COVID-19 FAQs: Health equity in a pandemic

This article is part of a series of COVID-19 resources on health equity.

Marginalized and minoritized patients have and will suffer disproportionally during the COVID-19 crisis due to the inequities in society perpetuated by systematic practices. The AMA is answering frequently asked questions on health equity in the pandemic response to equip physicians with the consciousness, tools and resources to confront inequities.

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State local and regional public health bodies have been key in the COVID-19 response, intervention and prevention through organizing public education, coordinating general health and medical provisions, advising public agencies and operationalizing national guidance.

While not a formal part of the public health infrastructure, social identity organizations and business associations (e.g. NAACP, UnidosUS, National Urban League, National Congress of American Indians, minority business associations, etc.) are trusted health equity messengers in communities of color.

Watch a TED Talk with APHA Executive Director Georges Benjamin about this topic: Everybody should recognize that their second job is public health.

Find more resources about this topic at COVID-19 and health equity literacy, under "Health equity policies and priorities".

The power and leadership of public health lies in the authority and trust of local, regional and state public health departments. Public health leadership often serves as advisors and play key administrative roles in managing the epidemic and the many facets of the emergency response.

Public health systems are often under-resourced, and while more diverse then health care, public health and its leadership is still not representative of the U.S. population. Further, similar to barriers in health care, public health barriers are often financial in nature. Many public health institutions are supported by short-term grants and rely on the philanthropy of third-party institutions.

The tenuous nature of funding public health institutions weighs uniquely on its leaders, who often sacrifice their own financial gain for the sake of the organizational standing, or find themselves spending more time vying for dollars to keep the institution afloat. These are sacrifices that are terribly costly for aspiring public health leaders to make. For persons of color who do not come from financially secure means, this is not only costly, but prohibitive— they may make pivotal decisions for the sake of seeing to the immediate needs of their families, and forego positions in public health leadership, which may not pay at a rate commiserate with the sacrifice.

For more readings:

• Ensuring a strong public health workforce for the 21st century: Reflections on PH WINS 2017
• The state of the U.S. governmental public health workforce, 2014–2017
• Understanding the dynamics of diversity in the public health workforce

Emergency care CME

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All physicians treating COVID-19 patients are experiencing unprecedented stress, including PTSD and burnout. Minoritized and marginalized physicians may experience more acute distress given the compounding factors their patients are dealing with related to their physical and social well-being. In addition, they are facing the realities of these structural inequities in these health care systems as they are not able properly care for their medical staff or their patients during this crisis.

The AMA is implementing research study of 1,136 physicians to identify the barriers and facilitators facing minoritized and marginalized physician sub-groups (by race/ethnicity: African American/Black, Latinx/Hispanic, Asian American & Native Hawaiian and other Pacific Islander, Native American as well as by ability, gender identity and sexual orientation) to:

• Inform AMA about the most pressing COVID-19 concerns/issues/challenges that certain physician sub-groups are dealing with and to uncover potential opportunities for the AMA to address.
• Identify key supports related to COVID-19 for minoritized and marginalized physician groups in order to leverage these supports as potential opportunities or partnerships for AMA.
• Disseminate research findings to broader audience to inform practice and advocacy efforts.

For more information about this survey, please reach out to the principal investigator, Diana Lemos, PhD, MPH, via e-mail at [email protected].

For more insights, watch Prioritizing Equity: Physicians of Color and COVID-19.

Bias plays a critical role in health inequity and perpetuate structural inequalities. Either explicit or unconscious physician bias will determine if a patient gets proper testing and treatment.

There is concern that minoritized and marginalized patients will bear an undue burden in morbidity and the mortality associated with COVID-19 and these inequities are amplified with reported shortages.

More information on this topic:

• Combating bias and stigma related to COVID-19 (PDF) 
• Questions of bias in COVID-19 treatment add to the mourning for Black families
• Strategies to provide equitable care during COVID-19 (PDF)

Many states and communities are implementing community actions designed to reduce exposures to COVID-19 and slow the spread of the disease. Unfortunately, in many instances, these policies lack provisions for those who are differently abled and may render them more vulnerable to the impacts of COVID-19 as many have health complications, rely on school-based supports, live in group settings, or depend on care staff for support.

More information on this topic:

• COVID-19 resources for the Disability community
• COVID-19's isolated world is the norm for people with disabilities

CDC recommends health care systems and health care providers can do the following:

• Implement standardized protocols in accordance with CDC guidance and quality improvement initiatives, especially in facilities that serve large minority populations.
• Identify and address implicit bias that could hinder patient-provider interactions and communication.
• Provide medical interpretation services for patients who need them.
• Work with communities and health care professional organizations to reduce cultural barriers to care.
• Connect patients with community resources that can help older adults and people with underlying conditions adhere to their care plans, including help getting extra supplies and medications they need and reminders for them to take their medicines.
• Learn about social and economic conditions that may put some patients at higher risk for getting sick with COVID-19 than others — for example, conditions that make it harder for some people to take steps to prevent infection.
• Promote a trusting relationship by encouraging patients to call and ask questions.

Many states, cities and community-based organizations are collaborating to address the health inequities facing racial/ethnic minoritized communities. We are looking to build a repository of racial/ethnic responses to COVID-19 across the country to share strategic practices and actions across the AMA network. 

If you are leading a COVID-19 racial/ethnic focused project or initiative, please submit your case study.  

Find more resources about this topic at COVID-19 and health equity literacy, under "Health equity policies and priorities".

About one in five Americans speaks a language other than English at home, according to census data, but persistent language barriers leave limited-English speakers with COVID-19 in a particularly dire situation: alone, confused and without the appropriate care.

Stories of the lack translation services delaying care or causing misdiagnosis, have become common occurrences during the pandemic.

One common barrier to providing quality information is that it is not routine or frequently updated as it is in English and therefore, materials in different languages may not be the most up to date information. In a time of COVID-19 this is particularly crucial given that information is changing rapidly as we are learning more and more about the virus.

With the emergence of telehealth and digital health, access to online translation services on digital and mobile platforms is essential but severely lacking. Additional supports are needed to ensure that these visits include translation support services.

Find more resources about this topic at COVID-19 and health equity literacy, under "COVID-19 resources for non-English speakers" and "COVID-19 resources for Spanish speakers".

Heightened anti-immigrant rhetoric and policies, xenophobia, increase in hate crimes may limit the patient’s ability to seek help. Further, fear can foster distrust of the medical system, thus delaying seeking care and early intervention and tracking is key to treating and limiting transmission.

For physicians working with immigrant and mixed documentation communities, ascertaining risk, susceptibility and treatment options requires discussions about patient-provider confidentiality in order to fully assess how patients will enact social distancing and offer suitable advice. It is not uncommon for immigrants or families of mixed documentation status to not be open about household size, living accommodations or working arrangements due to fear of being found out and reported to immigration authorities.

Furthermore, most federal relief efforts (CARES Act) and public healthcare insurance coverage programs (Medicaid, ACA) restrict access to undocumented or recent immigrants. Therefore, immigrants are less likely to have access to economic protections or unemployment benefits putting increased economic burden on these immigrants and families. Many will lose employer-provided insurance coverage. Furthermore, these exclusions severely impact their ability to seek needed or urgent testing, treatment and care due to concerns about financial and legal repercussions.  

Find more resources about this topic at COVID-19 and health equity literacy, under "Health equity policies and priorities" and Impact of COVID-19 on minoritized and marginalized communities.

Even outside of pandemic, women frequently do not or are unable to seek care for themselves. COVID-19 provides a further barrier to care. Measures meant to safeguard the general public may exacerbate domestic violence situations and limit the victim from seeking care or leaving the unsafe situation.

Women of color face the added concern of rising maternal mortality which can be further complicated by the situational stress presented by the pandemic.

For additional resources related to domestic violence, please refer to New York Times article A new COVID-19 crisis: Domestic abuse rises worldwide. Free registration is required to view content.

Find more resources about this topic at Impact of COVID-19 on minoritized and marginalized communities, under "The impact of COVID-19 on pregnant women and mothers".

There is an urgent gap in understanding how the LGBTQ+ community is impacted by COVID-19 due to systematic lack of sexual orientation and gender identity data collection at time of testing, case reporting, hospitalization or death generally but more specifically for COVID-19.

The LGBTQ+ community is adversely affected due to disproportionate rates of poverty, lack of access to adequate medical care, paid medical leave and basic necessities during the pandemic. The combination of these could put LGBTQ+ people at greater risk for acquiring and delaying care related to COVID-19 resulting in greater complications or fatalities amongst this group.

Like other highly affected groups, LGBTQ+ are more likely to work in highly affected industries including restaurants, food services and retail for whom paid leave and healthcare coverage is limited or unavailable. LGBTQ+ people also experience higher rates of unemployment and poverty that is linked to discrimination due to their LGBTQ+ identity.

Furthermore, even though the ACA prohibits discrimination based on gender identity and sex stereotypes and offers federal protections, discrimination in health care settings continues where LGBTQ+ people still are misgendered or delayed or denied care or treatment. These experiences impact LGBTQ+ communities’ trust with the medical community and may severely impact their ability to seek needed or urgent testing, treatment and care.

Find more resources about this topic at Impact of COVID-19 on minoritized and marginalized communities, under "The impact of COVID-19 on the LGBTQ+ community".

There are deep-seated inequities that disproportionately affect many communities of color including higher rates of chronic diseases (asthma, diabetes, hypertension), lower access to health care, lack of paid sick leave, lack of or inadequate health insurance, income disparities, any of which could heighten the effects of a crisis like the coronavirus outbreak. The epidemic is concentrating in urban areas with high population density, for the most part, where marginalized and minoritized individuals live. These concentrations are putting undue burden on already stressed hospitals in these regions.

Find more resources about this topic at COVID-19 and health equity literacy, under "Historical disparities and discrimination shape impact of COVID-19 in U.S." and Impact of COVID-19 on minoritized and marginalized communities.

To date, there is no comprehensive race and ethnicity surveillance data and research repository of COVID-19 testing, hospitalizations or mortality. The dearth of racially and ethnically disaggregated data reflecting the health of marginalized and minoritized persons and families underlies the struggles of the physician community to fully attend to, and be attuned to, the unique needs of their patients, and for legislators to design well-informed policies that will preserve lives. Finally, without collecting race and ethnicity data associated with COVID-19 testing (hospitalizations, morbidities, and mortalities) these communities are at greater risk of disease and death; and physicians and hospitals will not be able to properly care for their patients.

Find more resources about this topic at The role of data collection in the COVID-19 pandemic and States tracking COVID-19 race and ethnicity data, under "States reporting COVID-19 cases by race".

There is widespread and persistent under-representation of minoritized communities in national clinical trials despite growing evidence that drugs may have different effects on different populations. Thus, the lack of representation could have direct implication on the efficacy of future COVID-19 treatments and vaccines.

In order to increase representation in COVID-19 clinical trials, trusted sources must be enlisted to help educate and recruit underrepresented groups; and barriers like transportation, time off work, and childcare must be addressed to ensure full participation. Efforts to engage underrepresented minoritized communities should already be underway given the recent promising outcomes from two COVID-19 vaccine trials.

Digital health is revolutionizing health care delivery. It offers opportunities to reach hard-to-reach populations including low-income, rural, undocumented or immigrant communities. Opportunities include reducing long waiting times, long travel distances and more personalized care for those that are able to take advantage of this mode of delivery.

The digital divide surrounding digital health requires unique considerations to ensure access to different communities who have historical challenges with digital tools for accessing medical care. Although there is an unprecedented shift from in-person care to telehealth in health care settings, there are still gaps about who is receiving care. As digital health visits increase during the COVID-19 crisis, concerns exist that visits from minoritized and marginalized patients will decrease. Older adults, minoritized communities (Black and Brown), non-English speaking patients and rural communities face significant challenges with accessible, reliable and quality telehealth.

Digital literacy is a widespread concern amongst older adults, Black and Brown patients, and non-English speaking patients that experience challenges with utilizing technology that has not been created with their needs in mind. Furthermore, access to devices and WI-FI internet, aside from mobile internet, are additional barriers for minoritized and marginalized patients. This results in patients having to receive substandard care in the form of telehealth without any video connectivity.

Furthermore, lack of accessible translation services creates additional barriers for non-English speaking patients. Finally, lack of understanding about the digital health needs of minoritized and marginalized patients may lead to unintentional bias as these patients may not be offered or equipped with the skills and tools to engage in successful digital health visits.

For additional information:

• Addressing equity in telemedicine for chronic disease management during the COVID-19 pandemic

Minority owned small business are at risk for closing due to lack of funding directed at them which trickles down to loss of employment and opportunities within the minoritized communities. Additionally, there are limited protections and cash directives going to minoritized communities to help supplement their job losses or limited income. For example, many minoritized and marginalized community members work in retail and restaurants or small business and are considered gig workers and have been left without any income since the start of the epidemic or are still awaiting unemployment compensation payment. Additionally, immigrants and households with immigrants have been excluded from cash protection programs making them particularly vulnerable to experiencing increased financial burden during this time.

As a result, food, necessities and housing insecurity are pressing issues impacting marginalized and minoritized communities. High rates of unemployment, low access to cash reserves and increased burden on already underfunded community-based organizations have created a high demand for food and housing needs.

As states and local authorities implement social distancing and mask enforcement, minoritized communities, Black and Brown men, are at increased risk for disproportionate police enforcement and citations thereby increasing risk of police violence and death associated with police enforcement.

These added stressors and ongoing uncertainty have put minoritized and marginalized communities in extremely difficult situations. There are genuine concerns about increased rates of domestic violence, PTSD, anxiety and suicide within these communities.

Find more resources about this topic at Impact of COVID-19 on minoritized and marginalized communities.

Visit the COVID-19  health equity resources overview page or view featured topics for more resources:

• AMA and Center for Health Equity resources on COVID-19
• Health literacy resources on inequities & for non-English speakers
• The role of data collection in the COVID-19 pandemic
• Impact of COVID-19 on minoritized and marginalized communities