COVID-19 Contact Tracing and Health Inequity
by Gulzar H. Shah, PhD, MStat, MS, and Jessica Kronstadt, MPP
COVID-19 does not discriminate; or does it?
Many say, “COVID-19 is an equal opportunity offender,” implying that the virus treats rich and poor, urban and rural, and homeowners, renters, and unhoused individuals equally. Thinking superficially, the argument may seem convincing. However, true inequities and disparities arise from social structures and biases that minimize people’s ability to avoid risks, follow recommended practices to lower the risk of infection, assure best outcomes if infected with the virus, and avoid infecting loved ones, friends, coworkers, and others.
COVID-19 Contact Tracing and Health Equity Issues
In 2020, I and a team of my colleagues at Georgia Southern University had a chance to speak with COVID-19 contact tracing and disease investigation teams across the US from state and local health departments. The primary purpose was to collect qualitative data for a paper, commissioned by PHAB with support from RWJF, on The Administration and Management of COVID-19 Contact Tracing. I was struck by the overwhelming health equity issues that emerged related to contact tracing. Health inequities create disadvantages for many, even in the seemingly straightforward process of informing people that they have been identified as a “close contact” to someone who tested positive for COVID-19 and guiding them about how to watch for symptoms and isolate themselves so that others are not exposed. Health inequities arose when some people had to make tough choices.
Tough choices presented a sort of “catch-22”: Do good and honestly name all known close contacts and risk a “snitch” label; or avoid the label, yet leave friends, neighbors, or coworkers in the dark, let them find out in a hard way that they have been infected, and let the avoidable spread of disease continue. When identified as a close contact or COVID-19 positive, many low-income families had to make the tough choice between conforming to COVID-19 restrictions or losing income, and worse yet, risking job loss or antagonizing their employers by reporting that they got infected at work. Some had to choose between strictly quarantining and meeting basic needs–food on the table, the roof over their heads, utilities intact, and so forth.
The Magnifying Glass of COVID-19 Over Health Inequities
The unprecedented scale of the COVID-19 crisis and its acute consequences on health and well-being resulting from socioeconomic changes has placed a magnifying glass on inequities that always exist but were often masked in overall averages and small numbers presented in reports. These inequities are the results of systematic social injustices and biases. With COVID-19, the acuity of social determinants of health (SDoH) is immediately noticeable in the disproportionately higher rates of coronavirus infections and deaths in lower socioeconomic groups and racial and ethnic minorities.
Disproportionately, more African Americans and people of lower socioeconomic status perform essential services, exposing them to a higher risk of infection. Higher socioeconomic groups are often allowed to work remotely from home and are less likely to lose work if they have to quarantine. Poor and socially disadvantaged individuals are the ones who often cannot quarantine because of the nature of their jobs or because of a lack of needed supports.
Pandemic Preparedness Is Essential for Effective Response
Everything about the COVID-19 response in the US shows that public health and health care were inadequately prepared for its gravity. Like other systems dealing with the pandemic, the health departments that successfully weathered this storm stayed nimble and responsive to the changing realities. Some health departments had resources and strategies to step out of their traditional role and used a holistic approach. Isolation, loneliness, stress, and resulting behavioral health issues were noted and addressed as a part of the COVID-19 response. Some health departments addressed behavioral health issues emanating from isolation by connecting people with behavioral health services as needed. Others partnered with their communities and provided access to food, transportation, rent, mortgage, and other basic SDoH.
It is easy to share the national/state guidelines about social distancing, but for some, practicing them is not possible without public assistance. For example, crowded housing and multi-generational living arrangements made it difficult for the contacts to isolate themselves. Health departments identified the issues and, as their resources allowed, addressed the needs of individuals by making hotel arrangements. We spoke with a state health department representative who stated:
“We work really hard to provide support to assist with compliance, so if that means somebody needing a hotel because they live in a multigenerational home or need food services… We work so hard to ensure that the local health departments are connected to providing those resources to the people who might need them and identifying those needs.”
The COVID-19 pandemic has brought focus on the need for several policy/practice adjustments. Public health agencies need to assure a culturally competent workforce for health education and efficient contact tracing. Proper allocation of funds for public health agencies is essential to support policies and interventions designed to eliminate health inequities associated with disadvantages in SDoH. Health agencies may need to perform the “chief health strategist role” for influencing structural changes such as no-interest micro-financing, which may be necessary to eliminate financial hardship due to COVID-related job loss or lost income. They will also need to influence housing policy reforms to keep people from being unhoused and to address inequitable exposure due to crowded housing. It is our hope that health departments will continue to play a leading role in efforts to promote equity throughout the COVID response, recovery, and beyond.
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This blog is inspired by the above report authored by Dr. Gulzar Shah, Ms. Angie Peden, Dr. Bettye Apenteng, Dr. Samuel Opoku, Dr. Kristie Waterfield, and Ms. Osaremhen Ikhile. Sincere thanks to Dr. Waterfield for a thorough review of the blog.
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