In this study, we examined disparities in COVID-19 related mortality, adjusting for demographic characteristics and health-related factors in Texas. To date, few studies have examined associations between county demographics, health characteristics and COVID-19 fatalities in Texas. Our findings suggest that while COVID-19 might be an equal opportunity disease, counties with higher proportions of African Americans and Asians experience significantly larger mortality rates in Texas. All races demonstrated significant associations with mortality, however, African Americans and Asians experienced significantly larger magnitudes of association with COVID-19 fatalities. These findings align with other racial/ethnic reports on COVID-19 morbidity and mortality that suggest minorities, including African Americans, Hispanics, American Indian, Alaska Native, and Pacific Islander populations bear a disproportionate burden of disease [17]. Mahajan & Larkins-Pettigrew (2020), in their analysis of all US states, observed a weak but significant correlation between African American race and COVID-19 related mortality, indicating that counties with a higher proportion of African Americans have higher COVID-19 fatalities [18]. They also found that Asian Americans experienced a significantly higher burden of COVID-19 cases and mortality [18].
Several underlying factors could contribute to the greater risk of COVID-19 fatality among African Americans. African Americans face higher rates of chronic disease prevalence (5) and report poorer outcomes on several health indicators, compared to their non-Hispanic white counterparts [19]. Importantly, before the COVID-19 pandemic, there were major health disparities ingrained into the system that disproportionately impacted minority populations, making them more prone to chronic diseases. The preexistence of these chronic diseases further puts these individuals at risk of infection from COVID-19. Chronic diseases such as diabetes, heart disease, and obesity occur mainly because of lifestyle and environment factors (Kolb H, Martin S. Environmental/lifestyle factors in the pathogenesis and prevention of type 2 diabetes. BMC Med. 2017;15(1):131. Published 2017 Jul 19. doi:10.1186/s12916-017-0901-x). However, one’s lifestyle is not always created by choice. Many of these individuals work multiple jobs, leaving very little time or resources for them to prepare healthy meals at home, exercise daily, and/or get ample sleep, along with all the other obligations they may have. Many low-income neighborhoods also exist in areas without easy access to grocery stores that provide healthy eating options, or walkable neighborhoods (Child ST, Kaczynski AT, Fair ML, et al. 'We need a safe, walkable way to connect our sisters and brothers': a qualitative study of opportunities and challenges for neighborhood-based physical activity among residents of low-income African-American communities. Ethn Health. 2019;24(4):353-364. doi:10.1080/13557858.2017.1351923). In addition, African Americans are more likely live in densely populated areas where social distancing practices can be difficult to implement [20], making them more likely to contract the disease. Unfortunately, these inequities in these social determinants often result in healthcare being relegated a lower priority as more immediate concerns demand attention. These structural factors contributing to increased prevalence of chronic diseases in African American communities are then further exacerbated by a lack of trust in health care that exists due to historic injustices suffered by these populations.
Few studies have examined possible causes resulting in higher COVID-19 related mortality in Asian Americans. Abuelgasim et al (2020) postulated that the increased mortality in the Asian community may be correlated with the higher prevalence of comorbidities, such as heart disease, diabetes, and chronic kidney disease, all of which have been associated with more adverse COVID-19 outcomes, and more importantly, social factors such as a higher rate of multigenerational households that make it difficult to implement infection prevention practices[21]. However, this study was based on UK governmental data and may not apply to the United States. Further research is needed to identify contributors to excess mortality in Asian American communities.
In addition to the association with race/ethnicity, the presence of certain underlying medical conditions also portends higher risk of developing and dying from COVID-19 [22]. Our findings suggest that communities with higher proportion of adults with diabetes, and adults with self-reported fair/poor health had a higher likelihood of COVID-19 fatality. These findings are consistent with previous studies that reported greater mortality in patients with COVID-19 and diabetes [22]. For example, Kumar and colleagues reported a two-fold increase in mortality for diabetes patients, compared to non-diabetics [23]. The most significant increase in mortality, however, was in regard to self-reported fair/poor health, as defined by the CDC Heathy Days measure [24].This is consistent with prior studies that have shown a correlation between COVID-19 outcomes and lower health-related quality of life [25], as well as poorer outcomes for patients who have comorbid hypertension, diabetes, cardiovascular disease and respiratory diseases [26]. Altogether, these findings suggest that COVID preys on those who are most vulnerable in our communities, which is probably exacerbated by the sub-optimal healthcare access experienced by members of these communities.
Unexpectedly, we also found that smoking was associated with lower odds of COVID-19 fatality, contrary to some preliminary reports that showed no significant change in mortality or significantly worse mortality for those who smoked [27, 28]. However, our analysis corroborates that of Miyara et al. who found that daily smokers had a significantly lower probability of developing severe COVID-19 cases [29]. Individual-level data may provide additional insights beyond this index study to allow researchers accurately capture the impact of smoking, and smoking intensity, on COVID-19 fatality rates.
Another key finding was that counties with higher proportions of adults 65 and older were less likely to report a COVID-19 fatality. We hypothesize that counties with a higher proportion of older adults over 65 may be less populated and/or in rural areas with reduced exposure to the virus. It is also possible that infected older residents may travel to other larger /urban counties for advanced hospital care and may succumb to the disease in these larger/urban counties. These fatalities will be reported as occurring in the large/urban counties where these critical care hospitals are located. Another explanation is that COVID-19 related messages highlighting risk in elderly may have prompted older adults to adhere more strictly to stay-at-home recommendations.
This study is not without limitations. First, our analysis is at the county-level, using county level aggregates of health factors (% adults with diabetes, % adults with obesity, % smokers), healthcare access (%uninsured, primary care physician rates), and other county-level demographic characteristics (% racial/ethnic composition American, % rural, % unemployed, high school graduate rate, % unemployed). Findings using county aggregates may not generate similar findings if individual level characteristics are modeled. Notwithstanding, these findings highlight the need for targeted interventions to raise awareness of preventive measures in these communities most significantly impacted by COVID-19. Although it has been said that this virus “does not discriminate”, the setting of a global pandemic has only exacerbated disparities that already exist in our healthcare systems, making them more obvious and heightening the urgency to identify interventions to reduce health inequity.