PUBLIC HEALTH COVID-19 in Greater Minnesota

COVID-19 in Greater Minnesota Addressing structural inequities

BY CHARLIE MANDILE

The 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.

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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 COVID19 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.

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 educational materials, CHWs are an invaluable bridge brokering information drew on inherent strengths to provide for themselves. Unfortunately, new between the clinic and the community. As trusted and embedded community patterns of commerce—such as online grocery shopping, home delivery, members, they bring invaluable knowledge across the continuum of care, cashless transactions, virtual meetings, socially distanced childcare, or drawing on inherent capacities of communities to be healthy, and maximizing transportation—are often unavailable to those the impact of clinical interventions. with fewer resources. These communities have For example, at the outset of the outbreak, been traditionally excluded or marginalized our CHWs developed a “COVID-19 watchlist” from credit cards and the banking system, and of vulnerable patients who would benefit from disproportionately lack access to the internet. During mandatory quarantine or stay-at-home Rice County is home to some of the highest rates of proactive outreach and engagement. While our EMR and clinical tracking systems similarly orders, many of us fall back on the roof over our COVID-19 in Minnesota. informed this list, it was the deep, personal heads as an ultimate source of refuge. Mortgage community knowledge of our CHWs that helped forbearance or programs for landlords or tenants them identify dozens of patients who were perhaps have kept many folks in their homes, just when most vulnerable and who, in most cases, would not they needed it most. Somali and Latino families are have been captured by our clinical metrics alone. underrepresented in these segments of the economy, During their calls, CHWs were able to provide often with month-to-month contracts, informal arrangements, or by renting invaluable support to patients, whether they had COVID-19 or not. This type rooms within houses. There are no programs for such renters, and when faced of check-in kept patients healthy and connected just when they needed it most. with economic difficulty, these groups are often left with nowhere to go. CHWs were also able to inform our wellness staff that access to food Pandemic amplifies health disparities was one of the most pressing issues affecting the community during the The housing picture becomes even more complex for individuals diagnosed pandemic. This led to the creation of a food distribution system, transitioning with COVID-19. The number of our patients who have lost their housing— our waiting-room food pantry into an at-home delivery service that has not because they couldn’t pay, but because their landlords wanted them out distributed thousands of pounds of produce to patients who need it most. after a positive test result—is startling. While inconvenient, many people can imagine how they might distance or isolate a family member who COVID 19 in Greater Minnesota to page 234 has COVID-19, perhaps by having the infected individual use a separate bathroom or bedroom. But many underserved families live in multigenerational 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

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