Risk of Severe Illness or Death from COVID-19
Racial and Ethnic Health Disparities
Conditions in the places where people live, learn, work, play, and worship affect a wide range of health risks and outcomes, such as COVID-19 infection, severe illness, and death. These conditions are known as social determinants of health.
Some of the many inequities in social determinants of health that may increase risk of severe illness (such as hospitalization, intubation, and death) from COVID-19 include access to quality healthcare, general health status, education, economic stability, and many other factors that affect health risks and outcomes. Discrimination, which includes racism, shapes social and economic factors that put people at increased risk of severe COVID-19 illness.1,2,3,4,5 Unfortunately, discrimination exists in systems meant to protect well-being and health. For example, discrimination within the healthcare system may deter people from seeking or receiving timely testing and treatment for health concerns, including COVID-19.6
Evidence for factors that contribute to risk for severe illness from COVID-19
Severe illness means that the person with COVID-19 requires hospitalization, intensive care, or a ventilator to help them breathe. Severe illness can lead to death. Among adults, the risk of severe illness from COVID-19 increases with age, with older adults at highest risk. Additionally, people of any age, race, ethnicity, and sex with certain underlying medical conditions are at increased risk of severe illness from COVID-19. CDC continues to review the evidence and provide updates about the underlying medical conditions that might increase risk of severe illness from COVID-19. More detailed evidence summaries are also available.
COVID-19 is a new disease. Currently, few studies have examined the social factors that increase risk of severe illness from COVID-19. However, these limited studies have found differences between racial and ethnic groups in the health and social factors that may increase risk of severe illness or death from COVID-19.7–21 Some of the studies are from the entire United States; others are from specific cities and communities. These studies consistently identify underlying factors that are associated with increased risk of severe illness from COVID-19. CDC will continue to monitor the latest evidence and provide updated information.
In Atlanta, black patients with COVID-19 were more likely to be hospitalized than white patients*
Body of Graphic:
Y axis shows Percentage
X axis shows Hospitalized and Not hospitalized
Each racial/ethnic group has two vertical bars, different color—first color is blue for black persons, second color is green for white persons
Hospitalized: 79% black, 13% white
Not hospitalized: 45% black, 29% white
Bottom of graphic:
The federal government, public health professionals, community organizations, healthcare systems and providers, and individuals can take action to reduce health disparities
*In Metro Atlanta, March-April, 2020
Current evidence shows that the following factors are associated with increased risk of severe illness from COVID-19 for racial and ethnic minority groups:
- Healthcare: A recent study found that people from racial and ethnic minority groups were more likely to have increased COVID-19 disease severity upon admission at the hospital compared with non-Hispanic White people.7,8,9,10 Healthcare access can also be limited for these groups by other factors, such as lack of transportation or child care, inability to take time off work, communication and language barriers, cultural differences between patients and providers, not having a usual source of care, and historical and current discrimination in healthcare systems.11 Some people from racial and ethnic minority groups may hesitate to seek care because they distrust the government and healthcare systems. This distrust may be due to the roles of the government and healthcare systems in current inequities in treatment 12 and their responsibility for discriminatory, unethical, and abusive historical events. These historical events include the Tuskegee Study, which studied intentionally untreated syphilis in non-Hispanic Black men without their knowledge, and the sterilization of racial and ethnic minority people without their knowledge or permission. 13,14,15,16
A recent study found that people from racial and ethnic minority groups were more likely to have increased COVID-19 disease severity upon admission at the hospital compared with non-Hispanic White people. More severe disease increased the likelihood that these patients would need intubation, be admitted to the Intensive Care Unit, or die. 17 A separate study found that compared with non-Hispanic White people, non-Hispanic Black people were more likely to be hospitalized and were more likely to be tested for COVID-19 at a hospital than in the ambulatory (outpatient) setting. The researchers noted that the findings suggest non-Hispanic Black people may have delayed seeking care. 18
- General health status: Underlying medical conditions that increase risk for severe illness from COVID-19 may be more common among people from racial and ethnic minority groups.19 Common underlying conditions among those who require mechanical ventilation or died included diabetes, high blood pressure, obesity, chronic kidney disease on dialysis, and congestive heart failure. 20 It is important to note that many of the same social determinants of health that increase risk of COVID-19 illness also increase the risk of health conditions such as obesity, high blood pressure, and diabetes. These specific social determinants of health include education, economic stability, and physical environment, and healthcare system factors (e.g., insurance coverage, access to care and treatment).
A study in New York City found that non-Hispanic Black and Hispanic or Latino people had higher obesity rates and higher COVID-19 mortality rates compared with non-Hispanic Asian and non-Hispanic White people. 21 A study in Boston found that among patients hospitalized with COVID-19 at an urban medical center, non-Hispanic Black patients were more likely to have one or more underlying medical conditions than people from other racial or ethnic groups. In another study of patients hospitalized with COVID-19, non-Hispanic Black patients were more likely to have high blood pressure and diabetes compared with all other racial and ethnic groups combined. 22 Another study found that among Black patients hospitalized with COVID-19, those with higher body mass index at arrival to the hospital were more likely to die.23 Additionally, pregnant people may have an increased risk of severe illness from COVID-19. 24, 25 Given long-standing disparities in maternal health and birth outcomes, 26 it is important to consider how COVID-19 may affect these outcomes for people from racial and ethnic minority groups.
- Education, income, and wealth gaps: Inequities in access to high-quality education for people from racial and ethnic minority groups can lead to lower high school completion rates and barriers to college entrance.27 This may limit future job options and lead to lower paying or less stable jobs. People with lower paying jobs often do not have paid sick leave and cannot afford to miss work, even if they’re sick, because they would not be able to pay for essential items like food or other important living needs if their income decreased. Lower income is strongly associated with morbidity and mortality. Compared with non-Hispanic White people, American Indian, non-Hispanic Black, and Hispanic or Latino people have lower household incomes and shorter life expectancies, as well as higher rates of underlying medical conditions that increase risk of severe illness from COVID-19.28,29
As of August 2020, more Hispanic or Latino people (53%) and non-Hispanic Black people (43%) reported that they had lost a job or taken a pay cut because of COVID-19 compared with non-Hispanic White people (38%). More non-Hispanic Black and Hispanic or Latino people, 40% and 43%, respectively, reported that they had to use money from savings or retirement to pay bills since the outbreak began, compared with 29% of non-Hispanic White people. Additionally, 43% of non-Hispanic Black people and 37% of Hispanic or Latino people reported having trouble paying their bills in full compared with non-Hispanic White people (18%). 30
To reduce the substantial toll COVID-19 has had on individuals and communities, we need to work together to address inequities in the social determinants of health that increase risk of severe illness from COVID-19 for racial and ethnic minority groups. Learn more about what we can do to move towards health equity.
- COVID-19 Health Equity – Promoting Fair Access to Health
- CDC Social Determinants of Health: Know What Affects Health
- Environmental Public Health Tracking Network – Select “COVID-19” content area for options to view data on several factors related to increased risk of COVID-19
- Robert Wood Johnson Foundation’s 2020 County Health Ranking State Reportsexternal icon
- National Association of County and City Health Officials’ COVID-19 Resources for Local Health Departmentsexternal icon
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2. Millet GA, Jones AT, Benkeser D, et al. Assessing Differential Impacts of COVID-19 on Black Communities. Ann Epidemiol. 2020;47:37-44. DOI: https://doi.org/10.1016/j.annepidem.2020.05.003external icon.
3. Paradies Y. A Systematic Review of Empirical Research on Self-reported Racism and Health. Int J Epidemiol. 2006; 35(4):888–901. DOI: https://doi.org/10.1093/ije/dyl056external icon.
4. Simons RL, Lei MK, Beach SRH, et al. Discrimination, Segregation, and Chronic Inflammation: Testing the Weathering Explanation for the Poor Health of Black Americans. Dev Psychol. 2018;54(10):1993-2006. DOI: https://doi.org/10.1037/dev0000511external icon
5. Cordes J, Castro MC. Spatial Analysis of COVID-19 Clusters and Contextual Factors in New York City. Spat Spatiotemporal Epidemiol. 2020;34:100355. DOI: https://dx.doi.org/10.1016%2Fj.sste.2020.100355external icon.
6. Smedley BD, Stith AY, Nelson AR (Editors). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (with CD). 2003 [cited 2020 Aug 27] ISBN: 0-309-15166. Available from URL: https://www.nap.edu/catalog/12875/unequal-treatment-confronting-racial-and-ethnic-disparities-in-health-careexternal icon.
7. Berchick, Edward R., Jessica C. Barnett, and Rachel D. Upton Current Population Reports, P60-267(RV), Health Insurance Coverage in the United States: 2018, U.S. Government Printing Office, Washington, DC, 2019.
8. Agency for Healthcare Research and Quality. 2018 National Healthcare Quality and Disparities Report. Rockville, MD, 2019. Available from URL: https://www.ahrq.gov/research/findings/nhqrdr/nhqdr18/index.htmlexternal icon.
9. Streeter RA, Snyder JE, Kepley H, et al. The Geographic Alignment of Primary Care Health Professional Shortage Areas with Markers for Social Determinants of Health. PLoS One. 2020 Apr;15(4):e0231443. DOI: https://doi.org/10.1371/journal.pone.0231443external icon.
10. Gaskin DJ, Dinwiddie GY, Chan KS, et al. Residential Segregation and the Availability of Primary Care Physicians. Health Serv Res. 2012 Dec;47(6):2352-2376. DOI: https://doi.org/10.1111/j.1475-6773.2012.01417.xexternal icon.
11. Institute of Medicine (US) Committee on the Consequences of Uninsurance. Care Without Coverage: Too Little, Too Late. Washington (DC): National Academies Press (US); 2002. DOI: https://doi.org/10.17226/10367external icon.
12. Institute of Medicine. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press. DOI: https://doi.org/10.17226/10260external icon.
13. U.S. National Library of Medicine. Native Voices: Timeline: Government Admits Forced Sterilization of Indian Women [online]. 2011 [cited 2020 Jun 24]. Available from URL: https://www.nlm.nih.gov/nativevoices/timeline/543.htmlexternal icon.
14. Novak NL, Lira N, O’Connor KE, Harlow SD, Kardia SLR, Stern AM. Disproportionate Sterilization of Latinos Under California’s Eugenic Sterilization Program, 1920-1945. Am J Public Health. 2018;108(5):611-613. DOI: https://dx.doi.org/10.2105%2FAJPH.2018.304369external icon.
15. Stern AM. Sterilized in the Name of Public Health: Race, Immigration, and Reproductive Control in Modern California. Am J Public Health. 2005 Jul;95(7):1128-38. DOI: https://dx.doi.org/10.2105%2FAJPH.2004.041608external icon.
16. Prather C, Fuller TR, Jeffries WL 4th, et al. Racism, African American Women, and Their Sexual and Reproductive Health: A Review of Historical and Contemporary Evidence and Implications for Health Equity. Health Equity. 2018;2(1):249-259. DOI: https://dx.doi.org/10.1089%2Fheq.2017.0045external icon.
17. Joseph NP, Reid NJ, Som A, Li MD, Hyle EP, Dugdale CM, et al. Racial and Ethnic Disparities in Disease Severity on Admission Chest Radiographs among Patients Admitted with Confirmed COVID-19: A Retrospective Cohort Study. Radiology. 2020:202602. DOI: https://doi.org/10.1148/radiol.2020202602external icon.
18. Azar KMJ, Shen Z, Romanelli RJ, et al. Disparities in Outcomes among COVID-19 Patients in a Large Health Care System in California. Health Affairs. 2020;39(7):1263-1262. https://doi.org/10.1377/hlthaff.2020.00598external icon.
19. Davis J, Penha J, Mbowe O, Taira DA. Prevalence of Single and Multiple Leading Causes of Death by Race/Ethnicity Among People Aged 60 to 70 years. Prev Chronic Dis. 2017;14:160241. DOI: http://dx.doi.org/10.5888/pcd14.160241external icon.
20. Hsu HE, Ashe EM, Silverstein M, Hofman M, Lange SJ, Razzaghi H, et al. Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients with COVID-19 at an Urban Safety-Net Medical Center – Boston, Massachusetts, 2020. MMWR – Morbidity & Mortality Weekly Report. 2020;69(27):864-9. DOI: http://dx.doi.org/10.15585/mmwr.mm6927a3external icon.
21. El Chaar M, King K, Galvez Lima A. Are Black and Hispanic Persons Disproportionately Affected by COVID-19 Because of Higher Obesity Rates? Surgery for Obesity & Related Diseases. 2020;11:11. DOI: https://doi.org/10.1016/j.soard.2020.04.038external icon.
22. Gold JAW, Wong KK, Szablewski CM, Patel PR, Rossow J, da Silva J, et al. Characteristics and Clinical Outcomes of Adult Patients Hospitalized with COVID-19 – Georgia, March 2020. MMWR – Morbidity & Mortality Weekly Report. 2020;69(18):545-50. DOI: http://dx.doi.org/10.15585/mmwr.mm6918e1external icon.
23. Gayam V, Chobufo MD, Merghani MA, Lamichanne S, Garlapati PR, Adler MK. Clinical Characteristics and Predictors of Mortality in African-Americans with COVID-19 from an Inner-city Community Teaching Hospital in New York. Journal of Medical Virology. 2020;16:16. DOI: https://doi.org/10.1002/jmv.26306external icon.
24. Centers for Disease Control and Prevention. If You are Pregnant, Breastfeeding, or Caring for Young Children. 2020 [cited 2020 Aug 31]. Available from URL: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/pregnancy-breastfeeding.html
25. Ellington S, Strig P, Tong VT, et al. Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status – United States, January 22 – June 7, 2020. MMWR – Morbidity & Mortality Weekly Report. 2020;69(25);769-775. DOI: http://dx.doi.org/10.15585/mmwr.mm6925a1external icon.
26. Peterson EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-related Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017. MMWR – Morbidity & Mortality Weekly Report. 2019;68:423-429. DOI: http://dx.doi.org/10.15585/mmwr.mm6818e1external icon.
27. Egerter S, Bravement P, Sadegh-Nobari T, et al. Education Matters for Health. Issue Brief 6: Education and health. Robert Wood Johnson Foundation. 2009 [cited 2020 Aug 27]. Available from URL: http://www.commissiononhealth.org/PDF/c270deb3-ba42-4fbd-baeb-2cd65956f00e/Issue%20Brief%206%20Sept%2009%20-%20Education%20and%20Health.pdfpdf iconexternal icon. Last accessed August 26, 2020.
28. Khullar D, Chokshi DA. Health, Income, & Poverty: Where We are & What Could Help. Health Affairs Health Policy Brief. DOI: https://doi.org/10.1377/hpb20180817.901935external icon.
29. Centers for Disease Control and Prevention. Health, United States Spotlight: Racial and Ethnic Disparities in Heart Disease. 2019 [cited 2020 Sept 01]. Available at URL: https://www.cdc.gov/nchs/hus/spotlight/Spotlight_HeartDisease_2019_Pg2.png.
30. Parker K, Minkin R, Bennett J. Economic Fallout from COVID-19 Continues to Hit Lower-Income Americans the Hardest. Pew Research Center. 2020 [cited 2020 Sept 29]. Available from URL: https://www.pewsocialtrends.org/2020/09/24/economic-fallout-from-covid-19-continues-to-hit-lower-income-americans-the-hardest/external icon.