Paramedics wearing personal protective equipment take a patient to the ambulance amid the coronavirus disease outbreak in Boston, Massachusetts, US, April 3, 2020. Photo: Reuters/Brian Snyder
By this point in the pandemic, we have internalised that the coronavirus could affect any of us. But COVID-19 is not an equal-opportunity killer, either. No one is immune, but in the US, the disease has killed a disproportionate number of a few different demographic groups: men, older adults, and black people, according to preliminary data.
Scientists are scrambling to analyse and understand these disparities, says Lisa Cooper, a public health doctor and the director of the Johns Hopkins Center for Health Equity. But as states report more demographic data, she remains optimistic about the potential for intervention right now. “We might be able to learn what some of the best practices are and share them,” she says. Here’s a look at what scientists currently understand to be the reason for some of these differences in mortality rate.
The age gap
The coronavirus’s devastating effect on older adults has been heralded since the virus first emerged in China. All evidence indicates that an infected patient’s risk of dying from the coronavirus increases with every additional decade. In one study, published in the Lancet in March, researchers compiled data from 38 countries that suggests the virus kills up to 13.4% of patients 80 and older—compared with an overall estimated case fatality rate of 1.38%.
The primary reason is likely immunological, Cooper says. As people age, their immune system function declines as existing responders like macrophages and T cells slow down, and the body produces fewer new lymphocytes. With a weak immune system, it’s harder for the body to mount a defense against an invader, whether it’s the common flu or a novel virus. This is further exacerbated by preexisting conditions, like kidney, liver, heart, and chronic lung disease, from which many older adults suffer. “What happens is not only the infection they’re fighting, but they’re going into multisystem organ failure at the same time,” Cooper says.
The result is striking: One analysis from the Chinese Center for Disease Control and Prevention found that people with no underlying conditions had a fatality rate of 0.9%, but for people with cardiovascular disease, the fatality rate was 10.5%, and for people with respiratory disease, it was 6.3%. Even people with hypertension—a condition that affects an estimated 100 million Americans—had a fatality rate of 6%.
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Of course, the same things that put older adults at risk, like immunocompromised status or living with a chronic illness, can affect people of any age. In the US, hundreds of people in their 20s, 30s, and 40s have died from the coronavirus. Many appear to have had underlying conditions, including asthma, diabetes, and hypertension. But some of these cases can’t be explained by prior health issues, leading some scientists to speculate that there may be a genetic component to coronavirus deaths, or perhaps they are the paradoxical result of an overactive immune system, which can occur when the body triggers a “cytokine storm” and ends up attacking its own tissue.
In addition to these biological realities, Cooper says there may also be social factors contributing to the coronavirus’s outsize effect on older adults. Many of the most fragile older adults in the US live in group homes, where they’re cared for by the same handful of aides and nurses. The first major COVID-19 outbreak in the US, for example, occurred at a nursing home in Kirkland, Washington, where 37 people ultimately died.
The gender divide
Immune function may also explain the sex-based differences in COVID-19 deaths. While men and women have roughly similar rates of COVID-19 infection, more men are dying from the disease in every country. In China, where the virus originated, 64% of the dead were men. In Italy, 63% of coronavirus deaths have been among men. Though American data is still being gathered, in New York City, the epicentre of the North American outbreak, men made up 55% of known COVID-19 hospitalisations but 62% of fatalities as of April 3.
No one is certain what is driving this gendered gap in mortality. It’s likely there isn’t a single answer. Social factors may be at play. Globally, men are more likely than women to smoke, and smokers appear to be more vulnerable than nonsmokers to the coronavirus. Men are also less likely to wash their hands or, when they do wash, to use soap. They are also less likely to seek medical care. But none of these explanations can entirely account for the profound and persistent gender gap, suggesting there may be a more fundamental explanation to the problem.
A growing body of research on sex-based differences in the immune system may offer important insight. Biologically, females tend to have stronger immune systems: They have two X chromosomes, which store immunologically valuable genes and microRNA, and produce more estrogen, which may assist in immune cell activity. (Testosterone, by contrast, tends to suppress inflammation.) This allows women to mount a quicker and stronger response to infection, and coronavirus is no exception: A preprint paper suggested Chinese women with the virus had a higher level of antibodies than men did.
Persistent racial inequalities
In the US, racial minorities have been disproportionately affected by the coronavirus. In New York City, the virus has been twice as deadly for Latinos and black people than for white people. Nationwide, some of the highest infection rates in the country have been on Native American pueblos in New Mexico. In Michigan, where black people make up about 14% of the population, they’ve accounted for 40% of the deaths. While states have been slow to release COVID-19 demographic data, experts expect similar disparities in other parts of the country.
There has been a tendency to blame minorities, and black people in particular, for their coronavirus-related suffering. Ibram X. Kendi wrote in the Atlantic, “To explain the disparities in the mortality rate, too many politicians and commentators are noting that black people have more underlying medical conditions but, crucially, they’re not explaining why. Or they blame the choices made by black people, or poverty, or obesity—but not racism.”
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But, as Cooper points out, racism is certainly to blame. “The difference in this disease that we see in ethnic minorities is not due to biological factors,” she says. Rather, “it starts with structural racism.” Because of long-standing issues like redlining and policing, black people are more likely to live in communities without opportunities for exercise, recreation, and the purchase of healthy food. Add to that chronic stress, and you have increased rates of underlying conditions like hypertension and asthma. And then, because of gaps in employer-sponsored health insurance and the near absence of paid sick leave, people with hourly jobs aren’t able to self-isolate, and they also aren’t always afforded the protective equipment or private conveyance they need to stay healthy in their front-line jobs. So the risk of infection is high—and the subsequent risk of hospitalisation, intensive care, and even death are elevated too.
“You have a lot of things that shape the choices that people can make to be healthy,” Cooper says.
Even when black people receive health care, they often face profound bias. For example, providers tend to implicitly undervalue black pain, and redlining has led to minorities living in communities where hospitals lack adequate resources to treat even the patients who make it in. The case of Rana Zoe Mungin reveals the tragic potential of the current system. As the Appeal reported in April, the 30-year-old Brooklyn resident tried to get treated for her coronavirus symptoms three times before she was finally admitted to the hospital.
At one point, the EMTs she called to take her to the hospital decided her laboured breathing was not an infection but a panic attack, and left for their next call. “Often the most pernicious obstacle, the one that affects Black women regardless of their income, education, or baseline health, is what Mungin faced in her attempts to get treatment: simply not being believed or deemed worthy of treatment,” Erin Clare Brown wrote in the Appeal. Mungin died on April 27 from complications of COVID-19.
These issues will not be easy to solve, whether they’re inherent to the immune system or entirely human-caused. More data will help us understand the true scope of the problem. It’s helped older adults: Since it first became clear in China they were at a disproportionate risk of death, many Americans have worked to protect the elderly by encouraging them to shelter in place. But that lifestyle has only worked with the support of government programs, such as Medicare and Social Security, and community action in the form of food deliveries. Seeing the cost to other populations ought to force us to grapple with these structural problems that have long existed in American health care.
This piece was originally published on Future Tense, a partnership between Slate magazine, Arizona State University, and New America.