Since the outbreak of the COVID-19 pandemic, evidence has been accumulating about its disproportionate impact on racial and ethnic minorities, for a variety of health outcomes including infection, hospitalization, death, and vaccination rates. To address and quantify the extent to which minorities are disproportionally affected by COVID-19 is essential to understanding how to implement appropriate prioritization strategies for future vaccination campaigns.
As soon as COVID-19 hit the world, concerns about a disproportionate impact of the pandemic on racial and ethnic minorities were brought to center stage. In the US, on March 4, 2020 The Atlantic was the first to launch a cry for attention to the disproportionate impact of COVID-19 on African Americans. Early accounts by the media estimated that Black Americans were dying at a rate 2 to 3 times higher than their population share. In the UK, the racial issue jumped to public attention when the first eleven doctors who died from COVID-19 were all reported to belong to Black, Asian, and minority ethnic (BAME) communities.
The urgency of the racial issue was widely acknowledged also by the medical literature. While the higher risk of COVID-19 death among minorities tends to correlate with pre-existing health conditions, possibly because of genetic and biological factors, from the very start the consensus was that race differentials are also associated with socioeconomic disadvantages reflecting living and working conditions. Not only does a large share of minorities live in poor neighborhoods characterized by high unemployment, low housing quality, and unhealthy living conditions, but they are also not as able to adhere to social distancing restrictions, whether because of working as essential workers or because of living in more crowded dwellings.
Initially, however, the racial and ethnic demographics of the people who were affected were not released or even collected, so that an assessment of the unequal racial and ethnic impact of the pandemic turned out to be very hard to reach. Early evidence on disparities in COVID-19 fatalities was collected on the basis of an extraordinarily detailed daily dataset covering Cook County, Illinois (US), the county that includes the City of Chicago. The data is provided by the medical examiner and includes race among a wide array of other individual characteristics such as age, gender, pre-existing conditions, and even the home address of the deceased. We produced an initial assessment over the first window of three months of the course of the epidemic, starting on March 16 when the first death was recorded in Cook County, and ending on June 15 which marked the peak of the first wave. This data documents two facts. First, Black Americans in Cook County did die from COVID-19 at a rate higher than their population share and, second, they were hit earlier than other groups.
This is the detail: In those three months, the medical examiner reported 4,325 COVID-19 deaths, of which 35% of Black Americans against a Black population share of 27%. Thus, Black Americans have been dying at a rate 1.3 times higher than their population share. While these figures do confirm they overrepresentation in terms of fatalities, they also paint a somewhat more moderate picture, compared to the ones reported by media earlier on. This seeming inconsistency is explained by the different timing of the epidemic onset: Not only were Black Americans disproportionally affected by COVID-19, but they also started to succumb to it earlier than other groups, which explains the consequent decline in their share of cumulative fatalities as the epidemic followed its course. Thus, what the epidemiological curve reveals is an extraordinary degree of racial segregation, with different groups displaying distinct patterns in the extent and even in the timing of their exposure to the epidemic.
To search for the roots of the higher vulnerability to COVID-19, we dig into its potential determinants by exploiting information on the home address of the deceased, to show that the redlining policies dating from the 1930s still exert an effect, with a sharper increase in mortality, driven by Black and Latino minorities, in historically low-graded neighborhoods. Thus, residential segregation induces a higher degree of vulnerability to the epidemic which, far from being determined by genetic and biological factors, is caused by socioeconomic status and household composition. It is through these two channels that the legacy of historical discriminatory policies manifests itself.
A broader picture
Subsequent studies extended and confirmed these early findings. For the US and up to the end of 2020, estimates of excess deaths (that is, deaths in excess of those to be expected in the years prior to the pandemic) show that the mortality burden was borne by racial and ethnic minorities, who not only have died at greater rates, but also did so at younger ages. Overall, without taking the younger age of minorities into account, Black and Hispanic populations suffered the highest rates of excess death: Black Americans saw a 25 percent increase in mortality relative to trend, Hispanic Americans a 39 percent increase. These disparities widen further when excess mortality rates are age-adjusted: This implies that those who died on average had many more years of life left to live, compared to other groups in the population.
A systematic review of world-wide evidence collects information on the association between racial, ethnic and socioeconomic status and a broader variety of health outcomes, beside death from COVID-19 and excess death. The evidence documents that racial and ethnic minority groups also had higher risks of infection and hospitalization. Low level of education, poverty, poor housing conditions, low household income, and living in overcrowded households were cited as risk factors.
The vaccination phase
The latest and still developing wave of evidence has focused on racial and ethnic inequities in vaccination rollout, raising questions on how prioritization strategies should or should have been implemented. In the US, after having secured shots for health care workers and nursing homes residents, a debate arose on how to approach the next, large-scale immunization effort. Despite the acknowledgement of the above-documented disproportionate impact of the pandemic on racial and ethnic minorities, adoption of race and ethnicity among prioritization criteria was ruled out based on legal and ethical considerations, since the higher risk borne by minorities is not biological or genetic but rather driven by socioeconomic factors. Eventually, the CDC settled on a racially neutral approach and released guidelines placing first in line, immediately after the over-75, frontline essential workers, in the hope that this strategy would still be effective in mitigating health inequities, since minorities are overrepresented among essential workers.
In practice, few US states followed CDC guidelines closely, and a variety of schemes were adopted. Eligibility criteria for frontline workers have in fact been the most diverse, likely reflecting local political pressure. Preliminary evaluations showed that lower income was a predictor of a lower chance of having been vaccinated among equally prioritized groups, and that the vaccination rate for Black people was lagging behind, a fact that could be partially justified by their lower representation among the elderly but remained at odds with their higher representation among essential workers. A December 2021 report concludes that, while over the course of the immunization campaign Black and Hispanic people have been less likely than their White counterparts to receive a vaccine, these disparities have narrowed over time, particularly for Hispanic people. These improvements likely reflect a combination of factors, including efforts to increase information among disadvantaged groups and to reduce the indirect cost of vaccination, where the latter is explained by difficulties in taking time off from work and in reaching vaccination spots. Still, inequity is still present, with 58 percent of White people having received at least one vaccine dose, against 51 percent of Black people. The persistence of vaccine hesitancy among Black Americans has been linked to the lingering mistrust in medicine due to the infamous Tuskegee experiments, where for decades Black men were infected with syphilis and deliberately denied effective care.
Implications for policy
The position of ethnic and racial minorities is a critical issue that policymakers must address. While its relevance from a socioeconomic perspective was already well understood, the novel implications for global health took center stage as a result of the COVID-19 outbreak. It bears ramifications not only for how to handle public health systems but also for how to regulate future migration flows and preserve public trust in health authorities.
The first conclusion for policymakers is that there is a need for internationally-coordinated data collection to account for racial and ethnic factors. To address and quantify the extent to which minorities are disproportionally affected by COVID-19 is essential to understanding the effect of the pandemic on public health and its socioeconomic implications. In addition to health outcomes, data should include individual-level information – at the finest possible level of disaggregation – on characteristics such as age, sex, residence, and comorbidities, as well as socioeconomic information reflecting an individual’s income, work status, and educational attainment. Other relevant dimensions such as co-residence patterns, dependence on public transport, access to health, and participation in the activities of local communities, should also be documented. Crucially, given the relevance of the spatial dimension for the diffusion of the pandemic, individual data should be collected at the finest available disaggregation, such as the region, county, or municipality.
The second conclusion, also in light of the latest developments and in particular the spread of Omicron, is that – even after the ongoing effort to administer booster shots and to vaccinate children is completed – vaccination campaigns represent an enduring challenge for the years to come. Appropriate prioritization strategies need to be implemented for the time when the emergency will be over. The facts tell us that a disadvantaged socioeconomic status, which is highly correlated with race and ethnicity, represents an obstacle to obtain a vaccine. Furthermore, targeting essential workers proved ineffective, thus providing no support for the hypothesis that minorities can get vaccinated quickly in virtue of the fact that they are often employed as such. Not only should socioeconomically vulnerable groups be ranked highly in future prioritization strategies, but campaigns should be conducted in such a way to actually reach them. Vaccination drives should be organized at workplaces, in poor and crowded neighborhoods, and at other frequent points of contact such as places of worship and motor vehicle bureaus. Policies aimed at fostering trust in medicine should include employing race-concordant medical practitioners within Hispanic and Black communities and using the media to spread information and facilitate the endorsement of public health measures. Prioritization strategies for the future should take these evidence-based considerations into account.
About the Authors
Graziella Bertocchi is Professor of Economics at the University of Modena and Reggio Emilia and President of the Einaudi Institute for Economics and Finance. She earned a PhD from the University of Pennsylvania and has taught at Brown University and several other institutions. Her research focuses on the economics of culture, gender, race, education, growth, and institutions.
Arcangelo Dimico is Senior Lecturer at Queen’s University Belfast and Director of the Centre for Health Research at the Management School (CHaRMS). He earned a PhD from the University of Nottingham and his research focuses on modern development economics, with broad applications to labor, political economy, education, gender and family.
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