August 2020, Volume XXXIV, Number 5

  Public Health

COVID-19 in Greater Minnesota

Addressing structural inequities

he brutal murder of George Floyd at the hands of Minneapolis police reminds us of an ongoing reality: our society and culture does not value Black and Brown people. This tragedy is another violent symptom of underlying structural inequities and racism built into our power structures and society, and one that produces disparities in health.

Our rural communities of Faribault and Northfield are not exempt. Rice County is home to approximately twice the state average of Latino immigrants, and to one of the largest communities of Somali refugees and their families outside of the Twin Cities. COVID-19 infection rates highlight the fact that Rice County is not immune from structural inequalities and racism.

Numbers from the pandemic

Last month, Rice County Public Health reported that 36% of COVID-19 cases were diagnosed in individuals who identify as Black, and 33% of cases were in those who identify as Hispanic—rates far higher than the county’s percentages of 5.4% and 7.9% who identify as Black and Hispanic, respectively. As of June 12, 87% of Rice County’s COVID-19 cases resided in Faribault, even though Faribault makes up just 34% of the county’s population.

Overall, Rice County is home to some of the highest rates of COVID-19 in Minnesota, with the sixth-highest incidence rate in the state and the second highest in the Southeast region.

The statistics are shocking but not surprising. These disparities are a product of embedded inequities and underlying socio-economic disparities. Over two-thirds of the students in the Faribault school district qualify for free and reduced lunch (provided for families within 125% of federal poverty guidelines), and the disparity ratio between Latino and White poverty is among the highest in the state.

Rice County is home to some of the highest rates of COVID-19 in Minnesota.

These socioeconomic disparities have put Latino and Somali families on the front lines of feeling the effects of this pandemic. While many Rice County residents have the privilege of working from home, many of our Black and Hispanic residents work in jobs that have been deemed “essential,” including local agricultural processing facilities and other fabrication and manufacturing line work. Latino and Somali groups are over-represented in professions that require working in close proximity, indoors, for extended periods. While many employers supported their employees to take precautions such as PPE, testing, awareness, and paid time off, other employers did none of the above. All worksites in these industries have been impacted by outbreaks among their workers.

Despite the risks, these employees have been showing up to work—while putting their own health in danger—to support their community without question or hesitation. While many businesses were shut down by state order, our Black and Hispanic neighbors worked to ensure our society had what it needed when we were most vulnerable. Work such as food production, facility and custodial services, packaging, and fabrication happens in the background for many of us, but it is essential to our daily life and activities. However, the cost of this has been borne disproportionately by our Somali and Latino neighbors.

Longstanding barriers

This pandemic has amplified existing challenges for everyone. We have all had to re-think our modes of transportation, where and how we get our food, and how to go about our lives at home to ensure our own safety. This crisis has magnified structural barriers for the underserved and traditionally marginalized.

For example, we have all been inundated with messages of maintaining social distance at a time when public transportation and other public services have been limited or shut down. For essential workers in a rural area, there are even fewer options to get to work or the grocery store. As a result, our communities have developed robust networks of carpooling and ride-sharing. During the pandemic, nearly all workers share rides and airspace with not just a work team, but with a carpool group.

Informal networks of childcare, meal preparation, or grocery shopping are common sources of the strong community ties inherent to these cultures. While traditional structures and systems of societies have excluded underserved communities from participating in these systems, communities drew on inherent strengths to provide for themselves. Unfortunately, new patterns of commerce—such as online grocery shopping, home delivery, cashless transactions, virtual meetings, socially distanced childcare, or transportation—are often unavailable to those with fewer resources. These communities have been traditionally excluded or marginalized from credit cards and the banking system, and disproportionately lack access to the internet.

During mandatory quarantine or stay-at-home orders, many of us fall back on the roof over our heads as an ultimate source of refuge. Mortgage forbearance or programs for landlords or tenants have kept many folks in their homes, just when they needed it most. Somali and Latino families are underrepresented in these segments of the economy, often with month-to-month contracts, informal arrangements, or by renting rooms within houses. There are no programs for such renters, and when faced with economic difficulty, these groups are often left with nowhere to go.

Pandemic amplifies health disparities

The housing picture becomes even more complex for individuals diagnosed with COVID-19. The number of our patients who have lost their housing—not because they couldn’t pay, but because their landlords wanted them out after a positive test result—is startling. While inconvenient, many people can imagine how they might distance or isolate a family member who has COVID-19, perhaps by having the infected individual use a separate bathroom or bedroom. But many underserved families live in multi-generational households, sharing sleeping quarters and facilities that all but ensure spread once a family member is diagnosed.

Economic challenges are not new to health care, and existing barriers to care and insurance coverage continue to have an outsized impact during this time. It is common for facilities not to charge for COVID-19 testing. That being said, whether due to a mistake in the system or a built-in policy, it is not uncommon for patients to receive bills for testing. With economically vulnerable patients, one story or experience of being billed for a test can have a chilling effect on others seeking testing. Neighbors, family, or friends hear about the costs and become even more reticent to seek out a test.

Community-driven care

Just as these structural and embedded challenges have been with us for some time, so have tangible solutions. For as long as these communities have been facing institutional barriers, they have been creating structures and institutions to take their place, particularly during the current pandemic, giving neighbors rides to test sites; bringing food to quarantined friends; caring for children; renting a room in a house; raising voices in solidarity, and donating food, supplies, or dollars. This is our community helping and healing itself. In the face of longstanding and persistent challenges, our community has resilience and power that is unwavering.

At HealthFinders, our model of care is built around this concept. Health happens in community, and we have built an organization around this principle. Community health workers (CHWs) are a critical nexus, bringing a community context into clinical interactions, and clinical knowledge into community realities. Beyond culturally competent care or cross-cultural educational materials, CHWs are an invaluable bridge brokering information between the clinic and the community. As trusted and embedded community members, they bring invaluable knowledge across the continuum of care, drawing on inherent capacities of communities to be healthy, and maximizing the impact of clinical interventions.

Health happens in community.

For example, at the outset of the outbreak, our CHWs developed a “COVID-19 watchlist” of vulnerable patients who would benefit from proactive outreach and engagement. While our EMR and clinical tracking systems similarly informed this list, it was the deep, personal community knowledge of our CHWs that helped them identify dozens of patients who were perhaps most vulnerable and who, in most cases, would not have been captured by our clinical metrics alone. During their calls, CHWs were able to provide invaluable support to patients, whether they had COVID-19 or not. This type of check-in kept patients healthy and connected just when they needed it most.

CHWs were also able to inform our wellness staff that access to food was one of the most pressing issues affecting the community during the pandemic. This led to the creation of a food distribution system, transitioning our waiting-room food pantry into an at-home delivery service that has distributed thousands of pounds of produce to patients who need it most.

For patients seeking testing, CHWs were able to inform our outreach and educate the community on what to expect, amplifying the impact of our drive-through testing program. For patients testing positive for COVID-19, CHWs were vital members of an at-home monitoring program. While clinicians kept close tabs on vitals and symptoms, CHWs were navigating housing or employment challenges, family communications for hospital transfers, and much more. CHWs worked in close contact with clinicians to coordinate all aspects of patient care.

It’s everybody’s responsibility

It seems unimaginable how these tragic times are layering on top of each other. Whether emerging outbreaks, or symptoms of dynamics in place for centuries, what is certain is that they share the same underlying causes: ingrained inequities, persistent disparities, and institutional racism. These populations in rural Faribault are poised to grow, with over 30% of the births to non-White families, and the school district recently becoming majority non-White. Rural institutions, including health care, have been slow to adapt to these changing demographics, exacerbating both inequities and the impetus for immediate change.

We see this pain manifest in communities that carry the weight of institutional violence and racism at the hands of law enforcement, both of which have torn families apart. Trauma is caused by the violent images, narratives, and realities replaying without end, incessant messages that continue to devalue Black and Brown humans.

We did not build these structural challenges, but we all have the responsibility to change and dismantle them. This may seem daunting, but everyone can start with themselves. Our community engagement team facilitates an intercultural effectiveness seminar, unpacking individual and institutional biases and assumptions in a cross-cultural lens. After training hundreds of professionals across health, education, and social service sectors, we continue to see the impact of this work and the institutional change that begins with individuals.

The time is now to break the cycle. Physicians and health systems share in the responsibility to identify new ways of collaboration to solve issues that cut across our entire society and culture. Ask yourself what you can do today to change how you practice to dismantle the root causes of racism that have produced such disparate outcomes in our patients for too long.

Charlie Mandile is the Executive Director at HealthFinders Collaborative, a health care provider with offices in Northfield and Faribault. 

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Charlie Mandile is the Executive Director at HealthFinders Collaborative, a health care provider with offices in Northfield and Faribault.