In the Path of the Storm: North Carolina’s Response to COVID-19’s Impact on Historically Marginalized Populations

Introduction

As the SARS-CoV-2 (COVID-19) pandemic spread across the United States in 2020, it didn’t take long to realize the disparate impact that the virus was having among historically marginalized populations (HMPs). Members of African American, Hispanic/Latinx, American Indian, and immigrant and refugee communities, as well as other communities with high poverty and limited social and economic resources, were in the direct path of the COVID-19 storm from the onset of the pandemic. As of May 14, 2021, the Centers for Disease Control and Prevention (CDC) reports 32,681,787 cases of COVID-19 in the United States and an estimated 581,573 COVID-related deaths [1]. By the end of 2020, the United States surpassed 20 million infections from COVID-19 and more than 346,000 deaths. Historically marginalized populations shouldered a disproportionate burden of COVID-19-related mortality and morbidity and were 1 to 3 times more likely to contract, die, and become hospitalized from COVID-19 compared to Whites [2].

The disparate impact of COVID-19 on historically marginalized populations in North Carolina became abundantly clear when North Carolina’s Department of Health and Human Services (NCDHHS) became one of the first state government entities to monitor and publicly report demographic surveillance data trends highlighting COVID-19 deaths, cases, and hospitalizations by race, ethnicity, gender, and age.

On March 10, 2020, North Carolina Governor Roy Cooper declared a State of Emergency to direct resources and coordinate the state’s response and protective actions to address and stop the spread of COVID-19. Notwithstanding the fact that no individual is immune from contracting this highly contagious virus, early data trends shined a light on the disparate effect COVID-19 was having on North Carolina’s historically marginalized populations. Shortly after the State of Emergency was declared, in late March, NCDHHS Secretary Dr. Mandy Cohen authorized the creation of the HMP Workgroup to develop and provide strategic guidance on the state’s response to COVID-19’s disparate impact on these communities.

Recognizing that in order for state and systemwide responses to be effective those most impacted and working in local communities had to have a seat at the table, multiple state, local, and community stakeholders were invited to join the workgroup. These HMP stakeholders were instrumental in helping the state ramp up efforts and surge resources toward helping combat the spread of COVID-19 throughout communities in North Carolina, especially in rural and low-wealth areas with high percentages of historically marginalized groups. Community-level stakeholders and faith- and community-based organizations played key roles in helping the state mitigate the effects of COVID-19 and stop its spread in several important ways (Table 1).

In addition to the work of the state’s nationally recognized COVID-19 surveillance data system, the workgroup has played an important role in informing tactics that have proven effective in helping to better tailor strategies for decreasing disparities in COVID-related deaths, hospitalizations, and cases. These tactics include deploying community health workers as trusted points of contact for historically marginalized populations at the community level; conducting testing and vaccine events in partnership with community-based organizations (CBOs) and faith-based organizations (FBOs) using census tract data and vulnerability indices to more precisely reach these populations; hosting ongoing listening sessions and roundtables to engage and learn firsthand from these communities about which tactics were most effective in reducing the risks of exposure and preventing COVID-19 cases, deaths, and hospitalizations; and providing guidance to health systems and health departments on how to best connect with historically marginalized populations.

Notwithstanding the importance of continuing to utilize and promote these effective population health strategies to reduce the spread of COVID-19 in North Carolina, there is much work that remains undone to dismantle the structural and systemic factors that have contributed to the disparate impact of the virus on historically marginalized and vulnerable populations. In recognition of the need to make sure that equity is embedded in this work, the state has implemented the Healthier Together initiative, a new public-private partnership designed to increase the number of African American/Black, American Indian, Latinx, immigrant, and refugee persons vaccinated across the state of North Carolina [3].

Healthier Together capitalizes on the enormous assets of communities and influence of community stakeholders to build and earn trust on the ground with members of HMPs and other and the organizations they lead and support; co-create strategies in collaboration with nonprofit, grassroots, and community partners rooted in HMP communities; and use data on vaccination efforts to inform planning and investment of resources.

The COVID-19 pandemic did not create the disparities that resulted in a disproportionate number of HMPs shouldering a disproportionate share of the COVID-19 mortality and morbidity rates. But the pandemic has magnified the visibility of historical structural and systemic inequities in our state’s health care system and the broader society that have produced longstanding health disparities disproportionately burdening historically marginalized populations. While many challenges remain, North Carolina is heading in the right direction to build equity into its health and human services system in a way that better prepares the state for the next pandemic and protects HMPs from cumulative disparate health outcomes.