“Where the dead lie thicker”

It was evident soon after the onset of COVID-19 that it disproportionately harmed Black and Latino communities in the United States—hardly the great equalizer that some predicted the pandemic would be.  

Now three health economists have measured those inequities by analyzing and comparing death rates over the first year of the pandemic, and their results are especially stark, with challenging implications for health care policymakers. One conclusion is that the racial and ethnic inequities are primarily due to sociodemographic factors and their differing effects on historically disadvantaged groups, rather than preexisting health conditions. 

“The Great Unequalizer: Initial Health Effects of COVID-19 in the United States,” was published on Monday as a National Bureau of Economic Research working paper. The three co-authors, Harvard Kennedy School Professors Marcella Alsan and Amitabh Chandra, and Kosali I. Simon of Indiana University’s O’Neill School of Public & Environmental Affairs, are among the nation’s leading health policy scholars. 

They begin with some history of inequities in prior epidemics, beginning with a cholera outbreak in Boston in 1849 that killed Irish immigrants at a rate over twice that of native-born Bostonians. They also looked at the 1918 flu pandemic, and the HIV/AIDS outbreak in the 1980s. 

The authors quote Rudolf Virchow, the founder of modern cellular pathology, who wrote in 1848 on the need to measure the disparate impacts of infectious disease: “Statistics will be our standard of measurement: we will weigh life for life and see where the dead lie thicker, among the workers or the privileged.” 

Applying that same mortality yardstick, the three authors draw from available data to compare deaths during 2020 from COVID-19 in the United States and then quantify the inequalities. 

First, they note that the official tabulation of 378,000 COVID deaths for last year certainly is an undercount. Data show there were 504,000 more deaths in 2020 in the United States than in 2019, suggesting many COVID deaths went uncounted, and spillover deaths were not tabulated. They cite statistics showing that an estimated 41 percent of American adults delayed or avoided medical care due to pandemic-related concerns. At the same time, hospitals reduced non-COVID admissions by 40 percent during the first wave. 

Then the authors assess the impact of health inequality and find that “Black, American Indian, and Hispanic people died almost always at greater rates.” Black Americans suffered mortality 25 percent above the norm, and Hispanic deaths were 39.5 percent higher relative to the baseline trend.  

And the disparities were markedly worse for younger people of color. “The already higher number of Black and Hispanic pandemic-related deaths disproportionately occurred among the young.” Looking at those data through the lens of “years of potential life lost,” they find that Black Americans lost 4.2 times more years of life per person under age 65 than non-Hispanic white Americans, and Latinos lost 2.9 times more years of life.  

“Far from being an equal opportunity pathogen, SARS-Cov-2 has exposed societal cleavages between less privileged and more advantaged groups,” the authors write. 

The three authors have long track records examining public health policy issues and outcomes. Marcella Alsan is a medical doctor, a public health scholar, and a microeconomist studying health inequality. Amitabh Chandra, the Ethel Zimmerman Wiener Professor of Public Policy, is director of health policy research at the Kennedy School and also teaches at Harvard Business School. Kosali Simon is Herman Wells Endowed Professor at Indiana, associate vice provost for health sciences, and editor of the Journal of Health Economics. 

Their paper offers a framework for assessing the main factors in the disparities, with an eye toward helping policymakers in the years ahead. The authors describe three groups of factors:  

• Social determinants such as occupation, income and education. 
• Medical determinants, including healthcare quality, insurance, and comorbidities. 
• Long-standing institutional features of systemic racism and intergenerational poverty. 

The authors then examine the weight of each of these factors in disparate hospitalization rates. To isolate the effects of each factor, they drew from a database of commercial and Medicare Advantage claims covering 67 million people, and analyzed those of more than 400, 000 enrollees. These include all enrollees hospitalized due to COVID-19 during the first three quarters of 2020 and a 5 percent sample of enrollees not hospitalized for COVID-19.  

The researchers considered these claims based on people’s similar health preconditions. And they found that hospitalization for COVID-19 was 7 percentage points higher for Blacks than for non-Hispanic whites, and 4.6 percentage points higher for Hispanics.  

 The stark differences in health outcomes “cannot be attributed to a greater prevalence of pre-existing conditions, lower neighborhood levels of education, or geographical disadvantage alone,” the authors conclude. “Rather, otherwise similar Black and Hispanic individuals, all of whom are insured in our sample, are hospitalized at a higher rate than non-Hispanic whites.” 

These results “are consistent with the broader narrative that Black and Hispanic individuals face institutional disadvantages, including inconsistent providers, lower-quality care, and systemic racism, that worsen their returns to similar endowments and contribute to COVID-19 health inequality.” 

The starkly unequal mortality burdens borne in this pandemic “may serve as a catalyst for change—in particular for changing how Americans view the importance of public health and the social safety net.” 

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Banner image: Images of COVID-19 victims from Detroit are displayed in a drive-by memorial in Detroit, Michigan. Photo by Aaron J. Thornton/Getty Images