Early high-profile infections of COVID-19 in the United States were associated with foreign travel and celebrities. The "elite" connotations of this public health crisis quickly disappeared, as infection rates have increased among populations with underlying health conditions and relatively poor access to health care. In the Atlanta Fed's Sixth District,1 these factors are particularly acute among poor, African-American, Latinx, and rural residents, as pointed out in a recent Atlantic article. The piece draws on data from the Kaiser Family Foundation, which estimates that almost 41 percent of all adults (16 million) in states within the Atlanta Fed's District are at risk of complications from an infection due to preexisting health conditions,2 a higher share than the United States at large (38 percent).

Racial disparities among COVID death rates are also a serious concern, intensified by long-standing health, social, and economic disparities and barriers to accessing health care.3 An analysis by Policy Map demonstrated that in Chicago, where the death toll has been disproportionately high among African Americans, majority African-American neighborhoods in Chicago also face higher rates of hypertension, are of higher median age, and have higher shares of workers employed in health care fields, all factors that increase the risk of infection and mortality.4 The death toll among African-American populations is disproportionately high in other U.S. states and metropolitan areas as well, including Louisiana and Georgia in the Southeast. Many locations have not tracked infections and deaths by race, prompting calls for more complete collection of demographic information.5

The social determinants of health and COVID-19
The connection between the social determinants of health (or "where people live, learn, work, and play," according to the U.S. Centers for Disease Control [CDC] and Prevention) and health outcomes is well established.6 This understanding has led to new collaborations between the health care and community development sectors in the Southeast, as noted in an Atlanta Fed discussion paper. Given that economic, social, environmental, and educational factors are stronger predictors of health outcomes than genetics, it follows that without intervention, underlying inequities will likely be amplified by the current public health crisis from both a health and an economic standpoint.

As the virus spreads and strict social distancing policies have been enacted in most areas of the country, the economic impact has been disastrous. In the first five weeks of the unprecedented shutdown—from March 16 through April 18, 2020—of nonessential businesses in most states, over 26 million workers filed for unemployment insurance, while essential workers, such as frontline health care workers and grocery store employees, continue to work at considerable risk to their own well-being.7 Addressing the public health crisis clearly has an impact on the economic health of our communities, and our most vulnerable populations in particular, including racial and ethnic minority, rural, low-income, and low-wealth populations. Those individuals living in close quarters, such as patients in long-term care facilities, incarcerated populations, and people experiencing homelessness, are particularly vulnerable.

What can be done to mitigate the financial and health risks to vulnerable and disadvantaged populations?
The recent paper "Impacts of COVID-19: Mitigation Efforts versus Herd Immunity" by Karen Kopecky and Tao Zha, economists at the Federal Reserve Bank of Atlanta, explores the questions that must be answered prior to a return to business as usual, including the opening of businesses, schools, and other activities.

According to Kopecky and Zha, the Susceptible Infectious Recovered (SIR) model currently used by epidemiologists to understand the progression of COVID-19 requires numerous inputs: the length of infection, the probability of chance encounters with infected people, and the probability that these encounters result in new infections, for example. Most importantly, the SIR model requires a reliable estimate of the number of infected individuals. That means without widespread, randomized testing there is no reliable way to estimate infections, and the uncertainty in forecasting future infections and deaths is enormous. This is demonstrated by great differences in experts' forecasts of how long the outbreak will linger and how many lives will be lost, which range on the upper end from tens of thousands to more than a million individuals.

Given this uncertainty, it is unclear if the recent flattening of the death curve results from a slowing of the infection rate due to social isolation policies or from a slowing of the infection rate because we are approaching herd immunity. Herd immunity means that the number of immune individuals is high enough that the number of new infections, and consequently, the death rate, slows down and soon thereafter naturally declines. However, the death rate can also flatten due to social distancing, increased use of protective clothing among the population, and other mitigation policies that reduce the rate of transmission.

Assuming that herd immunity is nearly achieved without sufficient evidence is a potentially dangerous and economically damaging gamble, particularly given that the same experts cited in Kopecky and Zha's paper estimate that only 12 percent of infected cases have been reported. Failing to understand the infection rate creates the risk of a second, potentially larger, wave of infections and cascading economic consequences if we reopen the economy too soon.

Until a vaccine is available, randomized, widespread, and freely available testing will help to better understand the numbers of infected individuals and asymptomatic cases, as individuals who do not show symptoms of the virus are also known to be contagious and there is increasing evidence of a high asymptomatic rate. According to the World Health Organization, in order to lift restrictions and resume economic activity, governments should satisfy six conditions, including a requirement that health systems are able to "detect, test, isolate and treat every case and trace every contact," and that transmission is under control, hot spots are minimized in vulnerable places, preventative measures are in place in schools and workplaces, new cases can be managed, and communities have bought into prevention measures. Guidelines released by the White House in conjunction with the CDC also call for states to establish testing of symptomatic individuals in order to roll out its three-phase plan to open up the economy.

Making free testing available through a wide array of sites in all neighborhoods is important to ensure sufficient access for underserved populations. The CARES Act includes funding for community health centers and a stipulation that private insurers fully cover the costs of testing, yet out-of-pocket costs may arise, including health care costs and associated costs such as transportation. Furthermore, testing combined with surveillance is needed both to identify infected patients and to practice more targeted isolation and containment measures, which could provisionally allow businesses to reopen. Finally, officials must also collect important demographic information, like race and ethnicity of all COVID-19 patients and deaths as well as neighborhood-level data, to better understand the impacts on communities of color.

Testing and social isolation practices are implemented by an array of local and state governments. While this has allowed some flexibility in maintaining economic activity, the ongoing spread of the virus has been devastating, with more than 1 million cases nationwide as of April 29—more than any other country—and nearly 100,000 cases reported in the states that comprise the Atlanta Fed's District, according to the CDC. Clearer and more consistent social distancing guidelines are necessary, as are resources for addressing the public health crisis, including testing and contact tracing. Absent these measures, it is impossible to predict when and if additional infection hot spots will emerge. Notably, the northern prefecture of Hokkaido in Japan experienced such an outbreak a month after it observed a flattened curve.

For many people with underlying health conditions, greater exposure to infected individuals, more limited access to health care, or an inability to practice effective social distancing—such as workers in essential occupations—another wave of infections presents great health risks. Without a coordinated approach, there are complications to resuming work, such as ongoing school closures and lack of childcare options. To ensure a safe reopening of the economy, the population first needs widespread and ongoing testing to gauge current infection rates, which can be continuously monitored to prevent future waves of infection. Longer term, policies and investments in the recovery should consider the disparate impact of the pandemic and ensure that the most vulnerable populations are served and existing inequities do not widen.

By Ann Carpenter, CED director of policy and analytics


1 The Federal Reserve Bank of Atlanta's Sixth District comprises Alabama, Florida, Georgia, and parts of Louisiana, Mississippi, and Tennessee.

2 This includes elderly individuals and adults with serious medical conditions, such as heart disease, diabetes, lung disease, asthma, and obesity.

3 Artiga, Samantha, Rachel Garfield, and Kendal Orgera. (2020). "Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19."

4 According to the Chicago Sun-Times, 72 percent of COVID-19 deaths were among African-American residents in a city that is only 30 percent black.

5 For information on whether a state collects COVID data by race, see Johns Hopkins University Coronavirus Resource Center's Racial Data Transparency map.

6 See the CDC's Research on Social Determinants of Health for more information. To explore social determinants of health and health outcome data by county, see Robert Wood Johnson Foundation's 2020 County Health Rankings.

7 Artiga, Garfield, and Orgera. (2020). "Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19."