Understanding the decline in racial disparities in COVID

The School of Arts & Sciences’ Irma Elo and Samuel Preston, with a collaborative team of researchers, assessed racial disparities in U.S. COVID-19 deaths, calling for continued efforts to better understand and implement targeted strategies for addressing health inequalities

Young black man wearing surgical face masks while sitting and riding on a window seat of a tram
Image: iStockPhoto / AlexLinch

Racial disparities in COVID-19 deaths became a defining aspect of the pandemic’s first year in the United States, leading to national efforts to reduce the disproportionate toll among Black and Hispanic communities through vaccination drives and outreach in 2021.

Federal officials and the media touted major reductions in COVID mortality rate disparities during the delta and omicron waves, but researchers from the University of Pennsylvania and collaborators have shown that the declines in these disparities may not reflect improvements in population health to the extent previously thought.

Published in JAMA Network Open, the study found that disparities in U.S. COVID death rates between Black and white adults narrowed substantially from the first to the second year of the pandemic, from 339 deaths to 45 deaths per 100,000 people in 2021, after accounting for age.

“As the COVID-19 pandemic has evolved it continues to place a heavy burden on Black and Hispanic communities,” says Irma Elo, coauthor of the paper and professor in the Department of Sociology at the School of Arts & Sciences. “However, as it spread across the U.S., the geography of the pandemic shifted from urban centers to rural areas adding to the preexisting rural health disadvantage.”

This sharp decline mostly resulted from an increase in COVID deaths among white people, as well as a geographical shift in mortality from large cities to rural and smaller metropolitan areas, rather than from decreases in deaths among the Black population, she says.

Similarly, Hispanic-white disparities in deaths declined from 172 deaths to 12 deaths, with this decline entirely due to increased COVID deaths among white and rural populations.

While national COVID death rates for Black, Hispanic, and Asian populations decreased in 2021, death rates among these groups rose in rural areas during this time, surpassing white death rates.

“Contrary to popular media narratives, our findings indicate that decreases in racial and ethnic disparities in COVID were mostly explained by increases in mortality for white adults and changes in pandemic geography rather than decreases in Black and Hispanic mortality,” says study corresponding author Andrew Stokes, assistant professor of global health at the Boston University School of Public Health.

“This suggests that it may be premature to celebrate reductions in disparities because they did not largely represent reductions in mortality.”

As the Biden administration prepares to lift the COVID public health emergency on May 11, the researchers believe much more work still needs to be done to address this burden among all populations.

For the study, the team analyzed national data on COVID-related deaths among nearly one million U.S. adults aged 25 and older from March 2020 to February 2022. They examined these deaths by race and ethnicity across metropolitan and nonmetropolitan areas, using an innovative mathematical framework to identify factors contributing to the decline in disparities.

The researchers estimated that the rise in COVID deaths in rural areas, which increased from 5% of all rural deaths in 2020 to about 22% by March 2022, and the increase in white population mortality explained roughly 60% of the decline in disparities. The remainder was due to the national decline in deaths among the Black population.

“The emergence of a rural health disadvantage in COVID—as in so many other causes of death—is a significant trend, particularly so since much of this disadvantage seems to be driven by vaccination behavior,” says study coauthor Katherine Hempstead, senior policy advisor at the Robert Wood Johnson Foundation.

The team also observed concerning trends among the American Indian/Alaska Native (AIAN) population, with COVID deaths increasing at the national level during the delta and omicron waves, in both urban and rural areas.
The researchers point to multiple factors contributing to shifts in COVID mortality rates including social, political, geographical, and structural elements.

Vaccination and booster rates play a role, as the politicized nature of vaccines likely led to lower uptake among white and rural people. In addition, they note that Black, Hispanic, and AIAN people have received substantially fewer boosters than white people, and rural residents face higher rates of chronic diseases and greater difficulty accessing care.

The researchers urge community investments and policy changes that will remove social and economic barriers largely driven by structural racism, increase access to community resources, and close the racial health equity gap.

Irma Elo is a professor in the Department of Sociology in the School of Arts & Sciences and a research associate at the Population Studies Center and Population Aging Research Center at the University of Pennsylvania.

Andrew Stokes is an assistant professor in the Department of Global Health at the School of Public Health at Boston University.

Katherine Hempstead is a senior policy advisor at the Robert Wood Johnson Foundation.

Other contributors to the research are Penn’s Eugenio Paglino and Samuel H. Preston; Dielle J. Lundberg, Ahyoung Cho, Rafeya Raquib, and Elaine O. Nsoesie of Boston University; Elizabeth Wrigley-Field of the University of Minnesota; Ruijia Chen, M. Maria Glymour, and Yea-Hung Chen of University of California, San Francisco; Matthew V. Kiang of Stanford University; Alicia R. Riley of the University of California, Santa Cruz; and Marie-Laure of the Massachusetts Institute of Technology.

The research was supported by the Robert Wood Johnson Foundation (grant 77521), the National Institutes of Health (R01-AG060115, R01-AG060115-04S1, and K00-AG068431, P2C-HD041023, R00DA051534, P2C-HD041023), the W.K. Kellogg Foundation (P-6007864-2022), the Rockefeller Foundation (2020 EEO 026), and the Agency for Healthcare Research and Quality (T32HS013853).