Equitable Pandemic Preparedness and Rapid Response: Lessons from COVID-19 for Pandemic Health Equity

Abstract

The novel coronavirus pandemic has set in high relief the entrenched health, social, racial, political, and economic inequities within American society as the incidence of severe morbidity and mortality from the disease caused by the virus appears to be much greater in Black and other racial/ethnic minority populations, within homeless and incarcerated populations, and in lower-income communities in general. The reality is that the U.S. is ill equipped to realize health equity in prevention and control efforts for any type of health outcome, including an infectious disease pandemic. In this article, we address an important question: When new waves of the current pandemic emerge or another novel pandemic emerges, how can the U.S. be better prepared and also ensure a rapid response that reduces rather than exacerbates social and health inequities? We argue for a health equity framework to pandemic preparedness, grounded in meaningful community engagement that, while recognizing the fundamental causes of social and health inequity, has a clear focus on upstream and midstream preparedness and downstream rapid response efforts that put social and health equity at the forefront.

Full text

1
Forthcoming in an issue of Journal of Health Politics, Policy and Law. Journal of Health Politics, Policy
and Law is published by Duke University Press. DOI: 10.1215/03616878-8641469
Equitable Pandemic Preparedness and Rapid Response: Lessons from
COVID-19 for Pandemic Health Equity
Philip M. Alberti
Association of American Medical Colleges
Paula M. Lantz
University of Michigan
Consuelo H. Wilkins
Vanderbilt University Medical Center
Abstract
The novel coronavirus pandemic has set in high relief the entrenched health, social, racial, political, and
economic inequities within American society as the incidence of severe morbidity and mortality from the
disease caused by the virus appears to be much greater in Black and other racial/ethnic minority
populations, within homeless and incarcerated populations, and in lower-income communities in general.
The reality is that the U.S. is ill equipped to realize health equity in prevention and control efforts for any
type of health outcome, including an infectious disease pandemic. In this article, we address an important
question: When new waves of the current pandemic emerge or another novel pandemic emerges, how can
the U.S. be better prepared and also ensure a rapid response that reduces rather than exacerbates social
and health inequities? We argue for a health equity framework to pandemic preparedness, grounded in
meaningful community engagement that, while recognizing the fundamental causes of social and health
inequity, has a clear focus on upstream and midstream preparedness and downstream rapid response
efforts that put social and health equity at the forefront.
Keywords COVID-19, health equity, preparedness, pandemic, community engagement,
inequities
As epidemiologic data regarding the novel severe acute respiratory syndrome coronavirus 2
started to emerge in the United States in March 2020, it quickly became obvious that this virus is
not an equal-opportunity threat. The incidence of severe disease and mortality from COVID-19
(the disease caused by the virus) appears to be much greater in Black and other racial/ethnic
minority populations, within homeless and incarcerated populations, and in lower-income
communities in general (Artiga et al. 2020; Mosites et al. 2020). COVID-19-related health
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

2
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
inequities—from testing access to mortality—have captured the attention of the mainstream
media, clinicians, researchers, and health advocates alike.
Much discussion around COVID-19 inequities has focused on individual-level
characteristics and behaviors. Many reports explain the disproportionate burden of severe
COVID-19 morbidity and mortality among people of color by noting the higher prevalence
within those communities of underlying health conditions like obesity, diabetes, and asthma
(Kendi 2020). This includes Surgeon General Jerome Adams, who beseeched communities of
color to follow Centers for Disease Control and Prevention (CDC) behavioral guidelines to
prevent the further spread of COVID-19 within their families and communities, and to limit their
smoking, drinking, and drug use.
However, as data on COVID-19 inequities emerged, the immediate response of health
equity researchers and advocates was one of horror but not surprise, with a different set of
explanations and advice. First, at the individual level, people in different socioeconomic
circumstances do not have the same ability to follow the chorus of CDC advice: wash your
hands, stay home, and self-isolate if you have symptoms. Isolation is impossible in households
with multiple families or in settings like jails and prisons. Hand washing is impossible when your
water has been shut off. Further, some of CDC’s advice and state/local emergency orders, while
seemingly innocuous, were developed and communicated without consideration of the
implications for communities of color. For example, recommendations and mandates to wear a
face mask in public are problematic for many Black men who perceive covering their faces more
of a threat to their health than the coronavirus itself.
Second, the novel coronavirus has set in high relief the entrenched health, social, racial,
political, and economic inequities within American society. As a result of decades of public
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

3
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
policies that have further concentrated wealth and other resources in a smaller, privileged corner
of society, communities of color and other marginalized populations—those living in or near
poverty, the homeless, people within the carceral system, immigrants, etc.—find themselves with
limited to no economic cushion or social advantage while they grapple with physical and mental
health comorbidities caused, in part, by the same unjust policies that increase their communities’
vulnerability to COVID-19. In addition, the social and economic downsides of stay-at-home
orders and other necessary public health interventions also hit lower-income and minority
communities harder. Several health advocates, journalists, and researchers have provided insight
into how the novel coronavirus has exploited decades of structural inequity—no health
insurance, no paid sick leave, no affordable housing, deep underinvestment in inner cities, lack
of access to banking, reliance on public schools for food security, etc.—to disproportionally
strike historically marginalized and under-resourced populations (O’Donnell 2020; Tobin-Tyler
2020; Villarosa 2020).
Importantly, the inequities emerging in the COVID-19 pandemic are not due to race or
social class. Rather, they are the result of structural racism and social inequalities embedded
within the economic, political, education, health care, criminal justice and other systems and
social structures in the U.S. Understanding the fundamental causes of COVID-19 health
inequities requires appreciating that the more proximate causes—higher rates of serious medical
conditions, living in crowded housing, inability to work from home, etc.—are themselves the
result of social inequalities produced by social systems reinforced through public policy (Phelan,
Link and Tehranifar 2010). As Braithwate and Warren (2020) wrote: “Any virulent virus without
a vaccine is bound to become a human petri dish in which people of color in the U.S. today are
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

4
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
caught…The war against the coronavirus for people of color is part and parcel of the war to
eliminate historic inequities and to level the socioeconomic playing field.”
The sad reality is that the U.S. is ill equipped to realize health equity in prevention and
control efforts for any type of health outcome, including an infectious disease pandemic.
Solutions to the fundamental causes of health inequities will require deep, structural changes to
American policy, politics, mindset, and culture. While we endorse the vision of long-term
upstream policy and system change goals, we are skeptical that such dramatic transformations
are realistic in the short or mid-term. Thus, as the health equity community advocates for long-
term, structural changes, in the face of a novel infectious disease pandemic we must also prepare
for the interim and respond to the immediate.
In this article, we address an important question: When new waves of the current
pandemic emerge or another novel pandemic emerges, how can the U.S. be better prepared and
ensure a rapid response that reduces rather than exacerbates social and health inequities? We
argue for a health equity framework to pandemic preparedness that, while recognizing the
fundamental causes of social and health inequity, has a clear focus on upstream and midstream
preparedness and downstream rapid response efforts that put social and health equity at the
forefront.
A Model for Health Equity Infectious Disease Preparedness
Quinn and Kumar (2014) describe the distal and proximate causes of infectious disease–related
inequities and put forward a framework to intervene on both sets of risk factors. Building upon
Blumenshine et al.’s (2008) work on possible sources of disparate and unequal outcomes in an
influenza pandemic, this framework considers disparities based on social position (race/ethnicity
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

5
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
and socioeconomic status) at three levels: (1) in exposure to the virus; (2) in disease
susceptibility, if exposed; and (3) in timely and effective treatment, once disease has developed.
Key contributors to disparities include occupational factors, crowding in households, nutritional
status, stress, access to health care, primary language, and availability of antivirals.
Based on their prior work in India and the U.S., Quinn et al. (2011) and Kumar and
Quinn (2012) conceptualized the plausible causes of unequal burdens of illness and death during
a pandemic. Their 2014 conceptual model makes explicit that there are both proximal (i.e.,
downstream, behavioral, and biological) and distal (i.e., upstream, social, and policy) risk factors
that contribute to inequities in a pandemic. Key distal factors are population structure, access to
clean water, ability to stay away from work, and availability of quality health care. Proximal
risks for disparities are related to behaviors such as hand washing and social distancing,
immediate access to health care, and underlying susceptibility to disease due to nutritional status
and chronic stress, which causes physiological dysregulations, inflammation, and impaired
immune response (Juster, McEwen, and Lupien 2010).
In the sections below, we apply Quinn and Kumar’s model to the current COVID-19
pandemic by (1) connecting their framework’s “distal” and “proximate” causes of disparities to
current taxonomies regarding upstream and midstream social determinants of health and more
proximate downstream individual social risks; (2) recommending two specific paths of action,
one focused on social determinant–related health equity preparedness and the other on a set of
downstream, health equity–promoting rapid response efforts; and (3) underscoring and
strengthening the framework’s commitment to data collection and community engagement as
non-negotiable components of a health equity preparedness paradigm for infectious disease.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

6
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
Upstream and Midstream Social Determinants and Downstream Social Needs
There is now widespread recognition that health—at the individual, community, and population
levels—is the result of much more than health care quality and access (Solar and Irwin 2010;
Woolf and Braveman 2011). The main drivers of health are socioeconomic, environmental, and
behavioral factors that play out at multiple levels within society. The socioecological model of
population health and human development includes five levels at which social processes/factors
produce both health and health inequities (Richard, Gauvin, and Raine 2011). This includes
intrapersonal, interpersonal, institutional, community, and system or macro-level factors. All
levels are embedded within and influenced by higher levels in the model and create specific
types of health distributions and inequities. In addition, all levels in the model provide
opportunities for intervention, although it is the more upstream system or macro-level factors
that shape the midstream community and institutional factors, which in turn create unequal
health outcomes at the downstream, individual level.
The “distal” and “proximate” causes of pandemic inequalities can be further extended
using the socioecological and other models of the social determinants of health to distinguish the
system/macro-level or upstream determinants from the midstream (community and institutional)
determinants, and to distinguish both from the more downstream individual-level manifestations
of exposures, risks, and social needs (Castrucci and Auerbach 2019). Distinguishing between
upstream/midstream determinants of health and the downstream manifestations of those drivers
within individuals is important for both understanding the causes of health inequity and
identifying key focal points for intervention.
For example, there is a difference between identifying and assisting individuals who are
unable to afford rent during pandemic stay-at-home orders versus creating higher levels of
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

7
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
housing affordability and paid sick leave within communities and jurisdictions. This distinction
is crucial since interventions that address downstream social needs that benefit individuals often
do not impact community-level social determinants that are driven by policy choices and are
therefore not amenable to person-level action. In addition, focusing on the individual-level needs
and outcomes tends to prioritize health care/biomedical responses, conflating health with health
care and conflating social determinants of health with individual social needs (Alderwick and
Gottlieb 2019; Lantz 2019).
Quinn and Kumar’s (2014) “distal” and “proximate” causes of infectious disease
disparities map cleanly onto models of the social determinants of health at the midstream and
downstream levels. Institutional policies dictate whether certain classes of workers have the
flexibility to isolate at home. Health care provider shortage areas are driven, in part, by
government decisions that then unfairly predispose certain communities to inequitable access to
care and treatment during an infectious disease pandemic. To prepare for how upstream social
factors create health inequities means reforming those systems, policies, and structures to more
equitably distribute resources and reduce immediate burdens within and across communities.
That immediate burden (Quinn and Kumar’s “proximate causes”) is characterized by
what individuals within those communities need to survive an epidemic: a home in which to
shelter, running water, affordable and trusted health care when needed. The rapid responses
necessary to help individuals in crisis—temporary housing, flexible deployment of health care
resources—are distinct from longer-term policy changes necessary to prepare for and undo the
social determinants. Thus, we make two sets of recommendations below: actions to support
pandemic health equity preparedness at the distal/social determinant level, and actions to develop
a pandemic health equity rapid response at the proximate level. Our recommendations below
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

8
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
springboard from prior research and recommendations regarding the critical need for a strong
health equity perspective in disaster and pandemic planning efforts (Davis et al. 2010; Lichtveld
2018; Mays 2016) and from what has been observed in the current COVID-19 crisis to date.
Upstream/Midstream Preparedness and Downstream Rapid Response
We recommend that new or revised pandemic preparedness plans at the federal, regional, state,
and local levels be grounded in community engagement, built from community assets, and be
evidence- and data-driven (discussed in more detail below). We also recommend that these plans
identify the key ways in which policy, community, and institutional-level factors could create
differences in the ability of people of different socioeconomic positions or sociodemographic
groups to prevent exposure or avoid severe morbidity or mortality from an infectious agent.
Infectious disease preparedness needs, at a minimum, to address upstream and midstream
policy and institutional factors in certain key areas, as outlined in Table 1:
[Table 1 here]
We also recommend that a health equity lens be applied to preparations for downstream
rapid response. Pandemics place a substantial burden on the resources and capacities of
governments, public health, and health care systems, often exposing underlying weaknesses. As
these interconnected systems shift to crisis mode, implementing pandemic preparedness plans
may leave behind individuals and communities already socially vulnerable (Kayman and Ablorh-
Odjidja 2006). During an emergency, health equity must be a priority and intentional strategies
are required to embed distributive justice into the immediate response. Given the differing
sociocultural and economic needs of diverse populations, the specific strategies will vary in
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

9
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
important ways only identifiable through the meaningful community engagement described
below.
During an infectious disease pandemic, public health, government, and health care
systems must rapidly respond to prevent and address inequities in the areas outlined in Table 2
(Bedford et al. 2019; Vaughan and Tinker 2009; Zarocostas 2020):
[Table 2 here]
Data Collection and Community Engagement: Quinn and Kumar (2014: 268) also note the
importance of investing in surveillance systems that can both detect novel agents and outbreaks
early and capture sociodemographic and GIS information on incident cases to draw “attention to
the larger, social, economic and physical environments in which those cases occur.”
The United States’ ongoing difficulty with collecting and reporting race and ethnicity
data during the current coronavirus pandemic demonstrates how far we are from the health
equity–promoting surveillance capabilities Quinn and Kumar describe. Indeed, after government
and nonprofit entities demanded through letters and op-eds that the CDC release the data
stratified by race and ethnicity, 78% of the information on incident cases that CDC published
was missing race and ethnicity information (CDC 2020).
Race and ethnicity represent only the tip of the iceberg in terms of what information is
needed to orient infectious disease preparedness and rapid response activities toward health
equity. Indeed, neither race nor ethnicity are modifiable risk factors. Rather, they are poor
proxies for the social risks and social determinants to which communities of color and the
residents who live within them are exposed. Beyond sociodemographic data, we need
standardized, valid, inclusive data collection on the social needs and social determinants most
likely to correlate with increased exposure, susceptibility, and severity of infectious diseases.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

10
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
Fortunately, those data points are known. The CDC released a Social Vulnerability Index (SVI)
in 2011 and noted a “number of factors including poverty, lack of access to transportation, and
crowded housing may weaken a community’s ability to prevent human suffering and financial
loss in a disaster.” (CDC 2011). Unfortunately, the SVI was not incorporated into COVID-19
responses.
To successfully promote health equity, surveillance system data must:
1. Include standardized, core measures that all relevant sectors (health care, public health,
social services, etc.) agree to use.
2. Allow for data sharing across those sectors while protecting individuals’ information.
3. Relate to and complement other crucial data collections (such as using formal ICD-10 Z
codes to identify social needs in clinical settings, or vital statistics reporting for public
health departments).
4. Capture macro-level data on the social determinants of health geocoded to home
addresses when possible, at units of geography that correspond to meaningful, locally
defined neighborhoods (i.e., census block, not 5-digit zip code).
5. Capture self-reported social needs/vulnerabilities and sociodemographic data including
race and ethnicity in ways that allow for the valid, non-stigmatizing collection of
potentially sensitive personal information.
To achieve that final requirement, and indeed to make the health equity preparedness and
rapid response actions discussed above successful, patient and community engagement is crucial.
Broadly defined, community engagement is the application of institutional resources (e.g.,
knowledge and expertise of faculty and students, technical infrastructure, and physical space) to
address and solve challenges facing communities through collaboration with those communities
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

11
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
(Gelmon et al. 2005). Community engagement requires bidirectional relationships and
interactions that are built on trust, mutual respect, cultural humility, and mutual benefit (Wilkins
and Alberti 2019).
To develop appropriate sociodemographic and social-needs screening tools as well as the
clinical, public health, and social service workflows that will yield the most complete and valid
data, patients and community members must be engaged as equal partners in the work.
Community members must be seen as contributors whose wisdom and experience navigating
their communities can ensure the relevance and effectiveness of interventions to address the
social factors identified through the data collection. Further, this bidirectional engagement will
build trust between local communities and academic, heath care, and government institutions
without which public health guidance is less likely to be followed and data collection less likely
to be comprehensive and produce actionable information.
Conclusion
The novel coronavirus did not create the conditions for health and social inequity, nor did it
reveal heretofore unrecognized health or social injustices. Rather, the virus and its related illness
took advantage of longstanding health, social, political, and economic inequities in the U.S. to
once again ensure the most marginalized and under-resourced communities suffer the most.
While one could argue that the U.S. response to the pandemic was inadequate across the board in
terms of its timeliness and the seriousness with which initial warnings were translated into
action, the lack of an intentional equity-focused approach to both preparedness and rapid
response was especially egregious given that the results of that omission were so predictable.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

12
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
We propose twin agendas for action grounded in evidence and community expertise. The
first seeks to adjust our policies to specifically and intentionally ensure a more equitable
distribution of health-promoting resources in preparedness efforts to improve population health
in general and to mitigate the impact of social determinants of health during a pandemic crisis.
The second seeks to adjust our rapid response actions to ensure that when in crisis, we make
evidence-informed, community-engaged decisions about how to deploy those resources in ways
that ensure the health and well-being of all, not just a privileged few. When the next pandemic
hits, or when the next wave of this novel coronavirus crests, we hope this and other calls for
action significantly increase our nation’s ability to promote social justice and health equity in
both our responses and their outcomes.
  
Philip M. Alberti is senior director of health equity research and policy at the Association of
American Medical Colleges. He is an epidemiologist whose writing, research, speaking, and
service focus on building an evidence base for effective programs, protocols, policies, and
partnerships aimed at eliminating inequities in health and health care.
Paula M. Lantz is associate dean for academic affairs and the James B. Hudak Professor of
health policy at the University of Michigan Ford School of Public Policy. She also holds an
appointment as professor of health management and policy at the School of Public Health. She is
a social demographer and teaches and conducts research regarding the role of social policy in
improving population health and reducing social disparities in health.
Consuelo H. Wilkins is vice president for health equity at Vanderbilt University Medical
Center, associate dean for health equity and professor of medicine at Vanderbilt University
School of Medicine, and executive director of the Meharry-Vanderbilt Alliance. Dr. Wilkins is a
nationally recognized thought leader in health equity and community engaged research who has
pioneered new approaches to engaging vulnerable, socioeconomically disadvantaged, and
minority populations. Dr. Wilkins is principal investigator of three NIH-funded centers focused
on translational science, precision medicine, and disparities and a Robert Wood Johnson
Foundation award on engendering trust in health care among African-American men.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

13
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
References
Alderwick, Hugh and Laura M. Gottlieb. 2019. “Meanings and Misunderstandings: A Social
Determinants of Health Lexicon for Health Care Systems.” Milbank Quarterly, 97, no. 2:
407–19.
Artiga, Samantha, Kendal Orgera, Olivia Pham, and Bradley Corallo. 2020. “Growing Data
Underscore that Communities of Color are Being Harder Hit by COVID-19.” Kaiser
Family Foundation. Coronavirus Policy Watch. April 21. kff.org/coronavirus-policy-
watch/growing-data-underscore-communities-color-harder-hit-covid-19/.
Bedford, Juliet, Jeremey Farrar, Chikwe Ihekweazu, Gagandeep Kang, Marion Koopmans, and
John Nkengasong. 2019. “A New Twenty-First Century Science for Effective Epidemic
Response.” Nature 575 no. 7781: 130–136.
Blumenshine, Phillip, Arthur Reingold, Susan Egerter, Robin Mockenhaupt, Paula Braveman,
and James Marks. 2008. “Pandemic Influenza Planning in the United States from a
Health Disparities Perspective.” Emerging Infectious Diseases 14 no. 5: 709.
Braithwate, Ronald and Rueben Warren. 2020. “The African American Petri Dish.” Journal of
Health Care for the Poor and Underserved (preprint).
preprint.press.jhu.edu/jhcpu/sites/default/files/02_warren.pdf
Castrucci, Brian and John Auerbach. 2019. “Meeting Individual Social Needs Falls Short Of
Addressing Social Determinants Of Health.” Health Affairs Blog (accessed April 30,
2020).
Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry,
Geospatial Research, Analysis, and Services Program. 2011. “Social Vulnerability
Index.” Online Report. svi.cdc.gov/index.html (accessed April 30, 2020).
Centers for Disease Control and Prevention. 2020. “Coronavirus Disease 2019: Cases in the US.”
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-
us.html?utm_source=sfmc&utm_medium=email&utm_campaign=covidinternal&utm_co
ntent=newsletter#demographic-characteristics (accessed April 30, 2020).
Davis, Jennifer R., Sacoby Wilson, Amy Brock-Martin, Saundra Glover, and Erik R. Svendsen.
2010. “The Impact of Disasters on Populations with Health and Health Care Disparities.”
Disaster Medicine and Public Health Preparedness no. 4: 30–38.
Gelmon, Sherril B., Sarena D. Seifer, J. Kauper-Brown, and M. Mikkelsen. 2005. “Building
Capacity for Community Engagement: Institutional Self-Assessment.” Seattle, WA:
Community Campus Partnerships for Health. https://communityengagement.uncg.edu/
wp-content/uploads/2014/08/self-assessment-copyright.pdf (accessed April 30, 2020).
Juster, Robert Paul, Bruce S. McEwen, and Sonia J. Lupien. 2010. “Allostatic Load Biomarkers
of Chronic Stress and Impact on Health and Cognition.” Neuroscience & Biobehavioral
Reviews 35, no. 1: 2–16.
Kayman, Harvey and Angela Ablorh-Odjidja. 2006. “Revisiting Public Health Preparedness:
Incorporating Social Justice Principles into Pandemic Preparedness Planning for
Influenza.” Journal of Public Health Management and Practice 12, no. 4: 373–80.
Kendi, Ibram X. 2020. “Stop Blaming Black People for Dying of Coronavirus” The Atlantic,
April 14. theatlantic.com/ideas/archive/2020/04/race-and-blame/609946/.
Kumar, Supriya and Sandra Crouse Quinn. 2012. “Existing Health Inequalities in India:
Informing Preparedness Planning for an Influenza Pandemic.” Health Policy and
Planning 27, no. 6: 516.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

14
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
Lantz, Paula M. 2019. “The Medicalization of Population Health: Who Will Stay Upstream?”
Milbank Quarterly 97, no. 1: 36–39.
Lichtveld, Maureen. 2018. “Disasters Through the Lends of Disparities: Elevate Community
Resilience as an Essential Public Health Service.” American Journal of Public Health,
108, no. 1: 28–30.
Mays, Glen. 2016. “Zika, Flint, and the Uncertainties of Emergency Preparedness.” Health
Affairs (blog), June 22. 10.1377/hblog20160622.055487.
Mosites Emily, Erin M. Parker, Kristie E.N. Clarke, Jessie M. Gaeta, Travis P. Baggett,
Elizabeth Impert, Madeline Sankaran, et al. 2020. “Assessment of SARS-CoV-2
Infection Prevalence in Homeless Shelters—Four U.S. Cities, March 27 – April 15,
2020.” Centers for Disesase Control and Prevention Morbidity and Mortality Weekly
Report (MMWR) 69, no. 17: 521–522. cdc.gov/mmwr/volumes/69/wr/mm6917e1.html.
Quinn, Sandra Crouse and Supriya Kumar. 2014. “Health Inequalities and Infectious Disease
Epidemics: A Challenge for Global Health Security.” Biosecurity and Bioterrorism:
Biodefense Strategy, Practice, and Science 12, no. 5: 263–273.
Quinn, Sandra Crouse, Supriya Kumar, Vicki S. Freimuth, Donald Musa, Nestor Casteneda-
Angarita, and Kelley Kidwell. 2011. “Racial Disparities in Exposure, Susceptibility, and
Access to Health Care in the US H1N1 Influenza Pandemic.” American Journal of Public
Health, 101, no. 2: 285–293.
O’Donnell, Jayne. 2020. “Tackling Poverty in a Coronavirus-Inducted Economic Downturn: Is
it Too Risk or the Right Thing to Do?” USA Today, April 29.
www.usatoday.com/story/news/health/2020/04/28/coronavirus-poverty-fight-public-
health/5164303002/.
Phelan, Jo C., Bruce G. Link, and P. Tehranifar. 2010. “Social Conditions as Fundamental
Causes of Health Inequalities: Theory, Evidence, and Policy Implications.” Journal of
Health and Social Behavior 51: S28–40.
Richard, Lucie, Lise Gauvin, and Kim Raine. 2011. “Ecological Models Revisited: Their Uses
and Evolution in Health Promotion Over Two Decades.” Annual Review of Public Health
32: 307–26.
Solar, O. and A. Irwin. 2010. A Conceptual Framework for Action on the Social Determinants of
Health. Social Determinants of Health Discussion Paper 2 (Policy and Practice).
Geneva, Switzerland: World Health Organization.
Tobin-Tyler, Elizabeth. 2020. “In Allocating Scare Health Care Resources During COVID-19,
Don’t Forget Health Justice.” Health Affairs (blog), April 25.
10.1377/hblog20200422.50144.
Vaughan, Elaine and Timothy Tinker. 2009. “Effective Health Risk Communication About
Pandemic Influenza for Vulnerable Populations. American Journal of Public Health S2:
S324–32.
Villarosa, Linda. 2020. “A Terrible Price: The Deadly Racial Disparities of Covid-19 in
America.” New York Times, April 29. www.nytimes.com/2020/04/29/magazine/racial-
disparities-covid-19.html.
Wilkins, Consuelo H. and Philip M. Alberti. 2019. “Shifting Academic Health Centers from a
View of Community Service to Community Integration.” Academic Medicine 94, no. 6:
763–67.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

15
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
Woolf, Steven H. and Paula Braveman. 2011. “Where Health Disparities Begin: The Role of
Social and Economic Determinants – And Why Current Policies May Make Matters
Worse.” Health Affairs 30, no. 10: 1852–59.
Zarocostas J. 2020. “How to Fight an Infodemic.” The Lancet 395, no. 10225: 676.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

16
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
Table 1 Essential Multi-Sector Actions for Pandemic Health Equity Preparedness
Build Strong Public Health Infrastructure That Includes:
• Stockpiles of essential materials to prevent exposure (e.g., high-quality masks, hand
sanitizer, personal protective equipment, etc.).
• Stockpiles of essential materials for testing, diagnosis, antibody testing.
• Plans for the equitable distribution of stockpiled materials.
• Access to rapid disease testing, antibody testing, diagnosis and follow up.
• Rapid contact tracing.
• Increases in funding to local, state, regional, tribal and Federal public health agencies.
Ensure the Material Conditions of Health for All (as defined by the World Health Organization):
• Strong food access and security systems.
• High levels of housing security and affordability.
• Low levels of housing crowding.
• High levels of air and water quality.
• Prohibitions on evictions and significant rent hikes during epidemics/pandemics.
• Prohibitions on water and other utility shut-offs during epidemics/pandemics.
• Financial access to health care (health insurance coverage).
• Strong health care safety net system, including community health centers and public health
clinics.
• Sufficient health care providers (doctors, nurses, psychologists, community health workers,
etc.) to meet all communities’ needs.
Ensure Basic Economic Security for Individuals and Families:
• Living wage policy to reduce poverty and economic hardship in communities.
• Paid sick leave.
• Rapid and easy access to unemployment benefits and other public assistance.
• Consider Universal Basic Income (UBI) proposals.
Provide/Subsidize Access to Important Technology for Information, Home Schooling, Public
Services, Personal Finances, Public Health Surveillance and Voting:
• Widespread access to free or low-cost internet for individuals and families.
• Technology support for home-schooling and home-based work.
• Financial technology: Widespread access to online banking, automobile registration and
licensure, rent or mortgage payments, etc.
• Design and implementation of efficient and user-friendly systems for applying for and
receiving public assistance, financial assistance and social services.
• Smart-phone technology for infectious disease exposure and contact tracing.
• Clear policies that make voting by absentee ballot and by mail easy and secure.
Implement and Enforce Infectious Disease Prevention and Control in Congregate Settings:
• Better enforcement of current regulations in nursing homes, psychiatric hospitals,
rehabilitation centers, jails and prisons, shelter, transitional housing, etc.
• Plans for prevention/control of infectious disease in community epidemics/pandemics.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

17
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
• Reduce number of people incarcerated.
Safety Standards/Plans for Public Transportation:
• Protection of drivers and other essential workers.
• Plans for physical distancing boarding, disembarking and traveling.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

18
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
Table 2 Pandemic Health Equity Rapid Response Tactics
Effectively Communicate Health Risk:
• Engage trusted community organizations and leaders to develop and disseminate messaging.
• Develop messaging that is relevant to socially vulnerable communities and recognizes the
varying socioeconomic needs and differing levels of trust of health systems and government.
• Create materials at the appropriate reading level for broad audiences.
• Make information available in multiple languages using processes beyond translation that
include a cultural understanding of specific communities with limited English proficiency.
• Use channels viewed as trusted and credible by socially vulnerable communities.
Implement Socio-culturally Appropriate Surveillance and Risk Reduction Strategies:
• Create community-based surveillance programs that leverage community assets.
• Use community health workers and public health educators to collect surveillance data and
share risk reduction information.
• Distribute information and supplies for risk reduction such as masks and hand sanitizer via
community and faith-based organizations.
Have Emergency Policies/Executive Orders Ready to Be Rapidly Implemented:
• Determine before a crisis what constitutes “essential” versus “non-essential” services.
• Require employers of front-line service providers (e.g., grocery and other retail stores,
pharmacies, food plants, delivery services, etc.) to provide workers with PPE and paid sick
leave.
Ensure Timely and Easily Accessible Testing:
• Use community-level data such as social vulnerability indices, availability of transportation,
and population density to determine location and hours of operation for testing sites.
• Locate testing within the most socially vulnerable communities, ideally co-located with
trusted community organizations.
• Provide testing at no cost, regardless of insurance status.
• Offer free transportation to testing sites.
• Monitor testing access data disaggregated by race, ethnicity and language, and rapidly shift
or expand testing based on identified inequities.
• Provide resources and post-testing information in multiple languages.
Provide Equitable and Rapid Access to Quality Health Care:
• Broadly disseminate maps and location details of health care providers and clinics.
• Deploy mobile testing and treatment units in communities with limited transportation access.
• Engage trusted community organizations in messaging and ensure information is available in
multiple languages.
• Extend hours of access and provide free transportation.
• Suspend any requirements for insurance or documentation of residence.
• Prioritize support for health care providers in socially vulnerable communities.
o Local, state and national funds should give priority to safety net providers and
recognize differential needs given availability of resources at baseline.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020

19
Forthcoming in Journal of Health Politics, Policy and Law. DOI: 10.1215/03616878-8641469
o Government, public health and health systems with greater resources should share
tools, protocols and knowledge to enable community-level response.
• Compare hospitalizations, use of specific treatments, and deaths by race, ethnicity, language,
as well as social risk factors and determinants and create plans to address any differences
identified.
• Ensure treatment and discharge information is available at the appropriate reading level and
in multiple languages.
• Provide follow up care at no cost.
Provide Equitable and Rapid Access to Social and Economic Relief Programs:
• Prioritize distribution of economic relief to communities identified as having the most urgent
need based on surveillance data.
• Provide financial support to community- and faith-based organizations and other social
service agencies to ensure service continuity and capacity.
UNEDITED
MANUSCRIPT
Downloaded from https://read.dukeupress.edu/jhppl/article-pdf/doi/10.1215/03616878-8641469/804951/8641469.pdf
by guest
on 02 June 2020