Five Key Questions State Health Officials Can Ask Right Now to Advance Health Equity During COVID-19 Response Efforts

Tekisha Dwan Everette and Karen Siegel, Health Equity Solutions

Health equity ensures that everyone has the ability to attain optimal health without barriers and without regard to social demographic characteristics such as race, gender, socioeconomic status, or geography. Early evidence suggests there are health disparities based on race, gender, and geography in both the contraction of COVID-19 and deaths related to the virus.[1]^,[2] People of color and those who live in urban centers are faring worse from this pandemic.[3]^,[4] These higher rates of illness and death are rooted in longstanding, structural inequities in our country (i.e. structural racism, sexism, and differential investment in urban/suburban/rural areas).[5] While these inequities cannot be fixed overnight, states can begin to foster a more equitable and just COVID-19 response, relief, and recovery effort by employing a few key guidelines. Asking a series of core questions and immediately responding with appropriate action  can strengthen initial responses and lay the foundation for broader reforms to advance health equity.

Five Key Questions State Health Officials Can Ask Right Now to Advance Health Equity During COVID-19 Response Efforts

1. Have we identified a person or team of people to apply an equity lens to all our COVID-19 response and recovery efforts?

Embedding an equity monitor in your COVID-19 response ensures that the needs of underserved communities are considered in policy discussions and inform policy decisions. States that have applied an equity frame to their efforts by establishing an official or workgroup focused on equity and/or including a focus on equity in their reopening efforts include Michigan[6],  New Jersey[7], and Washington[8]. Effective workgroups leverage community partnerships to ensure policy responses meet the goals and needs of all residents. If your state has not taken this crucial step, identify who can you add to the COVID-19 response, relief, and recovery team(s) to lead this effort. Consider existing positions focused on equity such as: Health Equity Officer/Director, Office of Minority Health, or Statewide Public Health Association.

2. Have we identified vulnerable populations and targeted outreach and interventions specifically to those populations, employing national culturally and linguistically appropriate services standards (CLAS)?[9]

This may seem obvious, but it is often overlooked. How well are communication and outreach strategies reaching all of the state’s residents? Language access and sources of trusted information vary by community. For example, outreach to immigrant communities might focus on allaying fears about seeking testing or treatment.[10] Further, some communications tools may fail to reach certain populations: e.g. people who do not have access to cars are less likely to see highway billboards. Tailoring messages to address language needs, literacy levels, and community-specific concerns are important considerations to ensure effective dissemination of information to all communities.     

3. Have we issued any guidelines that foster health inequity?

Guidance on treatment and testing may inadvertently exacerbate inequities. For example, risk assessments that are used to target care and are based on claims data or comorbidities exacerbate disparities in access to care because groups with less access have fewer claims and higher rates of chronic disease.[11] For example, state issued guidelines regarding who gets ventilator treatment in a time of scarce resources may have civil rights implications for communities that are already at higher risk of death from comorbidities.[12]^,[13]  Further, testing structures that are not fully accessible or equitable in distribution of resources can limit testing of people who have limited mobility, who live far from testing sites, or who lack transportation.

4. Are we collecting, analyzing, reporting, and using demographic data for COVID-19 testing, hospitalizations, and deaths?

Consistently disaggregating data by race, gender, and geography provides the best view of who, how, and where individuals and communities are experiencing the COVID-19 pandemic. Disaggregated data illuminates disproportionate impact, unmet needs, and provides a pathway to equitable strategies to address the needs accordingly. The disaggregated data should be publicly reported and used in decision-making and it should include all testing data (i.e. test issued and positive tests), hospitalizations, and deaths.[14] Reporting this data regularly provides state residents, philanthropy,  and community-based organizations timely information on how to target their response efforts. It is most helpful to present the data in easily accessible and digestible formats such as data dashboards and other visualizations.

5. Have we maximized existing community health and lay health worker mechanisms and funding strategies to address gaps in outreach to vulnerable populations?

Successful contact tracing requires access to hard-to-reach communities. In Massachusetts,[15] community health workers, who are often from the communities they serve, are being engaged in the state’s contact tracing strategy. Other existing work forces such as peer support providers and census workers could also be mobilized to engage in contact tracing in communities that may be hesitant to interact with government or health systems.

[1] The COVID Racial Data Tracker. https://covidtracking.com/race

[2] National Vital Statistics System. Provisional Death Counts for Coronavirus Disease (COVID-19). Available at: https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm

[3] Kaiser Family Foundation. “COVID-19 in Rural America—Is there Cause for Concern?” https://www.kff.org/other/issue-brief/covid-19-in-rural-america-is-there-cause-for-concern/

[4] New York Times. “Coronavirus in the U.S.: Latest Map and Case Counts” https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html

[5] Cato Laurencin & Aneesah McCLinton. “The COVID-19 Pandemic: a Call to Action to Identify and Address Racial and Ethnic Disparities.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7166096/

[6] State of Michigan Office of the Governor. https://www.michigan.gov/whitmer/0,9309,7-387-90499_90705-526476–,00.html

[7] Official Site of the State of New Jersey. https://nj.gov/governor/news/news/562020/approved/20200427b.shtml

[8] Washington State, Office of the Governor. https://www.governor.wa.gov/news-media/inslee-rolls-out-covid-19-risk-assessment-dashboard-data.

[9] U.S. Department of Health and Human Services. National CLAS Standards. https://thinkculturalhealth.hhs.gov/clas

[10] For example: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le2292.pdf

[11] Ziad Obermeyer, Brian Powers, et al. “Dissecting Racial Bias in an Algorithm Used to Manage the Health of Populations.” https://science.sciencemag.org/content/366/6464/447

[12] Health and Human Services. “OCR Reaches Early Case Resolution With Alabama After It Removes Discriminatory Ventilator Triaging Guidelines.” https://www.hhs.gov/about/news/2020/04/08/ocr-reaches-early-case-resolution-alabama-after-it-removes-discriminatory-ventilator-triaging.html

[13] Massachusetts Department of Public Health. “Statewide Advisory Committee Recommendations for Standards of Care.” https://www.mass.gov/doc/statewide-advisory-committee-recommendations-for-standards-of-care/download

[14] State Health & Value Strategies. State COVID-19 Data Dashboards. https://www.shvs.org/state-covid-19-data-dashboards/

[15] Massachusetts Office of Health and Human Services. “COVID-19 Contact Tracing Resources and Information.” https://www.mass.gov/lists/covid-19-contact-tracing-resources-and-information