The Marginalized, the Homeless, and the Incarcerated are Disproportionately Affected by COVID-19

It is hard to imagine that there isn’t a person on our planet who hasn’t been affected in some way by the novel coronavirus. Although I am fortunate that I haven’t contracted COVID-19 (yet), my life has certainly changed: I lost two part-time jobs; I spent the rest of my spring semester online; I’ve slowly accumulated a small collection of face masks; and my in-person social interactions have dwindled to my two housemates and my dog.

One silver lining that I’ve found while sheltering at home is that I now have a wonderful opportunity to slow down, reassess my priorities, and remember how much I have to be grateful for.  I’ve been fortunate enough to have received a high-quality education. I have a safety net of resources and I actually live in a place where I can safely socially isolate. However, this is not the case for millions of Americans and others living across the globe.

What are vulnerable populations?

According to the American Journal of Managed Care, vulnerable populations include:

…The economically disadvantaged, racial and ethnic minorities, the uninsured, low-income children, the elderly, the homeless, those with human immunodeficiency virus (HIV), and those with other chronic health conditions, including severe mental illness. It may also include rural residents, who often encounter barriers to accessing healthcare services. The vulnerability of these individuals is enhanced by race, ethnicity, age, sex, and factors such as income, insurance coverage (or lack thereof), and absence of a usual source of care. Their health and healthcare problems intersect with social factors, including housing, poverty, and inadequate education.

It is easy to understand how vulnerable populations could be disproportionately impacted by COVID-19. “To shelter in place, one must have a shelter,” said Dr. Margot Kushel, professor of medicine at UC San Francisco, during a recent media briefing about populations vulnerable to COVID-19. People with fewer resources—who may be at an even greater economic disadvantage since March—might find it difficult to adequately care for themselves and their families. The virus spreads from person to person without discrimination, but the likelihood of contracting the disease and becoming severely ill is largely subject to economic disparities and systemic racism.

The media briefing addressed four different vulnerable populations and how they are each specifically affected by COVID-19: marginalized racial/ethnic groups, homeless populations, the incarcerated, and rural Americans.

Marginalized racial and ethnic groups

The color of your skin or which ethnic group you identify with affect how likely you are to contract COVID-19, how sick you become, and what kind of care you will receive. Racial and ethnic minorities are overrepresented in homeless populations, in prisons, and, in rural areas, one in five residents is a person of a racial or ethnic minority.

This website, produced by the American Public Media Research Lab, provides several graphs detailing the rates at which White, Indigenous, Asian, Black, and Latinx groups are dying in the US. The data show that the COVID-19 mortality rate for Black Americans is 2.3 times as high as the rate for White and Asian Americans and 2.2 times as high as the rate for Latin Americans. In other words, if Black Americans and Latin Americans had died at the same rate as White Americans, 14,400 Black Americans and 1,200 Latin Americans would still be alive today (as of June 10, 2020).

Dr. Sharrelle Barber, professor of epidemiology and biostatistics at Drexel University, expanded upon this data by stating that testing has been more limited in non-white communities. She said the following during the media briefing:

In Philadelphia, early data showed that black neighborhoods had less testing than white neighborhoods, despite being more likely to test positive for COVID-19. I also know from two reports from federally qualified health centers, one in a black community in St. Louis and one in the Mississippi Delta, that, at the onset of the pandemic, each of these federally qualified health centers only received a total of five tests while mostly white suburban and white neighborhoods around them received many more. In addition to access to testing, we also know that when blacks navigate the health care system, they are much more likely to experience bias and discrimination.

Barber also noted that many of our country’s low-income essential workers—including medical workers—are Black and Latin Americans. She stated that “they have been the least protected but the most exposed, lacking the personal protective equipment and income protection, such as paid sick leave and hazard pay, to ensure their safety during this pandemic.” And, due to racial residential segregation, there are “structural factors within communities that make exposure, transmission and death more likely. Crowded homes, lack of access to clean water, [and] exposure to environmental toxins are putting Blacks at risk during this pandemic.”

To return to a state of normalcy is not a valid option for Barber. She insisted that, with states reopening, we need to see strategies that center racial and economic equity and justice. Beyond the pandemic, she highlighted a few solutions to support all Americans: free, universal healthcare; a living wage for all; and dismantling systemic racism.

Homeless populations

While it is difficult for anyone to feel stuck at home, this hardship increases dramatically when the comforts of home are not available or when one must shelter with many others in close quarters. According to Kushel, since COVID-19 reached the US there have been major shelter outbreaks in Seattle, Boston, San Francisco, New York City, Dallas, Philadelphia, and many other cities. For instance, in a San Francisco shelter where one or two people were symptomatic, 66% of the residents were found to be infected upon testing, in addition to many of the staff. Kushel emphasized that this highlights how only testing those who are symptomatic is a strategy that’s bound to fail.

Kushel mentioned another important factor that supports high infection rates among homeless populations: the majority of homeless people are elderly. “Our research has shown that people who are 50 and older who are homeless have health conditions that make them much more similar to people in their 70s and 80s in the general population,” said Kushel. Another complicating factor is that, when a homeless person is infected, they are much more likely to seek hospitalization because they don’t have a safe, sanitary place to self-quarantine. This further exacerbates hospital overwhelm.

Kushel cited some positive steps that cities are taking, including moving homeless people to now-empty hotels and creating COVID-positive shelters. She stated that there is “no medicine as powerful as housing.”

Prison populations

People who are incarcerated during the pandemic are also exposed to unsanitary living conditions that support the spread of COVID-19. Although we’ve been hearing news that some states are “flattening the curve,” Dr. Brie Williams, professor of medicine at UC San Francisco, stated that this is not the case in prisons, and uses data from the California Department of Corrections and Rehabilitation (CDCR) as an example: while the State of California is still seeing a slow increase in confirmed cases, the per capita caseload in California prisons is now more than five times higher than the rest of the state (see Figure 4 for a comparison of caseloads between the State of California and the CDCR).

During the media briefing, Williams emphasized how overcrowding and high infection rates in prisons affect the surrounding communities: staff enter and exit prisons every day, increasing the chance that their families and fellow community members will also be exposed to COVID-19. An additional issue in prisons is that these facilities don’t provide hospital-level care, so anyone infected with COVID-19 must leave the prison and seek care at a nearby hospital. As many prisons are located near rural areas, and as rural areas typically have understaffed and understocked hospitals, it is easy for these hospitals to become overwhelmed with sick patients.

Williams suggests several strategies to support the health and safety of incarcerated people and of communities near prisons:

• Release elderly and ill people—and eventually younger and healthy people—from overfull facilities so that social distancing can be successfully practiced.
• Develop emergency task forces to develop plans of care for the released and those that remain in facilities.
• Create cohorts or mini communities within facilities to mitigate the spread of infection.
• Ramp up testing dramatically.
• Develop and implement ethical end-of-life practices. Everyone should be able to choose which medical interventions they want at the end of life, and no one should be dying alone.

Rural Americans

Many of the challenges that homeless and incarcerated populations face are also experienced by people living in rural America. According to Dr. Carrie Henning-Smith, professor of health and policy management at the University of Minnesota: “…rural areas are older on average. They have lower median income, lower educational attainment, higher poverty rates, higher rates of uninsurance, and higher rates of unemployment compared with urban areas. Rural residents also have lower life expectancy, higher rates of disability and higher rates of underlying health conditions compared with urban residents.”

Henning-Smith also cited that, of the 128 rural hospitals that have closed since 2010, three have closed since the pandemic began. In addition, rural areas face persistent health care workforce shortages, with “nearly 80% of rural areas designated as medically underserved.” With less access to reliable internet and cell service, it is more difficult for rural Americans to receive telemedicine. Lack of connectivity also makes it more difficult to stay connected to friends and loved ones.

Despite these challenges, there are resiliencies to be found in rural communities grappling with COVID-19. “…[T]here are also a number of bright spots within rural areas, [including] incredible resourcefulness. And rural areas are smaller, and sometimes that can be an advantage. It can allow them to be more nimble, more innovative, but only with sufficient resources to do so,” Henning-Smith said.

How can vulnerable populations be supported and protected?

There are overarching strategies that would collectively support racial/ethnic minorities, homeless people, the incarcerated, and rural populations:

• Expansion of testing.
• Implementation of affordable and accessible healthcare.
• Equitable investment in communities of color.

I hope, along with Barber, that our country doesn’t merely return to “normal.” I want this pandemic to be a wake-up call to my fellow citizens and to our government that our most vulnerable are disproportionately infected and dying because of long-standing systemic inequity. It’s time to create a new normal.