Health and health care
Crowded housing situations and education and income gaps among minority people are also contributory, and fewer minority people are in positions that afford the ability to take paid leave or to quarantine when ill. In addition to greater risk of hospitalization and death, there are also well-documented COVID-19 vaccine disparities among racial/ethnic groups. According to the US Centers for Disease Control and Prevention, of the 106,155,623 people who have received at least 1 dose of the COVID-19 vaccine and for whom there are race/ethnicity data, only 9.3% are Black, 15.9% are Hispanic/Latino, and 0.3% are American Indian or Alaskan Native persons as compared with 59.2% of non-Hispanic White patients. In contrast, Black and Latinx people make up 13% and 18% of the US population, respectively. The reasons for these disparities include misinformation, challenges with outreach to the most vulnerable patients, and medical mistrust due to historical and intentional medical atrocities performed against Black persons, such as the Tuskegee experiments, the gynecologic experiments of J. Marion Sims, and countless other examples.
Children likely lost a year of school, with more lost by students without access to summer enrichment, after-school activities, opportunity for personalized instruction, and staffing strategies that reduce class size. Schools provide access to educational, behavioral, and developmental support services, many of which were curtailed during the pandemic. Adequately funded schools also provide school nurses, introduction to the fine arts, and athletic opportunities.
Absenteeism, even with online learning, was reported to be high, particularly among children from lower-income neighborhoods. Teachers had no way of reliably checking on their students. Caregivers tried to assist their children, but many had to leave home for work. Caregivers with limited English proficiency were unable to help their children. Additionally, because inequities are passed down across generations, caregivers also likely experienced lack of resources for their own education, making it difficult to help their children.
The social and community context
The COVID-19 pandemic brought attention to persistent discrimination, racism, and violence directed at Black, Latinx, and Asian people and at immigrants. Redlining is a prime example of structural racism that disadvantages persons, families, and communities and persists over generations. It recently has attracted renewed attention during the pandemic. Redlining refers to the red color outlining areas of federal government maps of more than 200 metropolitan neighborhoods. These areas were considered too high-risk for mortgage lending. The consequence of redlining was that it flagged Black neighborhoods as too risky for the government to insure with mortgages. The effect still prevails in most US cities, with non-White areas having fewer resources: fewer parks and trees, fewer social services, and underresourced schools, all contributing to pandemic-related disparities. Redlining was a key factor in the development of the highly segregated, socioeconomically deprived neighborhoods that persist today, and these neighborhoods have features that may contribute to COVID disparities such as crowded housing and higher air pollution exposure.
Neighborhood and built environment
As the pandemic has unfolded, the importance of airborne transmission and the use of tools to clean the air, which use ventilation and filtration, has become clear. Ventilation is the process by which air in an indoor space is removed and replaced with cleaner air. Filtration is the process of removing contaminants, such as particles, from the air. Heating, ventilation, and air conditioning (HVAC) systems ventilate and filter the air. Opening windows and/or doors also provides ventilation and portable air cleaners (eg, high-efficiency particulate air purifiers) also provide filtration. Poor building conditions, such as those experienced by racial and ethnic minority populations, include inadequate ventilation and HVAC systems, which can contribute to increased COVID-19 risk. Poor ventilation has been documented in disadvantaged school districts while some wealthier schools have invested in upgrading buildings to optimize ventilation and filtration, furthering the inequity in school structures. There is less research on ventilation and filtration of low-income or subsidized housing, so whether poverty, race, and/or ethnicity increase the risk of living in a home with poor ventilation and filtration is less clear. Although there do not appear to be any studies examining the role of poor ventilation and/or filtration in homes and buildings in racial and ethnic disparities in COVID-19, it is plausible that subpar HVAC systems in schools or other indoor spaces could contribute to these disparities.
Long-term exposures may confer risk in that they increase the risk of comorbid conditions, such as cardiovascular disease and chronic obstructive pulmonary disease, which are risk factors for poor COVID-19 outcomes. Short-term exposure may directly act to increase susceptibility to infection or more severe disease by increasing susceptibility of the airways to infection with respiratory pathogens, including SARS-CoV-2. Given that racial and ethnic minority communities bear a higher burden of outdoor air pollution exposure, it is likely that air pollution exposure is a contributor to COVID-19 disparities. Although there are not yet published studies estimating the effect of inequities in air pollution exposure on COVID-19 disparities, there is strong circumstantial evidence that air pollution exposure may be an important contributor.
This profound economic hit and the other contributors to COVID-19 risk in the health care, educational, social context, and physical environment, layer on top of one another, resulting in a piling on of risk factors for COVID-19, so that these risk factors are concentrated among communities of color and thereby amplify COVID-19 disparities.
According to the US Centers for Disease Control and Prevention’s Office of Minority Health & Health Equity, “the future health of the nation will be determined to a large extent by how effectively we work with communities to eliminate health disparities among those populations experiencing disproportionate burden of disease, disability, and death.” We need to address the social context, access to education, and health care; ensure a safe, unpolluted physical environment; and equalize opportunities for people of color and end discrimination. We must provide understandable information for those with limited English proficiency, ensure Internet access for all, and provide adequate instruction in use of information technology. We must support, equip, and maintain public resources such as libraries, community health centers, schools, and federally qualified health centers or community centers, where these skills can be taught and learners are safe.
As allergist-immunologists we have unique training that potentially allows us to explain the immunology and science of the disease and the medical interventions. We need to consider and explain to patients how the SDOHs also threaten health and must be addressed. These arguments will be strengthened by increasing the diversity and numbers of our work force and by actively working within our communities to improve the SDOHs. As allergists–clinical immunologists, we and American Academy of Allergy, Asthma & Immunology members have a moral imperative to lobby for the health and welfare of all patients and to help ensure that these needed changes become reality.
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Published online: September 23, 2021
Received in revised form:
Supported by the National Institutes of Health (grants K24AI114769, R01ES023447 , and R01ES026170 [to E.C.M.] and grants R01HL143364 and U01 HL138687 [to A.J.A.]).
Disclosure of potential conflict of interest: P. U. Ogbogu reports serving on advisory boards of AstraZeneca and GSK and receiving research funding from AstraZeneca. A. J. Apter reports serving as a consultant for UptoDate. The remaining author declares that she has no relevant conflicts of interest.
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