Widening Disparities in COVID-19 Mortality and Life Expectancy Among 15 Major Racial and Ethnic Groups in the United States, 2020–2021

Data suggest that impacts of COVID-19 differ among U.S. racial/ethnic groups. This systematic review evaluates racial/ethnic disparities in SARS-CoV-2 infection rates and COVID-19 outcomes, factors contributing to disparities, and interventions to reduce them.

Question Are race and ethnicity–based COVID-19 outcome disparities in the United States associated with socioeconomic characteristics? Findings In this systematic review and meta-analysis of 4.3 million patients from 68 studies, African American, Hispanic, and Asian American individuals had a higher risk of COVID-19 positivity and ICU admission but lower mortality rates than White individuals. Socioeconomic disparity and clinical care quality were associated with COVID-19 mortality and incidence in racial and ethnic minority groups. Meaning In this study, members of racial and ethnic minority groups had higher rates of COVID-19 positivity and disease severity than White populations; these findings are important for informing public health decisions, particularly for individuals living in socioeconomically deprived communities. This systematic review and meta-analysis examines the association between race, ethnicity, COVID-19 outcomes, and socioeconomic determinants. Importance COVID-19 has disproportionately affected racial and ethnic minority groups, and race and ethnicity have been associated with disease severity. However, the association of socioeconomic determinants with racial disparities in COVID-19 outcomes remains unclear. Objective To evaluate the association of race and ethnicity with COVID-19 outcomes and to examine the association between race, ethnicity, COVID-19 outcomes, and socioeconomic determinants. Data Sources A systematic search of PubMed, medRxiv, bioRxiv, Embase, and the World Health Organization COVID-19 databases was performed for studies published from January 1, 2020, to January 6, 2021. Study Selection Studies that reported data on associations between race and ethnicity and COVID-19 positivity, disease severity, and socioeconomic status were included and screened by 2 independent reviewers. Studies that did not have a satisfactory quality score were excluded. Overall, less than 1% (0.47%) of initially identified studies met selection criteria. Data Extraction and Synthesis Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Associations were assessed using adjusted and unadjusted risk ratios (RRs) and odds ratios (ORs), combined prevalence, and metaregression. Data were pooled using a random-effects model. Main Outcomes and Measures The main measures were RRs, ORs, and combined prevalence values. Results A total of 4 318 929 patients from 68 studies were included in this meta-analysis. Overall, 370 933 patients (8.6%) were African American, 9082 (0.2%) were American Indian or Alaska Native, 101 793 (2.4%) were Asian American, 851 392 identified as Hispanic/Latino (19.7%), 7417 (0.2%) were Pacific Islander, 1 037 996 (24.0%) were White, and 269 040 (6.2%) identified as multiracial and another race or ethnicity. In age- and sex-adjusted analyses, African American individuals (RR, 3.54; 95% CI, 1.38-9.07; P  = .008) and Hispanic individuals (RR, 4.68; 95% CI, 1.28-17.20; P  = .02) were the most likely to test positive for COVID-19. Asian American individuals had the highest risk of intensive care unit admission (RR, 1.93; 95% CI, 1.60-2.34, P  < .001). The area deprivation index was positively correlated with mortality rates in Asian American and Hispanic individuals ( P  < .001). Decreased access to clinical care was positively correlated with COVID-19 positivity in Hispanic individuals ( P  < .001) and African American individuals ( P  < .001). Conclusions and Relevance In this study, members of racial and ethnic minority groups had higher risks of COVID-19 positivity and disease severity. Furthermore, socioeconomic determinants were strongly associated with COVID-19 outcomes in racial and ethnic minority populations.

Objectives: This study describes key population health concepts and examines major empirical trends in US health and healthcare inequalities from 1935 to 2016 according to important social determinants such as race/ethnicity, education, income, poverty, area deprivation, unemployment, housing, rural-urban residence, and geographic location. Methods: Long-term trend data from the National Vital Statistics System, National Health Interview Survey, National Survey of Children’s Health, American Community Survey, and Behavioral Risk Factor Surveillance System were used to examine racial/ethnic, socioeconomic, rural-urban, and geographic inequalities in health and health care. Life tables, age-adjusted rates, prevalence, and risk ratios were used to examine health differentials, which were tested for statistical significance at the 0.05 level. Results: Life expectancy of Americans increased from 69.7 years in 1950 to 78.8 years in 2015. However, despite the overall improvement, substantial gender and racial/ethnic disparities remained. In 2015, life expectancy was highest for Asian/Pacific Islanders (87.7 years) and lowest for African-Americans (75.7 years). Life expectancy was lower in rural areas and varied from 74.5 years for men in rural areas to 82.4 years for women in large metro areas, with rural-urban disparities increasing during the 1990-2014 time period. Infant mortality rates declined dramatically during the past eight decades. However, racial disparities widened over time; in 2015, black infants had 2.3 times higher mortality than white infants (11.4 vs. 4.9 per 1,000 live births). Infant and child mortality was markedly higher in rural areas and poor communities. Black infants and children in poor, rural communities had nearly three times higher mortality rate compared to those in affluent, rural areas. Racial/ethnic, socioeconomic, and geographic disparities were particularly marked in mortality and/or morbidity from cardiovascular disease, cancer, diabetes, COPD, HIV/AIDS, homicide, psychological distress, hypertension, smoking, obesity, and access to quality health care. Conclusions and Global Health Implications: Despite the overall health improvement, significant social disparities remain in a number of health indicators, most notably in life expectancy and infant mortality. Marked disparities in various health outcomes indicate the underlying significance of social determinants in disease prevention and health promotion and necessitate systematic and continued monitoring of health inequalities according to social factors. A multi-sectoral approach is needed to tackle persistent and widening health inequalities among Americans.