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Disparities in COVID-19 Outcomes: Understanding the Root Causes Is Key to Achieving Equity

Nesbitt, LaQuandra S. MD, MPH

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Journal of Public Health Management and Practice: January/February 2021 - Volume 27 - Issue - p S63-S65
doi: 10.1097/PHH.0000000000001272
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As the number of COVID-19 cases in the United States increased, and public reporting of demographic characteristics improved, the stark disparities in COVID-19–related incidence and mortality became evident.1 While these disparities were alarming to many, for others, they illuminated the unfortunate inequities in health and health care that exist and persist in the United States despite expanded access to health insurance coverage and advances in health care technologies.

Just as an effective response to the COVID-19 pandemic requires a whole of government and community approach, an effective approach to eliminating disparities in COVID-19–related health outcomes must (1) recognize that root causes are due to systemic causes that are beyond the acute nature of the emerging infectious disease; (2) engage multiple sectors of government beyond governmental public health and implement short- and long-term solutions; and (3) effectively mobilize public-private partnerships.

To eliminate disparities in COVID-19–related health outcomes, our collective actions must be intentional in 3 key areas: (1) access to health care; (2) social and structural determinants of health; and (3) structural and institutional racism. Fundamental to the success of this work is the need to have public dashboards with data by race/ethnicity and geography that not only create accountability for public health and elected officials but also allow private industry, health care providers, community-based organizations, and citizen scientists to contribute innovative solutions to the whole of community response.

Equitable Access to Health Care

The inequities and disparities in health care access and quality in the United States are well documented. The Agency for Healthcare Research and Quality released the National Healthcare Quality and Disparities Report in 2018. When compared with their White counterparts, Blacks, Asians, and Hispanics/Latinx were more likely to experience delays in receiving routine and emergency care and less likely to have a primary care provider. Individuals in low-income or poor households were also more likely to experience delays in receiving routine and emergency care and less likely to have a primary care provider than individuals in high-income households.2

The timely diagnosis of individuals with COVID-19, isolation of those diagnosed with COVID-19 who have the ability to transmit virus to others, and identification and quarantine of close contacts of those diagnosed with COVID-19 who may unknowingly spread the virus to others are the critical aspects of the public health strategy to flattening the curve in this pandemic. Widespread availability of diagnostic tests is a critical component of this strategy.

The COVID-19 pandemic has caused disruption to the health care ecosystem beyond what governmental public health and its health care partners anticipated in pandemic plans. This disruption is expected to last for several months. As a result, the way people seek and receive health care services will fundamentally change in the short and long terms, necessitating the expedient implementation of strategies designed to improve health care access for our most vulnerable residents.

Many jurisdictions have utilized mass testing sites to augment the existing health care infrastructure to ensure access to SARS-CoV-2 testing. To ensure equitable access to testing, communities with high proportions of racial and ethnic minority residents, low-income neighborhoods, and underresourced communities such as rural communities should be prioritized for these mass testing sites as well as outreach and education regarding the importance of COVID-19 testing.

Social and Structural Determinants of Health

The social and structural determinants of health are the primary drivers of population health outcomes in the United States. Early evidence suggests that not only the incidence of COVID-19 cases is disproportionately higher in racial and ethnic minority groups due to health care access and utilization, but also other key drivers of health may be contributing to these disparities.3

As states implemented stay-at-home orders in response to the rapid acceleration phase of the pandemic, in communities across the United States, racial and ethnic minorities were overrepresented in the critical infrastructure workforce such as food retail/grocery, public transportation, and allied health professions and unlicensed/uncredentialed health care workers. The disproportionate representation of racial and ethnic minorities in these employment categories, largely a function of access to educational opportunities, increased their risk of exposure to SARS-CoV-2, thus leading to higher COVID-19 incidence and disparities.

Short-term solutions to these social determinants of health may assist in disrupting chains of infections and closing the disparity gap in COVID-19–related health outcomes. For example, offering temporary housing to those who cannot isolate or quarantine at home may result in the reduced likelihood that an individual with COVID-19 will transmit the virus to others living in a multigenerational household. Providing home-delivered meals and groceries to those who are food insecure and would otherwise be unable to isolate or quarantine due to the need to leave home for sustenance can reduce transmission within the community. Providing temporary financial assistance for those who lack paid leave and would otherwise continue to work while symptomatic, thus exposing others who likely share their same racial, ethnic, and sociodemographics, can reduce transmission.

Several jurisdictions acknowledge that the root causes of these disparities, however, must be addressed in the long term and that this unprecedented public health and economic crisis presents the unique opportunity to rebuild communities with a focus on equity. In Washington, District of Columbia, the ReOpen DC Advisory Group recommendations were anchored in the city's core values of health, opportunity, prosperity, and equity (HOPE). The city's plan charged each of the 11 committees to provide equity considerations in their final recommendations. Key recommendations include addressing the underlying and structural disparities that contribute to racial/socioeconomic inequities in District of Columbia pre-COVID-19 including access to capital for small business owners, providing subsidies to ensures access to affordable bikeshare and transit services in low-income areas, and increasing investments and partnerships for connecting vulnerable populations to in-demand careers.4 Massachusetts convened the Health Equity Advisory Group to advise on the needs of communities disproportionately impacted by COVID-19. Key recommendations include implementation of “policies that increases housing stability” and the “development of pathways to financial freedom to prevent further disparities.”5

Structural and Institutional Racism

People of color experience discrimination and bias in the health care system.6 These experiences, which begin as early as the perinatal period, lead to disparities in health outcomes.7 The explicit and implicit bias, and lack of culturally competent and culturally appropriate services, may deter individuals from seeking timely services due to mistrust. These delays lead to poor outcomes at the individual level and, eventually, at the population health level. To eliminate disparities in COVID-19 outcomes, structural and institutional racism and biases in health systems must be addressed.

In order for governmental public health practitioners who will be responsible for developing education and outreach initiatives to increase the uptake of the SARS-CoV-2 vaccine, they must be aware of the unique concerns of people of color. Many of these concerns may be rooted in past experiences, directly and indirectly, with sanctioned activities by medical and governmental institutions such as those conducted through the US Public Health Service Syphilis Study at Tuskegee or the research conducted on Henrietta Lacks during her clinical treatment of cancer.

To ameliorate this mistrust, every effort must be taken to build trust, dispel myths, and correct misinformation that exists. This can be done through the effective use of credible messengers within communities. Effective credible messengers can be credentialed professionals as well as members of the community. The key is that the information that is shared must be factual, reliable, and consistent.


Disparities and inequities in health are not caused by one single factor and as such cannot be eliminated by a single intervention. Similarly, the root causes of disparities in any health indicator, including COVID-19, are multifactorial and require both short- and long-term interventions. The most sustainable impact will be achieved through the long-term interventions and investments that address the social and structural determinants of health—those that are designed to achieve equity—granting us all the opportunity to achieve our best health.


1. CDC COVID Data Tracker. Demographic trends of COVID-19 cases and deaths in the US reported to CDC. Accessed August 20, 2020.
2. Agency for Healthcare Research and Quality. 2018 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; 2020. Accessed August 18, 2020.
3. Bui DP, McCaffrey K, Friedrichs M, et al. Racial and ethnic disparities among COVID-19 cases in workplace outbreaks by industry sector—Utah, March 6-June 5, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1133–1138.
4. Chertoff M, Rice S. ReOpen DC Recommendations to the Mayor. Washington, DC: ReOpen DC Advisory Group; 2020. Accessed August 18, 2020.
5. Bharel M, Acevedo-Garcia D, Aviles-Hernandez M, Bassett M, et al. Department of Public Health COVID-19 Health Equity Advisory Group Recommendations. Boston, MA: COVID-19 Health Equity Advisory Group; 2020. Accessed August 18, 2020.
6. Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol. 2006;35(4):888–901.
7. Greenwood B, Hardeman R, Huang L, Sojourner A. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A. 2020. doi:10.1073/pnas.1913405117.
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