Injustice in Health: Now Is the Time to Change the Story
Authors: Gbenga Ogedegbe, Sharon K. Inouye
Journal: Annals of Internal Medicine (2021)

EditorialsJuly 2021Injustice in Health: Now Is the Time to Change the StoryFREEGbenga Ogedegbe, MD, MPH and Sharon K. Inouye, MD, MPHGbenga Ogedegbe, MD, MPHInstitute for Excellence in Health Equity, New York University Grossman School of Medicine New York, New York and Sharon K. Inouye, MD, MPHBeth Israel Deaconess Medical Center, Harvard Medical School, and Hebrew SeniorLife Boston, MassachusettsAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-1279 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Daily news headlines highlight the disproportionate effect of COVID-19 on minoritized (Black, Latinx, Asian, and Indigenous) communities, particularly those that are socioeconomically disadvantaged. (A "minoritized" group is often defined as a social group that is devalued in society and given less access to resources because of their race, ethnicity, or other attributes that are beyond their control.) Thus, the findings that Bilal and colleagues report (1) are unsurprising. Yet, they provide a level of granularity and clarity that reveals a stark story of a public health catastrophe in the making.Bilal and colleagues analyzed the correlation between the Social Vulnerability Index (SVI) for 281 ZIP codes in Chicago, Philadelphia, and New York City and department of health data on numbers of COVID-19 tests done, confirmed COVID-19 cases, and COVID-19 deaths. The SVI is a robust measure of social vulnerability and a marker of a community's ability to prevent human suffering and financial loss in the event of a disaster. It includes 15 variables from the American Community Survey, comprising 4 domains: socioeconomic status, household composition, race and language barriers, and housing and transportation. The authors found a striking relationship between higher SVI (more vulnerable) and lower testing rates, higher positivity rates, more confirmed cases, and greater COVID-19–related mortality. In fact, mortality increased by 50% for each SD increase in SVI. Of note, clusters of high SVI and high COVID-19 mortality occurred in well-recognized areas of extreme racial segregation and poverty, including West and North Philadelphia, the West Side of Chicago, and the Bronx.Important limitations of this study should be acknowledged. First, ZIP codes can contain heterogeneous populations. Thus, the SVI may not reflect all individuals in a ZIP code, which may have contributed to paradoxical findings in some ZIP codes. Second, the SVI is a gross indicator that cannot directly illuminate the mechanisms of increased infection and mortality. Poor outcomes were likely due to complex interactions of higher comorbidity burden, decreased access to health care, lower-quality hospitals, barriers to testing, and other factors. Finally, as the authors note, lack of testing in these areas made confirmation of cases difficult, and they may have underestimated COVID-19 cases and deaths.Despite these limitations, the findings have important implications. Although other studies have shown the disparate rates of COVID-19 mortality and hospitalization in minoritized populations (2), few offer insights into the role of structural inequities. Adhikari and colleagues (3) also showed in 10 major U.S. cities that ZIP codes with predominantly Black and Latinx populations had 3-fold higher rates of COVID-19–related hospitalizations and death regardless of socioeconomic status. Of note, the National Center for Health Statistics reported a loss of 3 years in life expectancy for Black men, versus 0.8 year for White men, in the first half of 2020 (4); this was largely attributed to the disparate effect of COVID-19 in minoritized populations. Bilal and colleagues confirm the role that residing in a socioeconomically disadvantaged community plays in this disparate effect.Unfortunately, this story continues with regard to COVID-19 vaccination. Recent age-adjusted data across 40 states show that Black and Latinx persons received a lower share of vaccinations than White persons relative to their share of cases and deaths and to their proportion of the population (5). As of 10 March 2021, about 1 250 370 residents of New York City had received at least 1 dose of the COVID-19 vaccine, reaching 19% of the White population but only 9% of the Black and Latinx populations who make up more than 50% of New York City's residents (6). If underlying structural inequities remain unaddressed, the persistent racial and ethnic disparities in rates of vaccination and health care delivery will continue to perpetuate the higher rates of COVID-19–related morbidity and mortality in minority communities.What is the way forward? The advent of COVID-19 vaccines has sharply reduced overall hospitalizations and mortality and could play a major role in reducing the racial gap in morbidity and mortality related to COVID-19. Recent discourse on low vaccination rates in minority populations has focused on "vaccine hesitancy" rather than on the structural inequities—reflected in high SVI scores—that likely drive poor access to vaccines. A recent analysis documented much lower access to vaccines for minoritized populations than White populations (7). A strong and immediate policy response is imperative to address these issues. Bilal and colleagues' study sheds light on the important role that structural inequities play in disparities in COVID-19 outcomes and also provides policymakers evidence that they must ensure and prioritize vaccine distribution to areas with high SVI. Equitable vaccine distribution targeted to low-income areas is critical to alter the current trajectory of poor vaccination access and poor COVID-19 outcomes in minoritized communities. Although the ethics and legality have been questioned (8), the National Academies of Sciences, Engineering, and Medicine recommend prioritizing vaccination of racial minorities (9). An alternative approach for vaccine distribution that does not include race might apply the area deprivation index, a measure of socioeconomic deprivation of a geographic area (block level) that is associated with health outcomes (10). Through deliberate application of such an approach, we can reduce racial disparities in vaccine access.Perhaps a silver lining of the COVID-19 pandemic is the renewed and sustained focus on the role that structural inequities play in racial disparities across not only health care but also the criminal justice, education, housing, and financial systems. This recognition has led to important initial steps to address the root causes of racial disparities in health care: establishment of the Biden-Harris COVID-19 Health Equity Taskforce to address structural inequity in health care; the Biden-Harris administration's pledge to make all adults eligible for vaccination against COVID-19 by 1 May 2021; and the recent Coronavirus Aid, Relief, and Economic Security Act to address poverty. In the words of Dr. Martin Luther King Jr., "Of all the forms of inequality, injustice in health is the most shocking and inhuman." We have the opportunity to change this storyline of pervasive and persistent racial disparities in health outcomes: Now is the time.References1. Bilal U, Tabb LP, Barber S, et al. Spatial inequities in COVID-19 testing, positivity, confirmed cases, and mortality in 3 U.S. cities. An ecological study. Ann Intern Med. 2021;174:936-944. doi:10.7326/M20-3936 Google Scholar2. Wadhera RK, Wadhera P, Gaba P, et al. Variation in COVID-19 hospitalizations and deaths across New York City boroughs. JAMA. 2020;323:2192-2195. [PMID: 32347898] doi:10.1001/jama.2020.7197 CrossrefMedlineGoogle Scholar3. Adhikari S, Pantaleo NP, Feldman JM, et al. Assessment of community-level disparities in coronavirus disease 2019 (COVID-19) infections and deaths in large US metropolitan areas. JAMA Netw Open. 2020;3:e2016938. [PMID: 32721027] doi:10.1001/jamanetworkopen.2020.16938 CrossrefMedlineGoogle Scholar4. Arias E, Tejada-Vera B, Ahmad F. Provisional life expectancy estimates for January through June 2020. National Center for Health Statistics; 2021. Accessed at www.cdc.gov/nchs/data/vsrr/VSRR10-508.pdf on 16 March 2021. Google Scholar5. Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations race/ethnicity. Kaiser Family Foundation. 17 March 2021. Accessed at www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity on 17 March 2021. Google Scholar6. NYC Health. COVID-19: data. City of New York; 2021. Accessed at www1.nyc.gov/site/doh/covid/covid-19-data.page on 13 February 2021. Google Scholar7. Boyd R. Black people need better vaccine access, not better vaccine attitudes. New York Times. 5 March 2021. Accessed at www.nytimes.com/2021/03/05/opinion/us-covid-black-people.html on 16 March 2021. Google Scholar8. Schmidt H, Gostin LO, Williams MA. Is it lawful and ethical to prioritize racial minorities for COVID-19 vaccines. JAMA. 2020;324:2023-2024. [PMID: 33052391] doi:10.1001/jama.2020.20571 CrossrefMedlineGoogle Scholar9. Gayle H, Foege W, Brown L, et al, eds. A framework for equitable allocation of vaccine for the novel coronavirus. National Academies of Sciences, Engineering, and Medicine; 2020. Accessed at www.nationalacademies.org/our-work/a-framework-for-equitable-allocation-of-vaccine-for-the-novel-coronavirus on 16 March 2021. Google Scholar10. Kind AJH, Buckingham WR. Making neighborhood-disadvantage metrics accessible — the Neighborhood Atlas. N Engl J Med. 2018;378:2456-2458. [PMID: 29949490] doi:10.1056/NEJMp1802313 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Ashok V DaftaryInternal Medicine: Sutter Gould Medical Group Stockton.3 April 2021 Racial Disparities This editorial and the article it makes comment restates a fact that is accepted by both the liberal and conservative elements of the political divide. The poorer outcomes from and lesser testing for Covid 19 infections is obvious in the zip codes studied. It is not a result of the color of skin, racial background or ethnicities of the populations involved. The studies fail to define financial status, education, employment and living conditions of these populations. I am sure that there will be disparities in all these measures. Attempts at correcting these first must be addressed rather that highlighting race and color. The problem cannot be illustrated using black and white alone as the root problem is the paucity of greenbacks. The medical profession in the trenches is also impacted by the same factors, unfortunately editorials such as this one amplify perceived grievances rather than offering solutions. Their view from the ivory tower is far removed from that in the trenches. The view from the trenches should also be portrayed. This could help narrow the racial divide rather than widening it Disclosures: None Olugbenga Ogedegbe, MD, MPH and Sharon K. Inouye, MD, MPHNew York University Grossman School of Medicine, Harvard Medical School9 April 2021 Authors' Response to Daftary We thank Dr. Daftary for his comment. We completely agree that the issue should not be race or ethnicity alone. However, we felt it important to address several inaccuracies in this comment. First, the Social Vulnerability Index used in the Bilal et al study accurately captured the financial status, education, employment and living conditions (transportation and housing) for the populations in the zip codes studied. Second, studies by other authors have shown that zip codes whose racial composition is predominantly Black and Hispanic have poorer health outcomes. Finally, the impetus of our editorial was precisely to highlight the role of social determinants of health—as astutely pointed out by Dr. Daftary—but in this case, driven by structural racism as the root cause of the racial disparities in COVID-19 related mortality observed in Bilal et al and other studies. We would like to emphasize that Black race and Hispanic ethnicity often co-segregate in zip codes with extreme poverty, poor education, low employment rates, and poor living conditions. Over time, government policies have contributed to this co-occurrence. For example, from 1933-1977, the redlining of neighborhoods where mortgages would not be insured was a government-backed mandate that effectively disinvested in zip codes with predominantly Black populations. Thus, our call to action was to find effective means through current policies and procedures to combat structural racism and to effectively deliver COVID-19 vaccines, tests, and high-quality medical care to the zip codes with the most vulnerable populations. We completely agree with Dr. Daftary about the importance of finding solutions to address problems "in the trenches"; and finding ways to narrow the racial divide are critical. Author, Article, and Disclosure InformationAffiliations: Institute for Excellence in Health Equity, New York University Grossman School of Medicine New York, New YorkBeth Israel Deaconess Medical Center, Harvard Medical School, and Hebrew SeniorLife Boston, MassachusettsFinancial Support: Dr. Inouye holds the Milton and Shirley F. Levy Family Chair at Hebrew SeniorLife/Harvard Medical School. The funding sources had no role in the design, conduct, or reporting of this article.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-1279.Corresponding Author: Sharon K. Inouye, MD, MPH, Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02459; e-mail,[email protected]harvard.edu.Current Author Addresses: Dr. Ogedegbe: Institute for Excellence in Health Equity, New York University Grossman School of Medicine, Center for Healthful Behavior Change, 180 Madison Avenue, 7-55, New York, NY 10016.Dr. Inouye: Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02459. This article was published at Annals.org on 30 March 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoSpatial Inequities in COVID-19 Testing, Positivity, Confirmed Cases, and Mortality in 3 U.S. Cities Usama Bilal , Loni P. Tabb , Sharrelle Barber , and Ana V. Diez Roux Metrics Cited byHow education and racial segregation intersect in neighborhoods with persistently low COVID-19 vaccination rates in PhiladelphiaHeterogeneity in Spatial Inequities in COVID-19 Vaccination Across 16 Large US Cities July 2021Volume 174, Issue 7Page: 1012-1013 ePublished: 30 March 2021 Issue Published: July 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...