Certain communities have suffered more than others since COVID-19 hit the United States. According to CDC data released to The New York Times, Latino and Black Americans were three times as likely to become infected and twice as likely to die from the disease from March through May compared to white Americans. Many Native American groups have also been disproportionately affected. Since the pandemic began, the Navajo Nation has had some of the highest novel coronavirus infection rates in the country.

No one factor explains the racial disparity being observed in COVID-19. Rather, the trend is the result of numerous forms of racism conspiring to make Black, Latino, and Indigenous people more vulnerable to the virus and its symptoms. Mental Floss spoke with experts in bioethics and medicine to learn more about the ways COVID-19 is impacting people of color in America.

1. Preexisting conditions play a big role.

Patients with certain underlying medical conditions are more likely to develop severe cases of COVID-19. Some of these conditions include chronic kidney disease, hypertension, obesity, asthma, and diabetes—all diseases that disproportionately affect nonwhite Americans. Black women in America are 20 percent more likely to have asthma than white women, and Black people are four times as likely to suffer from kidney failure.

2. Those preexisting conditions can result from systemic racism.

It’s not that nonwhite Americans are naturally predisposed to develop these conditions. The racial disparities can be explained by environment, living conditions, socioeconomic factors, and limited access to healthcare. Due to centuries of systemic racism, this cocktail of disadvantages uniquely harms people of color. “I cannot overemphasize enough that social injustice and systemic racism are the root problems in the disparities,” Geno Tai, M.D., an infectious diseases resident at Mayo Clinic and coauthor of a study on the disproportionate impact of COVID-19 on racial and ethnic minorities, tells Mental Floss. “The legacy of redlining, for example, has made African American households poorer; their communities have less resources decades after this policy.”

Utibe Essien, M.D., an assistant professor of medicine at the University of Pittsburgh School of Medicine and coauthor of a different study on COVID’s racial disparities, echoes this sentiment when speaking with Mental Floss. “It’s the food insecurity, it’s the poor neighborhoods, it’s the poverty really that drives a lot of the clinical diseases,” he says. “It’s the limited access to health care, whether it’s through insurance or through bias in our health system. It drives a lot of the chronic risk factors.”

3. People of color are more likely to be exposed to the virus.

Not only are Black and Latino Americans more likely to suffer severe cases of COVID-19, but they’re more likely to catch the disease in the first place. This is because chances are higher that they have jobs and living arrangements that make safe social distancing impossible.

While many people have had the opportunity to work from home in recent months, that hasn’t been the case for workers whose jobs are impossible to do from a home office. These frontline jobs are also less likely to come with salaries and paid time off. For many workers, being told to practice social distancing means having to choose between their health and their livelihoods. Harriet A. Washington, a professor of bioethics at Columbia University and the author of A Terrible Thing to Waste and Medical Apartheid, tells Mental Floss, “Telling people not to go into work, not to take public transit, not to have interaction with other people; that doesn’t work for people who simply have no other option. These essential workers, service workers, people who drive the trains and clean the floors and serve food—these people don’t have a choice. They have to go to work. If they didn’t go to work, they’d be fired.”

4. People of color have less access to COVID-19 testing.

When people of color do get sick, they can have a harder time getting tested than white people in America. Testing sites tend to be located in white neighborhoods, and white people are more likely to have health insurance and a regular physician.

Testing has been identified as a key tool in fighting COVID-19, and unequal access to tests seriously hinders any containment efforts. “Without testing, we’re not going to have the most accurate information as to who is being infected,” Essien says. “Without testing we won’t be able to do the necessary contact tracing to identify who was the exposee, so to speak, and who was the exposer to this infection. And without testing and knowing where the cases are, we really are limited in being able to distribute resources, whether it’s treatment, personal protective equipment for providers, and ultimately thinking about vaccination in these groups as well.”

Unequal access to testing also means that COVID-19’s racial disparity may be even greater than what the official numbers say.

5. COVID-19’s racial disparity is greater when adjusted for age.

In addition to preexisting conditions, age is the other major factor that determines COVID-19 severity. Elderly people are more likely to develop extreme COVID-19 cases and die from the disease, but the race disparity in older patients isn’t as great as it is among younger age groups. That’s because the senior population in America is whiter overall. “Unfortunately in our country, white Americans are more likely to live longer. And so the older population in our country does tend to skew white,” Essien says.

For his study, he and his colleagues adjusted for age to get a more accurate look at COVID’s racial impact. The results showed a disparity that’s even worse than what the plain numbers suggest. “The younger individuals who were dying were coming from vulnerable and marginalized groups. That is really of concern,” he says. “I think the fact that we’re looking at the age-adjusted analysis now takes away from this idea that this is just a problem in nursing homes.”

6. People of color are hit harder no matter where they live.

In the first few months of the pandemic, the New York City metro area was hit the hardest. Some speculated that dense, urban centers were more susceptible to the virus, and because cities tend to have greater nonwhite populations than rural areas, the virus’s racial disparities were amplified. But COVID-19’s disproportionate impact on people of color can’t be explained by the virus’s initial concentration in urban areas. The analysis from The New York Times shows that the disparity persists across different parts of the country, including suburban and rural areas. In recent weeks, it’s become clear that the novel coronavirus isn’t just an urban problem. Many current COVID-19 hotspots fall outside of cities, and rural counties are vulnerable to the disease in their own ways.

7. Native American reservations face numerous challenges for containing the virus.

Some of the communities that have been hit the hardest by the COVID-19 pandemic have been Native American reservations. In the Navajo Nation, which had a population of just under 174,000 in 2010, 8593 people have tested positive for the disease and 422 have died from it as of July 19. Indigenous people living on reservations face the same risk factors as people of color living in other parts of the U.S., including higher rates of preexisting conditions. They may also lack basic infrastructure that’s essential during a pandemic. On the Navajo reservation, 30 to 40 percent of residents don’t have running water, which makes safe hand washing practically impossible. Reservations don’t have the tax base that state and local governments do, and when non-essential businesses were forced to close, many of their regular revenue sources dried up. These factors make offering healthcare and other resources harder than ever in a time when it’s especially needed.

8. The racial demographic data for COVID-19 is incomplete.

Accurate statistics are necessary to tackle the racial disparity we’re seeing with COVID-19. Though reports on the subject are starting to come out, the data is still lacking. The New York Times was only able to publish its recent report after suing the CDC, and the documents the center released were missing race and ethnicity information from more than half of the cases. Essien says that when researching his study, which was released on May 11, only 28 states were reporting race and ethnicity related to coronavirus testing. He says that one reason for these omissions, at least early in the pandemic, may have been privacy issues. “It’s really a national pandemic now, and so I hope that the privacy issues are no longer a concern,” he says.

Some people in the medical community also hold the view that publishing more data will only make the disparity worse—something Essien disagrees with. “There’s also anecdotal concerns that releasing race and ethnicity data would racialize the disease. If we see that certain communities are being hit harder than others, especially if they are minority communities, then people are going to forget about the disease and not take it seriously. I think that is a really concerning mindset if it’s had by policy-makers or public health officials. The data drives so much around how we respond to this disease, so the more we have, the more we are helping those communities that are being most influenced.”

9. COVID-19’s racial disparity follows a familiar pattern.

There’s still a lot we don’t know about COVID-19’s relationship to race, but it’s not a totally new phenomenon. Similar trends emerged during the viral outbreaks and pandemics that occurred prior to this one.

“There’s little about it that’s truly novel,” Washington says. “We saw the same thing with HIV infections in the 1990s. We discovered that people of color were being infected disproportionately. The same thing happened with Hepatitis C.”

Even as demographic data related to COVID-19 takes shape, medical experts can look at patterns from the past to fight the current problem. Essien says, “I always like to remind folks that back in 2009 with the H1N1 flu pandemic, we saw very similar disparities around access to testing, access to treatments, and death in Black and Hispanic communities compared to white Americans. So we have a lot of lessons to learn from just 10 years ago. We don’t even need to go all the way back to 1918 like many do.”

10. The medical community needs to build trust with people of color.

Trust in the medical community is low among all racial groups in America right now, but it’s particularly low among Black Americans. According to the Pew Research Center, only 35 percent of Black Americans trust medical scientists to act in the public interest compared with 43 people of white Americans. Racism in medicine helps explain these numbers. “We have known for a very long time that African American reports of symptoms, especially pain, tend to be discounted,” Washington says. In one study published in 2016, nearly half of the medical students surveyed believed that Black patients experience pain differently than white patients.

During a pandemic, distrust in medicine can be fatal, and the medical community needs to gain goodwill with Black Americans and other marginalized groups in order to save lives. “The question often evoked is, ‘Why don’t African Americans trust the healthcare system? Why are they so fearful?'” Washington says. “These are all the wrong questions. The real question is: Why is the American healthcare system so untrustworthy that large swaths of people don’t trust it, even when they’re ill?”

Repairing this trust can be done on a doctor-to-patient level. “Medical professionals should focus on giving impeccable care to all patients while thinking about their social situations,” Tai says. “Implicit bias among clinicians is a pervasive problem … so clinicians must always reflect on this.”

But in order to combat the racial disparity we’re seeing with COVID-19, more work needs to be done on a large scale as well. According Essien, one of the most important things policy-makers and medical professionals can do in the short-term is listen to the communities that are suffering the most. “A lot of how we are going to be able to get these communities to trust us, which I think trust plays a big role in all of this, is to actually talk to them, is to hear what the Black and Hispanic and Native American communities who are being hit the hardest need from us in this moment,” he says. “We can’t just assume that they want the vaccine first, for example. We can’t just assume that they want the government coming into their communities, into their churches, or barbershops and offering testing. They might feel like that’s not appropriate in their different spaces. So actual communication, strong, thoughtful communication, with those communities is really critical.”