The COVID-19 Response: A Lesson on Equality Versus Equity in Wisconsin

A woman waits in the lobby of Milwaukee’s VA Medical Center, May 5, 2020 (Public Domain/United States Department of Veterans Affairs)

MADISON, Wisc. — While many have claimed the coronavirus would affect all Americans equally regardless of race and class, so far the COVID-19 pandemic has disproportionately burdened communities of color.

A state like Wisconsin could help the rest of country figure out how the current public health response needs to address different communities. The pandemic has brought into sharp relief the racial health disparities that have existed for decades—with Black and Latino Wisconsinites being dramatically over-represented in cases numbers and deaths.

“Being sure that we have opportunities to monitor for those disparities and watch very carefully how different groups may experience this pandemic and to intervene where possible to improve health outcomes is absolutely critical,” said Dr. Amy Kind, an associate professor of medicine in the Division of Geriatrics at the University of Wisconsin-Madison’s School of Medicine and Public Health.

Echoes of Long-Standing Community Health Concerns

The last few months have seen more cities and states collecting and reporting data on the racial and ethnic demographics of people who have tested positive for the coronavirus. However, absent reliable federal tracking of coronavirus outbreaks, not all jurisdictions are choosing to report that data.

That information helps hold state and federal governments accountable for their response to the pandemic, according to Dr. Lawrence Brown, a visiting associate professor at the University of Wisconsin-Madison’s Population Health Institute. It can also validate whether public messaging authentically speaks to the communities who are disproportionally bearing the burden of the virus.

“I think you have to start with the legacy of medical apartheid in America, where Black people’s pains, hurts, conditions, diseases are minimized, are sometimes stigmatized based on [the] medical condition or just plain out ignored in this country throughout its history,” Brown said.

Brown explained this often results in mistrust of the healthcare system or public health departments and officials.

Other communities, including Wisconsin’s Hmong population, have similar apprehensions about being treated fairly or respectfully by medical professionals. These concerns can be exacerbated by language barriers, according to Dr. Yang Sao Xiong, an assistant professor in UW-Madison’s School of Social Work and Asian American Studies Program.

Though Hmong are the largest Asian American group in Wisconsin, Xiong said that having access to an experienced, trained translator in a health clinic or hospital is not necessarily guaranteed, and health materials are not often translated into Hmong.

“Not knowing the language could mean not being able to seek [or] obtain timely health care and medical attention,” Xiong said.

During these uncertain times when information is changing rapidly, putting community health workers in charge of public health messaging could help make sure that communication resonates with the people who are disproportionately affected, according to Brown. As paid healthcare professionals with experience living in those neighborhoods, community health workers are trusted messengers who would more likely be listened to.

Aware of these impacts on public health, the University of Wisconsin, with the Wisconsin Partnership program, recently awarded grants to improve immediate community outreach efforts and health outcomes related to the COVID-19 pandemic.

However, these efforts remain fragmented, Brown added.

“That’s the kind of policy push that I’m not seeing on any sort of large-scale, widespread state and federal level,” Brown said.

Life Conditions Affecting Health

While so much is still uncertain about how the COVID-19 pandemic will affect the U.S., Brown cautioned that the situation will not stabilize in every community at the same time.

Social determinants of health —like unemployment, poverty, housing quality, and income— can greatly influence health behaviors and health outcomes, according to population health experts. These factors also overlap with racially discriminatory policies like redlining, the enduring practice of denying home mortgages to Black people and other people of color.

“I argue that many redlined Black communities were already in a state of emergency—from toxic lead poisoning to food insecurity to environmental injustice to police brutality to homicides,” Brown said. “So [now] you’re talking about a pandemic on top of emergency.”

Although both Madison and Milwaukee signed onto the Wisconsin Public Health Association’s resolution declaring racism a public health crisis, Brown contends that the pronouncement does little to address the issue without an explicit budget.

Milwaukee, along with several other Midwestern cities, is among the most hypersegregated cities in the country.

“Hypersegregation means there’s hyper-accumulation of resources in white communities and hyper-deprivation of resources in Black communities,” Brown said, and that hypersegregation allows for the differential allocation of resources. The distribution of those resources then affects public health, with an analysis of 38 states suggesting that increasing overall health outcomes rarely coincides with reducing health disparities in Black communities. For the time being, the statistics on the disproportionate burden of COVID-19 cases and deaths in the Black communities of cities like Milwaukee, Chicago, and New York also reflect that.

“It really does get down, at the end the day, to resources,” said Dr. David Kindig, an emeritus professor of population health sciences at the University of Wisconsin-Madison who has called for setting investment benchmarks to improve population health.

Additionally, whereas more coronavirus news coverage has focused on urban areas like New York, other challenges need to be considered as the virus spreads to rural areas.

“Many rural areas are highly disadvantaged along the social determinants [of health] just as inner-city urban cores are highly disadvantaged,” Kind said, referring to the Neighborhood Atlas she and her research team created. This tool maps the area disadvantage index —a measure of socioeconomic status based on metrics of education, employment, housing-quality, and poverty— onto census block groups, or “neighborhoods,” for all 50 states, the District of Columbia, and Puerto Rico.

Rural hospitals in Wisconsin and elsewhere were also already struggling to meet healthcare demands in their communities before the pandemic  “Even when we don’t have COVID-19 around, accessing advanced, particularly ICU-level care, is harder,” Kind said.

These challenges reinforce the urgency for states to carefully monitor their coronavirus outbreaks in both urban and rural areas. As Wisconsin ramps up coronavirus testing, making them accessible has involved bringing testing sites into more communities, including rural areas that may be harder to reach.

Challenges in Social Distancing for Vulnerable Communities

But social distancing can present other health risks in rural areas, especially for older populations and their caregivers, according to Kind, whose clinical practice specializes in caring for individuals with Alzheimer’s disease and their families.

“I worry a lot about the individuals who I care for as patients and who I know that are out there that are completely socially isolated,” Kind said. “Social isolation is unfortunately quite common, even outside of pandemics, for some older adult groups.”

Kind also noted the concern among healthcare professionals about how limited rural broadband capacity could affect the social and wellness support available for these older populations.

In general, older adults could be at risk if they fall while alone in their house or if they are unable to get the food and other resources they need. This makes wellness checks on older family members and neighbors even more urgent during this period, Kind added.

On the other hand, in redlined Black communities, the physical distancing measures imposed by shelter-in-place orders were simply never possible. Many of those individuals continued working essential jobs in critical infrastructure without sick leave, struggling to pay for bills and food — all the while increasing their exposure to the coronavirus through longer travel times on public transit to work and the grocery store.

Likewise, many people in immigrant communities are also still working in vulnerable positions, and little has been done to increase worker protections or wages, according to the social work professor Xiong. For example, from Wisconsin to North Carolina to Texas,  meatpacking plants across the country, several have faced complaints about workplace safety and thousands of new coronavirus cases. The federal government stepped in only to force the plants to stay open.

“The question is, will the emergency relief effort in these communities be equitable?”  Brown asked. “You can’t give an equal response when some communities are suffering disproportionately and call it a day.”

These unprecedented circumstances call for multiple strategies to meet the needs of many different communities. Any gaps in early physical distancing measures as well as those in coronavirus testing and contract tracing capacities will manifest as states begin their haphazard reopening strategies.

“For me, health equity means you’re engaging in restoration; you’re engaging in healing; [and] you’re engaging in making communities whole because they’ve been damaged by policies, practices, systems and budgets from the past up until now,” Brown said.

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Alejandra Canales is a PhD candidate at the University of Wisconsin in Madison. She tweets from @AllieCanales1.