By Michael Booth
Pandemics come for us all in equal measure, right? Aren’t we all equally vulnerable?
As the first cases of coronavirus arrive in the state, Colorado health and social services officials say they are striving to make sure lower-income residents and people of color are not disproportionately impacted by the illness and potential economic disruption.
As of March 6, Colorado had reported two coronavirus cases, both in patients who had recently traveled to highly infected areas. So far, no so-called “community” transmissions are reported, but public health officials expect they will show up. It's too early to tell the extent to which Coloradans will be impacted.
National and international studies of past pandemics have revealed inequities by race, ethnicity and income groups in everything from the level of exposure to the pathogen, to health care outcomes during and resulting from treatment, to loss of income and vulnerability to emergency health expenses. A study of the 2009 H1N1 virus outbreak published in the American Journal of Public Health documented major gaps in complications and hospitalization rates among Blacks, Hispanics, Indigenous people and whites, in areas as widespread as Boston, Chicago and Oklahoma.
In Oklahoma’s H1N1 cases, for example, 55% of Black patients were hospitalized, compared to 37% percent of Indigenous people and 26% of whites. The study discusses possible reasons for the disparities in exposure and severity levels during outbreaks, including racial gaps in the levels of uninsured, over-representation of lower-income and people of color in use of public transit and denser housing, and people of color getting antiviral drugs prescribed less frequently.
While Colorado as a whole scores well in experts’ national rankings of public health emergency preparedness (more on that shortly), past experience in addressing broad health challenges shows there will be pockets of the state facing extra health and daily living threats, said Glen Mays, chair of the Department of Health Systems, Management and Policy in the Colorado School of Public Health. Lower-income communities with fewer public resources and higher uninsured rates, or immigrants of color who fear contact with authorities because of documentation issues, are two examples.
“It boils down to these communities being less protected, with fewer resources to be deployed to screen and identify a threat,” Mays said. “When a new thing happens, you have to make choices every day. Ultimately, that means someone’s not going to get served.”
Potential school closures alone raise troubling equity issues, acknowledged Mark Wallace, MD, public health director for Weld County and board chair of Sunrise federally qualified health clinics in northern Colorado. Around the world, at least 300 million children are now missing school because of coronavirus lockouts.
“We have to be aware that we’re going to leave a bunch of children out in the cold where they won’t get an education, they won’t get food, and they won’t have access to school health centers. It ripples through very quickly,” Wallace said.
There are numerous potential unequal outcomes from a coronavirus pandemic in Colorado:
- With this virus most deeply affecting elderly patients with underlying conditions, skilled nursing facilities like the one in Washington state that has seen early U.S. fatalities are some of the most vulnerable spots. The majority of skilled-nursing patients in Colorado are low-income and their care is paid through Medicaid (Health First Colorado).
- Differences in outcomes can be affected by lower-income residents being more likely to live in public and/or multi-unit housing, and having reduced access to (high-quality, or any) health insurance and health care.
- Rural residents may have initial advantages in an outbreak from living in relative isolation, but also could face more barriers to effective care once a virus does reach their communities. Small local hospitals can quickly be overwhelmed—some rural Colorado hospitals have just a couple dozen beds or less at any given time—and local emergency services may need outside aid to handle higher volumes of cases.
- Lower-income residents with people-oriented service jobs, such as restaurant or retail workers, often don’t have paid sick leave, and could still feel compelled to go to work even if symptomatic, in order to stay employed and support families. That may not only endanger their own health, but circulate the virus within the broader community.
- Working families without child care backup may send symptomatic children to school instead of keeping them home, as recommended by health authorities, further spreading the illness.
- People without documentation may lack health insurance and may avoid seeking medical attention even at lower-cost clinics, for fear of coming in contact with immigration authorities or other bureaucratic hassles. The new federal “public charge” rule, blocking legal status for many families who use public aid, is likely to make some residents fearful of seeking care or giving names to people performing epidemiology investigations and tracing contacts.
- Families with high-deductible health insurance or lacking insurance altogether may either avoid seeking health care, or face surprise bills in the thousands of dollars for hospital quarantines over which they have no control. Stories have already landed of patients ordered to hospital isolation and coming home to $3,000 bills for ER visits, inpatient rooms, radiology and more.
- Public transit such as RTD, relied upon disproportionately by lower-income communities and communities of color, can be disrupted by worker illness shortages and changes to operations mandated by viral countermeasures.
- Quarantines and home isolations ordered by public health officials to contain outbreaks can lock working-class families away from jobs, and daily needs such as groceries and prescriptions. Emergency planning needs to include local human services agencies and nonprofits to fill gaps in delivering food, prescriptions and even emergency rent money to affected populations, Colorado public health officials said.
- Schools and other institutions have a widely varied range of available resources to take emergency measures, including remote learning through tablet or laptop devices, extra sanitary cleanings of school rooms, buses and equipment, and more.
“One thing is very clear: we are pretty far from the goal of equal protection when it comes to protecting people from large-scale disease outbreaks, like what coronavirus could become,” Mays said. “Where you live determines to a strong degree how protected you are from hazardous events like novel coronavirus.”
In addition to his position at Colorado School of Public Health, Mays directs the National Health Security Preparedness Index, created by the U.S. Centers for Disease Control and Prevention and supported by the Robert Wood Johnson Foundation. The index tracks multiple measures of states’ preparedness for public health threats, and ratings show how states vary from each other and improve or decline over time.
The index factors relevant data such as the number of epidemiologists per 100,000 population, strength of networking among public health agencies, institutions and nonprofits, and whether all hospitals participate in a formal emergency preparedness coalition.
Colorado does well, scoring a 7.1 on the index compared to the national average of 6.7. Colorado’s public health system has won praise in past events, such as a listeria outbreak transmitted by locally grown cantaloupe that killed dozens of people in 2011. Western neighbors score higher than average as well, including Utah and Nebraska, Mays noted.
Still, the national map points out potential inequities looming in future outbreaks, Mays said. States with higher poverty rates, those with larger populations of people of color, and larger rural populations score lower on the readiness index, and could face increased challenges from pandemics. Alaska and Nevada scored the lowest nationally.
“There are pretty clear geographic patterns to the data that correspond with some of the same demographic factors that drive inequities in access to health care and access to health outcomes generally,” Mays said. For example, the 2019 Colorado Health Access Survey results pointed to continued disparities among Coloradans in health care coverage and ability to cover medical bills, according to location, race, income, immigration status and other variables.
“The state lines mask a lot of inequity at the local level,” added Mays. Think of the San Luis Valley in southwestern Colorado, Mays said, with a higher proportion of Hispanic residents, lower incomes and lower local-government budgets. An already-understaffed local public health force there is already working to address opioid addiction and overdoses, teenage vaping, and elevated suicide rates, among several pressing issues.
Coronavirus cases will stretch them even further, Mays believes: “There are a lot of competing needs.” Communities like some in the San Luis Valley “tend to have multiple health threats that are ongoing crises.”
And while Colorado’s rural areas have planned well for health emergencies, they don’t always have the public health personnel needed to execute as quickly as urban areas, said Theresa Anselmo, executive director of the Colorado Association of Local Public Health Officers. The understaffing got worse in the years of public health budget cuts following the deep 2008 recession.
Public health leaders expect to soon have authorization to take coronavirus testing kits out to remote locations or homes, Anselmo said. But in a county health office with one to three overall employees, who can do that once the virus reaches the community?
“They don’t have the surge capacity. There just aren’t warm bodies to do that,” she said.
Public health planners spend a lot of time discussing how any given emergency might result in a “difference in disease burden in different communities,” said Bill Burman, MD, director of Denver Public Health. “How can our activities mitigate that? Equity is right at the center of our planning and implementation.”
A most recent example for Denver came with a hepatitis A outbreak that disproportionately impacted people experiencing homelessness or seeking shelter space, Burman said. A handful of Denver cases in late 2019 indicated a long-feared outbreak had finally arrived. Hepatitis A can be passed from one person to another by sharing contaminated food and other objects; poor hygiene increases the risk of transmission. A Denver Post report said hepatitis A had “swept through homeless shelters and street encampments in other U.S. cities since 2017, sickening about 22,000 people and killing 216—especially people who are vulnerable because of substance abuse and poor health care.”
Denver Public Health and allied nonprofits deployed mobile health units to administer free hepatitis A vaccinations at locations where vulnerable populations gathered, from downtown parks to riverside encampments and day or night shelters. “Anywhere where someone told us would be a reasonable place to meet persons at risk, we went there with vaccine,” Burman said.
The public health community also works hard on communication and targeted messaging—in the hepatitis A outbreak, for example, a general community warning wasn’t needed, and Denver Public Health primarily communicated through one-on-one health visits, nonprofit allies and word of mouth.
Another looming question is the future cost of any coronavirus vaccine, now under development and expected to be available in the next year or so. Public health officials can’t yet promise that any or all coronavirus vaccinations will be free once a vaccine appears, Burman said, though making it free to everyone who needs it is certainly a goal. State officials moved last week to make sure coronavirus testing would be free for patients with suspected cases. National and state leaders have also discussed new measures that would make all coronavirus testing and treatment free of charge to the patient.
The issues raised by potential school closures, job absenteeism, lack of paid sick-leave and social services for shut-in families will all be on the table if coronavirus hits Denver hard, Burman added. “We as the broader community need to be thinking about the specific ramifications of isolation or institutional closures,” he said. “A lot of equity issues rise there very quickly, and that’s not something our office can deal with on our own. We’re starting to ask those questions and reach out.”
Weld County Health is working with school superintendents and many other public and nonprofit officials to address equity concerns before they occur, Wallace said.
“Schools are incredibly vital to our populations who are more vulnerable—that’s where those kids are fed every day,” he said. “Look at our county’s largest school district—a significant number of our children are getting two meals a day Monday through Friday at school.”
Colorado’s organizations fighting food insecurity say they also are meeting early and often to be proactive in an outbreak, but they note that people are going underserved even before a new emergency.
Lynne Telford of the Care and Share Food Bank in Colorado Springs, which provides food to 150 pantries and meal sites in 31 southern Colorado counties, says her staff has just begun thinking about their response to an outbreak.
“We’re really good at reacting and we might make changes that limit human contact, such as leaving food outside the doors of the food bank.” But Telford is also realistic and says that “we’re not getting food to everybody who needs it now.”
The U.S. Department of Homeland Security recommends that people stock up with a two-week supply of water and food before a pandemic hits. But for families in Colorado already struggling with food insecurity, that may be difficult, if not impossible.
“People are starting to grasp the reality of the situation,” says Joel McClurg, policy and communications manager for Colorado Blueprint for Hunger, a food security advocacy program backed by the Colorado Health Foundation. “Most people getting SNAP [supplemental nutrition assistance program, formerly food stamps] work in retail or hospitality, and if there were to be effects, it would hit them first if stores and restaurants close temporarily and workers are not paid.”
Others at risk of going without a paycheck include employees for small businesses, and hourly wage earners such as child care providers and home health aides.
Wallace said two keys to effective policy and practice in a fast-moving situation like coronavirus are to be flexible in response, and for all parties to keep vulnerable groups and their potential reactions in mind when making decisions. The main Sunrise clinic in Evans, for example, is next to one of the county’s primary homeless shelters, as well as the Global Refugee Center. Medical staff can work with shelter staff on best practice for containing illness, and for communicating changes to vulnerable clients.
One automatic reaction might be to close a shelter that has an illness case, Wallace said. Yet that can create far more problems than it solves. People locked out of a shelter may double or triple up in cramped quarters elsewhere—the opposite of the goal in pandemics.
“If there’s someone who is sick, go in there and help them mitigate without leaving someone out in the cold for the night,” Wallace said. “It takes a lot of stepping up. We’ve got to be more comfortable working in a gray zone.”
That includes county officials holding preliminary talks with large and small employers of lower-wage workers, urging them to avoid cutting off paychecks to workers who call in sick, Wallace said. There doesn’t appear to be any state law protecting workers in such cases, but civic leaders can try to appeal for employer patience and compassion, he suggested.
The public health emergency decisions have to be made with wider social problems in mind, Wallace said, and he believes Colorado health leaders are doing that well.
Choices made with coronavirus “have to be relevant,” he said. “We have an obligation to residents of our community to make it relevant, and not just make a cold decision and say, ‘housing is not my problem.’ It is.”