Healthcare Researchers Probe Causes of Higher Black and Latino COVID-19 Infection Rates

One of the significant frustrations among healthcare policy leaders in the U.S. has been identifying the actual reasons for the often-noted higher rates of COVID-19 infection in Black and Latino communities nationwide. A team of healthcare policy researchers has examined the issue, with nuanced findings.

In an article published online on Aug. 27 in Health Affairs entitled “Community-Level Factors Associated With Racial And Ethnic Disparities In COVID-19 Rates In Massachusetts,” Jose F. Figueroa, Rishi K. Wadhera, Dennis Lee, Robert W. Yeh, and Benjamin D. Sommers attempted to probe the issue of why Black and Latino Americans continue to experience higher rates of COVID-19 infection nationwide than do non-Hispanic white Americans. They looked closely at a variety of statistics for Massachusetts residents, concluding that there are numerous factors involved, and much still to be learned.

Jose F. Figueroa, M.D., M.P.H. is an assistant professor of health policy and management in the Harvard T.H. Chan School of Public Health in Boston; Rishi K. Wadhera, M.D. is an instructor in medicine in the Division of Cardiology at Beth Israel Deaconess Medical Center in Boston; Dennis Lee is a research assistant in the Department of Health Policy and Management in the Harvard T.H. Chan School of Public Health; and Robert W. Yeh, M.D. is an associate professor of medicine in the Division of Cardiology at Beth Israel Hospital.

Figueroa et al note in their abstract to the article, “Massachusetts has one of the highest cumulative incidence rates of coronavirus disease 2019 (COVID-19) cases in the US. Understanding which specific demographic, economic, and occupational factors have contributed to disparities of COVID-19 is critical to inform public health strategies. We performed a cross-sectional study of 351 Massachusetts towns/cities (01/01/2020–05/06/2020) and found that a 10 percentage point increase in the Black population was associated with a 312.3 increase in COVID-19 cases per 100,000, while a 10 percentage point increase in the Latino population was associated with an increase of 258.2 cases per 100,000. Independent predictors of higher COVID-19 rates included the proportion of foreign-born non-citizens living in a community, mean household size, and share of food service workers. After adjustment for these variables, the association between the Latino population and COVID-19 rates was attenuated. In contrast, the association between the Black population and COVID-19 rates persisted, and may be explained by other systemic inequities. Public health and policy efforts that improve care for foreign born non-citizens, address crowded housing, and protect food-service workers may help mitigate the spread of COVID-19 among minority communities.”

Probing the deeper causes involved remains frustrating, because of data issues. “Although Black and Latino communities in Massachusetts have shouldered a larger burden of COVID-19, evidence regarding the community-level factors that may be contributing to these disparities remains sparse,” the researchers note. “Furthermore, because most data collected by Departments of Health focus on only a few demographic factors such as age, sex, and race/ethnicity, there has been a paucity of objective data on whether COVID-19 cases are characterized by disparities along other important dimensions. There is growing concern, for example, that lower-income and Black and Latino persons may be at greater risk of exposure to COVID-19 because they are more likely to be essential workers, and also tend to live in densely-populated areas and multigenerational households.6–8 Among immigrant communities, there are reports of foreign born non-citizens avoiding care (including testing and advice regarding COVID-19-like symptoms) for fear of deportation or risking their future legal resident status based on new federal ‘public charge’ regulations.”

The researchers note in the article that “We classified employed residents into essential workers and non-essential workers based on the state’s classification in the governor’s March 2020 emergency order.16 The following occupations were defined as essential: health care practitioners, technical occupations, and support services; construction and extraction; installation, maintenance, and repair; material moving occupation; production services; transportation; building and grounds cleaning and maintenance; food preparation and serving-related occupation; personal care and service occupation; and protective services.”

What’s difficult, they point out, is this: “Since the “essential occupations” designation aggregates a heterogeneous set of jobs that likely have different levels of risk, we tested a model that separately identified the three most common categories of essential work in our sample—healthcare-related, food services, and construction/extraction jobs.”

And, though they were stymied by gaps of important data long several dimensions, the researchers were able to come to certain conclusions. “Several factors were significantly associated with higher COVID-19 case rates across towns and cities in unadjusted models: higher average household size; and larger shares of essential workers, foreign-born non-citizens, and non-high school graduates,” they write. “After multivariable adjustment, mean household size and proportion of foreign-born non-citizens were still independently associated with higher COVID-19 rates. The model using normalized values for these covariates showed that the largest absolute risk factor was the share of foreign-born non-citizens (310.4 per standard deviation, 95% CI 253.5 to 367.2) and then mean household size (236.4 per SD, 95 percent CI 131.9 to 340.9). Older age was also associated with additional cases while larger population size was associated with slightly fewer cases but both were weaker predictors.”

And, drilling down into the occupations, the researchers found this: “Although the overall proportion of essential service workers was no longer associated with case rates in our multivariable analysis, an exploratory analysis of the three most common occupations found that employment in food service was significantly associated with higher case rates (71.4 per standard deviation, 95% CI 7.2 to 135.7).”

Demographically speaking, they write, “The proportion of foreign-born non-citizens was the strongest predictor of the burden of COVID-19 cases within a community, and in Massachusetts, this population includes sizable numbers of both Latin American (44.9 percent) and Asian individuals (30.7 percent). Furthermore, under the Trump Administration’s revised ‘Public Charge’ Rule, which took effect in early 2020, lawfully present immigrants who use public benefits from local, state, or federal governments may be at risk of being denied permanent residency status. Although the U.S. Citizenship and Immigration Services website now encourages immigrants to seek care for COVID-19-like symptoms, enrollment in Medicaid at the time of COVID-19-related care may still be used in the Public Charge analysis. Recent studies suggest that immigrant families have strong incentives not to enroll in public health insurance like Medicaid and may avoid seeking medical care if they develop COVID-19-like symptoms and require testing. In the absence of a positive test, these individuals are less likely to isolate and quarantine, which may impede public health efforts to control the spread of COVID-19.”

And, importantly, the researchers note, “These issues are likely only magnified by the fact that immigrants tend to live in larger households, which we also found to be an independent predictor of COVID-19 case rates. Policy approaches that reduce barriers to accessing medical care for immigrant populations and that address crowded housing—particularly when individuals have tested positive and need to be isolated—could be important avenues for reducing disparities and slowing the spread of infection.”