This article was written as part of The Michigan Daily’s investigation into the current state and future of health equity in Michigan. Read other stories from the project here.
As fear and uncertainty swept the nation in the early months of the COVID-19 pandemic, a concerning trend began to emerge: Black people were dying from COVID-19 at a 37% higher rate than white people. Michigan was no exception to this trend, with the COVID-19 mortality rate for Black individuals being significantly higher than that of white individuals in 2020.
These disparities, rather than being a novel phenomenon, were indicative of existing and pervasive race and ethnicity-based inequities in health care. The Michigan Daily spoke to researchers who conducted studies on racial and ethnic health disparities in Michigan in areas including COVID-19, cancer and mental health.
Sheria Robinson-Lane, assistant professor at the University of Michigan School of Nursing, was the first author of a 2021 study examining 60-day outcomes for post-COVID-19 hospitalization. The study looked at adults of different races and ethnicities who were hospitalized in one of 38 participating Michigan hospitals. Analysis revealed that Black patients had the lowest rate of physician follow-up post discharge. According to Robinson-Lane, a variety of factors likely contributed to this difference.
“The reality is that our health care system is still very much segregated because it’s based upon neighborhoods, which are also still very segregated in Michigan, like much of the rest of the country,” Robinson-Lane said. “When we think about what resources are available in communities that facilitate being able to easily access a doctor, that can vary by the community that you live in.”
Robinson-Lane was also a co-author of a 2022 study that examined differences in treatment and outcomes across racial and ethnic groups in adults from the same dataset as the 2021 study. One of the study’s main findings was that Black patients were less likely to receive dexamethasone and remdesivir, medications used to treat COVID-19. Robinson-Lane explained how the medications are related to improved COVID-19 outcomes.
“So when people have COVID, (remdesivir and dexamethasone are) two of the medications that are available that can make a large difference in the way that individuals experience symptoms,” Robinson-Lane said. “Predominantly, they help with breathing, which is why individuals that weren’t able to control their symptoms are more likely to end up either in the ICU or to die.”
The study also found that Black patients who died of COVID-19 had the lowest mean age at death, with the average age at death for Black patients being more than eight years younger than that of white and Asian patients. This reflects data that shows that while the overall mortality disparity between Black and white individuals in Michigan decreased over the course of the pandemic, Black individuals continued to have a higher age-adjusted mortality rate.
Other racial and ethnic groups in the state also faced health disparities in COVID-19 outcomes. One study found that Hispanic Michiganders were more likely to experience severe COVID-19 symptoms and to have longer hospital stays. In addition, state data shows that in 2021, Indigenous Michiganders faced the highest COVID-19 mortality rates of any racial or ethnic group in the state. Many other studies published over the past few years also examined inequities related to COVID-19. According to Robinson-Lane, research into health disparities is a crucial component of identifying causes of disparities and promoting more equitable care.
“This work is really important because as we move towards a more equitable and inclusive society, we have to be thoughtful about how bias plays a role at the various levels of health care delivery,” Robinson-Lane said.
Research on health disparities also extends to the field of mental health care, where studies have shown that there are differences in mental health care based on race and ethnicity. Michigan has the largest Arab American population of any state. One Michigan-specific study that examines this issue focused on mental health in Arab American Michiganders.
The study found that, compared to non Hispanic white Americans, Arab Americans had increased odds of reporting poor mental health via subjective measures but decreased odds of reporting poor mental health through objective measures. The data analyzed was drawn from the 2013 Michigan Arab Behavioral Risk Factor Survey. The subjective measure was based on how participants responded to a question asking about how they felt for the past 30 days, while the objective measure whether participants reported having ever been diagnosed with a depressive disorder. In an interview with The Daily, first author Nadia Abuelezam, an associate professor at Boston College’s Connell School of Nursing, explained the possible reasons for the difference in objective and subjective responses.
“In Arab culture, I think there’s a difference in the way that people think about mental health,” Abuelezam said. “The words depressed or anxious are not necessarily words that translate well into Arabic, or even into Arabic culture. And so if you were to flat out ask someone, ‘How many days in the last 30 days were you depressed,’ I think a lot of folks in our culture would immediately sort of think, ‘Oh, I’m not depressed’.”
According to Abuelezam, the results also reflect an underdiagnosis of mental health conditions among Arab Americans, which partially stems from stigma within the community.
“I definitely think that we have underdiagnosed mental health conditions, whether that’s depression, whether that’s anxiety, whether that’s other types of mental health issues,” Abuelezam said. “I think there’s a stigma to talking about it. I think there’s a stigma to getting help in particular.”
Abuelezam said she hopes the study will lead to better understanding of the nuances of mental health within Arab American communities.
“I think this study is important because it really indicates that there are better ways to ask these questions,” Abuelezam said. “And if we really are intentional about wanting to better understand the mental health of Arab Americans, we need to pay attention to how we’re asking these questions.”
Other studies have also examined racial and ethnic disparities in chronic conditions, such as cancer, within Michigan. In 2021, researchers from Wayne State University and Michigan State University published a review of various studies examining disparities in cancer care in the Detroit metropolitan area.
In an interview with The Daily, first author Dr. Michael Simon, an oncologist at the Karmanos Cancer Institute and professor at the Wayne State University School of Medicine, said previous data has established that Black individuals in Detroit have disproportionately high incidence and mortality of cancer, and many of the articles summarized in the review aimed to examine the causes of this disparity.
“We were trying to figure out causes for the difference, and a lot of studies have looked at trying to assess some measure of economic status,” Simon said. “Is it insurance, is it access to care? And in some studies, we show that the racial differences were taken into account by socioeconomic differences; once we adjusted for socioeconomic differences, there are no longer any differences (between racial groups).”
Simon said that while some of the studies in the review showed that adjusting for socioeconomic factors eliminates racial differences, other studies did not, showing that multiple factors affect disparities in cancer diagnosis, treatment and outcomes. He also emphasized the connection between race and socioeconomic status in the U.S. and said research into health disparities must account for this relationship.
“I think it all boils down to racism,” Simon said. “When you adjust for socioeconomic status, you’re kind of creating a world that doesn’t exist. You’re sort of saying, ‘Well, we all have the same education and income’ … and that just doesn’t exist.”
Studies summarized in the review showed numerous disparities in the Detroit area, including one study that Black patients with breast cancer are more likely have advanced cancer when diagnosed than white patients, three studies demonstrating that Black patients with prostate cancer were less likely to receive treatment than their white counterparts, and a study that reported oncologists had shorter interactions with Black patients than white patients and were less likely to mention clinical trials to Black patients. According to Simon, this research is important in addressing both structural factors and implicit biases that can impact care for Black individuals in Detroit.
“I think it’s overall important because Black patients specifically, and to a certain extent this is true in other ethnic groups, but Black patients specifically have poor outcomes, and that’s something that should be happening in 2024,” Simon said. “Everybody should be getting the same access to medical care.”
Daily News Editor Nadia Taeckens can be reached at taeckens@umich.edu.