A new analysis of one state’s Covid-19 data lays bare some of the reasons behind the disproportionate burden of Covid-19 infections on people of color, pinpointing in particular factors that heightened risks for Latino residents.
Researchers from the Harvard T.H. Chan School of Public Health tallied confirmed Covid-19 cases in all 351 Massachusetts cities and towns and determined that the biggest predictor of infection was being a recent immigrant to the U.S., followed by living in a household with a large number of people and working in the food-service industry. But that was true only for Latinos, not Black people.
“These three factors seem to explain the high Covid case rates among Latino communities. They did not explain the high Covid case rates among the Black community,” said Jose Figueroa, assistant professor of health policy and management at Harvard and an internist at Brigham and Women’s Hospital in Boston. He is a co-author of the study published Thursday in Health Affairs.
“That suggests that there are other factors at play that seem to be the primary drivers among those communities. We really need to try to understand all of this structural discrimination.”
The study found that a 10 percentage point increase in the Black population of a community was associated with an increase of 312 Covid-19 cases per 100,000, while a 10 percentage point increase in the Latino population was associated with an increase of 258 cases per 100,000. After controlling for the size of the community as well as income and education, the researchers found the three predictors of Covid-19 cases in the Latino population.
Figueroa said possible explanations linked to greater Covid-19 exposure among Black people include disproportionately high incarceration rates, being more likely to live in multiunit residential buildings whose population density is not captured by household size in state data, greater use of public transportation to get to work, and poorer access to high-quality health care. Access to good health care, including Covid-19 testing sites, is not equally distributed across the state or across populations, Figueroa said.
Georges Benjamin, executive director of the American Public Health Association, said the study in general “validates what we’re actually seeing in the real world” and illustrates how social determinants of health are playing out during the pandemic. An internist and lecturer at the George Washington University School of Public Health, he was not involved in the research. “If you don’t have health insurance, that is a social determinant that matters,” he said. “If you are lower-income, that’s probably a surrogate marker for your occupation that matters if in your job or industry, you don’t have paid sick leave.”
Among Latinos in Massachusetts, the city of Chelsea, bordering Boston, stood out. Covid-19 rates were five times higher there than the state average. Two-thirds of the people in Chelsea are Latino and nearly half are recent immigrants, coming to the U.S. within the last 10 years. About 70% of the adults in Chelsea are categorized as essential workers in occupations that increase their exposure to potential Covid-19 infection.
“That means that they work in food service, in the hospitality industry. They work in maintenance and cleaning services,” Figueroa said. “So you can see why a town like Chelsea is being devastated by the pandemic.”
One more factor may be crucial, Figueroa said. Early this year, the Trump administration’s “public charge” rule went into effect, under which an immigrant’s application for citizenship can be hurt by taking advantage of benefits such as Medicaid, food stamps, or subsidized housing. Fear of losing out on a chance for a green card could keep people from seeking medical care, undermining their own health and others’, especially if their jobs don’t offer paid sick leave.
“If someone starts getting sick, they still need to make ends meet. The consequence of them not working now is much higher because they cannot depend on food stamps. They cannot depend on housing,” he said. “You could imagine in communities with a lot of recent immigrants, they don’t want to call in sick. They might continue working and they might continue spreading Covid-19.”
The evidence of that fear is more than anecdotal. A survey of low-income people in Texas late last year found that nearly half were concerned about the public charge rule and 1 in 8 knew people who had avoided participating in Medicaid, the Supplemental Nutritional Assistance Program, or public housing, or decided not to visit a doctor or hospital because of their immigration-related concerns over the past year.
“It’s terrible policy at the worst time,” Figueroa said.
Benjamin pointed to low availability of testing, especially early in the pandemic, as another problem. “A lot of the early testing centers were not easy to get to if you didn’t have a car,” he said. “Massachusetts is very much like Chicago and many of our central cities, which still are pretty segregated.”
To remedy the disproportionate rates of infection among Black people and Latinos, Benjamin recommended better education and testing where people live or work, such as grocery store chains. Paid sick leave should be widely available, and if someone is sick, local governments should offer a place to quarantine to limit the spread among household members.
The study authors noted that Massachusetts ranks fourth in the U.S. for wealth and first for insurance coverage. That worries Benjamin.
“That means that the South is in trouble,” he said. “Texas and Florida are having problems for a variety of reasons. But they also have a problem because they don’t have health insurance coverage.”