Several studies have suggested that, across all countries, COVID-19 mortality is higher in people of colour. Keith C Ferdinand (Tulane University School of Medicine, New Orleans, USA) and his colleague, Samar Nasser, recently wrote in the Journal of the American College of Cardiology that the higher COVID mortality seen in African Americans was a “sentinel event”. Ferdinand talks to Cardiovascular News about the potential reasons for this higher mortality rate and the general implications for healthcare inequalities seen among racial/ethnic minority groups.
Prior to COVID-19, was there a disparity in mortality between African American communities and Caucasian communities?
The disparities in cardiovascular disease and mortality have long been well-known, as early as the Heckler Report that was published in 1985, and have been described in detail. The IOM Unequal Treatment in 2020 further delineated the white-black death gap. However, what has been known has yet to be addressed.
COVID-19 mortality seems to be higher in African Americans and in other people of colour than in Caucasian communities. What are the potential reasons for this?
The reasons are multifactorial; as noted in our editorial, social determinants play a large part in terms of increased infection rates—living and working conditions etc. On the other hand, comorbid risk factors increase mortality with COVID-19. For example, diabetes, obesity, cardiovascular disease, chronic kidney disease, and asthma. All of these are more common in black people. Similar trends have been noted in some Latinx populations and Southwest Indian tribal areas. Communities of colour are at ground zero for this crisis.
Specifically, what impact do you think cardiovascular risk factors have on this mortality rate? Diabetes and obesity are inflammatory states. The increases in cytokines is present before the cytokine storms that kill. Inflammation is also higher with atherosclerotic cardiovascular disease and even hypertension. Uncontrolled hypertension may increase intensive care unit admissions with COVID-19. Perhaps, only second to advanced age, obesity clearly leads to poorer outcomes, including mortality.
What can be done to address this mortality rate?
The underlying comorbid conditions need to be addressed as do the casual environmental factors. Universal insurance [in the USA], with identifiable primary care and earlier referral to cardiovascular disease specialists, would help prevent patients using the emergency department as a main means of care and presenting late in their disease processes with worse outcomes.
Politicians and pundits will often say that the USA has a broken healthcare system. We spend more dollars per capita than other developed societies but have a life expectancy that is far less than that seen in those societies (some data note that the USA is 13–16th in terms of life expectancy among developed countries).
However, this is not true. If you have health insurance, are educated, live in a stable environment and have an identifiable source of primary care with appropriate referral to specialists when needed, you will live as long as people in Japan, Canada, and Western Europe. The presence of these unacceptable disparities based on race/ethnicity, geography, and socioeconomic status is not a side issue and is the essential reason that US median life expectancy is so low.