COVID-19 exacerbating inequalities in the US

Aaron van Dorn, Rebecca E Cooney, Miriam L Sabin

Published: April 18, 2020


within New York City and other urban centres, African American and other communities of colour have been especially affected by the COVID-10 pandemic. Across the country, deaths due to COVID-19 are disproportionately high among African Americans compared with the population overall. In Milwaukee, WI, three quarters of all COVID-19 related deaths are African American, and in St Louis, MO, all but three people who have died as a result of COVID-19 were African American. According to Sharrelle Barber of Drexel University Dornsife School of Public Health (Philadelphia, PA, USA), the pre-existing racial and health inequalities already present in US society are being exacerbated by the pandemic. “Black communities, Latino communities, immigrant communities, Native American communities—we’re going to bear the disproportionate brunt of the reckless actions of a government that did not take the proper precautions to mitigate the spread of this disease”, Barber said. “And that’s going to be overlaid on top of the existing racial inequalities.”

Part of the disproportionate impact of the COVID-19 pandemic on communities of colour has been structural factors that prevent those communities from practicing social distancing. Minority populations in the US disproportionally make up “essential workers” such as retail grocery workers, public transit employees, and health-care workers and custodial staff. “These front-line workers, disproportionately black and brown, then are typically a part of residentially segregated communities”, said Barber. “They don’t have that privilege of quote unquote ‘staying at home’, connecting those individuals to the communities they are likely to be a part of because of this legacy of residential segregation, or structural racism in our major cities and most cities in the United States.”

14 US states (mostly in the south and the Plains) have refused to accept the Affordable Care Act Medicaid expansion, leaving millions of the poorest and sickest Americans without access to health care, with the added effect of leaving many regional and local hospitals across the US closed or in danger of closing because of the high cost of medical care and a high proportion of rural uninsured and underinsured people. People with COVID-19 in those states will have poor access to the kind of emergency and intensive care they will need.

Native American populations also have disproportionately higher levels of underlying conditions, such as heart disease and diabetes, that would make them particularly at risk of complications from COVID-19. Health care for Native American communities has a unique place in the US. As part of treaty obligations owed by the US government to tribal groups, the Indian Health Service (IHS) provides direct point of care health care for the 2·6 million Native Americans living on tribal reservations. According to the IHS, there are currently 985 confirmed cases of COVID-19 on tribal reservations, and 536 cases in the Navajo Nation alone (the largest reservation). However, the IHS’s ability to respond to the crisis might be limited: according to Kevin Allis, Chief Executive Officer of the National Congress of American Indians, the largest Native American advocacy organisation, the IHS has only 1257 hospital beds and 36 intensive care units, and many people covered by the IHS are hours away from the nearest IHS facility. The IHS also does not cover care from external providers.  Although there is a provision of the CARES Act stimulus bill that is intended to cover those costs, it is unclear how effective it would be if someone covered by the IHS is transferred to a non-IHS facility.


The Lancet Journal – DOI: