In New York City, high cases of COVID-19 continue to be reported with a high prevalence among racial and ethnic minorities.
Lisa A. Newman, MD, MPH, FACS, FASCO
Cancer has long been among the chronic diseases that vastly impact minority racial communities, like Hispanic/Latin Americans and African Americans, along with noncancerous burdens like diabetes, hypertension, asthma, obesity, cardiovascular/cerebrovascular disease, and venous thromboembolism. Now, the coronavirus disease 2019 (COVID-19) has joined the list after showing high prevalence among these racial groups.
In a presentation during the American Association for Cancer Research (AACR) Virtual Annual Meeting II, Lisa A. Newman, MD, MPH, FACS, FASCO, director, Interdisciplinary Breast Oncology Program, and medical director and founder, International Center for the Study of Cancer, Weil Cornell Medicine/New York Presbyterian Hospital Network, reported on public health disparities in New York City (NYC), the known United States epicenter of the COVID-19 pandemic.
“Disparities and comorbidities associated with metabolic syndromes, such as obesity, hypertension, and cardiovascular disease, are all well documented as contributing to the cancer burden of racial and ethnic minorities. These associations are multifactorial in ideology and the magnitude of the disparity varies by type of disease, population subset, and also by the extent to which individual factors account for the disparity,” Newman explained.
“The offense of systemic racism and socioeconomic disadvantages on access to health care, as well as our delivery of health care are dominating and pervasive factors in this complex picture. But other factors also contribute to varying degrees, such as the biology of disease, environmental exposures, germline genetics, and the epigenetic effects of lifetime stressors.”
COVID-19 morality has impacted all races, but statistics show a disproportionate mortality rate among African Americans and Hispanic/Latin Americans. For African Americans, the mortality rate is at least 2-fold higher than any other racial group in the United States, and notably, mortality rates are lowest among Caucasian Americans. The disproportionate mortality rates among African Americans compared with other racial/ethnic groups remained consistent, despite the region of the United States in which patients with COVID-19 lived and despite the percentages of African Americans residing in each state.
In New York state, African Americans make up 14% of the population, but have a COVID-19 mortality rate of 26%. The state of Michigan also has a 14% African American population, and the COVID-19 mortality rate among this population in Michigan is 41%. In the south, 32% percent of the population in Louisiana is African American and the mortality rate is 55%, and in Mississippi, African Americans make up 38% of the population and have a COVID-19 mortality rate of 52%.
Moving westward in the United States, African Americans fare better, but are still disproportionately dying of COVID-19. Specifically, the population of Texas is 12% African American and the COVID-19 mortality rate of that population is 18%. In Wisconsin, only 6% of the population in African American, yet this group accounts for 26% of COVID-19–related deaths. Finally, in California, where African Americans represent 6% of the population, the COVID-19 mortality rate is 10%.
In some US states, statistics around COVID-19–related deaths are not available to the public, including Hawaii, Nebraska, North Dakota, South Dakota, Utah, Wyoming, and West Virginia. Also, Newman noted that the data from Texas was of poor quality and the information obtained through the Centers for Disease Control and Prevention (CDC) is unclear because the CDC has a lag in obtaining the data, and some data are suppressed.
Since March 11, 2020, citizens of NYC from all racial backgrounds have been succumbing to COVID-19–related illnesses. In the beginning of April 2020, COVID-19–related deaths peaked in NYC with 590 occurring in a single day (April 7, 2020). The curve began to flatten in early June, during which time NYC saw the first day without any COVID-19–related deaths (June 4, 2020). Since the start of the pandemic (June 10, 2020 cutoff), 17,203 COVID-19 deaths have been reported in NYC, accounting for 15% to 19% of all the COVID-19–related deaths in the country. In terms of race, the highest number of COVID-19–related deaths occurred in the African American population.
According to an age-adjusted case rate per 100,000 people, 335 African Americans with COVID-19 were not hospitalized, 271 were hospitalized but did not die, and 92 died from complications of COVID-19. Morality in the Hispanic/Latino population was also high. There were 271 individuals who identified as Hispanic or Latino with COVID-19 who were not hospitalized, while 198 were hospitalized but lived, and 74 died due to COVID-19–related complications.
Among Caucasian Americans, there were 190 per 100,000 people with COVID-19 who were not hospitalized, 114 who were hospitalized and did not die, and 45 deaths. Asian Americans in NYC had the lowest rates, with 95 diagnosed with COVID-19 and not hospitalized, 82 had a non-fatal hospitalization, and 34 died.
Homing in on why COVID-19-related mortality rates are so high among minorities, Newman said, “African Americans, Hispanics, and Latinos were hit so hard by COVID in NYC, and many of these reasons are related to sociodemographics and exposure to viral load. These minority population subsets account disproportionately for our essential workers that kept the city going during the shutdown, such as hospital workers and employees of transportation and public service systems.”
“African Americans and Hispanic/Latino individuals are more likely to share multigenerational homes or to live in the housing environments that are less well equipped to comply with social distancing policies. Also, importantly, these minority population subsets are more likely to receive their health care in safety-net hospitals that are financially and resource-constrained,” Newman said.
Examining the neighborhoods in the New York metropolitan area, Newman pointed out that the most populous neighborhoods are Brooklyn and Manhattan. The wealthiest neighborhood in term of median household income is Staten Island, although a large percentage of NYC millionaires reside in Manhattan. In terms of poorer neighborhoods, Brooklyn comes in second behind the Bronx, where nearly 30% of residents live below the poverty line.
“These various factors are linked to COVID-19 burden in conflicting ways, as population density will clearly intensify the spread of a contagion, but wealth and better healthcare access can control its impact,” Newman stated.
Lack of racial and ethnic diversity in the New York boroughs is a contributor to the COVID-19 mortality issue, noted Newman. The population of Staten Island, which has the highest median household income, is more than 75% Caucasian, just over 10% Hispanic/Latino, less than 10% African American, and 5% Asian. In the poorest neighborhood, the Bronx, the population is predominantly Hispanic/Latino (+40%), followed by 35% African American, 29% Caucasian, and less than 5% Asian. The NYC neighborhood with the highest African American population is Brooklyn; however African Americans are still not the majority in Brooklyn or any other NYC borough. Asian Americans make up the smallest population of NYC, but have a greater presence in Queens than in any other NYC neighborhood.
The impact of these racial and ethnic patterns across NYC neighborhoods is that the poorer neighborhoods with the most African Americans and Hispanics/Latinos have the highest COVID-19 death rates, while predominantly Caucasian and wealthy communities, like Staten Island, have the lowest COVID-19 mortality rates.
In most NYC neighborhoods, the majority of COVID-19–related deaths occurred in African Americans, even in neighborhoods like Staten Island, where they account for less than 10% of the population. Hispanics and Latinos also saw mortality rates that were higher than Caucasian and Asians in neighborhood like Staten Island, and Manhattan, where they are a minority group.
Based on the same neighborhood socioeconomic realities, breast cancer diagnoses occur in the later stages more commonly among African Americans, Hispanic Americans, and Latinos than Caucasian Americans and Asian Americans. In NYC, patients with breast cancer in Brooklyn were the least likely to be diagnosed in the early stages of disease (60%), followed by the Bronx (61%), Queens (65%), Manhattan (68%), and Staten Island (69%). Patients in the Bronx have the highest rate of breast cancer mortality, and Staten Island and Queens are tied at the lowest.
In terms of race and ethnicity, the majority of the individuals who died from breast cancer in NYC were African Americans in Manhattan, followed by Caucasian Americans in the Bronx. These trends are cause for concern in NYC, said Newman, as cancer is a COVID-19 burden in of itself.
Highlighting once again the high prevalence of comorbidities in both the African American and the Hispanic/Latino populations, and also mentioning new genetic information around the biology of breast tumors in African Americans, Newman explained that these groups will continue to experience hardship as NYC and the rest of the country shift towards COVID-19 recovery.
“As we look to pandemic recovery, we should also be proactive in addressing the likely impact of COVID on cancer disparities, with breast cancer being a prime example of why this is important. During our medical response to managing the COVID health crisis, our mammography screening programs were placed on hiatus, and this will probably have a worse impact on communities, such as African Americans that were already more likely to have advanced breast cancer stage distribution,” said Newman. “Minorities will be more likely than others to lose their jobs and insurance coverage as a consequence of the COVID recession, and this will also impact breast cancer screening as well as treatment during COVID recovery.”
Newman LA, Partnerships between the breast oncology and public health communities to address disparities: lessons learned from the New York City COVID-19 epicenter. Presented during: AACR Virtual Annual Meeting II; June 22-24, 2020.