Abstract

This study aimed to analyze how scientific publications described and interpreted findings about the relationship between the Black population and events linked to COVID-19 in 2020. Narrative review with systematic search, in which a survey was conducted on articles published in 2020 in the Scopus, Medline/PubMed, and Web of Science databases. Initially, 665 articles were found, and after reading and applying the eligible criteria, the final number of 45 articles was reached. Epidemiological, observational studies, secondary data and developed in the United States predominated. Four groupings and respective findings emerged from the synthesis of information extracted: Main events in the Black population - high number of deaths and mortality rate; Direct relationships - poor health, housing, and work conditions; Intermediate relationships - low income and anti-Black prejudice; Comprehensive relationships - structural racism and social determinants of health. The identification of racial health disparities is an important finding about the dynamics of the pandemic among the Black population. However, multicausal explanations were limited. It is necessary to mobilize critical theoretical resources from ethnic and health studies to qualify research in order to support global actions to combat the SARS-CoV-2 epidemic in this group.

Keywords:
Racism; Public health; Social determinants of health; COVID-19

Introduction

At the end of 2019, cases of pneumonia of unknown cause in patients in Wuhan, China, led to the discovery of the virus called Coronavirus¹1 Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao GF, Tan W. A novel Coronavirus from patients with pneumonia in China, 2019. N Eng J Med 2020; 382(8):727-733.. Modern transport routes between mass populations²2 Mizumoto K, Chowell G. Transmission potential of the novel coronavirus (COVID-19) onboard the diamond Princess Cruises Ship, 2020. Infect Dis Model 2020; 5:264-270. favored rapid viral intercontinental dissemination, triggering a devastating international impact. In March 2020, The World Health Organization (WHO) declared the new Coronavirus a pandemic. Faced with this new global health situation, responses relating to risk groups, containment, mitigation, suppression, and recovery measures were the subject of actions and research in Public Health, produced at an unprecedented speed³3 Werneck, GL, Carvalho, MS. A pandemia de COVID-19 no Brasil: crônica de uma crise sanitária anunciada. Cad Saude Publica 2020; 36(5):e00068820..

Regarding risk groups, older adults were initially identified as the more vulnerable population⁴4 Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395(10223):497-506.. As soon as restrictive circulation measures began to be implemented, accompanied by socioeconomic government actions⁵5 Houvèssou GM, Souza TO, Silveira MF. Medidas de contenção de tipo lockdown para prevenção e controle da COVID-19: estudo ecológico descritivo, com dados da África do Sul, Alemanha, Brasil, Espanha, Estados Unidos, Itália e Nova Zelândia, fevereiro a agosto de 2020. Epidemiol Serv Saude 2020; 30(1):e2020513., the topic of social inequalities and illness from SARS-CoV-2 in different groups, such as the Black population, also gained interest among researchers.

The systematic review conducted by De Souza et al.⁶6 Souza TA, Silva PHAD, Silva Nunes ADD, de Araújo II, de Oliveira Segundo VH, de Oliveira Viana Pereira DM, Barbosa IR, de Vasconcelos Torres G. The association between race and risk of illness and death due to COVID-19: a protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99(46):e22828. (2020) in September 2020 to analyze the association of race with a higher risk of illness and death due to COVID-19 concluded that differences observed in hospitalization rates and mortality from SARS-CoV-2 “reflect the general trends” in racial/ethnic health disparities, which arise from interactions such as poverty, access to healthcare, individual factors, and chronic diseases.

While studies have already documented the identification of ethnic-racial inequalities in health in the Black population before the pandemic, explanations of the mechanisms for articulating and sustaining the health situation of this population group are still incipient. Therefore, when considering the magnitude of the COVID-19 pandemic in the Black population and the first studies on this topic, it is important to revisit this issue since, besides the historical record value, understanding the meanings of these synthesized findings also represents a new starting point, which can influence the direction of knowledge production on this topic.

Thus, this article aimed to analyze how scientific publications described and interpreted findings about the relationship between the Black population and events linked to COVID-19 in the first year of the pandemic.

Methods

This is a narrative review of scientific articles with a systematic search based on the Scale for the Assessment of Narrative Review Articles (SANRA)⁷7 Baethge C, Goldbeck-Wood S, Mertens S. SANRA-a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. [periódico na Internet] 2019 Mar [acessado 2023 mar 24] 26; 4:5. Disponível em: 10.1186/s41073-019-0064-8.
https://doi.org/10.1186/s41073-019-0064-... . We surveyed scientific articles indexed in Medline/PubMed, Scopus (Elsevier), and Web Of Science databases from December 2020 to March 2021.

After exploratory reading of thematic articles and consulting the Medical Subject Headings Terms (MeSH) of the United States National Library of Medicine (NLM), the search descriptors were defined as “COVID-19”, “Coronavirus”, “Race”, “Racism”, “Black People”, combining the descriptors associated with Boolean operators as shown in Chart 1. We included complete empirical articles published in scientific journals during 2020 that investigated the issue of COVID-19 among the Black population. We excluded duplicates, opinion articles, literature reviews, and theoretical essays, even if they addressed the topic.

We initially found 665 articles. Next, we proceeded with an exploratory reading of the titles and abstracts, following the eligibility criteria. After reading the articles in full, 45 final articles remained, as shown in Figure 1. Finally, we created data organization and analysis table containing the categories emerging from reading the content extracted from the “results and discussion” sections of the articles, namely, “main events in the Black population”, “direct relationships”, “intermediate relationships”, and “comprehensive relationships”.

Results

The results showed us that most studies are concentrated in the United States, as described in Table 1. The term “US counties”, to refer to American counties, was used in most articles to conduct a general analysis of the country’s population without specifying the State. We identified the predominance of observational epidemiological studies developed from secondary data from government databases and hospital services.

Concerning the findings that relate COVID-19 to the Black population, Figure 2 presents an overview of the synthesis, followed by a detailed description.

Main events in the black population - cases, hospitalizations, and deaths

The findings show that infection and illness, hospitalization, and deaths in the general population revealed inequalities between racial groups during the COVID-19 pandemic. Such events appear at different frequencies, ranging, in descending order, from the high number of deaths and mortality rates to risks, exposure, and vulnerability.

Thus, the Black population, especially when compared to the whites and Hispanics, is related not only to a high mortality rate but also to a higher risk of death, regardless of factors such as comorbidities, poverty, access to care health, and risk factors⁸8 Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med 2020; 382(26):2534-2543.

9 Li AY, Hannah TC, Durbin JR, Dreher N, McAuley FM, Marayati NF, Spiera Z, Ali M, Gometz A, Kostman JT, Choudhri TF. Multivariate Analysis of Black Race and Environmental Temperature on COVID-19 in the US. Am J Med Sci 2020; 360(4):348-356.

10 Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol 2020; 48:9-14.

11 Cowger TL, Davis BA, Etkins OS, Makofane K, Lawrence JA, Bassett MT, Krieger N. Comparison of weighted and unweighted population data to assess inequities in coronavirus disease 2019 deaths by race/ethnicity reported by the US centers for disease control and prevention. JAMA Netw Open 2020; 3(7):e2016933.

12 Mahajan UV, Larkins-Pettigrew M. Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties. J Public Health (Oxf) 2020; 42(3):445-447.^-1313 Golestaneh L, Neugarten J, Fisher M, Billett HH, Gil MR, Johns T, Yunes M, Mokrzycki MH, Coco M, Norris KC, Perez HR, Scott S, Kim RS, Bellin E. The association of race and COVID-19 mortality. EClinicalMedicine 2020; 25:100455.. This situation can also be seen territorially, where, in the United States, in general, counties with higher proportions of Black residents had more deaths from COVID-19, regardless of size¹⁴14 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020; 47:37-44.^,1515 Cheng KJG, Sun Y, Monnat SM. COVID-19 death rates are higher in rural counties with larger shares of Blacks and Hispanics. J Rural Health 2020; 36(4):602-608..

According to Bassett et al.¹⁶16 Bassett MT, Chen JT, Krieger N. Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: a cross-sectional study. PLoS Med 2020; 17(10):e1003402., the disproportional number of deaths indicates that potential years of life lost before 65 were experienced by Black and Hispanic populations compared to whites. However, the latter is the majority in the USA. Also, Black people accounted for 18.7% of overall deaths despite representing only 12.5% of the population in that country¹⁷17 Gold JAW, Rossen LM, Ahmad FB, Sutton P, Li Z, Salvatore PP, Coyle JP, DeCuir J, Baack BN, Durant TM, Dominguez KL, Henley SJ, Annor FB, Fuld J, Dee DL, Bhattarai A, Jackson BR. Race, ethnicity, and age trends in persons who died from COVID-19 - United States, May-August 2020. MMWR Morb Mortal Wkly Rep 2020; 69(42):1517-1521.. Thus, a question raised by Wrigley-Field¹⁸18 Wrigley-Field E. US racial inequality may be as deadly as COVID-19. Proc Natl Acad Sci U S A 2020; 117(36):21854-21856. indicates that the entire white population of the United States would need to “experience a level of excess mortality comparable to 90% of the official COVID-19 mortality rate (for all racial groups) in New York City” to achieve the highest Black mortality rates.

Regarding hospitalization, the Black population was identified as the racial group most hospitalized due to the new Coronavirus infection against patients from all racial groups testing positive, mainly when associating poverty, older age, male sex, and obesity, and this inequality persists even adjusting for age, sex, comorbidity and income¹⁹19 Patel AP, Paranjpe MD, Kathiresan NP, Rivas MA, Khera AV. Race, socioeconomic deprivation, and hospitalization for COVID-19 in English participants of a national biobank. Int J Equity Health 2020; 19(1):114.

20 Muñoz-Price LS, Nattinger AB, Rivera F, Hanson R, Gmehlin CG, Perez A, Singh S, Buchan BW, Ledeboer NA, Pezzin LE. Racial disparities in incidence and outcomes among patients with COVID-19. JAMA Netw Open 2020; 3(9):e2021892.

21 Gu T, Mack JA, Salvatore M, Prabhu Sankar S, Valley TS, Singh K, Nallamothu BK, Kheterpal S, Lisabeth L, Fritsche LG, Mukherjee B. Characteristics associated with racial/ethnic disparities in COVID-19 outcomes in an academic health care system. JAMA Netw Open 2020; 3(10):e2025197.^-2222 Azar KMJ, Shen Z, Romanelli RJ, Lockhart SH, Smits K, Robinson S, Brown S, Pressman AR. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff (Millwood) 2020; 39(7):1253-1262.. Corroborating this, Wiemers et al.²³23 Wiemers EE, Abrahams S, AlFakhri M, Hotz VJ, Schoeni RF, Seltzer JA. Disparities in vulnerability to complications from COVID-19 arising from disparities in preexisting conditions in the United States. Res Soc Stratif Mobil 69:100553. show that non-Hispanic Blacks are more vulnerable than non-Hispanic whites and Hispanics, both at comparable ages and regarding increasing age.

However, in ICU admission for the same cause, no association was identified between race/ethnicity and increased admission¹⁹19 Patel AP, Paranjpe MD, Kathiresan NP, Rivas MA, Khera AV. Race, socioeconomic deprivation, and hospitalization for COVID-19 in English participants of a national biobank. Int J Equity Health 2020; 19(1):114.

20 Muñoz-Price LS, Nattinger AB, Rivera F, Hanson R, Gmehlin CG, Perez A, Singh S, Buchan BW, Ledeboer NA, Pezzin LE. Racial disparities in incidence and outcomes among patients with COVID-19. JAMA Netw Open 2020; 3(9):e2021892.^-2121 Gu T, Mack JA, Salvatore M, Prabhu Sankar S, Valley TS, Singh K, Nallamothu BK, Kheterpal S, Lisabeth L, Fritsche LG, Mukherjee B. Characteristics associated with racial/ethnic disparities in COVID-19 outcomes in an academic health care system. JAMA Netw Open 2020; 3(10):e2025197.. Even so, the study by Arasteh²⁴24 Arasteh K. Prevalence of comorbidities and risks associated with COVID-19 among Black and Hispanic populations in New York City: an examination of the 2018 New York City Community Health Survey. J Racial Ethn Health Disparities 2021; 8(4):863-869. developed in New York identifies that predominantly Black and Hispanic neighborhoods, with a higher level of poverty, had 1 ICU bed for 900 adults aged 60 or over, compared to 1 ICU bed for 452 in predominantly white neighborhoods, with less poverty.

Regarding cases, the highest number of positive tests for SARS-CoV-2 was associated with the Black population⁸8 Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med 2020; 382(26):2534-2543.^,2020 Muñoz-Price LS, Nattinger AB, Rivera F, Hanson R, Gmehlin CG, Perez A, Singh S, Buchan BW, Ledeboer NA, Pezzin LE. Racial disparities in incidence and outcomes among patients with COVID-19. JAMA Netw Open 2020; 3(9):e2021892.^,2525 Vahidy FS, Nicolas JC, Meeks JR, Khan O, Pan A, Jones SL, Masud F, Sostman HD, Phillips R, Andrieni JD, Kash BA, Nasir K. Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population. BMJ Open 2020; 10(8):e039849.^,2626 Kabarriti R, Brodin NP, Maron MI, Guha C, Kalnicki S, Garg MK, Racine AD. Association of race and ethnicity with comorbidities and survival among patients with COVID-19 at an urban medical center in New York. JAMA Netw Open 2020; 3(9):e2019795.. We should underscore the study by Lieberman-Cribbin et al.²⁷27 Lieberman-Cribbin W, Tuminello S, Flores RM, Taioli E. Disparities in COVID-19 testing and positivity in New York City. Am J Prev Med 2020; 59(3):326-332. conducted in New York/USA, which points out that the number of total tests increased significantly with the increasing proportion of white residents. However, the ratio of positive tests to total tests has decreased significantly with the higher proportion of white residents in the area.

Also, regarding incidence and prevalence rates, the findings show the disproportionally high rates in the Black population, whether in territories with a Black majority or not, with rates higher than their territorial representations²⁸28 Moore JT, Ricaldi JN, Rose CE, Fuld J, Parise M, Kang GJ, Driscoll AK, Norris T, Wilson N, Rainisch G, Valverde E, Beresovsky V, Agnew Brune C, Oussayef NL, Rose DA, Adams LE, Awel S, Villanueva J, Meaney-Delman D, Honein MA; COVID-19 State, Tribal, Local, and Territorial Response Team. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5-18, 2020 - 22 States, February-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69(33):1122-1126.

29 Tirupathi R, Muradova V, Shekhar R, Salim SA, Al-Tawfiq JA, Palabindala V. COVID-19 disparity among racial and ethnic minorities in the US: a cross sectional analysis. Travel Med Infect Dis 2020; 38:101904.^-3030 Abedi V, Olulana O, Avula V, Chaudhary D, Khan A, Shahjouei S, Li J, Zand R. Racial, economic, and health inequality and COVID-19 infection in the United States. J Racial Ethn Health Disparities 2020; 8(3):732-742.. The Brazilian study by Polidoro et al.³¹ reveals that quilombola communities composed mainly of people of African descent and Indigenous people located in metropolitan areas of the Southern states, the region with the largest Caucasian population in the country, are among the total population of the three metropolitan regions most impacted by the accumulation of COVID-19 cases.

Direct relationships - health, work, and housing conditions

The articles establish a direct relationship between the findings described above and the Black population. These events are, to a greater or lesser extent, associated mainly with health, work, and housing conditions. The greater frequency of these findings among the other groupings that address “relationships” suggests a multifactorial perspective.

Thus, “chronic conditions”, “multiple comorbidities”, “underlying health conditions”, “disease burden”, and “pre-existing diseases” are the terms appearing most frequently related to more significant hospitalization and deaths due to COVID-19 in this group, with consequent increase in the mortality rate. Health problems such as obesity, chronic kidney disease, heart disease, hypertension, chronic respiratory disease, dementia, chronic lung disease, asthma, HIV, morbid obesity, liver disease, and diabetes are the most cited in studies⁸8 Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med 2020; 382(26):2534-2543.

9 Li AY, Hannah TC, Durbin JR, Dreher N, McAuley FM, Marayati NF, Spiera Z, Ali M, Gometz A, Kostman JT, Choudhri TF. Multivariate Analysis of Black Race and Environmental Temperature on COVID-19 in the US. Am J Med Sci 2020; 360(4):348-356.^-1010 Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol 2020; 48:9-14.^,2626 Kabarriti R, Brodin NP, Maron MI, Guha C, Kalnicki S, Garg MK, Racine AD. Association of race and ethnicity with comorbidities and survival among patients with COVID-19 at an urban medical center in New York. JAMA Netw Open 2020; 3(9):e2019795.^,3232 Jones J, Sullivan PS, Sanchez TH, Guest JL, Hall EW, Luisi N, Zlotorzynska M, Wilde G, Bradley H, Siegler AJ. Similarities and differences in COVID-19 awareness, concern, and symptoms by race and ethnicity in the United States: cross-sectional survey. J Med Internet Res 2020; 22(7):e20001.

33 Thomas MD, Michaels EK, Darling-Hammond S, Nguyen TT, Glymour MM, Vittinghoff E. Whites' county-level racial bias, COVID-19 rates, and racial inequities in the United States. Int J Environ Res Public Health 2020; 17(22):8695.

34 Renelus BD, Khoury NC, Chandrasekaran K, Bekele E, Briggs WM, Ivanov A, Mohanty SR, Jamorabo DS. Racial Disparities in COVID-19 Hospitalization and In-hospital Mortality at the Height of the New York City Pandemic. J Racial Ethn Health Disparities 2020; 8(5):1161-1167.^-3535 Raine S, Liu A, Mintz J, Wahood W, Huntley K, Haffizulla F. Racial and ethnic disparities in COVID-19 outcomes: social determination of health. Int J Environ Res Public Health 2020; 17(21):8115..

Besides these conditions, limited access and reduced routine to health services, primarily due to the difficulty in covering the costs are a widespread situation among “racial minorities” in the USA, especially in the Black population¹⁰10 Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol 2020; 48:9-14.^,2828 Moore JT, Ricaldi JN, Rose CE, Fuld J, Parise M, Kang GJ, Driscoll AK, Norris T, Wilson N, Rainisch G, Valverde E, Beresovsky V, Agnew Brune C, Oussayef NL, Rose DA, Adams LE, Awel S, Villanueva J, Meaney-Delman D, Honein MA; COVID-19 State, Tribal, Local, and Territorial Response Team. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5-18, 2020 - 22 States, February-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69(33):1122-1126.. This country’s population experiences difficulty accessing health insurance due to a lack of financial conditions, which was observed even before the pandemic¹⁰10 Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol 2020; 48:9-14.^,1414 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020; 47:37-44.^,2929 Tirupathi R, Muradova V, Shekhar R, Salim SA, Al-Tawfiq JA, Palabindala V. COVID-19 disparity among racial and ethnic minorities in the US: a cross sectional analysis. Travel Med Infect Dis 2020; 38:101904.^,3636 Alobuia WM, Dalva-Baird NP, Forrester JD, Bendavid E, Bhattacharya J, Kebebew E. Racial disparities in knowledge, attitudes and practices related to COVID-19 in the USA. J Public Health (Oxf) 2020; 42(3):470-478.. As a result, chronic diseases that require prolonged and regular use of health services deteriorate, making these subjects even more vulnerable, causing poor progress of the disease and adverse outcome¹²12 Mahajan UV, Larkins-Pettigrew M. Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties. J Public Health (Oxf) 2020; 42(3):445-447.^,1313 Golestaneh L, Neugarten J, Fisher M, Billett HH, Gil MR, Johns T, Yunes M, Mokrzycki MH, Coco M, Norris KC, Perez HR, Scott S, Kim RS, Bellin E. The association of race and COVID-19 mortality. EClinicalMedicine 2020; 25:100455.^,1616 Bassett MT, Chen JT, Krieger N. Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: a cross-sectional study. PLoS Med 2020; 17(10):e1003402.^,1717 Gold JAW, Rossen LM, Ahmad FB, Sutton P, Li Z, Salvatore PP, Coyle JP, DeCuir J, Baack BN, Durant TM, Dominguez KL, Henley SJ, Annor FB, Fuld J, Dee DL, Bhattarai A, Jackson BR. Race, ethnicity, and age trends in persons who died from COVID-19 - United States, May-August 2020. MMWR Morb Mortal Wkly Rep 2020; 69(42):1517-1521.. We should underscore other aspects related to access, such as the long wait for care and even the patients’ delay in seeking a hospital for fear of exposure to discriminatory situations⁸8 Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med 2020; 382(26):2534-2543.^,1919 Patel AP, Paranjpe MD, Kathiresan NP, Rivas MA, Khera AV. Race, socioeconomic deprivation, and hospitalization for COVID-19 in English participants of a national biobank. Int J Equity Health 2020; 19(1):114.^,2222 Azar KMJ, Shen Z, Romanelli RJ, Lockhart SH, Smits K, Robinson S, Brown S, Pressman AR. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff (Millwood) 2020; 39(7):1253-1262..

Still, in this sense, the Black population is described as the majority in essential service stations, which implies that they cannot perform their activities remotely and are in constant contact with the public, triggering elevated cases in this group. Cashiers and market clerks, bus drivers, subway drivers, nurses, doctors, other health workers, meat packers, farmers, police officers, and firefighters are the most cited jobs⁹9 Li AY, Hannah TC, Durbin JR, Dreher N, McAuley FM, Marayati NF, Spiera Z, Ali M, Gometz A, Kostman JT, Choudhri TF. Multivariate Analysis of Black Race and Environmental Temperature on COVID-19 in the US. Am J Med Sci 2020; 360(4):348-356.^,1414 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020; 47:37-44.^,2020 Muñoz-Price LS, Nattinger AB, Rivera F, Hanson R, Gmehlin CG, Perez A, Singh S, Buchan BW, Ledeboer NA, Pezzin LE. Racial disparities in incidence and outcomes among patients with COVID-19. JAMA Netw Open 2020; 3(9):e2021892.^,2424 Arasteh K. Prevalence of comorbidities and risks associated with COVID-19 among Black and Hispanic populations in New York City: an examination of the 2018 New York City Community Health Survey. J Racial Ethn Health Disparities 2021; 8(4):863-869.^,2727 Lieberman-Cribbin W, Tuminello S, Flores RM, Taioli E. Disparities in COVID-19 testing and positivity in New York City. Am J Prev Med 2020; 59(3):326-332.^,2929 Tirupathi R, Muradova V, Shekhar R, Salim SA, Al-Tawfiq JA, Palabindala V. COVID-19 disparity among racial and ethnic minorities in the US: a cross sectional analysis. Travel Med Infect Dis 2020; 38:101904.^,3737 Goyal MK, Simpson JN, Boyle MD, Badolato GM, Delaney M, McCarter R, Cora-Bramble D. Racial and/or ethnic and socioeconomic disparities of SARS-CoV-2 infection among children. Pediatrics 2020; 146(4):e2020009951.

38 Rozenfeld Y, Beam J, Maier H, Haggerson W, Boudreau K, Carlson J, Medows R. A model of disparities: risk factors associated with COVID-19 infection. Int J Equity Health 2020; 29;19(1):126.

39 Yilmazkuday, H. COVID-19 and unequal social distancing across demographic groups. Reg Sci Policy Pract 2020; 12(6):1235-1248.^-4040 Hawkins D. Differential occupational risk for COVID-19 and other infection exposure according to race and ethnicity. Am J Ind Med 2020; 63(9):817-820.. Keeping social distancing in the workplace among peers⁸8 Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and Mortality among Black Patients and White Patients with Covid-19. N Engl J Med 2020; 382(26):2534-2543.^,1212 Mahajan UV, Larkins-Pettigrew M. Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties. J Public Health (Oxf) 2020; 42(3):445-447.^,4141 Ojinnaka CO, Adepoju OE, Burgess AV, Woodard L. Factors associated with COVID-related mortality: the case of Texas. J Racial Ethn Health Disparities 2021; 8(6):1505-1510. was challenging in most of these functions.

Furthermore, Black people are those with more than one job, forced to show up for work for fear of dismissal, even in contravention of the most restrictive mobility measures or during lockdowns⁴²42 Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT Jr, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Lo Re V 3rd, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. PLoS Med 2020; 22;17(9):e1003379.^,4343 Milner A, Franz B, Henry Braddock J. We need to talk about racism-in all of its forms-to understand COVID-19 disparities. Health Equity 2020; 4(1):397-402.. While being a less frequently raised issue, unemployment also appears as a situation that affects the so-called “ethnic minorities”, in particular, a significant part of the Black population, often generating the need for more significant movement in search of employment and, therefore, greater exposure¹⁴14 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020; 47:37-44.^,3939 Yilmazkuday, H. COVID-19 and unequal social distancing across demographic groups. Reg Sci Policy Pract 2020; 12(6):1235-1248.^,4343 Milner A, Franz B, Henry Braddock J. We need to talk about racism-in all of its forms-to understand COVID-19 disparities. Health Equity 2020; 4(1):397-402..

Regarding the domestic environment, multigenerational and multi-family homes characterize most of the homes of American ethnic minorities, predominantly Black and Hispanic people. Multigenerational households are marked by coexistence between older adults, the leading risk group, and, therefore, the target of the ostensible recommendation of social distancing, with young Black adults of working age, most of the essential workforce²⁰20 Muñoz-Price LS, Nattinger AB, Rivera F, Hanson R, Gmehlin CG, Perez A, Singh S, Buchan BW, Ledeboer NA, Pezzin LE. Racial disparities in incidence and outcomes among patients with COVID-19. JAMA Netw Open 2020; 3(9):e2021892.^,2929 Tirupathi R, Muradova V, Shekhar R, Salim SA, Al-Tawfiq JA, Palabindala V. COVID-19 disparity among racial and ethnic minorities in the US: a cross sectional analysis. Travel Med Infect Dis 2020; 38:101904.^,3737 Goyal MK, Simpson JN, Boyle MD, Badolato GM, Delaney M, McCarter R, Cora-Bramble D. Racial and/or ethnic and socioeconomic disparities of SARS-CoV-2 infection among children. Pediatrics 2020; 146(4):e2020009951.. Multi-family homes and high-density environments hinder social distancing among residents¹⁴14 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020; 47:37-44.^,3535 Raine S, Liu A, Mintz J, Wahood W, Huntley K, Haffizulla F. Racial and ethnic disparities in COVID-19 outcomes: social determination of health. Int J Environ Res Public Health 2020; 17(21):8115..

Furthermore, the conditions of Black and Hispanic neighborhoods, where homes with these characteristics are located, make up territories marked by diverse issues that lead to exposure to infection, such as high population density²¹21 Gu T, Mack JA, Salvatore M, Prabhu Sankar S, Valley TS, Singh K, Nallamothu BK, Kheterpal S, Lisabeth L, Fritsche LG, Mukherjee B. Characteristics associated with racial/ethnic disparities in COVID-19 outcomes in an academic health care system. JAMA Netw Open 2020; 3(10):e2025197.^,4141 Ojinnaka CO, Adepoju OE, Burgess AV, Woodard L. Factors associated with COVID-related mortality: the case of Texas. J Racial Ethn Health Disparities 2021; 8(6):1505-1510.^,4444 Holmes L Jr, Enwere M, Williams J, Ogundele B, Chavan P, Piccoli T, Chinacherem C, Comeaux C, Pelaez L, Okundaye O, Stalnaker L, Kalle F, Deepika K, Philipcien G, Poleon M, Ogungbade G, Elmi H, John V, Dabney KW. Black-White risk differentials in COVID-19 (SARS-COV2) transmission, mortality and case fatality in the United States: translational epidemiologic perspective and challenges. Int J Environ Res Public Health 2020; 17(12):4322., hindering social distancing when accessing public roads, high air pollution levels, favoring respiratory problems¹²12 Mahajan UV, Larkins-Pettigrew M. Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties. J Public Health (Oxf) 2020; 42(3):445-447.^,1717 Gold JAW, Rossen LM, Ahmad FB, Sutton P, Li Z, Salvatore PP, Coyle JP, DeCuir J, Baack BN, Durant TM, Dominguez KL, Henley SJ, Annor FB, Fuld J, Dee DL, Bhattarai A, Jackson BR. Race, ethnicity, and age trends in persons who died from COVID-19 - United States, May-August 2020. MMWR Morb Mortal Wkly Rep 2020; 69(42):1517-1521. and, while not significant in the publications¹²12 Mahajan UV, Larkins-Pettigrew M. Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties. J Public Health (Oxf) 2020; 42(3):445-447., significant cases of arrests of residents, who are confined in jails and left without adequate conditions to comply with preventive measures.

Intermediate relationships - income and racial discrimination

Two issues stand out as an “additional layer” to compose the analysis of associations: income and racial discrimination. These elements aim to mediate relationships between the COVID-19 events and issues directly linked to the Black population, as set out in the previous section. The lower frequency of these findings also reinforces the multicausal perspective, as few studies develop mediations during the health-illness process.

Thus, the terms “low income” and “low socioeconomic status” in the Black population¹⁰10 Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol 2020; 48:9-14.^,2424 Arasteh K. Prevalence of comorbidities and risks associated with COVID-19 among Black and Hispanic populations in New York City: an examination of the 2018 New York City Community Health Survey. J Racial Ethn Health Disparities 2021; 8(4):863-869.^,2828 Moore JT, Ricaldi JN, Rose CE, Fuld J, Parise M, Kang GJ, Driscoll AK, Norris T, Wilson N, Rainisch G, Valverde E, Beresovsky V, Agnew Brune C, Oussayef NL, Rose DA, Adams LE, Awel S, Villanueva J, Meaney-Delman D, Honein MA; COVID-19 State, Tribal, Local, and Territorial Response Team. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5-18, 2020 - 22 States, February-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69(33):1122-1126.^,3737 Goyal MK, Simpson JN, Boyle MD, Badolato GM, Delaney M, McCarter R, Cora-Bramble D. Racial and/or ethnic and socioeconomic disparities of SARS-CoV-2 infection among children. Pediatrics 2020; 146(4):e2020009951.^,3838 Rozenfeld Y, Beam J, Maier H, Haggerson W, Boudreau K, Carlson J, Medows R. A model of disparities: risk factors associated with COVID-19 infection. Int J Equity Health 2020; 29;19(1):126.^,4242 Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT Jr, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Lo Re V 3rd, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. PLoS Med 2020; 22;17(9):e1003379. appear mainly related to the lack of access to health insurance²⁴24 Arasteh K. Prevalence of comorbidities and risks associated with COVID-19 among Black and Hispanic populations in New York City: an examination of the 2018 New York City Community Health Survey. J Racial Ethn Health Disparities 2021; 8(4):863-869. and deteriorated mental health, generating a negative perception about self-care³⁹39 Yilmazkuday, H. COVID-19 and unequal social distancing across demographic groups. Reg Sci Policy Pract 2020; 12(6):1235-1248. and greater dependence on public transport, which can lead the exposure of this population to the virus on the way to work, or even avoid using it to seek medical care in the face of COVID-19 symptoms¹⁶16 Bassett MT, Chen JT, Krieger N. Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: a cross-sectional study. PLoS Med 2020; 17(10):e1003402.. Renelus et al.³⁴34 Renelus BD, Khoury NC, Chandrasekaran K, Bekele E, Briggs WM, Ivanov A, Mohanty SR, Jamorabo DS. Racial Disparities in COVID-19 Hospitalization and In-hospital Mortality at the Height of the New York City Pandemic. J Racial Ethn Health Disparities 2020; 8(5):1161-1167. highlight that, even when working in essential services, the Black population receives the lowest wages.

Anti-black racial discrimination, more than discrimination against other ethnic-racial groups in the USA, is related to greater inequality in COVID-19³³33 Thomas MD, Michaels EK, Darling-Hammond S, Nguyen TT, Glymour MM, Vittinghoff E. Whites' county-level racial bias, COVID-19 rates, and racial inequities in the United States. Int J Environ Res Public Health 2020; 17(22):8695.. Long-term experience and exposure to discrimination, besides short-term effects, such as the activated stress process⁴³43 Milner A, Franz B, Henry Braddock J. We need to talk about racism-in all of its forms-to understand COVID-19 disparities. Health Equity 2020; 4(1):397-402., is associated with increased distrust in the health system, resulting in delays or even distancing from health services¹⁷17 Gold JAW, Rossen LM, Ahmad FB, Sutton P, Li Z, Salvatore PP, Coyle JP, DeCuir J, Baack BN, Durant TM, Dominguez KL, Henley SJ, Annor FB, Fuld J, Dee DL, Bhattarai A, Jackson BR. Race, ethnicity, and age trends in persons who died from COVID-19 - United States, May-August 2020. MMWR Morb Mortal Wkly Rep 2020; 69(42):1517-1521.. This situation contributes to factors that increase the risk of underlying conditions²⁸28 Moore JT, Ricaldi JN, Rose CE, Fuld J, Parise M, Kang GJ, Driscoll AK, Norris T, Wilson N, Rainisch G, Valverde E, Beresovsky V, Agnew Brune C, Oussayef NL, Rose DA, Adams LE, Awel S, Villanueva J, Meaney-Delman D, Honein MA; COVID-19 State, Tribal, Local, and Territorial Response Team. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5-18, 2020 - 22 States, February-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69(33):1122-1126.. Furthermore, racial discrimination is a barrier to access to real estate credit, leading to purchasing housing in poorer neighborhoods, often with high air pollution levels and multi-family homes⁴³43 Milner A, Franz B, Henry Braddock J. We need to talk about racism-in all of its forms-to understand COVID-19 disparities. Health Equity 2020; 4(1):397-402..

Comprehensive relationships - structural racism and social determinants of health

Although they are among the findings with the second lowest frequency of approach, we should underscore that some articles “rehearse” expanding, albeit succinctly and not very explicitly, the explanation for the poor living conditions of the Black population and their situation in the face of the COVID-19 pandemic.

Thus, structural racism is the term that appears in most articles when seeking an explanatory perspective for racial health disparities. Sometimes the term appears as something that “operates”, “determines”, “produces”, “leads to”, or “causes”¹¹11 Cowger TL, Davis BA, Etkins OS, Makofane K, Lawrence JA, Bassett MT, Krieger N. Comparison of weighted and unweighted population data to assess inequities in coronavirus disease 2019 deaths by race/ethnicity reported by the US centers for disease control and prevention. JAMA Netw Open 2020; 3(7):e2016933.^,1414 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020; 47:37-44.^,3232 Jones J, Sullivan PS, Sanchez TH, Guest JL, Hall EW, Luisi N, Zlotorzynska M, Wilde G, Bradley H, Siegler AJ. Similarities and differences in COVID-19 awareness, concern, and symptoms by race and ethnicity in the United States: cross-sectional survey. J Med Internet Res 2020; 22(7):e20001. and sometimes appears as something that “influences”, “reinforces”, “maintains”, “contributes”, “reflects”, “impacts”, and “affects”³3 Werneck, GL, Carvalho, MS. A pandemia de COVID-19 no Brasil: crônica de uma crise sanitária anunciada. Cad Saude Publica 2020; 36(5):e00068820.^,2828 Moore JT, Ricaldi JN, Rose CE, Fuld J, Parise M, Kang GJ, Driscoll AK, Norris T, Wilson N, Rainisch G, Valverde E, Beresovsky V, Agnew Brune C, Oussayef NL, Rose DA, Adams LE, Awel S, Villanueva J, Meaney-Delman D, Honein MA; COVID-19 State, Tribal, Local, and Territorial Response Team. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5-18, 2020 - 22 States, February-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69(33):1122-1126.^,4444 Holmes L Jr, Enwere M, Williams J, Ogundele B, Chavan P, Piccoli T, Chinacherem C, Comeaux C, Pelaez L, Okundaye O, Stalnaker L, Kalle F, Deepika K, Philipcien G, Poleon M, Ogungbade G, Elmi H, John V, Dabney KW. Black-White risk differentials in COVID-19 (SARS-COV2) transmission, mortality and case fatality in the United States: translational epidemiologic perspective and challenges. Int J Environ Res Public Health 2020; 17(12):4322.. Also, in this sense, the same term appears most of the time along with other socioeconomic elements: “structural racism and systemic roots”¹⁴14 Millett GA, Jones AT, Benkeser D, Baral S, Mercer L, Beyrer C, Honermann B, Lankiewicz E, Mena L, Crowley JS, Sherwood J, Sullivan PS. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020; 47:37-44.; “structural racism and income inequality”³²32 Jones J, Sullivan PS, Sanchez TH, Guest JL, Hall EW, Luisi N, Zlotorzynska M, Wilde G, Bradley H, Siegler AJ. Similarities and differences in COVID-19 awareness, concern, and symptoms by race and ethnicity in the United States: cross-sectional survey. J Med Internet Res 2020; 22(7):e20001.; “social determinants of health and structural racism”²⁸28 Moore JT, Ricaldi JN, Rose CE, Fuld J, Parise M, Kang GJ, Driscoll AK, Norris T, Wilson N, Rainisch G, Valverde E, Beresovsky V, Agnew Brune C, Oussayef NL, Rose DA, Adams LE, Awel S, Villanueva J, Meaney-Delman D, Honein MA; COVID-19 State, Tribal, Local, and Territorial Response Team. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5-18, 2020 - 22 States, February-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69(33):1122-1126.; “structural racism and violence”³¹31 Polidoro M, Mendonça FA, Meneghel SN, Alves-Brito A, Gonçalves M, Bairros F, Canavese D. Territories under siege: risks of the decimation of Indigenous and Quilombolas peoples in the context of COVID-19 in South Brazil. J Racial Ethn Health Disparities 2020; 8(5):1119-1129.; “systemic economic hardship, interpersonal racial discrimination, and structural racism”⁴⁵45 Morales DX, Morales SA, Beltran TF. Racial/ethnic disparities in household food insecurity during the COVID-19 pandemic: a nationally representative study. J Racial Ethn Health Disparities 2020; 8(5):1300-1314. and “environmental pollutants, social inequality, structural racism, food insecurity, poor housing and living conditions, illiteracy, low socioeconomic status and lack of healthcare resources”⁴⁴44 Holmes L Jr, Enwere M, Williams J, Ogundele B, Chavan P, Piccoli T, Chinacherem C, Comeaux C, Pelaez L, Okundaye O, Stalnaker L, Kalle F, Deepika K, Philipcien G, Poleon M, Ogungbade G, Elmi H, John V, Dabney KW. Black-White risk differentials in COVID-19 (SARS-COV2) transmission, mortality and case fatality in the United States: translational epidemiologic perspective and challenges. Int J Environ Res Public Health 2020; 17(12):4322.. Other variant terms that appear less frequently are “systemic racism”, “conditioning structural racism”, “institutional racism”, also follow the same logic mentioned above¹³13 Golestaneh L, Neugarten J, Fisher M, Billett HH, Gil MR, Johns T, Yunes M, Mokrzycki MH, Coco M, Norris KC, Perez HR, Scott S, Kim RS, Bellin E. The association of race and COVID-19 mortality. EClinicalMedicine 2020; 25:100455.^,2929 Tirupathi R, Muradova V, Shekhar R, Salim SA, Al-Tawfiq JA, Palabindala V. COVID-19 disparity among racial and ethnic minorities in the US: a cross sectional analysis. Travel Med Infect Dis 2020; 38:101904.^,4646 Hsu HE, Ashe EM, Silverstein M, Hofman M, Lange SJ, Razzaghi H, Mishuris RG, Davidoff R, Parker EM, Penman-Aguilar A, Clarke KEN, Goldman A, James TL, Jacobson K, Lasser KE, Xuan Z, Peacock G, Dowling NF, Goodman AB. Race/ethnicity, underlying medical conditions, homelessness, and hospitalization status of adult patients with COVID-19 at an urban safety-net medical center - Boston, Massachusetts, 2020. MMWR Morb Mortal Wkly Rep 2020; 69(27):864-869..

The term social determinant of health, which appears less frequently than the previous one, is positioned alongside ideas such as “boost”²2 Mizumoto K, Chowell G. Transmission potential of the novel coronavirus (COVID-19) onboard the diamond Princess Cruises Ship, 2020. Infect Dis Model 2020; 5:264-270.^,4141 Ojinnaka CO, Adepoju OE, Burgess AV, Woodard L. Factors associated with COVID-related mortality: the case of Texas. J Racial Ethn Health Disparities 2021; 8(6):1505-1510.; “affect”²⁸28 Moore JT, Ricaldi JN, Rose CE, Fuld J, Parise M, Kang GJ, Driscoll AK, Norris T, Wilson N, Rainisch G, Valverde E, Beresovsky V, Agnew Brune C, Oussayef NL, Rose DA, Adams LE, Awel S, Villanueva J, Meaney-Delman D, Honein MA; COVID-19 State, Tribal, Local, and Territorial Response Team. Disparities in incidence of COVID-19 among underrepresented racial/ethnic groups in counties identified as hotspots during June 5-18, 2020 - 22 States, February-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69(33):1122-1126. or even as “cause”¹⁰10 Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol 2020; 48:9-14.^,1919 Patel AP, Paranjpe MD, Kathiresan NP, Rivas MA, Khera AV. Race, socioeconomic deprivation, and hospitalization for COVID-19 in English participants of a national biobank. Int J Equity Health 2020; 19(1):114.; “lead to”²¹21 Gu T, Mack JA, Salvatore M, Prabhu Sankar S, Valley TS, Singh K, Nallamothu BK, Kheterpal S, Lisabeth L, Fritsche LG, Mukherjee B. Characteristics associated with racial/ethnic disparities in COVID-19 outcomes in an academic health care system. JAMA Netw Open 2020; 3(10):e2025197.; “explain”⁴⁴44 Holmes L Jr, Enwere M, Williams J, Ogundele B, Chavan P, Piccoli T, Chinacherem C, Comeaux C, Pelaez L, Okundaye O, Stalnaker L, Kalle F, Deepika K, Philipcien G, Poleon M, Ogungbade G, Elmi H, John V, Dabney KW. Black-White risk differentials in COVID-19 (SARS-COV2) transmission, mortality and case fatality in the United States: translational epidemiologic perspective and challenges. Int J Environ Res Public Health 2020; 17(12):4322.; “play a role”²²22 Azar KMJ, Shen Z, Romanelli RJ, Lockhart SH, Smits K, Robinson S, Brown S, Pressman AR. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff (Millwood) 2020; 39(7):1253-1262.. Also, like structural racism, it is mainly related to the idea of ethnic and racial disparities²⁵25 Vahidy FS, Nicolas JC, Meeks JR, Khan O, Pan A, Jones SL, Masud F, Sostman HD, Phillips R, Andrieni JD, Kash BA, Nasir K. Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population. BMJ Open 2020; 10(8):e039849.^,4141 Ojinnaka CO, Adepoju OE, Burgess AV, Woodard L. Factors associated with COVID-related mortality: the case of Texas. J Racial Ethn Health Disparities 2021; 8(6):1505-1510.^,4242 Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT Jr, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Lo Re V 3rd, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. PLoS Med 2020; 22;17(9):e1003379.. Often, the term appears “translated” as the negative conditions of work, housing, environment, education, socioeconomic status, income, food security, insurance, and transportation¹⁰10 Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol 2020; 48:9-14.^,2525 Vahidy FS, Nicolas JC, Meeks JR, Khan O, Pan A, Jones SL, Masud F, Sostman HD, Phillips R, Andrieni JD, Kash BA, Nasir K. Racial and ethnic disparities in SARS-CoV-2 pandemic: analysis of a COVID-19 observational registry for a diverse US metropolitan population. BMJ Open 2020; 10(8):e039849.^,4242 Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT Jr, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Lo Re V 3rd, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. PLoS Med 2020; 22;17(9):e1003379., even being stated as “different determinants” for each ethnic group⁴²42 Rentsch CT, Kidwai-Khan F, Tate JP, Park LS, King JT Jr, Skanderson M, Hauser RG, Schultze A, Jarvis CI, Holodniy M, Lo Re V 3rd, Akgün KM, Crothers K, Taddei TH, Freiberg MS, Justice AC. Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study. PLoS Med 2020; 22;17(9):e1003379..

Also, “Legal and economic structure” and “socioeconomic inequalities” appear, albeit less than the other terms, in a generalized way, with adverse effects on the total population, without considering racism as a structuring factor²⁴24 Arasteh K. Prevalence of comorbidities and risks associated with COVID-19 among Black and Hispanic populations in New York City: an examination of the 2018 New York City Community Health Survey. J Racial Ethn Health Disparities 2021; 8(4):863-869.^,3838 Rozenfeld Y, Beam J, Maier H, Haggerson W, Boudreau K, Carlson J, Medows R. A model of disparities: risk factors associated with COVID-19 infection. Int J Equity Health 2020; 29;19(1):126..

Discussion

The 2020 global health situation was often characterized as “exacerbating” a pre-existing reality in several social life dimensions. Even so, the health conditions of the Black population, which had already been described with negative metrics, ended up drastically taking a worse course, considering the impact of a pandemic, as shown in the summarized results.

Despite data showing high incidence, hospitalization, mortality from SARS-CoV-2, and less testing in this group, the search for the scientific meaning of these associations promotes the debate on the relationships between “the social” and “the pathological” elements. The magnitude of a pandemic demands global surveillance of the disease and its consequences from the scientific community to understand its several aspects, especially how historical, political, economic, and cultural features shape the distribution of health problems among different social groups in different countries.

Given that most of the articles in this scope result from research produced in the American reality, we should consider these results in their particular dimension: the underlying racial relationships and socio-health characteristics in this country. However, it is also essential to understand the historical processes of race relationships internationally since the health reality of this population during the COVID-19 pandemic has negative similarities in health conditions when compared to Black people in other countries.

Thus, the characteristics of the American health system, with a robust private weight, not universal, and structured in different types of health insurance, establish significant restrictions and control mechanisms in access to health care, unlike access in public and universal systems⁴⁷47 Giovanella L, Mendoza-Ruiz A, Pilar ACA, Rosa MCD, Martins GB, Santos IS, Silva DB, Vieira JML, Castro VCG, Silva POD, Machado CV. Sistema universal de saúde e cobertura universal: desvendando pressupostos e estratégias. Cien Saude Colet 2018; 23(6):1763-1776.. This is one of the elements to understand the data that show the prevalence of “chronic conditions”, “underlying health conditions”, and “pre-existing diseases” in vulnerable populations, since these issues are identified as risk factors for the worst outcome of cases due to SARS-CoV-2.

Furthermore, to understand how the nature of this commercial health system connects with the Black community, arguments associating this population with low income and unemployment are often shown in these articles, which implies obstacles to complete or even partial access to health insurance.

Therefore, it is necessary to identify that these conditions were shaped by racial segregationism that structured the country with discriminatory, so-called Jim Crow laws in the Southern States. Even after the struggles of the American black movements, in the context of the Civil Rights mobilization in the 1960s that put an end to formal segregation, marks of the impact of this historical process on American Blacks are still visible⁴⁸48 Morris A, Treitler VB. O ESTADO RACIAL DA UNIÃO: compreendendo raça e desigualdade racial nos Estados Unidos da América. Cad CRH 2019; 32(85):15-31.^,4949 Antunes JLF. Desigualdades em saúde: entrevista com Nancy Krieger. Tempo Soc 2015; 27(1):177-194..

Despite the particularities mentioned above, seeking to understand these processes in their complexity, a path that elucidates the poor health, work, and housing conditions and COVID-19 among the Black population of the wealthiest country in the world and in other economically more fragile nations, also includes the categories of African diaspora and Black genocide⁵⁰50 Ortegal L. Relações raciais no Brasil: colonialidade, dependência e diáspora. Serv Soc Soc 2018; 133:413-431.. The first allows us to perceive current experiences historically connected between the territories in which men and women, Black men and women, were trafficked during the slavery period, analyzing “the problem of racism in its historical format in modern times”; that is, racism was established as essential technology to build contemporary societies, structuring the former colonies, through large estates and enslaved labor, and the modern States that emerged from them, preserving super-exploitation of the work of Black men and women.

The second, arising from the previous category, gives an intentional character to the elimination of these groups, not only in the subjugations in the daily processes of life and death but also in the State’s discourse that denies and treats these situations as isolated cases to marginalize racially, upholding the overexploitation of their bodies⁵⁰50 Ortegal L. Relações raciais no Brasil: colonialidade, dependência e diáspora. Serv Soc Soc 2018; 133:413-431.. These categories allow demobilizing arguments of inertia/continuity of the disadvantaged situation of the Black population, leading to the naturalized health situation of this group during the pandemic.

Thus, while not comparable, one can notice a common event among the findings, such as in quilombola in the southern region of Brazil and Black people in the USA; negative health indicators are more significant than their territorial representations. In other words, numerical majority or minorities are not absolute parameters for interpreting the adverse effects on the health of Black populations, and attention must be paid to racism that starts from a social structure and sustains health inequalities when reproduced institutionally.

However, we should underscore that although most articles associate “structural racism” with the COVID-19 problems in the Black population, the term is presented without a clear distinction from other types of racism - cultural, institutional, and interpersonal. The “structural” qualifier in these cases only suggests an event found in all social environments, requiring other additional elements to determine the poor living conditions of the Black population, such as low income, lack of access to healthcare, and unemployment.

However, as a theoretical-analytical category, structural racism offers the analysis of social events, the understanding of racism as a historical and political process, which manifests itself structurally through ideology, politics, law, and economics, supporting conditions so that “racially identified groups” are systematically subjected to unequal social advantages and disadvantages⁵¹51 Almeida S. Racismo estrutural. São Paulo: Pólen Livros; 2019.. This “structural” conception delineates income inequalities, violence, systemic economic hardships, interpersonal racial discrimination, territories with a higher concentration of environmental pollutants, substandard housing, illiteracy, and lack of health resources in the Black population.

In this sense, the term disparity, often used to “reveal negative differences” between different ethnic-racial groups, requires more grounding to develop the analysis of the data presented. By restricting themselves to low indicators in the living standards of the Black population as the main reason for this group’s exposure to SARS-CoV-2 and its course and adverse outcomes end up dismissing more robust contributions from Human and Social Sciences that denaturalize this “evidence”. Although epidemiology takes health inequalities as a topic of investigative interest due to their global nature, revealing differences in life expectancy or burden of suffering⁵²52 Barreto ML. Desigualdades em saúde: uma perspectiva global. Cien Saude Colet 2017; 22(7):2097-2108., these explanations find diverse theoretical references within the health field.

In most of the articles analyzed, disparities are suggested as “social factors”, or even the “translation” of what social determinants of health are, understood as harmful elements that affect exposure, illness, and deaths among the Black population due to SARS-CoV-2. This perspective is insufficient because it is necessary to overcome the “linear conception of causality” in the cause-effect relationship between characteristics or social indicators and health problems⁵³53 Barata RB. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Fiocruz; 2012. to understand the dynamics of the complex relationship between these health and illness-producing elements.

Thus, from the perspective of social determination, understanding the health-disease process involves intertwining “the general logic of society with the more or less healthy or unhealthy ways of living of social classes”, crossed by ethnocultural and gender relationships⁵⁴54 Breilh J. Las tres 'S' de la determinación de la vida: 10 tesis hacia una visión crítica de la determinación de la vida y de la salud. In: Nogueira RP, organizador. Determinação social da saúde e Reforma Sanitária. Rio de Janeiro: Cebes; 2010. p. 87-125.. Breilh⁵⁴54 Breilh J. Las tres 'S' de la determinación de la vida: 10 tesis hacia una visión crítica de la determinación de la vida y de la salud. In: Nogueira RP, organizador. Determinação social da saúde e Reforma Sanitária. Rio de Janeiro: Cebes; 2010. p. 87-125. believes rethinking the power relationships that determine life and distribute inequality is challenging for scientific research, including epidemiology. Thus, advancing in understanding the race concept as an ideology that reveals power relationships also means overcoming biological and social determinism in producing knowledge in health. In other words, attributing the impact of COVID-19 on the Black population to macroeconomic, political, and social elements without seeking a dialectical relationship risks repeating ecological conceptions of health in new guises.

In this sense, the complexity surrounding how most of the Black population is in menial, low-paying jobs, with a significant level of exposure to infection, with pre-existing chronic diseases, and difficult access to health services due to lack of financial conditions to bear health insurance costs does not admit Cartesianism when seeking qualified scientific support to subsidize effective health policies to reverse the health catastrophe naturalized in this population.

Final considerations

The observation of the persistent racial inequalities in health in the first year of the COVID-19 pandemic, expressed mainly in data on high deaths and mortalities in the Black population, exposes the need to uncover events mostly revealed through numbers.

The notions of social determinants and structural Racism mobilized in these studies suggest the idea of overlapping layers of “social factors” that affect Black people and end up simplifying reality, resulting in multicausal explanations. In the opposite sense, understanding the critical racial theory and the dialectical theory of the health-disease process⁵¹51 Almeida S. Racismo estrutural. São Paulo: Pólen Livros; 2019.^,5454 Breilh J. Las tres 'S' de la determinación de la vida: 10 tesis hacia una visión crítica de la determinación de la vida y de la salud. In: Nogueira RP, organizador. Determinação social da saúde e Reforma Sanitária. Rio de Janeiro: Cebes; 2010. p. 87-125. offers more robustness to understanding the socio-historical complexity of the health situation.

This perspective offers quality scientific subsidies that allow formulating and operationalizing effective global actions in Public Health, such as equitable, intersectoral, and anti-racist policies in the face of the challenging SARS-CoV-2 pandemic and new pandemics that may arise anytime in the future.

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