Structural racism and COVID-19 response: higher risk of exposure drives disparate COVID-19 deaths among Black and Hispanic/Latinx residents of Illinois, USA

Abstract

Background: Structural racism has driven and continues to drive policies that create the social, economic, and community factors resulting in residential segregation, lack of access to adequate healthcare, and lack of employment opportunities that would allow economic mobility. This results in overall poorer population health for minoritized people. In 2020, Black and Hispanic/Latinx communities throughout the United States, including the state of Illinois, experienced disproportionately high rates of COVID-19 cases and deaths. Public health officials in Illinois implemented targeted programs at state and local levels to increase intervention access and reduce disparities.

Methods: To quantify how disparities in COVID outcomes evolved through the epidemic, data on SARS-CoV-2 diagnostic tests, COVID-19 cases, and COVID-19 deaths were obtained from the Illinois National Electronic Disease Surveillance System for the period from March 1 to December 31, 2020. Relative risks of COVID-19 cases and deaths were calculated for Black and Hispanic/Latinx vs. White residents, stratified by age group and epidemic interval. Deaths attributable to racial/ethnic disparities in incidence and case fatality were estimated with counterfactual simulations.

Results: Disparities in case and death rates became less drastic after May 2020, but did not disappear, and were more pronounced at younger ages. From March to May of 2020, the risk of a COVID-19 case for Black and Hispanic/Latinx populations was more than twice that of Whites across all age groups. The relative risk of COVID-19 death reached above 10 for Black and Hispanic/Latinx individuals under 50 years of age compared to age-matched Whites in the early epidemic. In all Illinois counties, relative risk of a COVID-19 case was the same or significantly increased for minoritized populations compared to the White population. 79.3 and 86.7% of disparities in deaths among Black and Hispanic/Latinx populations, respectively, were attributable to differences in age-adjusted incidence compared to White populations rather than differences in case fatality ratios.

Conclusions: Racial and ethnic disparities in the COVID-19 pandemic are products of society, not biology. Considering age and geography in addition to race/ethnicity can help to identify the structural factors driving poorer outcomes for certain groups. Studies and policies aimed at reducing inequalities in disease exposure may reduce disparities in mortality more than those focused on drivers of case fatality.

Keywords: COVID-19; Case fatality ratio; Diagnostic testing; Illinois; Racial disparities; SARS-CoV-2.

Fig. 1

Demographics of cumulative COVID-19 cases, hospital admissions, and deaths in the state of Illinois through December 31, 2020, by A race and ethnicity and B age group, compared with the composition of the general population

Fig. 2

Changing racial and ethnic composition of COVID-19 cases, admissions, and deaths through three epidemic intervals. 7-day moving averages (top) and weekly fraction by race/ethnicity (bottom) are shown for each indicator from March 1 to December 31, 2020: A cases B admissions and C deaths. COVID-like illness (CLI) admissions outnumber confirmed COVID-19 admissions in I-NEDSS

Fig. 3

Diagnostic testing intensity and test positivity rate by age and race/ethnicity through December 31, 2020. A 7-day moving average of tests administered per 1000 population. B 7-day moving average of test positivity rate

Fig. 4

Age-adjusted disparities in risk of COVID-19 case by race/ethnicity from March 1 to December 31, 2020. A 7-day moving average of COVID-19 cases per 10,000 population, by age and race/ethnicity. B-D Relative risk of COVID-19 case over three epidemic intervals. Horizontal lines indicate 95% confidence intervals

Fig. 5

Relative risk of COVID-19 cases for non-White individuals compared with White individuals, by county and age group, during each epidemic interval from March 1 to December 31, 2020. Color indicates x-fold increase in risk for non-White vs. White residents. Counties colored white had relative risk that was not significantly different from 1 based on a 95% CI. Relative risk was not calculated (gray) when a minimum of 10 non-White cases and 10 White cases was not met

Fig. 6

Age-adjusted disparities in risk of COVID-19 death by race/ethnicity from March 1 to December 31, 2020. A 7-day moving average of COVID-19 deaths per 100,000 population, by age and race/ethnicity. B-D Relative risk of COVID-19 death over three epidemic intervals. Horizontal lines indicate 95% confidence intervals. Deaths are binned into intervals based on the date of case, and interval 3 is truncated to remove lagged deaths

Fig. 7

COVID-19 deaths attributable to differences in age-adjusted incidence, case fatality ratio, or both, between Asian, Black, and Hispanic/Latinx populations compared to White. A Weekly actual and counterfactual deaths by date of first positive specimen. Solid lines represent the average of 1000 simulation runs; shaded areas are 95% confidence intervals. B Cumulative percent reduction of deaths, counterfactual vs. actual deaths