A longitudinal study of convergence between Black and White COVID-19 mortality: A county fixed effects approach

BACKGROUND: Non-Hispanic Black populations have suffered much greater per capita COVID-19 mortality than White populations. Previous work has shown that rates of Black and White mortality have converged over time. Understanding of COVID-19 disparities over time is complicated by geographic changes in prevalence, and some prior research has claimed that regional shifts in COVID-19 prevalence may explain the convergence. METHODS: Using county-level COVID-19 mortality data stratified by race, we investigate the trajectory of Black and White per capita mortality from June 2020–January 2021. We use a county fixed-effects model to estimate changes within counties, then extend our models to leverage county-level variation in prevalence to study the effects of prevalence versus time trajectories in mortality disparities. FINDINGS: Over this period, cumulative mortality rose by 61% and 90% for Black and White populations respectively, decreasing the mortality ratio by 0.4 (25.8%). These trends persisted when a county-level fixed-effects model was applied. Results revealed that county-level changes in prevalence nearly fully explain changes in mortality disparities over time. INTERPRETATION: Results suggest mechanisms underpinning convergence in Black/White mortality are not driven by fixed county-level characteristics or changes in the regional dispersion of COVID-19, but instead by changes within counties. Further, declines in the Black/White mortality ratio over time appear primarily linked to county-level changes in COVID-19 prevalence rather than other county-level factors that may vary with time. Research into COVID-19 disparities should focus on mechanisms that operate within-counties and are consistent with a prevalence-disparity relationship. FUNDING: This work was supported by the National Center for Advancing Translational Sciences [E.H.: UL1TR002553].