Structural racism and sociodemographic inequity have caused, and continue to cause, inequity in COVID-19 testing, treatment and outcomes. Infectious diseases physicians and public health professionals are deeply familiar with the profound health disparities that arise from structural racism. COVID-19 joins a long list of conditions with measurable health disparities, including HIV, sickle cell anemia, heart attacks, strokes, colon cancer, obstetrical care, organ transplants and many more. These disparities often arise directly from social determinants of health and have only been exacerbated by COVID-19 (Benfer, January 2021).
At the beginning of the COVID-19 pandemic, minority and underrepresented communities experienced a repeat of disturbing historical health patterns. Black, Latinx and indigenous patients were five times as likely to be hospitalized due to COVID-19 compared to White patients (CDC, April 2021). Black people accounted for almost one-quarter of COVID-19-related deaths, while making up only 13 percent of the overall population (CDC, 2023). Black, Hispanic, and American Indian and Alaska Native children were twice as likely to be hospitalized for COVID-19 compared to non-Hispanic White children (Oliviera, 2022). We can and must do better than these statistics.
State- or federal-level reporting requirements for disease outcomes improve surveillance data but can simultaneously represent a burden on local and state public health authorities to actively and continuously gather, verify and archive information (Martin, January 2023). As these requirements are removed, and community-based testing resources for SARS-CoV-2 are depleted, the breadth and depth of public health surveillance for COVID-19 is restricted. The consequences of these restrictions are felt more deeply in communities without access to resources to conduct surveillance even at baseline.
A lack of surveillance resources can paint an incomplete picture of reality — for example, falsely leading to the belief that COVID-19 has low severity in certain communities or that a community isn’t experiencing a surge in COVID-19. Beyond testing, the effect snowballs. If members of those communities do not have resources to seek care or cannot communicate their health status effectively, then they are also less likely to be treated for severe illness. It even could cause us to mistakenly believe that COVID-19 mortality rates are lower in certain underserved communities, for example, individuals without health insurance.
Simultaneously, temporary measures to reduce socioeconomic impacts of COVID-19, like paid sick leave, loan payment deferrals, and rent freezes or eviction moratoriums have been revoked or allowed to expire. A return to “business as usual” with the removal of these limited protective policies will disproportionately harm communities of color and could stand to widen the gap in health disparities.
The prevailing challenge and lesson to be learned in COVID-19 health equity is the lack of infectious disease policies crafted through a health equity lens (Dalva-Baird, August 2021). When policies assume that underlying epidemiological surveillance and treatment strategies promote equitable outcomes, they can lead to greater marginalization. Equity must be embedded through design, or these polices may enforce or exacerbate existing inequities. Unfortunately, many large-scale epidemiological surveillance systems do not explicitly consider collider bias or inequity in their assessments of COVID-19. When campaigns do not account for community resources or rollout strategies and surveillance at the local level, they may exacerbate existing inequity.
The ramping down of public health surveillance measures, in addition to the simultaneous removal of other COVID-19 pandemic protections, contributes to a landscape of inequity that affects testing, treatment and patient outcomes. Improving epidemiology through a health equity lens is critical for clinical decision-making and must be embedded at every touchpoint in patient care.