Dean's COVID-19 Commentary

Thirty years ago, I read an article—"Excess Mortality in Harlem”—that I have never forgotten. Written by two surgeons at Harlem Hospital (Harold Freeman and Colin McCord), the article compared all-cause mortality in Harlem to that across New York City and that of the US White population. The findings were startling; mortality was increased approximately three-fold for male and female Harlem residents under age 65 years. For men, life expectancy was less than for men in Bangladesh. There were other pockets in the city with similarly high mortality and also predominantly minority populations. The authors concluded: “A major political and financial commitment will be needed to eradicate the root causes of this high mortality: vicious poverty and inadequate access care to the basic health that is the right of all Americans.” Now, structural racism would be called out as one of the root causes. 

Income persists as a driver of life expectancy, even when its correlates, including race and ethnicity, are taken into account. Chetty and colleagues provide a powerful analysis for 2001-2014 based on income reported on tax returns. Across this period, life expectancy increased but less for those with lower income and not equally across the country. Chetty’s Opportunity Insights website provides tools for better understanding the consequences of race and income. 

Income and race have again synergistically collided with the COVID-19 pandemic, as with past pandemics over the centuries (read “An unequal blow” in the May 15 issue of Science). Two recent reports affirm the increased risk for African-Americans. In Atlanta, data from a single academic healthcare system showed that factors independently associated with hospitalization were age ≥65 years (adjusted odds ratio (OR) = 3.4); black race (OR = 3.2); having diabetes mellitus (OR = 3.1); lack of insurance (OR = 2.8); male sex (OR = 2.4); smoking (OR = 2.3); and obesity (OR = 1.9). A study carried out within the Ochsner health system in Louisiana also found that black race (compared with white race) was associated with an approximately two-fold increased risk for hospitalization after adjustment for other factors. For those hospitalized, race was not associated with risk for in-hospital death. These studies confirm that race and its powerful correlates of income, education, and employment likely contribute to becoming infected with SARS-CoV-2 and needing hospitalization because of the severity of the clinical picture. 

The concluding sentence of the McCord and Freeman paper still echoes, but that echo remains unheard by too many of those in power, as before. Starting with the protests, we need a new and sustained political commitment to address the sustained legacy of structural racism and the core economic inequities of our country. Public health will benefit. 

One person can make a difference in public health. An exemplar: Kirk Smith, professor of global environmental health at the University of California Berkeley’s School of Public Health who died last week. I first met Kirk in the early 1980s as he began to plan an investigation of household air pollution, a global problem that he was quick to recognize and attack after making the first measurements of airborne particles in the smoke from cooking over a biomass fire in India. Over the ensuing four decades, he was the champion of doing something about the problem. He showed the health consequences of household air pollution and how to reduce them through improved stoves and substitution of less polluting fuels. For example, his efforts in India contributed to initiation of a program that gave access to LPG to households, now totaling 80 million. Read about him: researcher and champion for policy change at the global scale.

Until next week,   




Jonathan Samet, MD, MS
Dean, Colorado School of Public Health