Health disparity and COVID‐19—A retrospective analysis

Abstract Background and Aims According to the World Health Organization (WHO), more than 75.7 million confirmed cases of coronavirus disease 2019 (COVID‐19), a global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), have been reported so far. Researchers are working relentlessly to find effective solutions to this catastrophe, using genomic sequence‐based investigation, immunological analysis, and more. The role of health disparity has also emerged as an intriguing factor that made a huge impact on the lives of people. Methods We analyzed various factors that triggered the health disparity in the United States of America along with the rate of COVID‐19 morbidity and mortality. Furthermore, we have also focused on the State of Mississippi, which is suffering from an extreme health disparity. Data have been obtained from publicly available data sources including, Center for Disease Control and Prevention and Mississippi State Department of Health. Correlation analysis of the dataset has been performed using R software. Results Our analysis suggested that the COVID‐19 infection rate per 100 000 people is directly correlated with the increasing number of the African American population in the United States. We have found a strong correlation between the obesity and the COVID‐19 cases as well. All the counties in Mississippi demonstrate a strong correlation between a higher number of African American population to COVID‐19 cases and obesity. Our data also indicate that a higher number of African American populations are facing socioeconomic disadvantages, which enhance their chances of becoming vulnerable to pre‐existing ailments such as obesity, type‐2 diabetes, and cardiovascular diseases. Conclusion We proposed a possible explanation of increased COVID‐19 infectivity in the African American population in the United States. This work has highlighted the intriguing factors that increased the health disparity at the time of the COVID‐19 pandemic.

What is known about this topic • There has been significant variation in the severity (morbidity and mortality) of the coronavirus disease 2019 (COVID-19) disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among people from diverse background.
• Few reports have suggested that incidences of COVID-19 cases, morbidity, and mortality among African American people are higher compared to white American people.
• Health disparity has been suggested to be one of the many factors responsible for the wide variation in the incidences as well as sufferings caused by COVID-19 in different population in the United States.

What this paper adds
• Our analyses show that various socioeconomic factors have resulted in health disparity among different population in the United States resulting in increased sufferings due to COVID-19 in African American.
• There is significant positive correlation among the number of COVID-19 cases and the total number of the African American population in the United States.
• Our analyses also suggested that in the state of Mississippi, a significant disparity between white and black American people in different socioeconomic factors is present, and this resulted in health disparity, which positively correlated to the COVID-19 disease severity.

| INTRODUCTION
The world is currently under threat due to an unprecedented pandemic situation, the novel coronavirus disease 2019  that originally started at Wuhan, China, in December 2019 and since then, has very rapidly spread to different parts around the globe causing about 75.7 million confirmed cases of COVID-19 and 1 690 061 deaths from 214 countries and territories. 1 The disease is caused by a coronavirus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has a positive-sense single-stranded RNA genome. 2 Although the virus can infect humans of all ages, sex, and ethnicities, the magnitude of suffering may vary greatly among the population depending on the age groups, sex, ethnicities, and comorbidities. 3 The SARS-CoV-2-infected individuals can either remain asymptomatic or may show a range of symptoms including but not limited to common cold such as fever, chills, muscle pain, fatigue, loss of taste or smell, vomiting, diarrhea, to more severe diseases like bronchitis, pneumonia, severe acute respiratory distress syndrome (ARDS), and multiorgan failure leading to death. 4 The mortality rate in COVID-19 diseases is around 6.3% in the United States (per CDC) although it varies depending upon the human population and the geographical regions. SARS-CoV-2 is primarily transmitted via the respiratory route by inhalation of respiratory droplets. 5 The incubation period of SARS-CoV-2 varies from 2 to 14 days with a median of 4-5 days. The virus binds to the cells of the upper respiratory tract expressing the entry receptor, angiotensin-converting enzyme 2, and the protease,TMPRSS2. 2,6 On entering the cells, the virus multiplies utilizing the host cell machinery, releasing the progeny virions resulting in pyroptosis of the host cells. 7 These, in turn, cause the release of damage-associated molecular patterns including adenosine triphoshate, nucleic acids, and Apoptosis-associated speck-like protein containing a C-terminal caspase recruitment domain oligomers, which are recognized by the adjacent epithelial cells, endothelial cells, and alveolar macrophages. 7 This leads to the expression of proinflammatory cytokines and chemokines including IL-6, IP-10, and macrophage inflammatory protein 1α (MIP1α), which attracts monocytes, macrophages, and T-cells to the site of inflammation further escalating inflammation and inflammatory mediators. 7,8 In the absence of a protective antiviral immune response, this overproduction of proinflammatory cytokines results in the tissue destruction of the lung leading to ARDS. 9 The proinflammatory cytokines reach other organs, causing tissue destruction eventually resulting in the multiorgan failure leading to the death of the infected individual.
In the United States, COVID-19 has made a huge impact on the lives and economy of people. To date, almost 15 million people are reported to be COVID-19 positive in the United States out of which 0.3 million people have died from this 4 (data accessed on December 7, 2020). Although the recovery rate is currently shown to be promising, but the severity of COVID-19 infection can also be dependent on the pre-existing health condition of the individual. 10 Reports have strongly suggested that pre-existing conditions are playing a crucial role in the devastating statistics of COVID-19 disease. 10,11 People affected with cardiovascular diseases such as ischemia, cardiac failure, etc., are found to have a poorer prognosis when got infected by the SARS-CoV-2 compared to the healthy individual. 12 It is also reported that type-2 diabetic patients suffering from high blood glucose levels and poorer immunity are affected heavily by this deadly virus. 10 Obese people are threatened by COVID-19 due to a weak immunity as well. 13 In the United States, people of color (mainly African American and Hispanics/Latinos) are generally tending to have a poor health index with decreasing socioeconomic status. 14,15 The challenges faced by the people of color are much more prominent compared to white Caucasians during any health crisis such as COVID-19 pandemic in the United States. [14][15][16] Epidemiological studies reveal that African Americans are more prone to develop hypertension, cardiac diseases, obesity, and diabetes in the span of their life compared to a white American. [17][18][19][20] States having a higher number of African American populations in the United States are facing severe health disparity. 15 For example, the state of Mississippi, which has the maximum percentage of the African American population (37% African American population according to census.gov) in the United States, is facing a severe health disparity (2009). 21 Mississippi has a 40% obesity rate in African Americans compared to 35% of the white population. The racial or ethnic differences that lie within the health sector are the determinants of Data for socioeconomic parameters were available from source livestories.com and data.census.gov.

| Data analysis
Initial steps of analysis included organizing and summarizing the collected data from different data sources.  The minority population is found to be severely affected by COVID-19 infection in the United States. 14 Pre-existing conditions, such as obesity, cardiovascular diseases, and type-2 diabetes, are suggested as crucial factors for triggering severe form of COVID-19 disease. 3 We were curious to analyze if the percentage of the African American  10 Incidences of COVID-19 are reported higher among the African American population, which is also reflected from these data.
Mississippi is one of the southern states of the United States, which has the highest African American population (37%) as of 2020.
This state is currently ranked as the most obese state (40.8% adult obesity, https://www.cdc.gov/obesity/data/prevalence-maps.html) in the United States and ranked as the second highest in the incidence of type-2 diabetes. 23 The African American population in this state is largely affected during the pandemic. Our effort was to analyze the impact of COVID-19 in each of the 82 counties in this state and examine any association between COVID-19 infection and death rate to the racial disparity and health disparity parameters.  to COVID-19 infections. 24 The pre-existing diseases including cardiovascular diseases, obesity, and type-2 diabetes are among the major ailments, which are studied in accordance with COVID-19 infection. [25][26][27] Data also suggest that cancer could play an important role in triggering the severity of COVID-19 due to a lowered immune
Our findings necessarily point out the lack of health access and increasing pre-existing conditions in the people of color in the State of Mississippi. Moreover, the insufficiency of proper nutritional choices is another contributing factor toward growing metabolic disorders and obesity. 36 As a fact, Mississippi is ranked as the most obese state in the United States, which is a major concern as the population with extreme obesity are the ones having a compromised immune system as well. Huizinga et al 13

CONFLICT OF INTEREST
The authors declare that there are no conflicts of interest. Debarshi Roy had full access to all the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

TRANSPARENCY STATEMENT
Debarshi Roy affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
The data supporting the findings of this study are available from the corresponding author upon reasonable request.