In a Research Letter in this issue of JAMA Internal Medicine, Chen et al use data from the Wide-ranging Online Data for Epidemiologic Research (WONDER) database of the Centers for Disease Control and Prevention (CDC) to explore how the COVID-19 pandemic has been associated with an increased risk of mortality from external causes such as drug overdose, homicide, and suicide.1 Their findings are sobering, estimating more than 17 000 additional fatalities from external causes during 2020 and also important racial and ethnic disparities. Black people were estimated to have experienced the highest excess homicide rate (6.7 per 100 000 population), and American Indian and Alaskan Native communities had the highest estimated excess deaths from drug overdose (11.21 per 100 000 population).

These disparities should be contextualized within the larger structures of racism built into communities, institutions, and policies. For instance, redlining practices of the 1930s that excluded Black individuals from obtaining government-backed home loans have led to the concentration of poverty in Black communities. Black families were then further destabilized by the war on drugs, which dates to 1971 in the US, and have experienced high rates of firearm violence even after controlling for socioeconomic status.2 Similarly, increased opioid overdoses are exacerbated by structural barriers to health care access. For example, buprenorphine is more likely to be prescribed to White patients and those who have private insurance or who can self-pay.³

The study by Chen et al1 also underscores a challenge to the use of large databases for health equity research. In the CDC’s WONDER database, large and diverse populations are aggregated into pooled groups such as Asian, Native Hawaiian, and other Pacific Islander. Future research should disaggregate race and ethnicity data across these diverse communities whose histories of immigration and colonization have influenced health status in different ways. Nonetheless, the findings of Chen et al¹ suggest that previously described racial and ethnic disparities in COVID-19 mortality may be underestimates, as external contributors to mortality were often not incorporated. There is an urgent need to actively address structural factors associated with disparities in health outcomes and mortality rates in already marginalized communities.

Published Online: May 9, 2022. doi:10.1001/jamainternmed.2022.1472

Corresponding Author: Cary P. Gross, MD, Yale School of Medicine, Primary Care Center, 333 Cedar St, PO Box 208025, New Haven, CT 06250 (cary.gross@yale.edu).

Conflict of Interest Disclosures: Dr Gross reported grants from NCCN (AstraZeneca), grants from Johnson & Johnson support for new models of clinical trial data sharing, and personal fees from Genentech Support for studies of molecular profiling use in real world practice outside the submitted work. No other disclosures were reported.