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Review 2: "The relationship between neighborhood poverty and COVID-19 mortality within racial/ethnic groups (Cook County, Illinois)"

This study adds to the literature on disparities in COVID-19 morbidity and mortality, though the data used may preclude some important, finer-grained analyses of different sources of outcome disparities.

Published onNov 16, 2020
Review 2: "The relationship between neighborhood poverty and COVID-19 mortality within racial/ethnic groups (Cook County, Illinois)"
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The relationship between neighborhood poverty and COVID-19 mortality within racial/ethnic groups (Cook County, Illinois)
Description

Abstract Background Prior research has identified higher rates of COVID-19 mortality among people of color (relative to non-Hispanic whites) and populations in high-poverty neighborhoods (relative to wealthier neighborhoods). It is unclear, however, whether non-Hispanic whites in high-poverty neighborhoods experience elevated mortality, or whether people of color living in wealthy areas are relatively protected. Exploring socioeconomic position in combination with race/ethnicity can lead to a more detailed understanding of the specific processes that result in COVID-19 inequities.Methods and Findings We used census and individual-level mortality data for the non-Hispanic white, non-Hispanic Black, and Hispanic/Latinx populations of Cook County, Illinois, USA. We excluded deaths related to nursing homes and other institutions. We calculated age and gender-adjusted mortality rates by race/ethnicity, census tract poverty quartile, and age group (0-64 and ≥65 years).Within all racial/ethnic groups, COVID-19 mortality rates were greatest in the highest-poverty quartile and lowest in the lowest-poverty quartile. The mortality rate for younger non-Hispanic whites in the highest-poverty quartile was 13.5 times that of younger non-Hispanic whites in the lowest-poverty quartile (95% CI: 8.5, 21.4). For young people in the highest-poverty quartile, the non-Hispanic white and Black mortality rates were similar. Among younger people in the lowest-poverty quartile, non-Hispanic Black and Hispanic/Latinx people had mortality rates nearly three times that of non-Hispanic whites. For the older population, the mortality rate among non-Hispanic whites in the highest-poverty quartile was less than that of lowest-poverty non-Hispanic Black and Hispanic/Latinx populations.Conclusions Our findings suggest racial/ethnic inequalities in COVID-19 mortality are partly, but not entirely, attributable to the higher average socioeconomic position of non-Hispanic whites relative to the non-Hispanic Black and Hispanic/Latinx populations. Future research on health equity in COVID-19 outcomes should collect and analyze individual-level data on the potential mechanisms driving population distributions of exposure, severe illness, and death.

RR:C19 Evidence Scale rating by reviewer:

  • Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.

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Review:

The paper offers an analysis of the interactions between race/ethnicity and neighborhood socioeconomic status in relation to COVID-19 deaths, using individual-level, open-access data from Cook County, Illinois.  Deaths that occurred in nursing homes were excluded as the neighborhood income for care home residents may not be an appropriate proxy measure of their socioeconomic status. The impact of this exclusion on the findings could be substantial if the associations between race/ethnicity, poverty, and COVID-19 are different in this population as 40% of COVID-19 related deaths took place in nursing homes and other institutions.  Findings are consistent with typical interactions between socioeconomic status and race/ethnicity in US populations—or example the finding that the death rate for older non-Hispanic white people in the poorest quartile was lower than that for non-Hispanic black and Hispanic/Latinx in the least poor quartile is similar to previous studies of infant mortality in relation to mother’s education status where college-educated black mothers have a higher risk of losing their babies than the least educated white women. This is a reliable study with its main claims justified by the quality of the data and the appropriately applied and straightforward analyses. The authors are cautious in stating that racial/ethnic inequalities in COVID-19 deaths are at least partly attributable to the higher average socioeconomic position of white people, and recognize that lower neighborhood socioeconomic status is a proxy for a wide range of factors that will be associated with higher COVID-19 deaths, including exposure to air pollution, and higher rates of essential workers unable to shield from exposure. This is a straightforward descriptive study with findings useful for future research and for policy; claims are generally supported by the data and methods used, and decision-makers should consider the claims in this study actionable with limitations (in that they do not apply to those living in care homes/institutions). I recommend acceptance of the manuscript without modification.

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