Eleven years ago, the H1N1 or “swine flu” pandemic tore through the US, hitting communities of color especially hard. Compared with white patients, nonwhite patients got sicker faster, recovered more slowly, and died at higher rates.
Epidemiologists who studied the outbreak identified key reasons for the disparities: Nonwhite workers had less access to sick leave, making self-quarantine difficult, even though they were more likely to be immunocompromised. Their environments contributed to elevated risk of other health problems, including hypertension, heart disease, and asthma, that aggravated the flu’s symptoms.
The conclusion: Certain communities are more susceptible to pandemics and need specific prevention efforts. Scientists hoped this knowledge would help the US prepare for a future pandemic. It didn’t.
As the novel coronavirus sweeps through the country, the same dynamics are at play. Again, nonwhite patients are succumbing to the disease at higher rates than white patients. Black residents account for 45 percent of the population of Washington, DC, but almost 80 percent of the fatalities. In Michigan, 40 percent of Covid-19 deaths are of black people, though only 14 percent of the state is. In Richmond, Virgina, 40 percent of residents are black, yet all but one of the city’s 17 deaths were black.
“Anyone who has been studying health disparities is not surprised by this,” says Sandra Quinn, associate director of the Maryland Center for Health Equity. “It has nothing to do with this virus per se. It has everything to do with racism, with poverty, with institutional structures and policies that have caused health disparities to be perpetuated decade after decade after decade.”
In a 2011 paper on the racial disparities of the H1N1 pandemic, Quinn found that lower-income and black workers were more likely to have public-facing jobs. Black workers were three times as likely as white workers to live in apartments, as opposed to single-family homes; they were twice as reliant on public transportation. How people live and work are hugely important in understanding why they get sick.
In 2012, Quinn reported on a second survey of thousands of adults to understand whether certain social policies increased the risk of exposure to influenza. Looking at factors like whether the person lived in a major city, had children, or the type of job they had, she and coauthors found that access to sick leave was crucial.
Sixty million people got sick during the H1N1 pandemic. With better access to sick leave, the study concluded, 5 million of those would not have been exposed. Hispanic workers were least likely to have sick leave, leading to a million more cases among them. Black and white workers reported similar rates of access to sick leave.
More than a decade after the H1N1 outbreak, black and white workers still have similar access to sick leave while Hispanic workers still have the least. This could partially explain disparities, as in the Mission district of San Francisco, where Hispanics are less than half of the population but make up 95 percent of people who have tested positive for Covid-19.
“Congress has talked some about” addressing the disparities, Quinn says. “Several states have taken action. But as a nation, have we really grappled with that issue since 2009? The answer’s no.”
In Richmond, where all but one of those who have died from Covid was black, health director Dr. Danny Avula says people are trying to stay home and abide by physical distancing. But, he adds, “they're doing jobs that they can't telework from, be it cashiers or frontline social workers, or they’re [nurses] at a nursing home or a custodian in an essential business.”
A 2018 report from the Bureau of Labor Statistics found that only 20 percent of black workers had the option of working from home, compared with 30 percent of white workers and 37 percent of Asian workers.
Virginia's Health Department is setting up mobile testing sites in each of the city’s six largest public housing projects, known collectively as “the courts.” Roughly 8,000 people, most of them black, live in the courts, where Covid-19 is likely to worsen an already stark health disparity. Avula spoke to WIRED just after leaving Gilpin Court, where life expectancy is 63 years—16 years less than the state average.
“Richmond is a southern city, the former capital of the Confederacy, and has had a long and difficult history for African Americans,” Avula says.
Dr. Kevin Fiscella, a medical professor at the University of Rochester, studied how underlying conditions like diabetes, asthma, and HIV, all of which occur at disproportionately high rates among black patients, helped explain why the H1N1 influenza was more lethal in black communities.
“We often focus on individual choice,” Fiscella says. “But social context, physical context, access to health care and [healthy] foods, the list goes on and on—we are influenced in ways we don't recognize.”
Fiscella and Quinn point to what the National Academy of Medicine terms “social determinants of health,” interconnected environmental factors that impact someone’s risk for conditions like diabetes, asthma, or hypertension. For example, obesity rates are higher among African-Americans and Latinos. That, in turn, increases the risk for hypertension, diabetes, heart disease, and even chronic kidney disease, all of which are risk factors for Covid complications. “These are driven by structural factors and by the environment around the person,” Fiscella says. “I don't think we can enter into victim blaming.”
While independent researchers emphasized the importance of connecting structural factors to susceptibility to pandemics, the federal response was less specific. A 2012 “retrospective” report from the Department of Health and Human Services noted that minorities were hospitalized due to H1N1 complications at higher rates but said “the reasons for these disparities are unknown.” It said access to care and underlying health conditions “may play a role.”
In a second report, HHS noted that low-income and minority residents had less access to H1N1 vaccines, because they were primarily available through major retailers and private physicians. This year, the same problem reemerged.
In March, President Trump announced partnerships for Covid-19 tests with CVS, Walgreens, and Walmart. But an analysis by Vox on the Chicago sites found these test centers were largely inaccessible for black residents.
Social determinants, like whether testing or vaccinations are even available in your area, are crucial in understanding the potential dangers of underlying health conditions, the role of individual choice, and resisting victim blaming. But, this social data is rarely recorded by the very institutions now scrambling to understand these disparities.
“As you think about our health care data systems, they're optimized for incentives around reimbursement,” says Hilary Placzek, a senior public health researcher at Clarify Health Solutions who also studied the racial dynamics of the 2009 H1N1 pandemic.
She says hospitals typically record quantitative data on a patient’s procedures, diagnoses, or length of stay, but little social data. “You don't know about all of these other crucial components that are putting people at elevated risk for exposure or susceptibility or access to health care that are impacting our outcomes,” she says.
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