Health Inequities in the U.S. Coronavirus Disease 2019 Pandemic and Response

Abstract
Coronavirus disease 2019 (COVID-19) was first detected in the United States in January 2020. Because it is a respiratory pathogen, nonpharmacological measures such as physical distancing, sheltering in place, and mask wearing were deemed important early interventions while treatments and vaccinations were being developed. Although these interventions are effective for some, many people across the United States do not have the luxury or ability to physically distance from one another because of their housing and place of employment. According to available data, individuals in historically underserved communities are experiencing disproportionate rates of COVID-19 infection and mortality. COVID-19 has exacerbated health inequities among people of color, individuals with home and food insecurity, individuals with underlying health conditions, those living with disabilities, and those living in underserved communities. Due in part to a lack of sufficient data collection (e.g., on demographic characteristics), a lack of testing to identify affected individuals, and community-specific response delays, COVID-19 has continued to spread widely across the United States. Federal, state, tribal, and local officials must prioritize comprehensive and transparent COVID-19 data collection, effective contact tracing, and widely accessible and accurate testing and employ culturally appropriate and community-based public health interventions that address underlying health inequities.

Relationship to Existing APHA Policy Statements

• APHA Policy Statement 20189: Achieving Health Equity in the United States
• APHA Policy Statement 20177: Improving Working Conditions for U.S. Farmworkers and Food Production Workers
• APHA Policy Statement 20166: Opportunities for Health Collaboration: Leveraging Community Development Investments to Improve Health in Low-Income Neighborhoods
• APHA Policy Statement 20158: Preventing Occupational Transmission of Globally Emerging Infectious Disease Threats
• APHA Policy Statement 201015: Securing the Long-Term Sustainability of State and Local Health Departments Policy Statement
• APHA Policy Statement 20091: Support for Community Health Workers to Increase Health Access and to Reduce Health Inequities
• APHA Policy Statement 200412: Support for Community Based Participatory Research in Public Health
• APHA Policy Statement 200311: Opposition to Eliminating or Compromising the Collection of Racial and Ethnic Data by State and Local Public Institutions
• APHA Policy Statement 20017: Research and Intervention on Racism as a Fundamental Cause of Ethnic Disparities in Health
• APHA Policy Statement 20015: APHA Position Paper on the Health Status of American Indians and Alaska Natives
• APHA Policy Statement 20005: Effective Interventions for Reducing Racial and Ethnic Disparities in Health

Problem Statement
Physical distancing, sheltering in place, and mask wearing are essential nonpharmacological prevention measures for coronavirus disease 2019 (COVID-19). In addition, widespread testing and contact tracing are effective strategies to identify and isolate COVID-19-positive individuals and their contacts.[1] However, in the United States, implementation of and funding for these strategies vary widely by state and regional authority.[2] The lack of a national strategy for safe physical distancing, testing, and contact tracing has significantly dampened the ability of states, tribes, and local communities to stop COVID-19 transmission. Underserved communities that face endemic systemic, institutional racism and poverty are experiencing disproportionately high morbidity and mortality from COVID-19.[3]

An examination of 1,320,488 laboratory-confirmed COVID-19 cases in the United States between January and May 2020 showed that Hispanic and Latinx individuals of any race accounted for 33% of cases, non-Hispanic Black individuals accounted for 22% of cases, and non-Hispanic American Indian and Alaska Native individuals accounted for 1.3% of cases. In contrast, Black, Hispanic and Latinx, and American Indian/Alaska Native communities make up 13%, 18%, and 0.7% of the U.S. population, respectively.[4] This study also demonstrated the frequency of missing data; data on race and ethnicity were not reported for 45% of cases.[4] Often, race and ethnicity data are not included (i.e., the area to provide this information is left blank) on reports to public health. Lacking incentives, health care systems irregularly collect and report these data. There are also significant data delays, which continue to leave decision makers and communities unable to understand the scope of the problem.[5]

This policy statement aims to identify underserved populations at elevated risk for COVID-19 morbidity and mortality, describe delays and missing information affecting COVID-19 prevention and containment, and advocate for action steps to meaningfully address health inequities in the U.S. COVID-19 pandemic and response.

Underserved populations by race and ethnicity: Black Americans are facing systemic “racism, segregation, and economic disinvestment” that contribute to disproportionate levels of poverty and chronic disease relative to non-Black Americans.[6] While Black Americans represent 13% of the U.S. population, they accounted for 34% of all deaths from COVID-19 as of April 2020.[7] Black Americans are less likely to be screened for COVID-19 due to implicit bias and lack of access to health care resources and insurance.[7] In a cross-sectional study examining COVID-19 surveillance data in the greater Houston, Texas, area, 20,228 individuals were tested and 1,551 tests were positive. Among those testing positive for COVID-19, 22% were Black Americans. The odds of testing positive were 2.23 times in the non-Hispanic Black population than in the non-Hispanic White population. The authors attributed the higher risk in Black Americans to be associated with lower socioeconomic position and higher population densities in Black communities.[8]

Reports show a disproportionate impact of COVID-19 cases and deaths on Hispanic and Latinx communities. An analysis of 79 counties in the United States with COVID-19 hotspots revealed that Hispanic individuals were the largest population group living in a hotspot. This disproportionate impact is possibly due to employment in essential industries, multigenerational and multifamily households, and social inequities contributing to chronic disease and environmental exposures.[9]

Indigenous people in the United States and its territories include American Indian and Alaska Native, Native Hawaiian, and Pacific Islander populations. Often, information on race and ethnicity among American Indian/Alaska Native and Native Hawaiian/Pacific Islander groups is limited, missing, or misclassified in federal, state, and local reportable disease and health data systems, including COVID-19 data systems.[10,11] Frequently, these data are not reported publicly by federal, state, and local health departments and researchers because of statistically small numbers.[10] Yet, early on, American Indian/Alaska Native communities experienced sustained, widespread outbreaks, and from limited data researchers noted laboratory-confirmed incidences of COVID-19 among American Indian/Alaska Native individuals that were 3.5 times higher than those among non-Hispanic White individuals.[11]

In April 2020, data suggested that in six western U.S. areas, Native Hawaiian/Pacific Islander COVID-19 case rates were higher than those in other racial/ethnic groups.[12] For example, the Native Hawaiian/Pacific Islander rate in California was 217.7 cases per 100,000 people, while the statewide overall rate was 62.43 per 100,000 people.[12] Native Hawaiian/Pacific Islanders have some of the highest rates of essential workers in California and Hawaii. A high percentage of Native Hawaiian/Pacific Islanders live in multigenerational homes, and a significantly large percentage are uninsured and underinsured.[12]

One analysis examining COVID-19 hotspots showed that although Asian Americans are not commonly living in counties with hotspots, they are overrepresented in cases relative to their population proportions.[9] Asian American communities vary extensively, but most COVID-19 data are reported in aggregate. Without data disaggregation, community-specific needs cannot be identified. The high prevalence of underlying health conditions is a large contributing factor. Asian Americans face xenophobia and one third of this population has limited English proficiency, which can create a substantial barrier to accessing routine health care.[13] Similar to Pacific Islanders, Asian Americans make up a large proportion of essential workers in nursing, medicine, manufacturing, and retail.[13]

Underserved communities and their intersection with determinants of health: Health inequities are a result of institutional racism that continues to impact living conditions, working conditions, political voice, power, and self-determination. Health inequities worsen the prevalence of chronic diseases and contribute to poverty and environmental exposures.[14]

As a result of explicit government actions to enforce racial segregation, underserved communities are more likely to live in densely populated housing. Structural racism in housing has been propelled by redlining, exclusionary zoning, gentrification, racism, restrictive covenants, and lending practices.[15] As a consequence, housing negatively influences health due to the biological and chemical hazards in these areas.[15] People living in densely populated housing struggle to maintain physical distancing and face challenges isolating sick family members from non-sick individuals.[15] Black American, Latinx, and low-income individuals are 1.7 to 2.2 times more likely to live in low-income and underinvested neighborhoods.[15]

People experiencing homelessness have high rates of chronic mental and physical health conditions and large barriers to medical care.[16] Underserved communities are also overrepresented among people experiencing homelessness, and those who lack housing are at greater risk of contracting infectious diseases.[16] According to a study examining 2,729 patients who presented to Boston Medical Center with COVID-19, one in six were experiencing homelessness.[17] People living in institutional settings such as skilled nursing and group home facilities are at significant risk for COVID-19 due to congregate living and elderly residents. Several studies indicate disproportionate morbidity and mortality among these residents as well as staff members.[18,19]

One study conducted in New York showed that individuals with disabilities living in institutional facilities or group homes were more than five times as likely to contract COVID-19, with congregate settings being the primary risk factor. People with disabilities have an elevated risk of chronic disease and other underlying health conditions, which can worsen the severity of COVID-19.[20] Individuals with disabilities are also facing unprecedented discrimination regarding resource allocation. One complaint filed in Tennessee described how the state’s crisis standards of care initially discriminated against people with disabilities by preventing allocation of ventilators to this population in times of scarcity.[21]

Individuals who are incarcerated have an increased prevalence of infectious and chronic diseases, and people of color are overrepresented in incarcerated settings due to systemic racism and discriminatory policing policies.[22] As a result of crowded living conditions that prevent adequate physical distancing, as well as poor ventilation, restrictions on hygiene products, and an increasingly aging population, incarcerated individuals remain at high risk for COVID-19.[23] Preliminary COVID-19 data among state and federal prisons indicate that the prevalence of COVID-19 cases and mortality is 5.5 times higher than the U.S. population rate.[24]

People belonging to underserved populations are at risk for COVID-19 due to working conditions. Between April and May 2020, 87% of COVID-19 cases in 239 meat-packing plants occurred among individuals who were members of racial or ethnic minority groups.[25] In Utah between March and June 2020, 58% of COVID-19 cases occurred in the manufacturing, wholesale trade, and construction sectors. Hispanic and non-White workers make up 24% of Utah workers but accounted for 73% of workplace outbreaks.[26] People in underserved communities fill many of the jobs identified by the U.S. Department of Homeland Security as those that are essential for economic sustainability.[27] These jobs often involve prolonged interaction with the public or lack the potential for physical distancing. In addition, 24% of the U.S civilian workforce does not have paid leave. Lack of paid time off may promote attendance at work despite sickness or recent illness exposure.[28]

Front-line patient care and non–patient care workers are disproportionately impacted by COVID-19. Initial reports suggest critical shortages of personal protective equipment (PPE) for the medical community, and despite an increase in capacity some personnel report limited PPE availability.[29] One study showed that front-line health care workers’ risk of reporting a positive COVID-19 test was 3.4 times higher than in the general community. The same study revealed that Black, Asian, and other underserved health care workers’ risk was 4.88 times that of the non-Hispanic White population.[29] Many case-reporting platforms across the United States do not report occupation or health care worker status. According to the Centers for Disease Control and Prevention, data on health care provider status are missing in 84% of reported cases.[30]

Rural communities experience greater barriers in accessing care, as indicated by fewer physicians across specialties. These communities are marked by aging populations, higher disability, greater uninsured rates, and reduced Internet access.[31] Rural communities may lack sufficient local resources and often must wait for state and federal resources to address limits in testing and treatment for COVID-19. Lower numbers of health care providers and facilities may delay treatment. In addition, limited Internet access may prevent individuals from working from home and may affect the feasibility of implementing telehealth services.[31]

Individuals who identify as LGBTQ (lesbian, gay, bisexual, transgender, and queer) have higher rates of chronic diseases and cancer, placing them at greater risk for significant morbidity and mortality related to COVID-19. Reduced access to health care services will worsen the impact.[32] Individuals identifying as LGBTQ also have higher rates of mental illness and suicidality due, in part, to societal discrimination and stigma, and COVID-19 is predicted to worsen these effects.[32] However, the true impact of COVID-19 on the LGBTQ community is unknown, as relevant data are not collected. Immigrants constitute another underserved group impacted by COVID-19. While less than 10% of U.S. citizens are uninsured, the percentage among immigrants is 23%. That percentage increases to 45% among undocumented immigrants.[33] Furthermore, language barriers, lack of paid sick leave, and the cost of seeking medical care affect the health of immigrant communities.[28] Immigrants fear legal and deportation repercussions for seeking care or enrolling in health insurance, and reimplementation of the Public Charge Rule perpetuates these fears and concerns.

Intersectionality: In many instances, affected individuals share more than one of the above characteristics and identities, which may amplify the effects. There are also populations inadvertently missing from this statement for which data are emerging, including pregnant women of reproductive age, who are at an increased risk for severe COVID-19 infection.[34] Missing and incomplete data on COVID-19 cases make it challenging to identify every affected population. More research and better data are needed to explore the impact of intersectionality on COVID-19 risk and identify all individuals at an increased risk based on determinants of health and discrimination.

U.S. COVID-19 surveillance: Federal public health spending continues to decrease while state public health workforces are chronically underfunded and overburdened.[35] As such, state, tribal, and local public health response work for COVID-19 is hampered. Concerns consistently raised about data collection include reporting delays, incomplete reporting, and reports missing sociodemographic elements. These issues limit public health understanding about the burdens of COVID-19 and contribute to gaps in response capacity, especially for underserved populations.[9,24,26,30] Basic epidemiological data dashboards are insufficient to provide answers to simple community questions about COVID-19. For example, what percentages of COVID-19 cases and deaths come from specific underserved communities? What are the COVID-19 prevalences and trends among essential workers, those with chronic illnesses, and older people? Cumulative reporting provides no information about gaps and successes within communities, and it stigmatizes hard-hit communities. More granular data, such as information on patients’ zip codes, neighborhoods, occupations, and location densities, are needed for allocating resources, tailoring interventions to fit community needs, and empowering impacted communities to respond.[36]

Historically, people of color have been underrepresented in clinical trials. Emerging data on COVID-19 treatment show that studies are being conducted among majority White participants.[37] Data are also needed on the distribution of COVID-19 treatment, the effectiveness of contact tracing, and testing availability in communities of color. In New York, data suggest that COVID-19 testing frequency is highest in predominantly White communities. However, the highest numbers of positive tests have been recorded in non-White neighborhoods.[38]

Evidence-Based Strategies to Address the Problem
Comprehensive COVID-19 public health surveillance, research, and evaluation: Comprehensive data collection on and analyses and evaluations of COVID-19-related interventions, care, supplies, and system capacity need to be transparent and readily available to community leaders, public health workers, and the public.[39] Data must be collected on race, ethnicity, neighborhood, housing status, disability, sexual and gender identity, industry and occupation, and other social and environmental determinants of health. The frequency of sociodemographic information collection is inadequate. According to a systematic review evaluating 13 studies, only one of the studies contained any indicator of socioeconomic position.[5] The authors attributed this lack of data collection to the World Health Organization standard for case reporting and clinical processes at many public health and health care institutions.[5] However, integrating COVID-19 data collection with electronic health records, integrated health data exchanges, and existing public health surveillance systems can help gather these needed data.[40] Data dashboards created for data transparency during COVID-19 must also contain robust case information about the social determinants of health.[41] Few current COVID-19 dashboards provide such important, specific data as opposed to including only cumulative data by race, ethnicity, and other special populations.[3]

Mandating the collection of these data through legislation may be effective. Although not comprehensive, federal agencies such as the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration have begun to require and incentivize health care entities to systematically collect and report data on race and ethnicity.[42,43] Several states have enacted legislation that requires providers to collect specific sociodemographic data for each COVID-19 patient encounter, which is anticipated to help bolster the states’ COVID-19 response.[44] Canadian health organizations found that asking patients to self-report these demographic data was a successful means of data collection.[45]

Actively address health disparities and disparities created by COVID-19: All stakeholders must actively address health disparities and access to care among underserved populations in the COVID-19 response. COVID-19 testing should be freely available for all workers, including individuals living and working in institutional facilities. The evidence suggests that frequent testing, especially in communities with dense living conditions (e.g., skilled nursing facilities), can detect circulating disease in asymptomatic individuals and reduce disease transmission.[18,19] Employers must also ensure the availability of PPE for those at increased risk of contracting COVID-19 at work. Concurrently, paid sick leave and physical distancing measures must be implemented to support individuals who work in at-risk settings and live in dense housing.[6] Extensions on moratoriums for evictions and foreclosures, access to clean water and healthy food, and advocacy for legislation that promotes clean air can help reduce existing health disparities.[6] Focusing on employing trained community health workers, expanding the Supplemental Nutrition Assistance Program, enhancing school lunch programs, and ensuring universal broadband access can also narrow disparities and build community resilience.[46]

Empower all communities in public health practice and research decision making: A core component of public health work is empowering the community from design to implementation, evaluation, and dissemination to find feasible evidence-based solutions. Public health must enhance efforts to engage with local community leaders and organizations to provide critical messaging about COVID-19 infection and to collaborate for community-based testing and contact tracing. Seeking community input and partnership is necessary for community uptake and can help ensure that credible information is distributed across neighborhoods. One study suggests that implementation of community engagement and culturally aligned interventions leads to significant increases in favorable health behaviors.[47] Contact tracing should also be conducted in a manner that aligns with the needs and culture of a population. Indigenous and rural populations benefit from face-to-face contact tracing that can help uncover sick individuals, can identify other health needs, and can help families follow quarantine procedures.[48] The research and allocation process for COVID-19 treatment and vaccinations must involve community members from development to implementation. One way is to implement the new standards of practice for meaningful patient and community engagement from the Patient Centered Outcomes Research Institute and the National Institutes of Health.

Opposing Arguments/Evidence
Collection of sociodemographic data, while critical for scientifically informed decisions, may pose risks to confidentiality and privacy. If these data are not kept private, their release may lead to negative social and professional consequences.[49] In tandem with building up systems to support sociodemographic data collection for COVID-19 reporting, public health and federal entities must also build systems and processes to limit the use of protected health information and educate and train staff.[40] Sociodemographic-specific data are subject to misinterpretation by the public if taken out of context. Special care must be taken to ensure that these data are properly translated and accurately reported by public health practitioners and the media to empower rather than mislead communities and avoid stigmatizing or blaming them.

Others have suggested that the United States should focus on gaining natural herd immunity while a vaccine is being developed as opposed to building up nonpharmacological strategies to prevent COVID-19. However, epidemiological models show that large proportions of the population would need to be infected, and many of those infections could result in death.[50] Considering that underserved populations are already experiencing disproportionate impacts of COVID-19-related morbidity and mortality, the natural herd immunity strategy would widen these disparities and be unethical.

Eliminating health disparities requires providing concentrated resources in areas of need.[14] This raises financial concerns as robust financial support is needed to prioritize resources according to levels of risk, and others may want to equally allocate financial resources across all communities. This argument of equality versus equity is examined often, and the primary suggestion is that health disparities of all forms are best addressed through health equity.[14] Ample evidence suggests that ignoring health disparities perpetuates a greater long-term economic burden on society.[14]

Alternative Strategies
COVID-19 is a novel condition, and data supporting strategies to address this disease and the resulting disparities are fairly limited. One alternative proposed strategy is to develop local, state, and national task forces and response teams on health equity to address COVID-19 health disparities. At present, more than 10 states have enacted this strategy, but most lack sufficient funding to address the root causes of health disparities, and sociodemographic data collection on COVID-19 is incomplete.[44] Formulation of task forces requires substantial funding and proper infrastructure and, without such support, is unlikely to lead to sustainable progress.

Action Steps
APHA calls on the U.S. Congress, the federal government, and state, local, and tribal governments and their supportive agencies and organizations to take the following steps:

1. Declare disparities in the COVID-19 pandemic and current delayed public health responses as unacceptable threats to the health and well-being of all U.S. communities
2. Prioritize funding and mobilize stakeholders to enable timely and sustainable scientifically informed actions in addressing direct and indirect COVID-19 impacts to prevent further transmission, treat COVID-19 illnesses and related health risks, and provide economic and psychosocial support to at-risk communities. All testing should include availability of mobile and walk-up options to improve accessibility.
3. Support timely, community-level interventions and policies by funding and staffing near-real-time, flexible, integrated, secure, and transparent public health surveillance, evaluation, and research through epidemiological standards of practice.
4. Enact and fund legislation and enable adequate personnel levels to comply with federal and state initiatives to address missing sociodemographic data in COVID-19 case reporting. Surveillance systems should implement expanded data analyses examining sociodemographic data to provide communities with timely and actionable information.
5. Fund and recruit the active engagement of individuals from underserved communities at all stages of clinical trial research, development of guidelines, compassionate use implementation, and allocation of novel therapeutics and vaccines to ensure that their distribution is equitable and scientifically informed.
6. Fund and implement evidence-based interventions that address health disparities and ensure timely and sustainable access to health care (including mental health care), healthy food, clean water, reliable Internet service, health insurance, affordable medications, housing, and transportation.
7. Empower community leaders and members to plan and implement COVID-19 prevention and mitigation strategies and evaluate their effectiveness. All community-level messaging should adhere to the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.
8. Enact specific legislation and rules that protect workers at risk for COVID-19, such as health care and essential workers and their families, by ensuring equitable distribution of personal protective equipment and financial and health assistance. The Occupational Safety and Health Administration and state-equivalent agencies must enact and enforce strong infectious disease control workplace standards to protect against workplace transmission and provide rules covering employee sick leave that include COVID-19 as a workplace hazard.
9. Collect, , fund, disseminate, and translate rigorous, scientifically peer-reviewed and community-engaged research on the effectiveness of COVID-19 interventions, paying particular attention to social determinants of health in preparation for future public health emergencies.

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