Our study adds empirical data to the mounting evidence that racial/ethnic minorities are at elevated risk during the H1N1 pandemic. Existing health disparities may increase the likelihood of severe clinical complications following H1N1 infection. Recent reports have discussed differential exposure or susceptibility as potential sources of racial/ethnic disparities in H1N1 hospitalization rates,3,8
and our study confirms the existence of significant racial/ethnic disparities in potential exposure risk, susceptibility to complications, and access to health care. If our results can be generalized to the US population, these would be cause for urgent action.
Others have made the compelling case that existing disparities could worsen a pandemic, but our study provides empirical evidence for the conceptual model of Blumenshine et al. in the context of a real pandemic,1
and it provides necessary insights into considerations for planning countermeasures and mitigation strategies. We are deeply concerned that the additive effects of higher exposure, susceptibility to severe disease, and less ability to access health care place racial/ethnic minority populations at greater risk from H1N1 infection and its complications.
Discussions about policies for social distancing fail to account for the reality of differential exposure in a society in which race/ethnicity already contributes to health disparities. Our study confirms the existence of racial/ethnic disparities in ability to impose social distance, just as Blendon et al. found in the context of a hypothetical pandemic.15
Of particular concern is the fact that school closures may have a disproportionate impact on minority families who are unable to work at home or who do not have child care that limits exposure to other (potentially infected) children. School closings may be particularly difficult for single mothers and women in the workforce; thus, the impact of gender on the ability to impose social distance should be a subject of future research.
Disparities in susceptibility to complications from H1N1 were measured by self-reports of chronic conditions and immunosuppression. We are aware that our data do not correlate prevalence of chronic diseases with actual incidence of either H1N1 infection or complications. However, CDC data suggest that patients suffering from chronic diseases have increased susceptibility to complications from H1N1.25,47
In our survey, Blacks were highest on the susceptibility index, followed by Whites and then Hispanics. Spanish-speaking Hispanics were lowest on the susceptibility index, presumably because of their younger age. However, if we were successful in removing the effects of SES and other demographics, race/ethnicity alone does not seem to explain the susceptibility to complications. Still, we believe there is an urgent need for targeted, culturally appropriate communication that elucidates elevated risk from existing diseases. The CDC, health departments, and professional organizations such as the American Medical Association and the American Academy of Pediatrics all must clearly communicate this information to health care providers who serve minority patients.
Significant differences in access to health care and with greater perceived discrimination in health care place Blacks and Spanish-speaking Hispanics at greater risk of receiving later—and perhaps poorer—health care. This finding is particularly troublesome because the pandemic is colliding with severe budget crises that hamper the availability and delivery of health care. Additionally, the highly politicized furor against treating undocumented immigrants is a major point of contention in the current health care reform debate. These dynamics, along with fear of deportation by immigration and naturalization authorities targeting health clinics, may result in fewer Hispanics seeking timely care for H1N1, particularly those who are Spanish speakers. As a population, Hispanics are younger, have more women of childbearing age, and experience disparities in health conditions, further exacerbating the potential for disproportionate morbidity and mortality. Because our study occurred prior to vaccine availability and the designation of priority groups, we did not explore any possible interaction between race/ethnicity and one’s ability to access the vaccine.
Although the issue of mistrust is beyond the scope of this study, the literature confirms that this factor may influence willingness to accept a vaccine, even when it is available.22,46,48–50
In our study, we found significant differences in experiences with discrimination in the health care setting, which could contribute to mistrust. There is already evidence of lower uptake of H1N1 vaccine among minorities.51
Clearly, future research should examine the extent to which trust plays a role in H1N1vaccine acceptance and the extent to which minorities seek the H1N1 vaccine.
To address the factors affecting racial/ethnic disparities in the H1N1 pandemic, we offer these recommendations:
- The CDC and health departments must include race/ethnicity in reporting on H1N1 hospitalizations and deaths. These data will facilitate deliberate communication strategies for minority populations, which could encourage minorities to perceive their own susceptibility and to take timely action for prevention and to seek care.
- Targeted, culturally appropriate risk communication, using trusted spokespersons and channels, is critically important.49,50 That communication must focus on underlying conditions and other factors (e.g., young age, pregnancy) that place racial/ethnic minorities at greater risk for complications following H1N1 infection.
- Engaging both national and local organizations that represent minority populations is necessary to get the message to at-risk groups.22,49,50
- Continuous communication to and education of health care providers is critical to ensure that they recognize higher-risk individuals and aggressively deliver adequate care to them.
- Although the identification of priority groups for initial vaccine allocations is essential, minority groups may misinterpret that policy as exclusionary, which could contribute to mistrust. Engaging minority organizations in communication about the rationale for priority groups could enhance understanding and prevent mistrust.
- Local and state health departments, federally qualified health centers, and other health care providers must partner now with community-based organizations that serve at-risk populations.49 This step is particularly essential for undocumented immigrants, who must be encouraged to seek care without risk of detention or deportation.
- Policymakers must ensure that undocumented immigration status does not present a barrier to the health care of immigrants, which would place them, their families, and the broader public at increased risk for H1N1 infection.
- The US Congress and states must move to pass paid sick-leave legislation that enables low-income and private-sector workers to adhere to social-distancing recommendations even when they lack paid sick leave.
Most H1N1 pandemic planning and response has not recognized the extent to which racial/ethnic health disparities have placed segments of our population at risk for increased morbidity and mortality. Although it may not be easy to change some of the factors that drive exposure and susceptibility, we can act with urgency and ensure that those experiencing disparities know their level of risk, and we can help them to trust that they will receive timely care from health care providers.