Sandro Galea M.D.

Talking About Health

COVID-19 Is Bad for All but Devastating for the Poor

New research shows how the disease threatens the most vulnerable.

Posted May 08, 2020

Co-written with Neil Schluger.

Do you want to know your chance of surviving an episode of coronavirus infection? Check the median income of people living in your county. The coronavirus epidemic is providing a dramatic example of the devastation that serious infectious diseases can wreak on large urban populations. Our medical systems are overwhelmed with the sick and dying. As more and more data become available, however, it becomes clearer that what is really happening is an epidemic of a serious infection layered on top of health disparities that mirror structural inequalities in our society.

The consequences of this epidemic are bad for all but devastating for the poor. We spent recent weeks looking at patients who presented at the Columbia Presbyterian ICU. They painted a striking picture of these health disparities.

Case fatality rates—the chance that someone with the infection will die of it—from coronavirus in New York City and its surroundings show marked differences. The rate in Brooklyn is 7.8 percent, in the Bronx 6.5 percent, Queens 6.8 percent, Manhattan 5.9 percent, and in Richmond 4.4 percent. On the other hand, the fatality rate in Nassau county is 3.8 percent, in Suffolk 2.6 percent, in Westchester 2.8 percent, and in Rockland 2.7 percent. Why should some New York City residents have nearly a three times higher rate of death from coronavirus than people living in the suburbs? This seems unlikely to be due to the quality of acute care they are receiving at the moment. The New York region is blessed with outstanding medical centers, and we know from our own experience and observations that doctors and nurses are working heroically to save absolutely everyone they can, regardless of who they are. Rather, the evidence strongly points in the direction of a whole host of underlying vulnerabilities to death from infection that is linked to income inequality and other forms of disparities.

We examined a multitude of factors that might be associated with susceptibility to death from infection, including the prevalence in New York area counties of diabetes, hypertension, smoking, and obesity. Although several factors correlated with the death rate, the most striking and statistically strongest relationship was between median income in each county and the case fatality rate from COVID-19:

Original graph
Figure 1.
Source: Original graph

The horizontal axis shows median income in the five boroughs and four surrounding counties, and the vertical axis shows the case fatality rate from COVID-19. It is a striking relationship, and in statistical terms, median income explains a stunning 65 percent of the variance in the death rates.

It is also probably not surprising that in New York City, mortality from COVID-19 is disproportionately affecting Black and Hispanic residents. Those two groups make up 51 percent of the population of New York City, but 62 percent of the deaths from coronavirus. Across the state as a whole, 21 percent of residents are Black or Hispanic but 31 percent of those who have died.

What do these data tell us? Remember, the data in the graph describe the chance that a person will die from coronavirus infection once infected, not the chance that a person will be infected in the first place. News reports are full of stories of celebrities of all sorts—professional athletes, actors, royalty—who become sick. We have deep empathy for anyone who is sick with this disease, but it is important to remember that people with access to resources, the rich and the well-connected, have a much better chance of surviving than poor people. 

What does average income have to do with poor outcomes from coronavirus infection? The diseases that are more prevalent in poor and minority communities reflect decades of structural inequalities, of the burden of racism, income inequality, and marginalization all of which add up to populations that are simply much more vulnerable to any stressors—and COVID-19 is no exception—than those who are richer, more connected, and have the resources to buy their health, in good times and bad. If there ever was an illustration of the fact that the virus does indeed discriminate, it is this. Yes, we may all be at risk of contracting the virus, but even when we do, some of us are much more likely to die than others.

Coronavirus highlights the link between social inequality and health in stark and serious ways. Marginalized populations of all kinds stand a greater chance of dying of acute illness because of the chronic circumstances in which they find themselves. This isn’t a problem that can be solved with more ventilators, as essential as those are right now. Could recognizing this at this point in time finally lead us to tackle the structural issues that have long plagued us? Could we take this as the long-awaited encouragement we need to recognize that a healthier world will not be possible unless we invest in safe housing, good schools, livable wages, gender equity, clean air, drinkable water, and a fair economy for all?