It is important to recognize that disease risk is not spread evenly within or between populations. Diseases combine and interact to create a syndemic, where the coexistence of two or more conditions exacerbates the effects of one or all conditions. A syndemic (versus a pandemic, for example) takes into account social, political, economic, and environmental factors that increase risk for the clustering of two or more diseases (Singer et al. 2017). One of the first syndemics identified involved substance abuse, violence, and AIDS. In inner cities in the U.S., the health crisis around HIV/AIDS was related to tuberculosis, sexually transmitted infections, hepatitis, cirrhosis, infant mortality, drug abuse, suicide, and homicide. These were connected to poverty, homelessness, unemployment, poor nutrition, lack of social support, and social and ethnic inequality (Singer et al. 2017). Together, these factors and others, like health policy and unequal access to health care, form an ecological model of health and disease, one that moves beyond biology and medical intervention (Sallis et al. 2008).
The COVID-19 pandemic represents a syndemic in which systemic racism in the healthcare system, differential access to diagnosis and treatment, income, employment, housing, family structure, pre existing conditions, and public health policies combined to result in higher rates of infection and death for African Americans, Native Americans, Asians, and Hispanic populations in the United States (Figure 16.11).
Figure 16.11: Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. Race and ethnicity are risk markers for other underlying conditions that affect health, including socioeconomic status, access to health care, and exposure to the virus related to occupation, e.g., frontline, essential, and critical infrastructure workers. Credit: Risk for COVID-19 Infection, Hospitalization, and Death by Race/Ethnicity by the Centers for Disease Control and Prevention is in the public domain.
| Rate ratios compared to White, Non-Hispanic persons |
American Indian or Alaska Native, Non-Hispanic persons |
Asian, Non-Hispanic persons |
Black or African American, Non-Hispanic persons |
Hispanic or Latino persons |
| Cases |
1.6x |
.8x |
1.1x |
1.5x |
| Hospitalization |
2.7x |
.8x |
2.3x |
2.0x |
| Death |
2.1x |
.8x |
1.7x |
1.8x |
COVID-19 was the third leading cause of death in the U.S. in 2020 and 2021 (NIH 2022; Figure 16.12), but morbidity and mortality was not equally spread across the population. Working-class people and people of color in the U.S. are more likely to live in poverty, in areas with high rates of crime and violence, and in close proximity to freeways and environmental threats like petrochemical plants and waste incinerators (Singer and Baer 2012). Many such neighborhoods are also food “deserts” without ready access to a healthy, affordable diet, made more challenging by residents not owning a car (Food Empowerment Project n.d.). Low-income people also often lack access to high-quality health care and delay or avoid preventive care and health screenings (Ross et al. 2007). These factors contributed to higher rates of preexisting conditions, including obesity, diabetes, hypertension, asthma, heart disease, chronic obstructive pulmonary disease (COPD), and smoking behavior, which then led to more complications and higher death rates from COVID (Ghosh et al. 2021).
Family structure also affected COVID exposure and severity. Many Americans live in multigenerational households, including 27% of Hispanics, 29% of Asians, 26% of African Americans, and 20% of Whites (Cohn and Passel 2018). Not all multigenerational households are equal, however. Over twice as many African Americans as Whites are in multigenerational families in which at least one family member is unemployed, and over three times as many African Americans are in multigenerational families in which everyone is simultaneously unemployed (Park, Wiemers, and Seltzer 2019). Family members in multigenerational households were at a much higher risk of developing more severe forms of COVID due to decreased personal space and multiple exposures to the virus, as well as higher rates of diabetes, smoking, and residents living below the poverty line (Ghosh et al. 2021). While aimed at reducing overall infection rates from COVID, public health measures such as mandatory lockdowns only exacerbated the situation in overcrowded and multigenerational housing, resulting in higher rates of infection and death in these communities.
Figure 16.12: Top five causes of death in the U.S. and worldwide since 2020. Credit: Top five causes of death in the U.S. and worldwide original to Explorations: An Open Invitation to Biological Anthropology (2nd ed.) by Joylin Namie is under a CC BY-NC 4.0 License. Based on data from Shiels et al. 2022 and Traeger 2022.
| United States |
Worldwide |
| 1. Heart disease |
1. Heart disease |
| 2. Cancer |
2. Stroke |
| 3. COVID-19 |
3. COVID-19 |
| 4. Accidents |
4. Chronic Obstructive Pulmonary Disease |
| 5. Stroke |
5. Lower respiratory infections |
| |
|
There is a long history of systemic racism and discrimination in the medical system in the United States (Washington 2006). African Americans have been subjected to medical testing and experimentation without their consent or knowledge since the time of slavery. They continue to routinely receive care of poorer quality than whites (Williams and Wyatt 2015), less pain medication during treatment and hospitalization (Green et al. 2003), and differential treatment during pregnancy and childbirth (Washington 2006). Many Americans, including 50% of White medical students and residents in one recent study (Hoffman et al. 2016), hold at least one false belief about African Americans, including “Black people’s skin is thicker than white people’s skin,” “Blacks have stronger immune systems than whites,” and “Blacks’ nerve endings are less sensitive than whites’.” Such beliefs affect health care for African Americans in medical emergencies and for chronic conditions.
During the COVID-19 pandemic, patients with darker skin in the United States were negatively affected by the very medical device most commonly used to assess oxygen levels in their blood. The pulse oximeter, a small device that clips onto the tip of your index finger and measures blood oxygen levels, experienced increased use in home, clinical, and hospital settings during the COVID-19 pandemic. Decisions regarding treatment and hospital admission for patients infected with COVID were often based on pulse oximeter readings (Valbuena, Merchant, and Hough 2022). The problem is the device overestimates oxygen saturation in patients with darker skin, an issue which has been recognized for over thirty years (Valbuena, Merchant, and Hough 2022). It would be as if a standard thermometer reported lower body temperatures for patients of color, making it seem as if they did not have a fever when they actually did. In the case of COVID-19, Asians, Hispanics, and African Americans experienced inaccurately high readings of their oxygen levels (with African Americans and darker-skinned Hispanics having the highest), resulting in delays in treatment, hospital admission, and access to medications to treat COVID and contributing to higher severity of illness and higher death rates among these populations in comparison to whites (Fawzi et al. 2022).
Employment was also a factor in unequal exposure to and death from COVID-19 (Raifman, Skinner, and Sojourner 2022), with many low-income workers making the choice (which, realistically, may not be a choice at all) to expose themselves to COVID in order to earn the funds necessary to purchase food, housing, and other necessities. Many such workers were then forced to miss work due to COVID infection. With only 35% of low-wage workers (as opposed to 95% of high-wage workers) having paid sick leave, this left many families struggling financially. Three years into the pandemic, low-wage workers continue to have the least access to COVID vaccines and boosters. The U.S. also lacks federal workplace-safety regulations with regard to vaccine and masking mandates that other nations enforce in times of high transmission, and it does not provide high-quality masks to its essential workers. Many occupations deemed essential by the CDC during the height of the pandemic—such as health care, emergency services, meat packing, agricultural work, teaching, and jobs in the hospitality sector—experienced higher rates of morbidity and mortality from COVID. Many of these fields disproportionately employ people of color (McKinsey and Company 2021). Given this, future policies that address the pandemic at a structural level—for example, providing monetary assistance to people who work in environments with a high risk of infection, such as cleaning, nursing, transportation, retail, restaurant work, and factory work, so that they can remain at home—may function more effectively to prevent transmission and curb future outbreaks (Arnot et al. 2020).
