Coronavirus disease 2019 (COVID-19) was first detected in the United States in January 2020, although some evidence suggests that COVID-19 was circulating in the country even earlier. Because it is a respiratory pathogen, nonpharmacological measures such as physical distancing, face coverings, and proper ventilation are important prevention methods. Although these interventions are effective for some, many people across the United States do not have the ability to practice all of these measures because of their housing, employment, and use of public transportation. 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, those living in underserved communities, and essential workers, especially those in low-wage industries. As a result of an uncoordinated public health response following years of public health funding cuts, COVID-19 has continued to spread widely across the United States. In 2020, COVID-19 was one of the leading causes of death in the country, and its burden has fallen largely on communities of color and underserved communities. Now, with the availability of safe and effective vaccines, inequities in vaccination access alongside misinformation and partisan politics have challenged the U.S. COVID-19 response. Federal, state, tribal, and local officials must prioritize public health infrastructure and COVID-19 data collection, ensure equitable access to COVID-19 vaccines, and employ culturally responsive and community-based public health interventions that address underlying health inequities.
Relationship to Existing APHA Policy Statements
- APHA Policy Statement LB20-04: Structural Racism is a Public Health Crisis: Impact on the Black Community
- APHA Policy Statement 20189: Achieving Health Equity in the United States
- APHA Policy Statement 20178: Housing and Homelessness as a Public Health Issue
- 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
The coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV-2 virus has exacerbated racial, economic, and health inequities. Health inequities worsen the prevalence of many diseases and contribute to poverty and environmental exposures. Physical distancing, the use of face coverings, frequent handwashing, and avoiding crowds and poorly ventilated indoors spaces are essential nonpharmacological prevention measures for COVID-19. Concurrently, early testing, contact tracing, isolation and quarantine, and available vaccinations are effective strategies to mitigate disease spread and reduce severe outcomes.[2,3] In the United States, implementation of and funding for these strategies vary widely by state and regional authority. Consequently, most communities across the country have seen large COVID-19 outbreaks resulting in significant morbidity and mortality. Worsening the problem, data pertaining to these social determinants of health are often not available in public health reports. In addition, there are significant data reporting delays, which continue to leave decision makers and communities unable to clearly see the problem. Unfortunately, the pandemic has also exacerbated the impact of chronic underfunding of America’s public health and emergency preparedness systems, and communities with the least resources have been gravely affected.
Underserved populations by race and ethnicity: Black Americans have historically and continually faced systemic “racism, segregation, and economic disinvestment” throughout American history, significantly contributing to disproportionate levels of poverty and chronic disease relative to non–Black Americans. As of July 2021, Black Americans were 2.8 times more likely to be hospitalized and 2.0 times more likely to die from COVID-19 than White Americans. Reports also show a disproportionate number of COVID-19 cases and deaths in Hispanic and Latinx communities. As of July 2021, Hispanic or Latinx persons were 1.9 times more likely than White Americans to contract COVID-19, 2.8 times more likely to be hospitalized, and 2.3 times more likely to die from COVID-19. In addition, in May and June 2020, self-reported symptoms of depression and suicidal thoughts and ideation were more frequent among Hispanic persons than non-Hispanic White and non-Hispanic Black persons. Hispanic persons have also reported greater stress about not having enough food or stable housing than White persons during the pandemic.
The Centers for Disease Control and Prevention (CDC) reported that, as of July 2021, COVID-19 incidence was 1.7 times higher, hospitalizations were 3.4 times higher, and deaths were 2.4 times higher among American Indians and Alaska Natives than among non-Hispanic Whites. Issues associated with access to health care, infrastructure, and education compound these inequities. Native Hawaiian and Pacific Islander populations have high representation in essential workplaces such as the military and service and health care industries in California and Hawaii. A high percentage of Native Hawaiians and Pacific Islanders live in multigenerational homes, and a significantly large percentage of that population is uninsured and underinsured. Often, race and ethnicity data for American Indians/Alaska Natives, Native Hawaiians, and Pacific Islanders are limited, missing, or misclassified in federal, state, and local reportable disease and health data systems, including those for COVID-19. Most data are not reported separately for American Indian and Alaska Native communities, and frequently these data are not reported publicly by federal, state, local, and tribal health departments because of statistically small numbers. These data challenges prohibit implementation of specific public health strategies tailored to the needs of these communities. Similarly, data aggregation by race is also thought to potentially mask disproportionate impacts of COVID-19 on Asian subpopulations.
Underserved and disenfranchised communities and their intersection with social determinants of health: More than 1.4 million people experience homelessness annually and homeless shelters, despite their best efforts, can enable transmission of COVID-19 due to congregate living. In the United States, the peak infection rate was modeled to be nearly 40% among homeless individuals, with 4.3% of these individuals likely to be hospitalized. Persons experiencing homelessness have high rates of chronic mental and physical health conditions and large barriers to medical care. Similarly, people living in institutional settings such as skilled nursing and group home facilities are at significant risk for COVID-19 as a result of congregate living and underlying risk factors including advanced age. Several studies indicate disproportionate morbidity and mortality among these residents and among staff members. Finally, individuals with disabilities have an elevated risk of chronic disease, which can worsen the severity of COVID-19. Individuals with disabilities are also facing unprecedented discrimination due to ableism in resource allocation guidance.
Persons who are incarcerated have an increased prevalence of infectious and chronic diseases, and persons of color are overrepresented in incarcerated settings as a result of systemic racism and discriminatory policing policies. During incarceration, these persons are more susceptible to COVID-19 spread due to restricted movement, confined spaces, and limited care. In March 2020, the first case of COVID-19 was diagnosed on Rikers Island (New York City), and within two weeks more than 200 positive cases were found. Studies suggest that COVID-19 case rates were two to four times higher among Black inmates than White inmates.
Most U.S. workers cannot work from home, and those who work in proximity to others tend to have lower incomes, have less access to health insurance, and lack paid sick leave. A lack of paid time off may promote attendance at work despite sickness or recent illness exposure. These working conditions are also risk factors for preexisting conditions that increase COVID-19 severity. Black, American Indian and Alaska Native, and Hispanic and Latinx workers are more likely to have jobs with lower incomes, to use public transportation to commute, and to live in densely populated areas, and they are less likely to have health insurance. Workers of color also have lower job control and greater job insecurity, and they face workplace harassment and other work hazards.[24,26] A study of poultry workers showed that physical proximity to other workers and shared equipment can facilitate SARS-CoV-2 transmission at work. However, engineering and administrative controls might reduce SARS-CoV-2 transmission risk for workers on the production floor. Other work settings with significant outbreaks of COVID-19 include correctional facilities, nursing homes and long-term care facilities, homeless shelters, and manufacturing plants. Because work data are not being systematically collected and reported for people with infections, information about worksite exposures is largely limited to news reports.
Front-line patient care, emergency medical service, and non–patient care health care workers are disproportionately impacted by COVID-19. One study showed that front-line health care workers’ risk of reporting a positive COVID-19 test was 3.4 times higher than that of 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. A second study showed that emergency medical service workers in New York City had a fatality risk 14 times higher than that of firefighters in the same department and 36% higher than that of the U.S. population. Despite improvements in case reporting completeness, occupation and health care worker designations are still frequently missing from cases reported to the CDC.
During the first year of the pandemic, the Occupational Safety and Health Administration (OSHA) issued unenforceable guidelines to employers on how to protect workers from exposure to SARS-CoV-2. In addition, OSHA issued guidance relaxing important requirements for employers to provide respiratory protection and perform recordkeeping. During this period, OSHA did not respond to thousands of complaints about unsafe conditions and retaliatory action by employers against workers who complained about such conditions. States were left to develop their own approach to worker protection, leading to inconsistent and inadequate standards and enforcement. On June 21, 2021, OSHA issued an emergency temporary standard to address workplace SARS-CoV-2 exposures that applied only to health care settings in which there were known or suspected patients with SARS-CoV-2 infection. This is wholly inadequate, as many other workers are at risk of contracting COVID-19 at work. A disproportionate number of these workers are people of color. The mission of OSHA under the law is to issue enforceable standards to protect workers from death and serious harm. Employers must comply with OSHA standards, while OSHA guidelines are not enforceable. Some states amended their policies so that COVID-19 infections in certain workers, mainly health care workers and first responders, are presumed to be work related and covered under workers’ compensation. Such a presumption would benefit all essential workers nationwide.
Rural communities, including reservation and frontier communities, experience greater barriers to accessing care as indicated by fewer physicians across all specialties. These communities are marked by aging populations, higher disability, greater uninsured rates, reduced access to water and electricity, transportation difficulties that affect travel to and from health care facilities, and reduced Internet access and communication systems. The lower number 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 implementation of telehealth.
Individuals who identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ) are at greater risk for suicide, HIV, unemployment, and homelessness and are vulnerable to the impacts of COVID-19. Limited available research indicates that COVID-19 has reduced access to HIV testing and providers and to preexposure and postexposure prophylaxis medications, in addition to increasing discrimination and worsening feelings of social isolation and loneliness.[36,37] There is clear underreporting of sexual and gender identity demographic data in COVID-19 case reports, so the impact of COVID-19 on the LGBTQ community is not well known.
Immigrant persons constitute another underserved group impacted by COVID-19. While less than 10% of U.S. citizens are uninsured, 23% of immigrants of legal status are uninsured. That number increases to 45% for undocumented immigrants. Language barriers, lack of paid sick leave, and high medical costs have a negative impact on immigrant communities. Immigrant workers, including those who are undocumented, are more likely to live in shared housing, rely on shared transportation, and work in poorly ventilated work settings. Despite these increased risks, immigrant persons fear deportation for seeking health care, enrolling in health insurance, or seeking vaccines.
Pregnant people are at increased risk for severe illness and hospitalization from COVID-19 relative to nonpregnant people. Pregnant and nursing persons are often excluded from clinical trials for therapeutics and vaccines, limiting the availability of data on these populations. It has been shown that, after adjustment for age, underlying conditions, and race and ethnicity, pregnant women are 5.4 times more likely to be hospitalized and 1.5 times more likely to be admitted to the intensive care unit. A study examining COVID-19 vaccination rates among persons who are pregnant revealed that only 11.3% of pregnant women were fully vaccinated and that vaccination rates were lowest among pregnant Black and Hispanic women and pregnant persons 18–24 years old.
Because of frequent interactions with others to obtain or use substances and the disproportionate effects of housing and food insecurity, reduced access to health care, and stigma and shame, persons with substance use disorder are at increased risk of contracting COVID-19. Use of tobacco, cannabis, or other smoked substances may also increase susceptibility to respiratory infections. In addition, many in recovery may have experienced reduced access to treatment or support services, particularly during a time of high stress. Those with and without substance use disorder also experience increased stress and triggers that could lead to drug usage, recurrence of drug use, or a higher volume of use.[43,44] In a June 2020 survey, younger adults, persons who are Hispanic, essential workers, and adult caregivers who are unpaid were most likely to report increased substance misuse and worse mental health during the pandemic. Several other vulnerable communities experience health inequities exacerbated by COVID-19. For example, persons living with HIV, organ transplant recipients, persons with cancer or in remission from cancer, and persons with autoimmune disorders may have compromised immune systems due to their conditions or the medications they take. Many of these individuals are at increased risk of severe COVID-19 infection. While these individuals are indicated for vaccination, it is currently not known whether undergoing immunosuppressant therapy or being immunocompromised affects the efficacy of a COVID-19 vaccine.
Intersectionality: Information about affected populations who share characteristics and identities that multiply COVID-19 risks is emerging but often unaddressed in COVID-19 reporting. Missing and incomplete data in COVID-19 reports make it challenging to identify every affected population. For example, evidence suggests that having roles as parents and/or unpaid caregivers has disproportionately impacted mental health during the pandemic. The intersections of this association with other social identities such as minority race and ethnicity, sexual identity, lower income, and low-wage employment likely magnify the impact, but these data are not often sufficiently robust to be analyzed together. Increased quality and quantity of data are needed.
Health literacy and health communication is a significant contributor to infection control during COVID-19, and leveraging technology to disseminate accurate information through trusted messengers can facilitate health communication. However, given the degree of misinformation, politicization, and lack of access to digital platforms, adequate health literacy and appropriate messaging have continued to be a challenge. One study suggests that persons with inadequate health literacy have a poorer understanding of COVID-19 symptoms, are less able to identify behaviors to prevent infections, and are less likely to follow social distancing guidelines. While health literacy concerns affect all people, older adults and adults with a greater burden of disease often face greater barriers to health literacy as well.
U.S. COVID-19 surveillance: Chronic underfunding and overburdening of public health entities compounded by a lack of standardized electronic case reporting procedures contribute to case reporting and contact-tracing delays. U.S. COVID-19 case data also fail to comprehensively capture race, ethnicity, neighborhood, housing status, disability, sexual and gender identity, industry and occupation, and other social and environmental determinants of health and consequently leave at-risk communities uninformed.[8,37] While modest improvements in race and ethnicity data collection have been noted, these efforts still need improvement.
COVID-19 vaccinations: Despite being disproportionately impacted by COVID-19, communities with higher social vulnerability indices have lower COVID-19 vaccination coverage rates. Particularly, vaccination coverage is lower in counties with lower per capita incomes, poorer health, less education, more people living with disabilities, and more single-parent households. A lack of convenient and extended hours for access to vaccines and reduced knowledge of and confidence in vaccines are thought to be precipitating factors in vaccination inequities. In July 2021, the CDC reported inequities in vaccination rates by race and ethnicity, and the data showed that Black and Hispanic Americans were less likely to be fully vaccinated. However, there was an increase in the number of Black and Hispanic Americans receiving vaccines within the preceding 14 days, suggesting that vaccine accessibility and uptake may be improving.
Evidence-Based Strategies to Address the Problem
Coordinate and fund a universal public health system that equitably supports communities: COVID-19 has accelerated the convergence of underfunded public health systems, rising health care costs, and inequitable access to health care services.[6,52] Health inequities exist in U.S. communities with disproportionately lower access to health care, reduced economic investments, and a lack of coordination between public health and health care.[7,52] Countries that have fared better during COVID-19 provide universal health care to their residents and have interconnected public health prevention and mitigation strategies. Public health systems need increased funding and coordination among local, state, tribal, and federal systems to respond more rapidly.[6,53] As was the case in the United States, a delayed and disjointed response to COVID-19 led to a surge in cases concentrated in underserved communities.[6,7,18]
Collect comprehensive sociodemographic data: Sociodemographic COVID-19 case data have been inadequate to provide a sufficient understanding of the extent of health inequities exacerbated by the pandemic. Local and state public health systems must be funded and equipped to enable comprehensive sociodemographic data collection including disability status, race and ethnicity, sexual and gender identity, concomitant disease states, and other relevant factors.[13,37] Funding must also be extended to the platforms and technologies needed to store and analyze the data. Scientists argue that data collected by public health entities must be disaggregated and shared among relevant stakeholders. Evidence supports disaggregating data into relevant subgroups at the local public health level. Hawaii, for example, has seen success in this approach by representing specific Asian subpopulations separately to demonstrate heterogeneity in COVID-19 impact that would not normally be observed with aggregated race reporting.
Actively address underlying inequities compounded by COVID-19: Universal health care access, including mental health care, that is affordable and available to meet the needs of every community is one important strategy in addressing underlying health inequities.[6,18,52] Emerging evidence suggests that as many as one in three individuals with COVID-19 experience lasting health sequelae. Readily available health care to address these syndromes positioned in accessible locations, including underserved communities, will be needed to prevent further inequities. Several social policies that extend beyond clinical medicine are also needed to address health inequities. Some health equity researchers suggest that a universal food income program, unemployment insurance reform, and investments in affordable housing and local economic opportunities can help close equity gaps exacerbated by COVID-19. Additional social policies that sustain moratoriums for evictions and foreclosures, improve access to clean water and healthy food, and advocate for legislation that promotes clean air can help reduce existing health inequities. Focusing on employing trained community health workers who provide culturally responsive interventions, expanding the Supplemental Nutrition Assistance Program, improving health literacy, enhancing school lunch programs, and ensuring universal broadband access can also narrow disparities and build community resilience in times of emergency and disaster. For those with substance use disorder, providing resources such as reliable Internet service and a smartphone to access telehealth treatment, continued reimbursement for telehealth services, clean needle services, and stronger integration between primary care and substance use treatment will be needed to reduce stigma and ensure accessible care. Specifically, smoking cessation options should be readily available by trusted community partners to improve access to treatment.
Empower and engage communities in public health practice: Taking lessons from the Ebola outbreaks in West Africa, public health must enhance efforts to partner with local community leaders and organizations, engaging in multisector collaborations with universities, public health departments, and community-based and faith-based organizations to provide critical messaging about COVID-19 infection and work together in community-based testing, contact tracing, and vaccinations. COVID-19 vaccines should be offered at expanded hours to meet the needs of working persons and directly in communities by trusted partners such as faith-based and community-based organizations. Vaccine clinics should be accessible for individuals with disabilities, and offering door-to-door vaccine opportunities can be effective. Also, as recommended by CDC public health guidelines, such prevention and mitigation efforts must be made available to school-aged children, children in child care, and persons who are pregnant. Seeking community input and partnership from planning to implementation for interventions that improve health equity is necessary for community uptake and sustainability. One study suggests that when community engagement and culturally aligned interventions were implemented, there was a significant increase in favorable health behaviors.
Support the establishment of enforceable workplace safety and health standards and workplace protection programs: Enforceable workplace safety and health standards have a proven record of reducing workplace injury and illness. For example, hepatitis B infections among health care workers declined from 17,000 in 1983 to 400 in 1995 after OSHA promulgated an enforceable bloodborne pathogen standard in 1991 mandating that health care employers provide hepatitis B vaccine to all employees with a potential for exposure to blood. OSHA standards are unable to address all immediate workplace concerns. To address this gap, worker communities have proposed public health councils and other collaborative methods of COVID-19 workplace protection, but data are still emerging on their efficacy. Allocating paid sick leave for all employees is another effective strategy workplaces can propose to improve occupational health and promote equity. A study comparing those with and without paid sick leave showed that those without were more likely to attend work ill. Since a lack of paid sick leave is more common among individuals in lower wage jobs, paid sick leave can address relevant health inequities by allowing these individuals to stay home while ill without loss of income or job retaliation.
COVID-19 has been undoubtedly linked with a partisan political climate rife with misinformation. Simple measures of participation in vaccinations, mask compliance, and physical distancing are divided and polarized along party lines. These political beliefs influence the responses of U.S. states to COVID-19, belief in COVID-19’s existence and severity, and the effectiveness of the response to COVID-19.[66,67] One opposing view is to support states’ rights and politics in determining their population’s COVID-19 response despite what the latest scientific evidence supports. However, emerging evidence suggests that states that took less restrictive COVID-19 measures than what was recommended by experts saw more COVID-19 spread. By allowing political beliefs and individual determination of risk to dictate public health activities, communities facing a greater burden of disease will bear the brunt of an inequitable response. In addition, reducing health inequities will require large financial investments to support the comprehensive development of equitable systems and processes. For example, in the state of California alone, lawmakers are suggesting that more than $400 million be invested annually “to correct the decades-long underinvestment in [the state’s] public health system.” One opposing view is that these investments are costly, and some disagree with the magnitude of funding needed to support public health. Prior to COVID-19, there were reductions in public health funding at all levels, and some still perceive COVID-19 to be a once-in-a-lifetime event. However, research supports that health inequities are best addressed through an upstream and adequately funded approach using a health equity framework that provides affected communities sufficient resources to address and prevent disease and foster public trust.
One alternative strategy is to develop local and state health equity response teams to address COVID-19 health disparities. While several states have adopted this strategy with good intentions, the root causes of health inequities transcend state borders and require immense resources to address. The formulation of task forces requires substantial funding and, in all likelihood, coordinated efforts at the national and community levels to effect change widely and permanently.
APHA calls on external stakeholders to take action to address health and social inequities as follows.
1. The U.S. Congress and state legislatures should provide continuing funding for coordinated federal, state, local, and tribal public health systems that remains ready for use in responses to public health events. It is recommended that federal, state, local, and tribal public health systems take the following steps:
a. collect comprehensive and disaggregated sociodemographic data accurately through each phase of the COVID-19 case investigation process
b. interact and bidirectionally share information with coordinating public health systems at all levels
c. seek input on community-driven public health interventions from communities experiencing the greatest inequities
d. collect laboratory and surveillance data on emerging variants, COVID-19 reinfections, and vaccine breakthrough infections to better inform public health decision making
e. support the training of public health and health care professionals in collecting and analyzing high-quality public health case data using the best available evidence and technology
2. The U.S. Congress, state legislatures, and local and tribal governments should expand, fund, and ensure access to health care, healthy food, clean water, reliable universal broadband Internet, affordable housing, transportation, mental health and substance use treatment, and resources for telehealth among those currently lacking access.
3. U.S. health care and behavioral health providers, delivery systems, and insurers should implement evidence-based strategies that increase timely and sustainable access to health care for those currently lacking care, and these services should remain indefinitely to help reduce health inequities over time.
4. U.S. health care and behavioral health providers, delivery systems, and insurers, in conjunction with the federal government; local, state, and tribal governments; and local and state health departments, should fund and increase the availability, accessibility, and equitable distribution of COVID-19 vaccinations, therapeutics, and testing by:
a. ensuring that all care and services remain free of charge for patients, including zero cost copayments and out-of-pocket expenses for those insured by public and private insurance programs and for those who are uninsured
b. administering COVID-19 vaccines currently authorized by the Food and Drug Administration and performing best-practice COVID-19 testing within communities (e.g., in neighborhoods, through mobile clinics, at workplaces, through door-to-door outreach), during extended hours (e.g., evenings, weekends), and with stable availability and presence in communities
c. supporting and sustaining community-based and faith-based organizations that work to foster trust and improve health literacy through education
d. ensuring continued access to culturally responsive health care services to address lasting physical and mental health sequelae from the COVID-19 pandemic
e. implementing a federal plan to coordinate employer COVID-19 case reporting of all employee COVID-19-related illness with OSHA and federal, state, tribal, and local health agencies
f. evaluating the impact of such interventions on communities disproportionately burdened
5. In line with public health guidance, the U.S. Congress should mandate universal paid sick leave and supported isolation and quarantine for all U.S. workers regardless of hours worked.
6. OSHA should:
a. enact an emergency temporary standard to protect workers not included in the June 21, 2021, health care emergency temporary standard from exposure to SARS-CoV-2
b. place the establishment of a permanent infectious disease standard as a top priority in its regulatory agenda
c. require states that do not provide OSHA coverage to public employees and farmworkers to adopt the emergency temporary standard for these at-risk populations
7. OSHA should engage in timely investigations and enforcement of worker whistleblower laws in response to COVID-19 safety and health complaints.
8. A work-related presumption should be established for state and federal workers’ compensation systems for workers who develop COVID-19 on the job.
9. The U.S. Congress should provide funding for and researchers should disseminate findings on the efficacy of worker public health councils and alternative methods of workplace protection enforcement in settings where OSHA protections are insufficient.
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