2002; Hoffman & Paradise, 2008); individuals without health insurance coverage have been found to be less likely to receive medical care and more likely to experience worse health outcomes (Bovbjerg & Hadley, 2007). In 2018, the U.S. Census Bureau (2019c) found that, compared with those who identify as NH White, Hispanics were three times more likely and NH Blacks nearly twice as likely to be uninsured. While the Affordable Care Act has substantially increased insurance rates for all races and ethnicities over the past 10 years (Artiga, Orgera, & Damico, 2020), health outcomes for uninsured patients of color remain a major concern during the COVID‐19 pandemic.

Although many states have implemented stay‐at‐home orders in an attempt to contain COVID‐19's rapid spread, many individuals employed by “essential” businesses are unable to remain at home. U.S. Bureau of Labor Statistics (2020) data reveal that, in general, 19.7% of NH Black and 16.2% of Hispanic workers report being able to work from home versus 29.9% of NH White workers (U.S. Bureau of Labor Statistics, 2019). This gap highlights systemic and racial injustices that may be perpetuated by COVID‐19 exposure. Our current study aimed to investigate racial disparities in COVID‐19 mortality among essential workers in the USnited States to establish a deeper understanding of the compounding factors and indicators contributing to the inequalities permeating the novel coronavirus. Our central hypothesis was that COVID‐19 mortality was higher among NH Blacks compared with NH Whites because NH Blacks hold more essential‐worker positions.

Materials and Methods

Results

Discussion

In one of the first descriptive studies to examine racial disparities in COVID‐19 mortality among essential workers in the United States, we identified a disproportionate number of deaths among NH Blacks relative to their distribution in state populations. For example, NH Blacks comprised 36.49% of COVID‐19 deaths in Wisconsin despite making up only 6.17% of the state's population. With similar trends observed nationwide, our findings contribute to the existing knowledge base concerning health status and outcome inequalities in the United States for NH Blacks compared with NH Whites (Farmer & Ferraro, 2005; Hatzenbuehler, Phelan, & Link, 2013).

NH Blacks were more likely than NH Whites to hold occupations considered essential (e.g., in transportation, health care, food preparation, and cleaning services). NH Blacks disproportionately occupied the top nine occupations that placed them at high risk for contracting COVID‐19 and for potentially infecting their households. In March 2020, disaggregated occupational data from Amazon emerged that corroborate our findings, revealing that workers at 10 Amazon warehouses nationwide tested positive for COVID‐19 (Greene, 2020). December 2019 workforce data showed that 26.5% of Amazon workers identified as NH Black and 18.5% as Hispanic (About Amazon Staff, 2019). This compares with an overall representation in the U.S. population of 13.4% for NH Blacks and 18.3% for Hispanics (U.S. Census Bureau, 2019d).

Our findings confirmed our central hypothesis that COVID‐19 mortality was highest among NH Blacks compared with NH Whites due to NH Blacks holding more essential‐worker positions. Although our findings revealed state‐specific occupational differences in states with denser NH Black populations, they consistently showed that disparities in NH Black–White mortality were high not only in COVID‐19 hotspots but also nearly everywhere across the United States.

Chambers (2020) and Schumaker (2020) report that varied COVID‐19 exposure and transmission levels in communities of color stem from a lack of personal protective equipment (PPE) and inability to fully practice social distancing. Nearly half of all urban NH Blacks in the United States live under conditions of hypersegregation and concentrated poverty (Massey, 2004). NH Black essential workers living in high‐density housing may be unable to practice social distancing at home, rendering those they live with disproportionately vulnerable to COVID‐19 exposure.

We found that NH Blacks residing in the Midwest—specifically, Wisconsin, Kansas, Missouri, Michigan, and Illinois—have been the hardest hit by COVID‐19, with mortality rates ranging from nearly three to six times higher than those of NH Whites. While many Midwestern cities are often designated among the “best places to live” in America (Mishkin, Bhardwaj, Raimonde, & Wilt, 2019; US News & World Report, 2020), for NH Blacks they are among the worst places to call home due to well‐documented racial disparities in education, incarceration, employment, income, health, medical care, homeownership, voting access, wages, and numerous other socioeconomic factors (Boen, 2016; Council on Ethical and Judicial Affairs, 1990; Geruso, 2012; Stebbins & Comen, 2018; Williams & Jackson, 2005).

Despite historical pandemics such as HIV and H1N1 serving as potential guides for early intervention and improved response (Andrulis, Siddiqui, Purtle, & Cooper, 2012; Denning & DiNenno, 2010; Quinn et al., 2011), our findings reveal a lack of progress toward health equity in pandemic response efforts in the United States. The 1985 Heckler report highlighted how NH Black Americans experienced significantly worse health outcomes than their NH White counterparts (Nickens, 1986). Over three decades later, our study magnifies how occupational disparities contribute to the persistence of racialized health inequities. Existing structural injustices will continue to shape racial disparities in this pandemic if essential workers are treated as expendable, and unless companies and governmental leaders prioritize workplace safety and protection as a matter of public health.

A central moral dilemma of the COVID‐19 pandemic revolves around “restarting America” to save the economy. We suggest that policymakers must first recognize the economic harms that structural racism has caused for NH Black families across the country. Historical evidence confirms that reallocating medical expenditures to social programs and public health interventions can be of greater benefit to the nation's economy and health than cutting public health budgets (Correia, Luck, & Verner, 2020; Masters, Anwar, Collins, Cookson, & Capewell, 2017; Tran, Zimmerman, & Fielding, 2017). Delays in implementing pandemic mitigation interventions (e.g., stay‐at‐home orders, ramp‐up of domestic PPE production) interacting with structural racism may explain the high COVID‐19 mortality among NH Blacks in the Midwest, but ethical questions surrounding structural inequities in the health‐care system require additional interrogation as data on racial disparities in cases and deaths continue to emerge.

Conclusions and Policy Implications

While it is evident that COVID‐19 does not discriminate, the same cannot be said about the U.S. health‐care system. Although we were unable to confirm this for the current study due to a lack of COVID‐19–specific provider‐level data, overwhelming evidence exists that racial/ethnic minority patients continue to receive worse health care than NH White patients (Agency for Healthcare Research and Quality, 2020; Satcher et al., 2005; Smedley, Stith, & Nelson, 2003). Moreover, when accounting for patient‐level factors, health‐care providers have been found to exhibit significant implicit bias against NH Blacks (Maina, Belton, Ginzberg, Singh, & Johnson, 2018). The need for policy addressing mandatory provider implicit bias training married to rapid progress toward universal health coverage has been amplified due to COVID‐19. Future research should consider modeling the cost‐effectiveness role of universal health coverage and public health interventions in overcoming COVID‐19.

We conclude from our study that structural disparities, not biology, continue to increase COVID‐19–related racial inequalities. In agreement with the findings of Laster Pirtle (2020) and Milam et al. (2020), our study reveals the need for interventions to address social inequality among groups most at risk for unfair or unequal treatment. The racial disparities among essential workers in the United States that we highlight are a byproduct of longstanding systemic racism and structural inequalities, combined with a lack of public policy aimed at protecting the lives of essential workers who risk their lives daily to protect and/or provide for others. Complementing recommendations by Gross et al. (2020), increased vigilance around policy development and comprehensive strategies requiring the timely collection and public dispersal of state‐ and county‐level data disaggregated by race and ethnicity are critical to enable timely adjustments to response practices during public health crises.

Supporting information

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