Racial and Economic Disparities During COVID-19

Interview with Matthew Raifman on the disproportionate burden of the disease

Posted Jun 25, 2020

Matthew Raifman, used with permission
Source: Matthew Raifman, used with permission

Injustice takes many shapes and forms, including the disparities in healthcare that have been exacerbated by COVID-19. Pre-existing racial and economic divides that have already harmed millions are now creating more problems. Changes in policy, advocacy, and research are needed for some of these wrongs to be righted.

Matthew Raifman is a Ph.D. student in Environmental Health at Boston University, whose research focuses on how policies to address climate change also produce benefits to the public’s health. He has served as a Senior Advisor with the Bloomberg Philanthropies What Works Cities initiative at Johns Hopkins University, where he supported on developing performance analytics and open data programs. He has also served as Science and Technology Fellow at the U.S. Department of Energy, transportation performance management lead in the Governor’s Office in Maryland, and as delivery unit expert in the President’s Office of the World Bank.

JA: How did you first get interested in this topic?

MR: Like many public health researchers, we wanted to inform the public health response to the novel coronavirus pandemic. While there was groundbreaking research on transmission and treatment, we felt there was a relative dearth of discussion about risk factors, the disproportionate burden of disease by race and ethnicity, and the importance of recognizing these disparities in developing public policy.

When we conceptualized this analysis in early March 2020, relatively little was known about COVID-19 illness. Early reports were coming in of cases and deaths, but unfortunately, the slow ramp-up in testing made these data unreliable. The general sentiment was that COVID-19 was something that would only affect a small number of Americans who were already very sick or elderly. The official guidance in the U.S. was that Americans should not wear face masks. Further, only a few states and cities had released data on cases and outcomes by race or ethnicity.

While it was clear from these initial reports that COVID-19 was affecting Black Americans, in particular, more severely, this critical disparity was not yet part of the mainstream conversation. In this study, we started with a simple question: How many Americans were at risk of severe illness from COVID-19, and did risk factors differ by race/ethnicity and income? Our hope was that these results could potentially inform policymaking and communication around the risk of illness from COVID-19.

JA: What was the focus of your study?

MR: In this study, we started with that simple question surrounding the risk factors of race/ethnicity and income. Early on in the pandemic, the CDC released a list of conditions that put Americans at higher risk of severe illness from COVID-19 infection. Most of these conditions were chronic health conditions, like asthma or kidney disease, and some were demographic in nature, for example, those who were 65 years old or older. We used a nationally representative survey of health called the Behavioral Risk Factor Surveillance System with over 400,000 respondents to estimate the number of Americans who had these risk factors. We broke down the prevalence of risk factors by race/ethnicity and income to better understand if certain populations were at higher risk of illness.

JA: What did you discover in your study?

MR: We found that in contrast to prevailing opinion, around 40% of adult Americans (97 million) had at least one of the CDC risk factors for severe COVID-19 illness. We also found substantial disparities in risk factors by race and income. Among those under 65, Black adults were 22% more likely to have at least one risk factor than White adults and 27% more likely to have multiple factors. Similarly, we found that American Indians were 53% more likely to have one factor than Whites and 115% for multiple factors. About 25 million adult Americans who are living in households receiving less than $25,000 a year had at least one risk factor and were 63% more likely to have a risk factor than those with higher income.

JA: Is there anything that surprised you in your findings, or that you weren't fully expecting?

MR: In some sense, the most shocking aspect of this analysis is also the least surprising. Decades of inequitable policies have created a situation where substantial disparities by race and income exist in access to health care, wealth, education, employment, and other conditions. In the face of the current pandemic, these conditions have compounded to put Black and American Indian Americans at higher risk of severe illness from COVID-19. There also appears to be racial disparities in exposure to COVID-19 driven by what types of jobs are classified as essential and who is able to work from home.

The takeaway here is not that COVID-19 has a differential impact on people of color, rather it’s that we live in a society that enables these inequities through disparities in chronic conditions, exposure, diagnosis, treatment, health insurance, and other factors that impact health.

JA: How might readers apply what you found to their lives?

MR: It is very important to recognize that almost half the U.S. adult population has a condition that puts one at a higher risk of severe illness from COVID-19. This means all of us need to continue taking precautions to reduce transmission, both for our own health and the health of those we come in contact with throughout the day. That means wearing a mask in public even if it’s uncomfortable, washing hands regularly, avoiding large gatherings, and the other guidance we’ve received from the CDC and health officials.

I hope that we all can internalize that we live in a fundamentally inequitable system when it comes to health care, environmental exposures, and, yes, now COVID-19 as well. We all have a role to play in disrupting that status quo, whether it is highlighting inequities we see in our daily lives, pushing for reform through the political process, or other avenues of change. The disparities we identified with risk factors for COVID-19 illness, and the subsequent analysis from many on disparities in cases and deaths, are just the most recent chapter in the long book of injustice.

JA: What are you currently working on that you might like to talk about?

MR: When not running a daycare for my young son, as so many of us are, I am working on better understanding the health impacts of increased physical activity from an initiative aimed at reducing transportation greenhouse gas emissions on the East Coast, called the Transportation Climate Initiative. While my main focus is on environmental health, I am also continuing to look for ways to contribute to better understanding disparities around COVID-19. Along with some collaborators at MIT, I am working on a study that explores the role of racial segregation in shaping COVID-19 cases and deaths. We hope this research will be published sometime this summer.


Raifman MA, Raifman JR. Disparities in the Population at Risk of Severe Illness From COVID-19 by Race/Ethnicity and Income [published online ahead of print, 2020 Apr 27]. American Journal of Preventive Medicine. 2020;S0749-3797(20)30155-0. doi:10.1016/j.amepre.2020.04.003

Funding source: This research was supported by training grant number 5T32ES014562-13 from the NIH National Institute of Environmental Health Sciences.