The president of the largest historically Black academic health center lays out the pandemic’s effects on different populations
In this year, the 40th anniversary of the CDC’s report of unusual immune deficiency found among young gay men, eventually leading to the discovery of HIV, CROI examined the COVID-19 pandemic in relation to the AIDS epidemic. James E.K. Hildreth, PhD, MD, President of Meharry Medical College, in Nashville, the nation’s largest private, independent, historically Black academic health center, was invited to speak to the history of HIV and SARS (severe acute respiratory syndrome) and their unequal impact on specific groups of people. Dr. Hildreth began his plenary talk, “Disparities in Health: From HIV to COVID-19 and Beyond,” with that CDC report, and how the fact that only gay men were affected created an atmosphere of discrimination. It was a discrimination that quickly encompassed other oppressed groups.
“It’s important to know that many elected officials, from the president to senators to elected representatives in Congress, really treated this problem with outright disdain because of the strong association with being gay at the time,” Dr. Hildreth said. But, “by the late ’80s and early ’90s, an interesting thing occurred when the majority of cases diagnosed in Stage 3 AIDS were among African Americans and Hispanics.
“You can actually see that for the decade from 1985 to 1995, there was a steady decline in whites who were diagnosed with AIDS. The situation for African Americans was just the opposite. There was a steady increase in the percent of African Americans who were representing the AIDS cases, and those two lines crossed. [Cases among African Americans continued to increase as the cases among whites continued to drop.]
“And even though antiretrovirals were available, there continued to be more and more diagnosed cases of AIDS in African Americans because they often came in late to care. And by the time they arrived for health care, their immune system had been destroyed, and there was not much that could be done for them. Even as late as two years ago, 2018, we still see that for the most part, African Americans especially, and Hispanic men who have sex with men, account for more than half of all the new HIV infections here in the United States.
“So, for almost the whole time we’ve known about HIV/AIDS, it’s been a problem of African Americans and people of color around the world and here in the United States. Again, more than half of all the new cases occur among gay and bisexual men.
“In December 2019, officials in China reported dozens of cases of pneumonia of unknown cause. In early January they identified a novel coronavirus. On January 19, 2020, the first case was reported outside of China, in Thailand. On January 30, the World Health Organization, W.H.O., reported it to be a public health emergency of international concern. Quite honestly, it should have been declared a pandemic at that time. And then March, as we approach the first anniversary, W.H.O. declared it an outright pandemic.
“In China, an observation was made pretty early on that in a racially homogenous nation of over a billion people, seven out of 10 of those persons who died from COVID-19 shared something in common. They all had a co-existing comorbid condition: hypertension, diabetes, ischemic heart disease, chronic lung diseases. They’d had a stroke, or suffered from congestive heart failure.
“So, it’s not a surprise that here in the United States, the burden of disease and death from COVID-19 has been borne by Black and Brown people, because all of those underlying conditions that made persons in China subject to severe disease and death are disproportionately present in minority communities. Half of African Americans or thereabout have some cardiovascular disease. A third, almost half, of them have hypertension. The overall rate of hypertension in the United States is 33%, but among African Americans it’s much higher than that. For Blacks and Hispanics also there’s a huge proportion of these individuals who are obese, and obesity has turned out to be a major determining factor for severe disease and death from COVID-19. And of course, diabetes as well.
“So, it is not a surprise that African Americans and Hispanics, who have all of these major conditions at a much higher rate than whites, have borne a disproportionate burden of severe COVID-19 disease and death.
“In data from late summer last year from just four states—Michigan (mostly Detroit), Illinois (mostly Chicago), North Carolina, and Louisiana (mostly New Orleans)—the differential rate of deaths between Blacks and whites per 100,000 individuals was almost ten-fold in Michigan and five-fold in Louisiana. [The rate for Blacks in Illinois was 7.2 and 1.3 for whites; in North Carolina, it was 0.6 for Blacks and 0.4 for whites.]
“These numbers and these statistics are quite alarming. And this has been consistent throughout this crisis. I should say even today there are counties in the country where the differential rate of death from COVID-19 is at least six-fold in some instances.
‘...health equity does not mean we need equality in health care. What we need to do is make sure that each person has their needs met and each community has their particular needs met.’
“So, it’s not an exaggeration to say that COVID-19 has been devastating for people of color.
“If you look at the two pandemics spaced 40 years apart, both HIV and SARS reveal a deep chasm in the health status between African Americans and Hispanics and Caucasians. Both of these were also highlighted by failed national leadership because of politics and prejudice that delayed the response to these pandemics, but also made for an ineffective national response early on. And the longstanding disparities in chronic diseases are major contributors to the disproportionate impact of both of these viruses on disadvantaged communities. In order to understand the inequities revealed by HIV/AIDS and COVID-19, they are best understood in the context of what is called ‘social determinants of health.’
“The W.H.O. definition of social determinants of health [SDOH] is ‘the conditions in which people are born, grow, live, work, and age. SDOH are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world.’
“There are five major categories. First, education, or the quality of education, and access to it. Then health care quality and access to it, and the built environment and nature of the neighborhoods we live in. There’s also social and community context, and of course our economic status.
“The education status is important in this context because access to health information is also limited when there’s limited access to quality education and educational institutions. I mentioned before one of the main concerns for HIV and the fact that so many African Americans were being diagnosed with late-stage disease is that oftentimes these individuals came into care very late, after the virus had decimated their immune systems.
“Another aspect of COVID-19 is that many of these individuals have poorly managed chronic conditions, like hypertension and asthma, because they don’t have access to quality health care or many of them don’t have a primary care physician. So access to health care and the quality of health care is a major social determinant of health that has been revealed by both of these pandemics.
“As just one example of the neighborhood and the built environment, which could also apply to the social context, many individuals who have been really stricken by COVID-19 live in multigenerational households where the virus can spread very quickly, especially when there are grandparents and older individuals living in those households. That’s been a major contributor to the COVID-19 challenge.
“Also, as just one example of deaths related to both HIV and COVID-19, is mass incarceration, which is a big problem in this country for huge numbers, especially Black males, who have been incarcerated from an early age. That congregate setting has proven to be devastating for the spread of COVID-19. Many of the deaths that have happened here in the United States from COVID-19 have been because so many people have been incarcerated and the prisons were not tested quickly early on for the virus. And also for HIV, mass incarceration also created some social networks that made it quite easy for the virus to spread in Black communities. So, this social context and community context are really important social determinants of health as related to the two pandemics.
“One of the other factors that relate to both of these pandemics is access to health care and the quality of health care. And also the numbers of African Americans and Hispanics who are part of the healthcare system, especially as physicians. Between 1908 and 2008, the percentage of Black physicians in the United States never got to be more than 2.5%. It was only in 2008 that that number began to climb. And it still sits just under 5%. So, just under 5% of physicians in the United States are Black even though African Americans represent 13% of the population.
“There are a number of factors related to this. One of them has to do with pipelines. Not enough individuals, especially Black males, make it through college prepared to go to medical school. And that relates to what happens in high school. A lot of individuals do not make it through high school, so they don’t have the opportunity to go to college in the first place. That observation is also true for Hispanics. That number is just under 6% of the physicians in this country even though they represent about 20% of the overall population.
“The disparity in access to health care is exacerbated by the fact that so few physicians are physicians of color. There are many data to demonstrate that the outcomes for minority communities and having access to primary care providers would be greatly enhanced if there were more physicians of color to take care of their communities. This is a really challenging problem that we need to find a way to deal with.
“I want to make the point that transitioning to health equity does not mean we need equality in health care. What we need to do is make sure that each person has their needs met and each community has their particular needs met. Our goal should be for each person to achieve their personal best health and wellness. Not every solution would be the appropriate one for all people.
“A great example of this is that the approach the United States took to dealing with COVID-19 was basically a population approach that assumed that the risk of COVID-19 was the same for all of the people in our country. That was clearly not the case.
“There are vulnerable populations that we knew about from the beginning—older individuals, people living in nursing homes and assisted living facilities, and also people of color in poor communities.
“We should have taken a more focused approach that recognized that the challenge in dealing with COVID-19 was not the same across the board for the whole population. So, the population approach was contributing to the inequities in outcomes of COVID-19. Achieving health equity does not mean equality in what we do for our communities. It means customizing our approaches to meet the needs of those communities and individuals who live there.
“So, two pandemics—HIV/AIDS and COVID-19—40 years apart, reveal a wide gap in health status in minorities compared to whites in the United States. Truthfully, this gap is longstanding, and is best understood in the context of the social determinants of health. Our goal should be for each person to achieve their best personal health and wellness. That means recognizing and meeting individual needs and community needs, and knowing that the same approach would not work for all. Closing the health gap here in this country, revealed by these two pandemics, is going to require coordinated efforts across a range of organizations, not just health care itself. Because again, health care only accounts for about 10 to 15% of the overall health of an individual. The rest of it is determined by social conditions and behaviors.”
“So we’re going to need a coordinated effort for over an extended period of time from national agencies and organizations, businesses, and agencies to solve this problem.
“I would also say that I hope that both of these pandemics make it clear that what we need to do in this country to make sure that this does not happen again is to take a more focused approach the next time we deal with a public health crisis like this, because it would result in many more lives being saved and less resources being needed to deal with it.”
Dr. James Hildreth serves as Associate Director of the Tennessee Center for AIDS Research (CFAR) and was appointed to President Biden’s COVID-19 Health Equity Task Force.