As the old adage goes, “when White America sneezes, Black America gets the flu.”
That saying precedes the contemporary terms “health equity” and “social determinants of health.” It reflects a reality that, for African Americans, life in the United States is unequal, unjust, and rooted in longstanding structural racism, with de facto and de jure discrimination. Immoral and persistent health inequities – such as higher rates of heart disease, diabetes, stroke, and kidney disease, and disparities in life expectancy – are not surprising to most African Americans.
Nonetheless, there was a collective shock when the first reports of COVID-19 disease documented that African Americans were dying at a disproportionate rate compared to whites. The report of the first 12 fatalities in St. Louis on April 8 indicated that all were African Americans. That report by the city’s health director mirrored data across the country; in Louisiana, for instance, African Americans represent 70 percent of the dead but only 33 percent of the population. In Michigan, African Americans comprise 33 percent of the infected but 40 percent of the fatalities.
The epidemiology of COVID-19 has vividly illustrated that this is not “flu on steroids,” as many are apt to believe. SARS-Cov-2, known as the novel coronavirus, is 2.5 times more infectious than the flu and 10-20 times more fatal, and thus more likely to overwhelm susceptible populations. We define “susceptible populations” as those who are unable to reach their full health potential because of social and structural barriers to health, including poverty, joblessness, inadequate housing, food insecurity, lack of access to affordable healthcare, and inadequate education.
The rampant spread of COVID-19 in the St. Louis region provided a unique opportunity to study the relationship between social and structural determinants of health and adverse outcomes, including death in African Americans and whites infected with COVID-19.
Consequently, in the study “The Disproportionate Impact of COVID-19 on Black and African American Communities in the St. Louis Region,” commissioned by the Missouri Hospital Association, the authors sought to disentangle the complex interactions between upstream social determinants of health and downstream health outcomes. The study examined COVID-19-related health disparities in the St. Louis region using ZIP code-level data on confirmed cases and demographic composition. The report is the first systematic examination of issues related to race and social determinants of health in the context of the COVID-19 outbreak in Missouri.
Prior studies have shown that ZIP code of residence is highly correlated with a number of social determinants of health — defined as the conditions in which people are born, grow, live, work and age. Building on those studies, this analysis included data on confirmed COVID-19 cases and racial composition for 113 ZIP codes across the St. Louis region, defined as the City of St. Louis, St. Louis County, St. Charles County, Jefferson County and Franklin County. St. Louis regional ZIP codes were organized by the percentage of the total population being African American and evaluated by the number of confirmed COVID-19 cases.
Confirmed COVID-19 cases were largely clustered in communities in North St. Louis city and county on April 20, as a rate of the population of each ZIP code in the St. Louis region. ZIP codes were organized into groups that categorized the proportion of the African-American population in each ZIP code at less than 5%; between 5% and 50%; and over 50%. It was noted that ZIP codes with a majority African-American population accounted for 16% of the region’s population, but 34% of its confirmed COVID-19 cases.
Race appeared to be the strongest predictor of confirmed COVID-19 cases per 100,000 residents among ZIP codes in the St. Louis region. A vivid example lies in comparing Maplewood and the Ville neighborhood, two locations with similar population density and separated by only three miles, yet with a 10-fold difference in the rate of confirmed COVID-19 cases on April 20.
The analysis was not structured to fully explain the causal pathway of observed disparities in COVID-19 for communities of color in the St. Louis region. Namely, the data did not account for differences in other community risk factors, such as socioeconomic status, population density, household composition, labor force composition, including the proportion of essential workers, the related ability of individuals in different areas to shelter at home versus continuing to work, presence of comorbid conditions or prevalence of testing.
As the COVID-19 crisis in our community unfolds, the results of the study underscore the need for targeted individual and neighborhood-level data collection, along with interventions and policies such as directing enhanced education, awareness, expanded COVID-19 testing and contact tracing resources for the African-American community. The PrepareSTL initiative is an example of a successful community-led COVID-19 awareness and education campaign that is effectively engaging the African-American community.
“The Disproportionate Impact of COVID-19 on Black and African American Communities in the St. Louis Region” reveals the consequences of decades of economic disinvestment, generational poverty, and toxic stress associated with structural racism on the health of the African-American community. Immediate and long-term interventions should focus on public health and trauma-responsive approaches that mitigate the impact of social determinants of health that act on the African-American community, and allocation of resources that promote healing – physical, mental, and social.
Will Ross, MD, MPH, is an alumnus endowed professor of Medicine and principal officer for Community Partnerships at Washington University School of Medicine. Dr. Ross is a co-author of “The Disproportionate Impact of COVID-19 on Black and African American Communities in the St. Louis Region.”