High infection and hospitalisation rates

Spanning across the United Kingdom (UK), Brazil, Norway, Sweden and the United States (US), international data consistently suggest that minority communities are subject to disproportionately high rates of infection and hospitalisation. Although a recent UK census indicates that racial and ethnic minorities comprise about 14% of the UK population, on 1 May 2020, the UK's Intensive Care National Audit and Research Centre reported that racial and ethnic minorities made up 2300 (34%) of 6770 critically ill COVID-19 patients [7].

Analogously, using multivariate logistic regression, clinical data from Brazil revealed that, of 10 713 COVID-19 positive patients, only those who had Asian, indigenous or ‘unknown race’ backgrounds were at increased risk for hospitalisation [Reference Soares, Mattos and Raposo8]. In Norway, individuals with Somalian backgrounds have had COVID-19 infection rates that are greater than 10 times the national average, representing 1586 per 100 000 (vs. national average: 140 per 100 000). In Sweden, a Public Health Agency survey demonstrated that, despite comprising 0.5% of Sweden's population, immigrants from Somalia, Syria and Iraq made up 5% of confirmed COVID-19 cases [Reference Yaya9]. Broadly, throughout Europe, the Roma minority has experienced staggeringly disproportionate COVID-19 risks [Reference Matache and Bhabha5].

Moreover, a recent US study that analysed data from 14 states found that, of 580 COVID-19 positive hospitalised patients, 261 (45.0%) were non-Hispanic white (‘white’), 192 (33.1%) were non-Hispanic Black (‘Black’), 47 (8.1%) were Hispanic, 32 (5.5%) were Asian, 2 (0.3%) were American Indian/Alaskan Native and 46 (7.9%) were of other or unknown race [Reference Garg10]. Given that, for example, approximately 76.5% of the US population is white while only 13.4% of the US population is Black (United States Census Bureau, 2019) [11], these COVID-19 hospitalisation rates of 45.0% white vs. 33.1% Black are disproportionate. Finally, in terms of indigenous communities, the Navajo Nation in the US surpassed all of New York in terms of numbers of per capita COVID-19 cases [Reference Curtice and Choo12].

High death rates

On an international scale, COVID-19 deaths are recurrently and disproportionately impacting minority communities. In the UK, even when controlling for differences in frontline worker positions, data indicate that healthcare staff in the National Health Service (NHS) who identify as racial and ethnic minorities have experienced disproportionate COVID-19 mortality rates [7]. Furthermore, an analysis run the UK Office for National Statistics has indicated that, compared to white individuals in the UK, risk of COVID-19-related death is much higher for many racial and ethnic minorities in the UK. In particular, after controlling for age, the analysis revealed that, compared to white men and white women, Black men and Black women are, respectively, 4.2 and 4.3 more likely to experience COVID-19-related deaths while UK individuals of Bangladeshi, Pakistani, Indian or mixed race backgrounds had a statistically significant higher risk of COVID-19-related mortality [13]. Consistently, another study found that, while Black individuals in the UK were more than four times more likely to die from COVID-19, individuals in the UK of Bangladeshi, Pakistani, Chinese and mixed race backgrounds were approximately 1.8 times more likely to experience COVID-19-related mortality [Reference Yaya9].

In Brazil, one report suggested that its indigenous communities are potentially experiencing double the amount of COVID-19 deaths than the rest of its population [Reference Curtice and Choo12]. Additionally, of 11 321 confirmed COVID-19 positive hospitalised patients in Brazil, mixed race (Pardo) and Black (Preto) patients had a significantly higher risk of mortality than white (Branco) patients (hazard ratio, 95% CI 1.45–1.33–1.58 for Pardo; 1.32, 1.15–1.52 for Preto). Moreover, after age, mixed race was the second most meaningful risk factor in predicting death [Reference Baqui14]. In the US, a set of New York City data revealed that death rates for Black individuals (92.3 deaths per 100 000) and Hispanic individuals (74.3 deaths per 100 000) were higher than death rates for white individuals (45.2 deaths per 100 000) and Asian individuals (34.5 deaths per 100 000; Bureau of Communicable Disease Surveillance System, 2020) [15].

At work

Transmission risks are particularly high for individuals in industries designated as essential, in that they must continue to work on the frontlines despite outbreaks. In particular, high rates of transmission and death have occurred in the service industry and factory-farming industry, including meatpacking facilities [Reference Waltenburg16]. These contexts are generally comprised of minimal resources (such as protective equipment), densely packed working conditions, low wages and low mobility. Low mobility includes the inability to leave or take time off from a dangerous job due to financial pressure. In short, individuals in low-wage occupations are often working in enclosed, high-transmission contexts without the financial option to leave.

To a skewed degree, many of the frontline workers in these essential industries are people of color and immigrants. For instance, in the US, low-wage, frontline occupations are disproportionately comprised of Black individuals, Hispanic individuals and immigrants [Reference Poteat4, Reference Clark17]. Specifically, Hispanic individuals account for 17% of the total US workforce; yet approximately 53% of individuals working in agricultural sectors are Hispanic. Analogously, Black individuals comprise about 12% of the total US workforce; yet approximately 36% of individuals working as nursing, psychiatric or health home aides, 31% of individuals working as security guards and surveillance gaming officers and 30% of individuals working as licensed practical and licensed vocational nurses are Black [18]. Compounding transmission inequities, individuals working in low-wage sectors may be unable to leave their occupations or receive healthcare due to lack of living wages, no paid sick leave and/or no health insurance, which people of color in the US disproportionately lack access to [Reference Poteat4, Reference Bartel19]. Without access to these essential healthcare resources, individuals may be unable to take time off from work, despite being a carrier for SARS-CoV-2.

Undeniably, many essential industries are high-risk transmission environments [Reference Poteat4, Reference Clark17]. For instance, from 9 March to 20 April 2020, a total of 2494 COVID-19 deaths from the working age population (aged 20–64) of the UK were recorded. Compared to the death rates among people of the same sex and age in the general population, the following groups had significantly higher COVID-19 death rates: (a) males working as security guards (45.7 deaths per 100 000), (b) males working in construction (25.9 deaths per 100 000), (c) males working in service occupations (19.3 deaths per 100 000 males) and (d) males and females working in social care (which includes transport workers; 23.4 deaths per 100 000) [Reference Windsor-Shellard and Kaur20]. Analogously, a recent Centers for Disease Control and Prevention (CDC) study found that, in just 239 US meat and poultry processing facilities, 16 233 COVID-19 positive cases were reported throughout April and May. Among the 9919 cases in which race and ethnicity were recorded, racial and ethnic minorities comprised 87% of COVID-19 positive individuals [Reference Waltenburg16].

At home

Racial and ethnic minorities disproportionately live in densely populated areas, which can contribute to high transmission rates [Reference Rocklöv and Sjödin21]. Specifically, racial residential segregation is tied to higher population density and greater health disparities, such as a greater distance to facilities, a larger frequency of adverse health outcomes, including mortality [Reference Hearst, Oakes and Johnson22] and a higher likelihood of underlying health conditions, including diabetes [Reference Bravo23]. In brief, with more comorbidities and less access to necessary facilities, such as grocery stores and hospitals, many people of color, immigrants and indigenous communities are particularly susceptible to SARS-CoV-2 transmission and mortality.

In health

In the UK, compared to white people, disproportionate risks of in-hospital COVID-19 deaths for Black individuals and individuals with Asian backgrounds have been consistently attributed to deprivation [Reference Yaya9, Reference Williamson24]. In Brazil, that white (Branco) individuals are more likely to survive COVID-19 than mixed race (Pardo) individuals has been partially attributed to data that reveal (a) white individuals are more likely to be admitted to the ICU once hospitalised and (b) white individuals have greater access to private hospital settings [Reference Baqui14]. In the US, multivariate regression modelling from four distinct datasets consistently indicated that, compared to white individuals, Hispanic individuals have statistically significantly lower rates of paid-leave access [Reference Bartel19]. Moreover, across ages, Black individuals were found to be far more likely than white individuals to report not having been able to see a doctor in the past year due to cost, regardless of desire or need [Reference Cunningham25]. Finally, the median household income for Native Americans on or affiliated with US tribal reservations is approximately $39 700 (a sharp contrast to the median household income for the rest of the US, $57 600) and one of the primary income sources, casinos, are now completely shut down. With Native American tribes' tax base drastically cut, tribal governments no longer have the funds to run health clinics, significantly undermining access to healthcare [Reference Dorn, Cooney and Sabin26].

Racial bias can also occur in the healthcare system, which (a) may lead to decreased trust in healthcare and (b) has been strongly tied to worse treatment outcomes for people of color. For instance, a pivotal study that included white medical students and white residents demonstrated that some falsely believed there were biological differences in Black and white individuals; these false beliefs predicted a racial bias in pain perception and treatment recommendation accuracy [Reference Hoffman27]. In terms of COVID-19, data have already begun to suggest that, when reporting the same symptoms as white individuals, Black and Hispanic individuals are less likely to receive testing and treatment [28].

Finally, a key question is: how feasible is access to medical care for detainees? A recent US study used a stochastic susceptible−exposed−infected−recovered model to (a) estimate the rate of SARS-CoV-2 transmission within 111 US immigration and Customs Enforcement (ICE) detention centres and (b) evaluate the impacts on regional hospital intensive care unit (ICU) capacity. The study found that, assuming the most optimistic parameters (R ₀ = 2.5), 72% of individuals would be expected to be infected by day 90. With more pessimistic parameters (R ₀ = 7), nearly 100% of individuals would be expected to be infected by day 90. Assuming all ICU beds were made available for infected detainees, in the most optimistic scenario, SARS-CoV-2 outbreaks among a minimum of 66 ICE facilities (59%) would overwhelm ICU beds within a 10-mile radius over a 90-day period; outbreaks among a minimum of nine ICE facilities (8%) would overwhelm local ICU beds within a 50-mile radius over a 90-day period [Reference Irvine29]. Hence, the impact of SARS-CoV-2 transmission in detention facilities is both lethal within and beyond these spaces.

In public spaces

Ranging from highly efficient filtration respirators to less efficient cloths, a critical component of reducing transmission is wearing a mask. Even cloth can help the wearer reduce viral transmission (if infected) and, conversely, can protect one from becoming infected [Reference Feng30]. However, reports have indicated that Black individuals, particularly Black men, may not wear protective masks because they are concerned about experiencing greater racial profiling from police [Reference Taylor31]. Racial profiling is characterised as consciously or subconsciously using an individual's race or ethnicity as the basis for suspecting them of having committed an offense. Across the globe, from the UK to Canada to India to South Africa to Japan to the US, people of color and immigrants have historically been disproportionately subjected to police contact, scrutiny and force, which has frequently been attributed to racial profiling [Reference Weber and Bowling32–Reference Pierson34]. In brief, the stereotypes, bias and racism that many people of color and immigrants already face may be an additional barrier to safely protecting themselves and others from SARS-CoV-2 transmission.

In incarceration

As enclosed spaces with high population densities, minimal resources, and few mobility options, incarcerated spaces are breeding grounds for viral transmission. As of 15 March 2020, the World Health Organization (WHO) issued suggestions for prisons and other places of detention to implement [35]. While the suggestions to protect the health, safety and human rights of incarcerated individuals are sound, many facilities cannot or will not implement this guidance due to a combination of being understaffed, lacking funding for and access to basic medical supplies and prioritising security over health [Reference Williams36]. Due to institutionalised racism, communities of color are often disproportionately represented in incarcerated spaces [Reference Alexander37] and, therefore, will disproportionately bear the negative impacts of SARS-CoV-2 transmission.

Occurring on massive, rapid and global scales, many prison and jail outbreaks and deaths from COVID-19 have occurred. For instance, in Wuhan, China, almost half of reported COVID-19 incident cases (233 of 565) were from the prison system. Analogously, in Shendong, China, 450 miles away, a separate, major prison outbreak was traced back to officials who had visited Wuhan and then infected seven prison guards and 200 inmates [Reference Barnert, Ahalt and Williams38]. Similarly, in the US, a state prison in Ohio reported that 78% of inmates (2011 individuals) tested positive for COVID-19. As of 22 April 2020, Ohio's incarcerated population makes up 20% of the entire state's positive coronavirus cases [Reference Bates39]. In Brazil, an estimated 80% of the prison population will be infected with COVID-19, of which 20% may need hospitalisation [Reference Shadmi40]. Importantly, although inmates are confined, jail and prison guards are also exposed to SARS-CoV-2; on a daily basis, guards actively exit the complexes. Therefore, jail and prison outbreaks are not isolated events; SARS-CoV-2 outbreaks in these confined spaces may easily result in major transmission events in surrounding areas.

Notably, prisons, jails and ICE detention centres may be privately owned. When private ownership applies, these spaces are not subject to crucial governmental jurisdictions. Private companies manage 8.4% of the US prison population and 5.4% of the US jail population [Reference Gaes41]. Privately owned prisons and jails have received attention for human rights violations due to overcrowding, an issue that is particularly deadly during a pandemic. Most detained US immigrants are housed in one of the 250+ local detention facilities that operate under either intergovernmental service agreements or private facilities. These facilities are not subject to the Performance-Based National Detention Standards [Reference Page42].