December 4, 2020 Special Topic 2020 12 04

reduce SARS-CoV-2 exposure if they are at higher risk of severe illness, isolating outside of the household if ill with
COVID-19, or accessing medical care without delay.

Unlike income, wealth can be accumulated and passed down through generations. A 2017 study estimated that
60% of wealth held in the US was inherited, rather than produced through income by the current generation.
Efforts by African American persons to build wealth have been impeded across generations through slavery,
segregation, and contemporary systemic inequalities in homeownership, education, and income.

Homeownership is a key pathway to build wealth and most household wealth is derived from the value of one’s
home. Due to historical policies such as redlining, or the denial of mortgages for racial/ethnic minorities to
preserve the racial demographics of affluent neighborhoods, the rate of homeownership among American
Americans is lower compared with White persons (42% vs 72% in 2017). Higher income can also facilitate building
wealth, but racial disparities in public education funding and quality, educational attainment, and employment
result in African American persons having a lower average hourly wage compared with White persons ($21.05 vs
$28.66 in 2019).

These factors contribute to the racial wealth gap, whereby households headed by White persons had a higher
median household wealth compared with those headed by African American persons in 2016 ($171,000 vs
$17,000). This disparity is reflected in differences in the amount of household cash reserves available even after
controlling for education and homeownership (Figure 4A). A recent study found that neighborhoods with lower
median household income had higher SARS-CoV-2 infection rates (Figure 4B).16,17

Figure 4

Note: Adapted from the (A) Economic Policy Institute and (B) Emeruwa et al.18 (A) Mean cash reserves by race/ethnicity,
education, and homeownership, 2016. Cash reserves include cash, checking or savings accounts, stocks, bonds, and mutual
funds. Original data from the Federal Reserve Board’s Survey of Consumer Finances. (B) The probability of SARS-CoV-2 infection
by neighborhood median household income. Neighborhood-level median household income from the US Census Bureau’s
American Community Survey were correlated with probability of SARS-CoV-2 infection during universal screening of pregnant
women at New York City hospitals. Shaded regions represent the 95% confidence interval based on the logistic regression
model for the probability of SARS-CoV-2 infection.

Housing and Living Conditions

In part due to the economic insecurity from wealth and income disparities, African American persons are more
likely to live in crowded houses (e.g., smaller homes, shared or multigenerational homes) and more densely
populated neighborhoods (Figure 5). Although multigenerational housing has economic and social benefits, higher
level of crowding contributes to an elevated risk of household and community transmission (Figure 6).

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Figure 5

Note: Adapted from the Economic Policy Institute. Original data from the American Community Survey 2018 and US Census
Bureau. (A) Higher rates of African American multigenerational households. Generations can be younger (e.g., children) or older
(e.g., grandparents). (B) Higher rates of African American persons living in densely populated housing. Single family homes
including semidetached townhouses or row houses are considered one unit.

Figure 6

Note: Adapted from Emeruwa et al.18 The probability of SARS-CoV-2 infection by neighborhood-level household membership
(A) and household crowding rate (B), New York City. Neighborhood socioeconomic factors from the US Census Bureau’s
American Community Survey were correlated with probability of SARS-CoV-2 infection during universal screening of pregnant
women at New York City hospitals. Shaded regions represent the 95% confidence interval based on the logistic regression
model for the probability of SARS-CoV-2 infection.

Likely due to crowding and difficulty implementing physical distancing and infection prevention and control,
correctional and detention facilities have been the site of several outbreaks of COVID-19 affecting both
incarcerated persons and staff.19 It’s important to note that African American persons are incarcerated at
disproportionately higher rates than White persons (1,501 vs 268 per 100,000 adults ages 18 and older in 2018).
They are more likely to be stopped by police and receive longer prison sentences for the same crime than the
general population.

Increased Occupational Risk

African American persons are more likely to work in a sector considered ‘essential’ that may have an increased risk
for exposure to SARS-CoV-2 (Figure 7).20,21 African American persons also had lower access to paid sick leave and
the ability to telework, increasing the chance of SARS-CoV-2 occupational transmission (Figure 8). Given disparities
in wealth, education, and employment, African American persons are less likely to be able to able to stop working
or readily change professions to a field with lower risk of SARS-CoV-2 exposure.

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Figure 7

Note: Adapted from the Centers for Economic and Policy Research. Percentage of workers in ‘essential’ sectors who are African
American, 2014-2018. African Americans make up 11.9% of the workforce but are overrepresented in ‘essential’ sectors that
involve close contact with others and elevated risk for SARS-CoV-2 infection.

Figure 8

Note: Adapted from the Economic Policy Institute. Original data from the US Bureau of Labor Statistics. Percentage of workers
who have access to paid sick leave and telework, 2017-2018.

Less Coverage by Health Insurance

African American persons also are less likely to have health insurance than White persons (Figure 9). Lack of
insurance can lead to delays in receiving medical care and financial hardship, which, in turn, can undermine
people’s efforts to manage certain chronic medical conditions that increase risk of severe illness from COVID-19. It
can also reduce the likelihood of prompt diagnosis of these conditions, thereby increasing the potential for
progression to severe illness or death if they become infected with SARS-CoV-2.

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Figure 9

Note: Adapted from the Kaiser Family Foundation. Percent of the population aged 0 to 64 years without health insurance by
race and ethnicity, 2010-2018. Original data from the American Community Survey 2010-2018.

Increased Prevalence of Chronic Medical Conditions

The inequities in social determinants of health have also led to higher prevalence of chronic conditions such as
cardiovascular disease, diabetes, and obesity among African American persons (Figure 10). Chronic medical
conditions increase the risk of hospitalization and death from COVID-19. Disparities in chronic medical conditions
are multifactorial and extend beyond lower rates of having health insurance. As detailed in the Institute of
Medicine report, Unequal Treatment, African American persons and other racial/ethnic minority groups may
receive unequal treatment by healthcare providers for many diseases.22 African American persons also have higher
distrust of the healthcare system in part due to current and historical mistreatment ranging from coercion to
medical experimentation.23 African American persons build greater trust, communicate better, and have improved
health outcomes when cared for by African American providers,24,25 yet African American providers remain
underrepresented in medical occupations.26

Figure 10

Note: Adapted from the Economic Policy Institute. Prevalence of diabetes, hypertension, and obesity by race and ethnicity,
2017–2018. Original data from the 2018 National Health Interview Survey and 2017–2018 National Health and Nutrition
Examination Survey.

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12. Azar KMJ, Shen Z, Romanelli RJ, et al. Disparities In Outcomes Among COVID-19 Patients In A Large Health
Care System In California. Health affairs. 2020:101377hlthaff202000598.
13. Suleyman G, Fadel RA, Malette KM, et al. Clinical Characteristics and Morbidity Associated With
Coronavirus Disease 2019 in a Series of Patients in Metropolitan Detroit. JAMA Network Open.
2020;3(6):e2012270-e2012270.
14. Karaca-Mandic P, Georgiou A, Sen S. Assessment of COVID-19 Hospitalizations by Race/Ethnicity in 12
States. JAMA Internal Medicine. 2020.
15. Pollack CE, Cubbin C, Sania A, et al. Do wealth disparities contribute to health disparities within
racial/ethnic groups? J Epidemiol Community Health. 2013;67(5):439-445.
16. Raifman MA, Raifman JR. Disparities in the Population at Risk of Severe Illness From COVID-19 by
Race/Ethnicity and Income. American Journal Of Preventive Medicine. 2020;59(1):137-139.
17. Tai DBG, Shah A, Doubeni CA, Sia IG, Wieland ML. The Disproportionate Impact of COVID-19 on Racial and
Ethnic Minorities in the United States. Clinical Infectious Diseases. 2020.
18. Emeruwa UN, Ona S, Shaman JL, et al. Associations Between Built Environment, Neighborhood
Socioeconomic Status, and SARS-CoV-2 Infection Among Pregnant Women in New York City. JAMA. 2020.
19. Wallace M HL, Curran KG, et al. COVID-19 in Correctional and Detention Facilities — United States,
February–April 2020. MMWR Morbidity and Mortality Weekly Report. 2020;ePub: 6 May 2020.
20. Hawkins D. Differential occupational risk for COVID-19 and other infection exposure according to race and
ethnicity. American Journal Of Industrial Medicine. 2020.
21. McCormack G, Avery C, Spitzer AK-L, Chandra A. Economic Vulnerability of Households With Essential
Workers. JAMA. 2020.
22. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care..
Washington (DC): National Academies Press (US); 2003.
23. Washington HA. Medical apartheid: The dark history of medical experimentation on Black Americans from
colonial times to the present. New York: Doubleday; 2006.
24. Alsan M, Garrick O, Graziani G. Does Diversity Matter for Health? Experimental Evidence from Oakland.
American Economic Review. 2019;109(12):4071-4111.
25. Shen MJ, Peterson EB, Costas-Muñiz R, et al. The Effects of Race and Racial Concordance on Patient-
Physician Communication: A Systematic Review of the Literature. Journal of Racial And Ethnic Health
Disparities. 2018;5(1):117-140.
26. Lett LA, Murdock HM, Orji WU, Aysola J, Sebro R. Trends in Racial/Ethnic Representation Among US
Medical Students. JAMA Network Open. 2019;2(9):e1910490-e1910490.

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