SARS-CoV-2 is a novel and highly contagious coronavirus that has been a major threat to the public’s health. Seemingly, COVID-19, the viral illness that manifests as a result of SARS-CoV-2 infection, would not discriminate among people with various ethnic or racial backgrounds. However, as the pandemic spread across the United States, it has become abundantly clear that vulnerable populations include not only the elderly, individuals with disabilities, and those who are homeless or incarcerated but also African Americans (AAs), Latinx Americans, and Native Americans.1 A study by Mahajan and Larkins-Pettigrew is the first nationwide analysis of COVID-19 and race on a county level; this study primarily focused on AAs as this demographic group has been previously reported to be at high risk for mortality from COVID-19.2 As such, comments in this article are focused on the Black American patient experience, inclusive of AAs.
Are Black Americans at higher risk for COVID-19 infection and mortality? If disease is more severe in these populations, how can physiatrists intervene to improve functional outcomes in survivors?
The study found that AAs have a higher percentage of COVID-19 confirmed cases, confirmed deaths, and case mortality on a county-level analysis. These findings support many city and statewide analyses, and there is a need for targeted resources, including rehabilitation care, to examine and address this at-risk population.
WHY IS THIS RELEVANT TO PHYSIATRY?
As experts in function and disability, physiatrists have a unique role in addressing the anticipated surge in short- and long-term rehabilitation needs of COVID-19 patients. Although the full clinical spectrum of associated impairments of COVID-19 remains unknown, recent data indicate multisystem impact with neurologic, musculoskeletal, and cardiovascular sequelae. Given the disproportionate racial demographics of COVID-19, physiatrists can help forge a path to recovery with timely rehabilitative interventions. In the context of health disparities, a concerted effort is needed to provide equitable rehabilitation services for COVID-19 survivors from marginalized communities, with future research focused on social determinants of health.
The study included 2886 counties (96% of all US counties) with confirmed COVID-19 cases categorized by racial group (AAs, Asian Americans, and Whites).2 There were weak positive correlations (r < 0.3) between case mortality rates (number of deaths divided by number of confirmed cases) and racial makeup (AAs and Asians). Individuals with COVID-19 were more prone to die if they resided in a county with higher proportions of AAs and Asians. The opposite was true for individuals in predominantly White communities. Interpretation of the study findings must be tempered by its limitations.2 There was no adjustment for potential confounders such as comorbidities and social determinants of health. Albeit significant (P < 0.0001), correlations with negligible magnitudes (r ≅ 0) are insufficient to draw meaningful conclusions. Large enough sample sizes alone may yield statistically significant P values. Big data analysis is able to treat type 1 errors (alpha) but is not as good with type 2 errors (beta). The study highlights COVID-19 racial disparities but fails to explore underlying potential bias and confounders.
IMPACT OF THESE FINDINGS ON PHYSIATRIC CLINICAL PRACTICE
This study highlights the higher morbidity and mortality due to COVID-19 faced by AAs and further supports known health inequities manifested across underrepresented communities in the United States. The disproportionate numbers of Black patients with severe COVID-19 infections are a harsh reminder of how vital rehabilitation services will be in the recovery of communities of color. Healthcare access is one of the metrics that determines the health outcomes of a community, and socioeconomic pandemic-related factors such as loss of employment and health insurance will further exacerbate access issues for Black adults and children. It behooves us as physiatrists to recognize the multitude of sequelae faced by COVID-19 survivors and prioritize rehabilitation services. We must look at social determinants of health and break down barriers to ensure that Black communities have access to high-quality rehabilitation treatment that is effective, comprehensive, and long-term.
WHAT QUESTIONS REMAIN OUTSTANDING?
In this report, lens is turned toward the disproportionately high rate of Black Americans affected by severe COVID-19 infections. This study combined with other research (e.g., Tuskegee syphilis study, infant and maternal mortality studies), and in conjunction with mortality and morbidity data from the Centers for Disease Control and Prevention, paints a deeply troubling picture of the disparate effects of the virus on the Black community in the United States. Research on causality is evolving; however, almost certainly, the reasons are multifactorial and involve health-related factors that are supported by a well-documented history of racism with inadequate responses to date. Analyzing current data shows that if Black patients with COVID-19 died at the rate of White patients, many thousands of Black Americans would be alive today. As physiatrists, we must focus our professional work on the survivors of COVID-19. Because we know that a disproportionate number of Black Americans who survive COVID-19 will have a more severe course of disease, we can anticipate that they will need multidisciplinary rehabilitation services throughout the care continuum. Physiatrists, together with the entire rehabilitation community, must heed a call to action and be intentional in seeking referrals of critically ill Black patients. Once referred, programs must be administered in a way that is geographically accessible to Black communities and be culturally competent. The pandemic has laid bare systemic inequities that preferentially disadvantage marginalized communities. However, physiatry has the ability to change the narrative and show that “Black Lives Matter” is more than a slogan, but a foundational principle of the field.
1. Okonkwo NE, Aguwa UT, Jang M, et al.: COVID-19 and the US response: Accelerating health inequities [published online ahead of print June 3, 2020]. BMJ Evid Based Med
2. Mahajan UV, Larkins-Pettigrew M: Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties. J Public Health (Oxf)