Racial, ethnic health disparities, already prevalent, growing worse due to COVID-19
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Health equity and acknowledgment of disparities among Black and Hispanic individuals is of paramount concern, especially amid the COVID-19 pandemic, according to a presentation at the virtual Cardiometabolic Health Congress.
“Health equity is our final goal by targeting programs to reach down and give people a platform where they can stand in order to reach health equity,” Keith C. Ferdinand, MD, FACC, FAHA, FASPC, Gerald S. Berenson Chair in Preventive Cardiology and professor of medicine at Tulane University School of Medicine and Cardiology Today Editorial Board Member. “[Martin Luther King, Jr.] said in 1966, ‘Of all of the forms of inequality, injustice in health care is the most inhumane.’ These cardiometabolic and cardiovascular disparities by race, ethnicity, geography and socioeconomic status exist. They are sizable. They are likely multifactorial, but rarely due to genetics. They are persistent and I think all of us will agree, unacceptable.”
Between 2000 and 2014, the overall trend in CV mortality was on the decline, but death associated with heart disease, stroke, cancer and any CVD was significantly more prevalent among non-Hispanic Black individuals compared with white individuals.
Additionally, Black men were found to have a nearly 5-year shorter life expectancy compared with white men and Black women a nearly 3-year shorter life expectancy compared with white women.
Ferdinand hypothesized that current health inequities affecting Black individuals were less of a genotypic issue of race and/or ethnicity, but more a roadblock at the crossroads of environmental factors such as diet, physical activity and obesity, and the social determinants of health.
“These social determinants were outlined in an American Heart Association scientific statement several years ago, and they listed socioeconomic position, race, ethnicity, social support, culture, language, access to care, residential environment, along with several material conditions, including health education, political voice, social, connection and, again, the environment,” Ferdinand said during the presentation. “Even physical insecurity, crime and violence all play a part in adverse cardiovascular outcomes. Race and ethnicity ... are really social constructs with little biological genetic basis, per se, and within clinical care, implicit bias and stereotyping are real phenomena.”
Ferdinand added that the prevalence of achieving at least five of the goals set in the AHA’s Life’s Simple 7 guidance was lowest among non-Hispanic Black adults aged 20 years or older. Troublingly, the same trend was evident among non-Hispanic Black and Hispanic youth aged 12 to 19 years.
Although total cholesterol among non-Hispanic Black adults was not particularly higher than levels observed among white and Mexican American individuals, prevalence of diabetes was markedly elevated among both Black and Hispanic populations compared with white people.
The Black population also had the greatest proportion of younger than high school age children diagnosed with diabetes.
Ferdinand also cited hypertension as a critical factor in racial disparities in CV outcomes.
"Hypertension is a potent driver of risk, especially in African Americans, and using the newer criteria of equal to or greater than 130/80 mm Hg, as much as 60% of non-Hispanic Black adults will be defined as having hypertension. Furthermore, when we look at the attainment of the blood pressure goal of less than 130/80 mm Hg, there are disparities with low levels of that particular goal, both in Blacks, Hispanics and Asians, in terms of control.
“Note that the rates of awareness and actual treatment are similar in non-Hispanic Blacks,” Ferdinand said during the presentation. “The goal, therefore, is to control risk factors, not simply to identify risk factors.”
Despite accounting for approximately 13.6% of the overall U.S. population, Black individuals represent nearly 32% of all end-stage renal diseases in the U.S. population, nearly three times more than the predicted proportion, Ferdinand said.
Another issue is that nearly half of Black individuals and more than half of Black women aged 20 years or more could be considered obese.
“Obesity is another cardiometabolic risk, which is higher in non-Hispanic Blacks, especially women, and Hispanics,” Ferdinand said during the presentation. “In terms of diet, an analysis from the REGARDS study suggests that the so-called Southern diet, which has high fat, high sodium and is low in potassium, is associated with an increase in blood pressure and other risks including stroke, coronary heart disease, end-stage renal disease, chronic kidney disease, sepsis, cancer, mortality and cognitive decline.”
According to the presentation, since the emergence of COVID-19 in the U.S. (Feb. 1 to June 27, 2020), the virus became the third-leading cause of death in the country, behind heart disease and cancer.
Among patients hospitalized with COVID-19, the most common comorbidities included hypertension, obesity, chronic lung disease, diabetes and CVD.
Ferdinand added that this becomes most concerning upon the realization of the high prevalence of these diseases among the Black population.
Compared with the non-Hispanic white population, the Black population experienced nearly three times greater prevalence of cases of COVID-19, nearly five times greater prevalence of hospitalization due to the disease and twice the COVID-19-related mortality, according to the presentation.
In his presentation, Ferdinand attributed this to several factors, including a high prevalence of Black individuals working in the service industry or having essential jobs; a high prevalence of Black individuals using public transportation; a lack of early testing; and an historical distrust of the U.S. health care system.
“I was very distressed when we found this increase in COVID-19 mortality, especially in African Americans. I decided that perhaps we should call it a sentinel event,” Ferdinand said during the presentation. “When the Joint Commission evaluates hospitals, if there are cases of patients who fall out of the bed and break their hips or retained objects after surgery, the Joint Commission will look at that hospital as a place where there's poor care that needs to be mitigated. Similarly, the disparate African American COVID-19 mortality rates reflect long standing unacceptable U.S. racial and ethnic and socioeconomic cardiovascular inequities. COVID-19 doesn't cause them, but it unmasks system failures and unacceptable care that needs to be caught and mitigated.”
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Ferdinand KC. Impact of ethnicity and race in cardiometabolic health: Implications for risk assessment and management. Presented at: Cardiometabolic Health Congress; Oct. 21-24, 2020 (virtual meeting).
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