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Disasters and Healthcare Disparity
Topic Collection
August 29, 2024

Topic Collection: Disasters and Healthcare Disparity

Healthcare inequity has always been a challenge across the U.S. The rate of disasters has increased over the years and the COVID-19 pandemic has ravaged the country, striking communities of color and other underserved populations especially hard. Healthcare professionals and emergency managers may benefit from a better understanding of the complex relationships that affect fair access to healthcare. For example:

The Health Resources & Services Administration (HRSA) defines health equity as “the absence of disparities or avoidable differences among socioeconomic and demographic groups or geographical areas in health status and health outcomes such as disease, disability, or mortality.”

The Office of Minority Health defines health equity as “the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”

Healthy People 2030 lists five domains of social determinants of health: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context.

The resources in this Topic Collection highlight these considerations, factors, and lessons learned from a variety of natural and human-caused disasters and provide guidance for healthcare practitioners who are committed to addressing healthcare disparity.

Stakeholders may also wish to access the following related ASPR TRACIE collections: COVID-19 and Minority/Vulnerable Populations: Resources for Outreach and Protection of At-Risk Individuals in a COVID-19 Environment; Access and Functional Needs; and Rural Disaster Health.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

Must Reads

Agency for Toxic Substances and Disease Registry. (2024). CDC/ATSDR Social Vulnerability Index. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

The CDC/ATSDR Social Vulnerability Index (CDC/ATSDR SVI) uses 15 U.S. census variables to help local public health officials and emergency response planners meet the needs of socially vulnerable populations in emergency response and recovery efforts.

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Alderwick, A. and Gottlieb, L.. (2019). Meanings and Misunderstandings: A Social Determinants of Health Lexicon for Health Care Systems. Milbank Quarterly. 97(0):1-13.

This article reviews definitions for key terms related to social determinants of health, with the goal of clarifying differences between terms that are sometimes confused.

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American Hospital Association. (2020). Ensuring Access in Vulnerable Communities *.

This taskforce report outlines nine emerging strategies that can help preserve access to healthcare services in vulnerable rural and urban communities.

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American Medical Association. (n.d.). Reducing Disparities in Health Care. (Accessed 11/15/2021.)

This webpage outlines the American Medical Association’s work to reduce healthcare disparities, and provides resources for physicians, and other healthcare practitioners. The resources provided include: a downloadable toolkit targeted to physicians to provide education on cultural competence and literacy; research on eliminating healthcare inequalities, and related articles on healthcare disparities.

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American Public Health Association. (2020). COVID-19 and Health Equity: Exploring Disparities and Long Term Health Impacts *.

This webinar, held in April 2020, is one of several “#COVID19Conversations” sponsored by the American Public Health Association. The esteemed panel participating in this webinar explores the disproportionate impact that COVID-19 is having on communities of color, specific steps that healthcare professionals can take to combat the inequities, and how best practices from past pandemics can lay the foundation for removing obstacles.

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ASPR TRACIE. (2023). Health Equity Officer Job Action Sheet (PDF).

This job action sheet (JAS) is modeled after the Hospital Incident Command System (HICS) JAS. It was initially developed by Hennepin Healthcare in Minneapolis, MN and was reviewed and modified by national experts. While not an official HICS component, health care planners may tailor it to their systems interested in incorporating a dedicated health equity officer position. Access the Word version here: https://files.asprtracie.hhs.gov/documents/health-equity-officer-job-action-sheet.docx

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Centers for Disease Control and Prevention. (2021). Health Equity in COVID-19. U.S. Department of Health and Human Services.

This web page includes various resources related to vaccine health equity and features information in multiple languages on CDC’s COVID-19 Health Equity Strategy. Subpages focus on health equity considerations for racial and ethnic minority groups, what can be done to promote health equity, examples of equity in action, information on racial and ethnic health disparities, and links to health equity news and resources.

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Crimmins, A.R., C.W. Avery, D.R. Easterling, K.E., et al. (Eds). (2023). Fifth National Climate Assessment. U.S. Global Change Research Program.

This report highlights observed and projected vulnerabilities, risks, and impacts associated with climate change across the country. It includes sections on physical science, national topics (e.g., air quality, indigenous peoples, agriculture, and social systems and justice), and concerns by region. Examples of response actions that focus on community mitigation and adaptation are also included.

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National Association of County and City Health Officials. (2021). Roots of Health Inequity.

The Roots of Health Inequity is an online learning collaborative for the public health workforce. The course includes “interactive maps and timelines, geographic story-telling, resource libraries, video presentations, and ‘Voices from the Field,’ which are interviews with practitioners with different perspectives on public health.”

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Office of Minority Health. (n.d.). National Stakeholder Strategy for Achieving Health Equity. (Accessed 11/18/2021.) U.S. Department of Health and Human Services.

This document provides a roadmap for using collaborative and strategic actions to eliminate health disparities. It includes “Blueprints for Action” aligned with the strategy and specific initiatives for partners across the public and private sectors can engage in to support this effort.

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Office of Minority Health. (2013). Cultural Competency Curriculum for Disaster Preparedness and Crisis Response. U.S. Department of Health and Human Services.

This set of courses is designed to integrate knowledge, attitudes, and skills related to cultural competency to help lessen racial and ethnic healthcare disparities brought on by disaster situations.

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Oregon Health Authority. (2020). Principles in Promoting Health Equity During Resource Constrained Events.

This resource is an “interim statement outlining principles in promoting health equity in resource constrained settings” issued by the state of Oregon as the first step in rewriting its crisis care guidance to be centered around equity. The key principles for allocating scarce resources are described: non-discrimination; health equity; patient-led decision-making; and transparent communication.

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Pan American Health Organization. (2020). Key Considerations for Integrating Gender Equality into Health Emergency and Disaster Response: COVID-19.

This report discusses why gender should be considered in the development of response plans, and key considerations for integrating gender equality into health emergency and disaster response, using the COVID-19 pandemic for context.

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Rural Info Hub. (2019). Rural Health Disparities.

This webpage describes health disparities faced by rural Americans. Responses to frequently asked questions are provided, as are links to supporting resources.

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Santana, M.P. (2020). Community Mobilization as a Model for Preparedness with Equity. Migrant Clinicians Network.

This blog post describes a “community mobilization” model used in Puerto Rico to incorporate equity into emergency preparedness and response. In this model, community health centers build connections between their patients and government agencies before an emergency happens, and then leverage those connections to have government support communities, which define barriers to preparedness and response for themselves.

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Trust for America’s Health. (2021). Ready or Not: 2021 Protecting The Public’s Health from Diseases, Disasters, and Bioterrorism.

Included in the 2021 issue of this annual report that serves as a “scorecard” of states’ preparedness, is an interview with public health professionals about barriers to vaccination in communities of color entitled, “Earning Vaccine Confidence in Communities of Color” (see p. 12). Practical communication strategies for addressing barriers, such as misinformation and distrust of government, are discussed.

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Williams, D. and Cooper, L. (2020). COVID-19 and Health Equity-A New Kind of “Herd Immunity” *. Journal of the American Medical Association. 323(24):2478-2480.

This editorial (published 5/11/2020) summarizes three articles documenting evidence for systemic inequities in healthcare and how this leads to blind spots from the healthcare system when providing culturally competent care to people of color, including testing obstacles during a pandemic. Additionally, the author provides an explanation of what is meant by the term “herd immunity.”

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Education and Training

* American Hospital Association. (2020). Ensuring Access in Vulnerable Communities *.

This taskforce report outlines nine emerging strategies that can help preserve access to healthcare services in vulnerable rural and urban communities.

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American Public Health Association. (2018). Get Ready Report Podcast, Episode 51: Preparedness and Health Equity.

In this podcast, Nicolette Louissaint, executive director of Healthcare Ready, speaks with Get Ready about disaster preparedness and how it relates to health equity.

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National Association of County and City Health Officials. (2021). Roots of Health Inequity.

The Roots of Health Inequity is an online learning collaborative for the public health workforce. The course includes “interactive maps and timelines, geographic story-telling, resource libraries, video presentations, and ‘Voices from the Field,’ which are interviews with practitioners with different perspectives on public health.”

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* Office of Minority Health. (n.d.). National Culturally and Linguistically Appropriate Services Standards. (Accessed 11/16/2021.) U.S. Department of Health and Human Services.

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care are a set of 15 action steps that provide guidance for providing health care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.

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Office of Minority Health. (2013). Cultural Competency Curriculum for Disaster Preparedness and Crisis Response. U.S. Department of Health and Human Services.

This set of courses is designed to integrate knowledge, attitudes, and skills related to cultural competency to help lessen racial and ethnic healthcare disparities brought on by disaster situations.

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U.S. Food and Drug Administration. (2021). Topics in Public Health.

These free webinars offered by the U.S. Food and Drug Administration focus on a variety of topics, including disparity in disaster response and the impact of racism and discrimination on health.

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Education and Training: COVID-19

Administration for Strategic Preparedness and Response. (2020). Telehealth for Community-Based Organizations Webinar Series. U.S. Department of Health and Human Services.

This webpage provides links to the “Telehealth for Community-Based Organizations Webinars” developed by ASPR's At-Risk Individuals Program. This three-part series focuses on implementing telehealth services to address the access and functional needs of at-risk individuals in partnership with HUD during the COVID-19 pandemic.

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American Public Health Association. (2020). COVID-19 and Health Equity: Exploring Disparities and Long Term Health Impacts *.

This webinar, held in April 2020, is one of several “#COVID19Conversations” sponsored by the American Public Health Association. The esteemed panel participating in this webinar explores the disproportionate impact that COVID-19 is having on communities of color, specific steps that healthcare professionals can take to combat the inequities, and how best practices from past pandemics can lay the foundation for removing obstacles.

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ASPR TRACIE. (2020). Child Emotional and Social Effects.

This second webinar in the speaker series focuses on the emotional and social effects of COVID-19 on children. Panelists discuss food and financial insecurity, racial disparities, the impact of social determinants on children’s health, return to school and daycare, and alternate childcare.

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Better Care Playbook: Center for HealthCare Strategies. (2020). How Community Health Workers and Promotors Can Support Individuals with Complex Needs amid COVID-19 *.

This webinar explores opportunities for health systems and plans to work with community health workers and health promoters to support people with disabilities and address long-term impacts of COVID-19.

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Health Care for the Homeless. (2020). Community of Practice: Addressing Racial Inequities in Health Care.

This resource is a link to recordings of a 2-part series that examined racial inequities in health care for “distressed populations of color (especially those experiencing homelessness)” in the context of COVID-19 response and recovery.

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National Center for Disaster Medicine and Public Health. (2021). The Impact of COVID-19 on Children and Families.

The speakers explain the role of the pandemic on children and families, highlight helpful resources, and discuss vaccine disparity and progress being made to address it.

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Region II Public Health Training Center. (2020). COVID19: Using a Health Equity and Human Rights Lens to Protect Vulnerable Populations during this Pandemic and Beyond *.

This module identifies key principles of the health equity and human rights frameworks to protect vulnerable and marginalized populations during COVID-19 pandemic and beyond. For additional COVID-19 related training and resources visit https://region2phtc.org/ *

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Equity in Incident Command

* ASPR TRACIE. (2023). Health Equity Officer Job Action Sheet (PDF).

This job action sheet (JAS) is modeled after the Hospital Incident Command System (HICS) JAS. It was initially developed by Hennepin Healthcare in Minneapolis, MN and was reviewed and modified by national experts. While not an official HICS component, health care planners may tailor it to their systems interested in incorporating a dedicated health equity officer position. Access the Word version here: https://files.asprtracie.hhs.gov/documents/health-equity-officer-job-action-sheet.docx

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Spence, N., Kara, T., Plamondon, K. et al. (2019). Adopting a Health Equity Lens in Emergency Management. Haznet.

Though using Canadian populations and emergency management frameworks for context, this article describes the need for incorporating health equity into emergency management globally. The authors review the challenges of doing so, noting that the root causes of inequity must be considered in planning, and policies and practices are inconsistent across, and within countries.

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Equity in Incident Command: COVID-19

Goralnick, E., Serino, R., and Clark, C. (2021). Equity and Disasters: Reframing Incident Command Systems. (First page only.) American Journal of Public Health. 111(5):844-848.

In this editorial, the authors discuss why a “structural change” is needed in the national Hospital Incident Command System (HICS) guidelines to ensure inclusion of an Equity Officer and subject matter experts in health care equity. They discuss lessons learned from their hospital, which established a “diversity, equity and community health response team” during the COVID-19 pandemic.

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The Bay Area Regional Health Inequities Initiative (BARHII) and The Public Health Alliance of Southern California (The Alliance). (2020). COVID-19 Lessons: Embedding Equity Into Emergency Operations.

This webpage includes key takeaways from a webinar entitled, “Embedding Equity into Emergency Operations: Strategies During COVID-19 and Beyond” held in August 2020. On this webinar, “national equity leaders” shared lessons learned from embedding equity into their jurisdiction’s emergency response. The link to the webinar may be found towards the bottom of the page.

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The Bay Area Regional Health Inequities Initiative (BARHII) and The Public Health Alliance of Southern California (The Alliance). (2020). Embedding Equity into Emergency Operations: Strategies for Local Health Departments During COVID-19 & Beyond. Public Health Alliance of Southern California.

This resource was developed for health departments in California to provide them with “practical strategies for integrating a robust equity response” into their emergency planning and disaster response. It includes local and national case studies, best practice recommendations, and other resources in support of the strategies, which may be adapted by other jurisdictions.

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* University of Minnesota, National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM). (2021). Embedding Equity throughout the COVID-19 Response Organizational Structure.

This resource describes how the Minnesota Department of Health (MDH) proactively incorporated equity considerations into its Incident Command System (ICS) during the response to COVID-19. The placement of equity-focused staff within the MDH ICS, and position descriptions, are included.

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Guidance and Frameworks

* Administration for Strategic Preparedness and Response. (2023). Equitable Disaster Recovery Assessment Guide & Checklist.

In disaster events, many of the existing health disparities and inequities faced by underserved communities, particularly those residing in communities with high social vulnerability indices, are exacerbated. This tool can help state, local, or tribal partners create or implement disaster recovery plans by highlighting data sources, metrics, outcomes, and key stakeholders engaged in supporting whole-of-community approaches for disaster recovery (e.g., disaster equity or health equity training, review of inequitable practices, an equitable community engagement process).

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Alderwick, A. and Gottlieb, L.. (2019). Meanings and Misunderstandings: A Social Determinants of Health Lexicon for Health Care Systems. Milbank Quarterly. 97(0):1-13.

This article reviews definitions for key terms related to social determinants of health, with the goal of clarifying differences between terms that are sometimes confused.

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* American Hospital Association. (2020). Ensuring Access in Vulnerable Communities *.

This taskforce report outlines nine emerging strategies that can help preserve access to healthcare services in vulnerable rural and urban communities.

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American Medical Association. (n.d.). Reducing Disparities in Health Care. (Accessed 11/15/2021.)

This webpage outlines the American Medical Association’s work to reduce healthcare disparities, and provides resources for physicians, and other healthcare practitioners. The resources provided include: a downloadable toolkit targeted to physicians to provide education on cultural competence and literacy; research on eliminating healthcare inequalities, and related articles on healthcare disparities.

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Berg, A. (2020). 4 Ways to Integrate Equity Into Public Health Emergency Response. American Medical Association.

This article discusses ways that equity can be equity can be incorporated into how organizations respond during public health emergencies, namely: acknowledge the historical impact of racism on public health; engage communities to mitigate disparities as a form of preparedness; strengthen workforce diversity; and enhance data collection around the social determinants of health in a neighborhood. The webpage also links to other resources, including a web series on equity.

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Boston Medical Center. (2020). Racial Bias and Equity *.

This website by Boston Medical Center includes a wide variety of materials addressing Racial Bias and Equity in general and during the pandemic.

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Centers for Disease Control and Prevention. (2021). Social Determinants of Health: Know What Effects Health.

This webpage includes resources on social determinants of health, the “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.” There are links to data, research, and tools for action, programs, and policy which may be used by public health and health care professionals.

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Drexel University. (n.d.). The National Resource Center on Advancing Emergency Preparedness for Culturally Diverse Communities *. (Accessed 4/10/2023.)

This web-based library targets public health, healthcare and emergency management providers and focuses on topics such as disaster preparedness for culturally diverse communities and other at-risk populations.

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Federal Emergency Management Agency. (2023). Inclusion, Diversity, Equity and Accessibility Guide Webinar Session 1. U.S. Department of Homeland Security.

This guide can help emergency managers ensure their exercises: are inclusive and diverse, incorporate community demographics, make information accessible, include underserved communities, and are tailored to meet the unique needs of specific segments of the whole community.

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Gilbert, N., Savoia, E., Elqura, L., et al. (2009). Emergency Preparedness for Vulnerable Populations: People with Special Health-care Needs. Public Health Reports. 124: 338-343.

The authors describe a conceptual framework developed by participants of “Equity in Preparedness: A Collaborative Symposium for Populations with Special Health-Care Needs in Boston.” The framework addresses medical, communication, supervision, and transportation needs while maintaining functional independence.

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Los Angeles County Department of Public Health (LACDPH). (n.d.). Strategies for Inclusive Planning in Emergency Response. (Accessed 11/15/2021.)

This resource was developed following a 2017 workshop hosted by LACDPH entitled “Incorporating Inclusive Planning into EOC Activations” with contributions from public health, emergency management, and subject matter experts. The overview document discusses inclusion planning generally, while the appendices offer tools and examples planners may use to ensure that operations center plans include considerations for individuals that are disproportionately affected by disasters.

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O’Kane, M., Agrawal, S., Binder, L., et al. (2021). An Equity Agenda for the Field of Health Care Quality Improvement. The National Academy of Medicine.

The authors list current “impediments to equity in health care quality” (e.g., racism, discrimination, inadequate integration of social determinants of health, lack of trust in the healthcare system) and strategies to improve upon these challenges (e.g., increasing patient trust and involvement and community engagement and improving data, leadership, and culture).

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Office of Minority Health. (n.d.). National Stakeholder Strategy for Achieving Health Equity. (Accessed 11/18/2021.) U.S. Department of Health and Human Services.

This document provides a roadmap for using collaborative and strategic actions to eliminate health disparities. It includes “Blueprints for Action” aligned with the strategy and specific initiatives for partners across the public and private sectors can engage in to support this effort.

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Office of Minority Health. (2021). Advancing AANHOPI Health Equity Practices. U.S. Department of Health and Human Services.

This blog provides a new perspective on how to help advance health equity practices among the Asian American and Native Hawaiian and Other Pacific Islander population.

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Office of the Administration for Strategic Preparedness and Response. (n.d.). Disaster Response for Homeless Individual and Families: A Trauma-Informed Approach. (Accessed 5/10/2023.) U.S. Department of Health and Human Services.

This tipsheet provides guidance on acknowledging past trauma and the current impact it may have on the lives of people experiencing homelessness after a disaster.

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Oregon Health Authority. (2020). Principles in Promoting Health Equity During Resource Constrained Events.

This resource is an “interim statement outlining principles in promoting health equity in resource constrained settings” issued by the state of Oregon as the first step in rewriting its crisis care guidance to be centered around equity. The key principles for allocating scarce resources are described: non-discrimination; health equity; patient-led decision-making; and transparent communication.

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Public Health Training Centers. (2022). Racial Justice Competency Model.

This webpage describes the process the Public Health Training Center Network has followed to develop a racial justice competency model for public health professionals with the goal of providing public health agencies with resources to develop racial justice education and training. Users can register to download the competencies here: https://rjcmph.org/feedback/

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Rural Info Hub. (2019). Rural Health Disparities.

This webpage describes health disparities faced by rural Americans. Responses to frequently asked questions are provided, as are links to supporting resources.

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The Bay Area Regional Health Inequities Initiative (BARHII). (2020). Farther Together: Seven Best Practices for Engaging Communities to Create a Healthy, Resilient Region for All.

This resource provides guidance for public agencies to “engage communities impacted by inequities in climate resilience planning.” It includes case studies of promising practices.

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U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. (2006). Delivering Gender-Informed Health Services in Emergencies.

In emergencies, the physical and mental health of girls, women, boys, and men can be affected in a variety of ways. Differences are correlated to gender in terms of exposure to and perceptions of risk, preparedness, response, and physical and psychological impact, as well as capacity to recover. Gender groups may also experience trauma in different ways. This tip sheet describes considerations for gender-informed planning for disasters.

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Vawter, D.E., Garrett, J.E., Gervais, K.G., et al. (2011). Attending to Social Vulnerability When Rationing Pandemic Resources. (Abstract only.) Journal of Clinical Ethics.

The authors provide an overview of the Minnesota Pandemic Ethics Project, an effort focused on rationing scarce health resources during a severe influenza pandemic. The authors list seven recommendations that can help vulnerable populations (and those who serve and treat them) before, during, and after an influenza pandemic.

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Guidance and Frameworks: COVID-19

Administration for Strategic Preparedness and Response. (2021). Engaging Community-Based Organizations: Promising Practices for Reaching At-Risk Individuals for COVID-19 Vaccination and Information. U.S. Department of Health and Human Services.

This resource includes strategies for engaging community-based organizations (CBOs) to address “equity towards overcoming barriers to reach underserved communities.” The strategies are aligned with the CMIST (Communication, Maintaining health, Independence, Support and Safety, and Transportation) framework for meeting the access and functional needs of at-risk individuals.

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American College of Obstetricians and Gynecologists. (2020). Addressing Health Equity During the COVID-19 Pandemic *.

This Position Statement from 5/11/2020 provides useful and practical examples of steps that healthcare professionals can take to eliminate racial inequities in maternal health access, quality of care, and health outcomes.

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American Hospital Association. (2021). Responding to COVID-19: AHA Resource Guide. (Added 1/11/2021.)

The resources linked from this page are categorized as: recovery, protecting and enabling health care workers, caring for patients and communities, addressing health care disparities, telehealth and virtual care, and cybersecurity resources. Links to AHA’s professional membership groups are also provided.

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American Medical Association. (2020). COVID-19 Health Equity Resources *.

This webpage includes links to several up-to-date articles, videos, survey data, dashboard metrics, and other resources for the healthcare workforce in serving communities of color in the wake of the COVID-19 pandemic.

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ASPR TRACIE. (2020). Rural Health and COVID-19.

This ASPR TRACIE resource lists challenges faced by rural areas specific to COVID-19. The challenges are grouped into two main categories: those specific to healthcare facilities, and those related to at-risk populations who reside in rural areas.

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Association of State and Territorial Health Officials. (2021). Health Equity.

This webpage includes links to articles on everyday issues related to health equity, as well as to articles that discuss emergency/disaster-related health equity issues (primarily due to COVID-19).

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Center to Advance Palliative Care. (2021). Addressing Disparities.

This webpage includes links to resources on equitable palliative care access during and beyond the COVID-19 pandemic.

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Lopez, L. III, Hart, L.H. III, and Katz, M.H. (2021). Racial and Ethnic Health Disparities Related to COVID-19. Journal of the American Medical Association. 325(8):719-720.

This resource discusses how pre-existing racial and ethnic disparities were exacerbated during COVID-19, as reflected in observed differences in morbidity and mortality. Three strategies for addressing disparities are recommended: 1) expand access to health care; 2) establish equitable care models; and 3) address social determinants of health.

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* National Academy for State Health Policy. (2020). States Launch Initiatives to Address Racial Inequities Highlighted by COVID-19 *.

This article highlights how some states are approaching high rates of COVID-19 cases and deaths in communities of color. There are recommendations from state task forces that target response efforts and address inequities in communities most impacted.

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National Association of Community Health Centers. (2020). The Impact of COVID-19 on PRAPARE Social Determinants of Health Domains.

This fact sheet outlines how PRAPARE SDOH domains may be associated with individuals’ risk of morbidity and mortality from COVID-19.

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Pan American Health Organization. (2020). Key Considerations for Integrating Gender Equality into Health Emergency and Disaster Response: COVID-19.

This report discusses why gender should be considered in the development of response plans, and key considerations for integrating gender equality into health emergency and disaster response, using the COVID-19 pandemic for context.

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Robert Wood Johnson Foundation. (2020). Health Equity Principles for State and Local Leaders in Responding to, Reopening and Recovering from COVID-19 *.

This Issue Brief posted in May, 2020 outlines a compass for healthcare professionals when treating and responding to communities in the wake of a global pandemic. This article details five principles for leaders to use as a path forward in advancing health equity in ways that are not just the status quo, but are transformative in improving the quality of lives for its citizens.

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Substance Abuse and Mental Health Services Administration. (2020). Confronted with Multiple Crises, Latinos Draw Upon Culture and Community (Enfrentando multiples crisis, los latinos recurren a la cultura y a la comunidad). U.S. Department of Health and Human Services.

This webpage describes the effect of COVID-19 on the LatinX population, highlights resources that document successful interventions, and provides links to resources available in Spanish and English that can help reach community members.

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Toner, E., Barnill, A., Krubiner, C., et al.. (2020). Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States. (Added 12/28/2020.) Johns Hopkins Bloomberg School of Public Health, Center for Health Security.

This report offers an ethical allocation framework and suggestions for vaccine distribution. The framework is based on wellbeing and promoting the common good; justice, fairness, and equity; legitimacy, trust, and sense of ownership in a pluralist society; combining and balancing ethical values and principles; adapting to changing conditions and evolving evidence; and linking ethical values and principles with policy goals and objectives.

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U.S. Department of Health and Human Services. (2020). HHS Initiatives to Address the Disparate Impact of COVID-19 on African Americans and Other Racial and Ethnic Minorities.

This fact sheet provides links to steps HHS has taken to address the disparate impact of COVID-19 on African Americans and other racial and ethnic minorities.

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Various Authors. (2020). The Framework for an Equitable COVID-19 Homelessness Response.

This framework identifies strategies and activities related to unsheltered people, shelter, housing, diversion and prevention, and strengthening systems for the future for communities to address through COVID-19 response and recovery funding. Please check here to confirm the most recent version: http://housingequityframework.org/.

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Virginia Department of Health - Office of Health Equity. (2020). COVID-19 Response Efforts for Vulnerable Populations *.

This website identifies programs and services that focus on strengthening the health of rural communities, minorities, underemployed, and uninsured citizens. While specific to the state of Virginia, the programs, tools, and resources noted may be valuable for emergency planners in other jurisdictions.

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Williams, D. and Cooper, L. (2020). COVID-19 and Health Equity-A New Kind of “Herd Immunity” *. Journal of the American Medical Association. 323(24):2478-2480.

This editorial (published 5/11/2020) summarizes three articles documenting evidence for systemic inequities in healthcare and how this leads to blind spots from the healthcare system when providing culturally competent care to people of color, including testing obstacles during a pandemic. Additionally, the author provides an explanation of what is meant by the term “herd immunity.”

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Guidance and Frameworks: COVID-19 Vaccines

American Pharmacists Association. (2021). Vaccine Hesitancy: Understanding and Addressing Vaccine Hesitancy During COVID-19. (Added 1/11/2021.)

This updated fact sheet provides information for pharmacists’ conversations with their customers about immunization, including tips for addressing vaccine hesitancy generally and in racial or ethnic minority populations more specifically.

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Blythe, A. (2021). Celebrating the COVID-19 Vaccine at This Hispanic Community Clinic.

This article describes a successful partnership between a faith-based organization and a health clinic to provide COVID-19 vaccinations to Latino and other immigrant community members in Durham, North Carolina.

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Centers for Disease Control and Prevention. (2021). A Guide for Community Partners: Increasing COVID-19 Vaccine Uptake Among Members of Racial and Ethnic Minority Communities. U.S. Department of Health and Human Services.

This resource is targeted to community-based organizations (CBOs) that want to support enhanced COVID-19 vaccination confidence and access in racial and ethnic minority communities. It includes tools and strategies and discusses ways that CBOs can coordinate efforts with states, territories, and localities.

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Centers for Disease Control and Prevention. (2021). COVID-19 Vaccination Program Interim Playbook for Jurisdictions Operations Annex - Considerations for Increasing COVID-19 Vaccination: Reaching and Increasing Uptake in Priority Populations. (Added 2/4/2021.) U.S. Department of Health and Human Services.

This annex to the COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations provides guidance on when and how to transition from vaccinating initial to additional priority populations; a framework for balancing equitable access, service delivery, and demand; tools for engaging priority populations and increasing vaccine confidence; and strategies to leverage private-public partnerships.

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Centers for Disease Control and Prevention. (2021). COVID-19 Vaccine Equity for Racial and Ethnic Minority Groups. U.S. Department of Health and Human Services.

This webpage includes links to resources that can help emergency planners “engage with communities that have been affected by COVID-19.” The materials may be adapted for racial and ethnic minority groups.

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Centers for Disease Control and Prevention. (2021). Health Equity in COVID-19. U.S. Department of Health and Human Services.

This web page includes various resources related to vaccine health equity and features information in multiple languages on CDC’s COVID-19 Health Equity Strategy. Subpages focus on health equity considerations for racial and ethnic minority groups, what can be done to promote health equity, examples of equity in action, information on racial and ethnic health disparities, and links to health equity news and resources.

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Centers for Disease Control and Prevention. (2021). How to Conduct a Rapid Community Assessment. U.S. Department of Health and Human Services.

This resource is intended to help understand a community’s needs regarding COVID-19 vaccines to “identify areas of intervention and prioritize potential intervention strategies to increase confidence in and uptake of COVID-19 vaccine.”

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DeCosta-Klipa, N. (2021). 4 Proposals to Improve the Massachusetts Vaccine Rollout. Boston Globe.

This newspaper article describes strategies for supporting equitable vaccine access in Massachusetts. It includes considerations for a “one-stop” appointment portal and phone hotline to streamline registration and improve access for seniors and others struggling with technology; a pre-registration system so people could register and then be notified when an appointment was available, instead of having to check back repeatedly for open appointments; and mobile vaccination sites staffed by medical professionals and community workers to bring vaccines to communities with high case counts.

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Federal Emergency Management Agency. Office of Equal Rights. (2021). FEMA Advisory: Civil Rights Considerations During COVID-19 Vaccine Distribution Efforts. (Added 3/25/2021.) U.S. Department of Homeland Security.

This checklist offers federal, state, local, and tribal authorities elements to ponder in the categories of inclusive planning, effective communication access, language access, and physical accessibility, as they plan equitable vaccine distribution in their communities.

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Jean-Jacques, M. and Bauchner, H. (2021). Vaccine Distribution—Equity Left Behind? Journal of the American Medical Association. 325(9):829-830.

This editorial offers ideas for minimizing disparities in vaccine distribution when demand exceeds supply.

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McClung, N., Chamberland, M., Kinlaw, K., et al. (2020). The Advisory Committee on Immunization Practices’ Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine – United States, 2020. (Added 12/28/2020.) Morbidity and Mortality Weekly Report. 69(47):1782-1786.

The report identifies four ethical principles that guide the Advisory Committee on Immunization Practices’ recommendations for initial allocation of limited COVID-19 vaccine: maximizing benefits and minimizing harms, promoting justice, mitigating health inequities, and promoting transparency.

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Schmidt, H., Gostin, L. and Williams, M.A. (2020). Is It Lawful and Ethical to Prioritize Racial Minorities for COVID-19 Vaccines? Journal of the American Medical Association. 324(20):2023-2024.

This editorial advocates for the use of the Area Deprivation Index (ADI) instead of the Social Vulnerability Index (SVI) for vaccine allocation because it does not “explicitly prioritize on the basis of race,” and so would be less vulnerable to legal challenge. Rather the ADI uses income, education, employment, and housing quality as proxies for race, because minorities tend to be economically disadvantaged.

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Schmidt, H., Pathak, P., Sönmez, T. and Utku Ünver, M. (2020). Covid-19: How to Prioritize Worse-off Populations in Allocating Safe and Effective Vaccines. British Medical Journal. 371:m3795.

The authors discuss why “an external, value-based reference point” distinct from the Social Vulnerability Index (SVI) used by the National Academies of Sciences, Engineering, and Medicine’s 2020 Framework for Equitable Allocation of COVID-19 Vaccine is needed and offer potential reference points for consideration.

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Schoch-Spana, M., Brunson, E., Hosangadi, D., et al. (2021). Equity in Vaccination: A Plan to Work with Communities of Color Toward COVID-19 Recovery and Beyond: Working Group on Equity in COVID-19 Vaccination. Johns Hopkins Center for Health Security.

This plan includes 5 key principles (Iteration, Involvement, Information, Integration, and Investment) and related actions for a vaccination campaign that provides Black, Indigenous, and People of Color (BIPOC) communities equitable access. Though geared towards elected and appointed officials, the plan may be referenced by public health, healthcare, and non-governmental organizations in supporting a community’s vaccination plans.

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* The National Academies of Sciences, Engineering, and Medicine. (2020). Framework for Equitable Allocation of COVID-19 Vaccine. The National Academies Press.

This consensus study report offers a phased framework based on ethical and procedural principles for equitable allocation of COVID-19 vaccine that reduces severe morbidity and mortality and negative societal effects of the pandemic. In addition to the framework, the authors addressed implementation challenges related to program administration, risk communication and community engagement, vaccine acceptance, and global equity in allocation.

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Trust for America’s Health. (2020). Ensuring COVID-19 Vaccine Access, Safety, and Utilization: Building Vaccination Confidence in Communities of Color. (Added 12/28/2020.)

This webinar offers suggestions on how to build vaccine confidence and access in communities of color.

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Trust for America’s Health, National Medical Association, and UnidosUS. (2020). Building Trust in and Access to a COVID-19 Vaccine Among People of Color and Tribal Nations: A Framework for Action Convening.

This resource summarizes discussions and policy recommendations from an October 2020 meeting that included experts in racial justice and equity, community engagement, public health, healthcare and science to “generate specific, actionable steps to be taken by policymakers both before and after the vaccine becomes available.” While geared toward government agencies, the principles and recommendations the report includes may be translated into action by healthcare organizations, as well.

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Lessons Learned

Bay Area Regional Health Inequities Initiative. (2013). Health Equity and Community Engagement-BARHII.

While not disaster-focused, this document summarizes the results of focus groups and recommendations for public health and community partners to work together to address inequity. These recommendations could be extrapolated to emergency/disaster planning, response, and recovery efforts.

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* Crimmins, A.R., C.W. Avery, D.R. Easterling, K.E., et al. (Eds). (2023). Fifth National Climate Assessment. U.S. Global Change Research Program.

This report highlights observed and projected vulnerabilities, risks, and impacts associated with climate change across the country. It includes sections on physical science, national topics (e.g., air quality, indigenous peoples, agriculture, and social systems and justice), and concerns by region. Examples of response actions that focus on community mitigation and adaptation are also included.

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Crowder, S., Tanner, A., Dawson, M., et al. (2022). Better Together: Coalitions Committed to Advancing Health Equity. Nursing Outlook.

The authors reviewed information collected from five coalitions developed to address healthcare disparities (Latinx Advocacy Team and Interdisciplinary Network for COVID-19, Black Coalition Against COVID, Camden Coalition, National Coalition of Ethnic Minority Nurse Associations, and The Future of Nursing: Campaign for Action). This article provides an overview of each coalition and how they emphasized relationship building and unique strategies to serve their populations and address COVID-19, different kinds of disparities, and other barriers to health.

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Do, V., McBrien, H., Flores, N., et al. (2023). Spatiotemporal Distribution of Power Outages with Climate Events and Social Vulnerability in the USA. Nature Communications. 14. .

The authors reviewed power outages from 2018–2020, and found "an average of 520 million customer-hours total without power annually across 2447 US counties (73.7% of the US population)." Longer outages were more likely to occur in northeastern, southern, and Appalachian counties, while counties in Arkansas, Louisiana, and Michigan experienced both frequent 8+ hour outages and higher social vulnerability and prevalence of electricity-dependent durable medical equipment use. Considerations for disaster preparedness and response are included.

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Farber, D. (2007). Disaster Law and Inequality. Minnesota Journal of Law and Inequality. 25:2; 297-321.

This slightly dated resource provides an extensive overview of disparities experienced by vulnerable groups, and how they are worsened during disasters. The author also discusses potential legal remedies to address disparities in disaster preparation, response, and recovery, which include mitigation of disparities before disasters happen.

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Flores, A.B., Collins, T.W., Grineski, S.E., et al.. (2021). Environmental Injustice in the Disaster Cycle: Hurricane Harvey and the Texas Gulf Coast. Environmental Justice. 14(2).

The authors synthesized the literature that examined disparities experienced by Hurricane Harvey survivors based on race/ethnicity and socioeconomic status (SES) across the disaster phases. The authors found that physical and health impacts from the hurricane “disproportionately” affected minority and low SES groups.

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Gearhart, S., Perez-Patron, M., Hammond, T.A., et al. (2018). The Impact of Natural Disasters on Domestic Violence: An Analysis of Reports of Simple Assault in Florida (1999–2007). Gender and Violence. 5(2).

The authors analyzed data on interpersonal violence (IPV) following natural disasters from 1999-2007. They found that reports of IPV increased with longer exposure to natural disasters (measured by disaster declarations), and advocate for disaster relief programs to address the IPV that increases due to housing insecurity and broken community networks.

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Knox, R. (2009). Officials Find Swine Flu Hits Minorities Harder. National Public Radio (NPR).

The author of this article discusses how certain factors (e.g., lower income, higher incidence of asthma, lower rates of vaccination) contribute to the disproportionate effect of swine flu on minorities.

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Kondo, K.K., Ayers, C.K., Williams, B.E., et al. (2020). Health Inequalities in Infectious Disease Epidemics Predating COVID-19 in the United States. Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-225.

This resource reports results of a “systematic review of infectious disease epidemics predating COVID-19 to better understand the potentially modifiable factors that may have contributed to differential infection rates and health outcomes, as well as the interventions and programs implemented to mitigate them.” The studies reviewed consistently noted that structural and work-related exposure to infection were underlying disparities, while the impact of comorbidities infection severity and higher rates of mortality was less clear.

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LA County Department of Mental Health. (2017). Providing Effective Services to Members of the LGBTQI2-S Community Following Disasters, Public Health Emergencies and Mass Fatality Events.

Terrorist incidents such as the Pulse Night Club Shooting in June 2016 illustrate how important it is for emergency managers and disaster responders to understand and provide culturally competent disaster assistance to the Lesbian, Gay, Bisexual, Transgender, Questioning, Queer, Intersex, and Two-Spirit (LGBTQI2-S) community; particularly if members of the community are targeted or impacted by a particular disaster. This document lists barriers community members may encounter after an incident and strategies for helping them access services. Links to related resources are provided at the end. Spanish version also available: https://files.asprtracie.hhs.gov/documents/lgbtqi2-s-spanishfac-handout-la-county-dmh-7-17-18-final.pdf

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Lichtveld, M. (2018). Disasters Through the Lens of Disparities: Elevate Community Resilience as an Essential Public Health Service. American Journal of Public Health. 108(1): 28–30.

Using examples from past disasters, the author discusses how inequities prevent communities from adequately preparing for disasters, and how poor preparedness negatively impacts mitigation, response, and recovery. She advocates for making resiliency an essential public health service.

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National Network of Public Health Institutes. (2019). Community Resilience and Equity in Disaster-Related Recovery: An Interview with Robin Pfohman, Public Health – Seattle & King County.

In this interview transcript, the Community Resilience + Equity Program Manager from a county health department discusses her experience working to address health recovery needs of “groups impacted by inequity” after disasters. She advocates for “getting into the community, building relationships, [and] listening” to learn about a community’s capacity to partner with public health and emergency management agencies in preparedness and response activities.

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Plough, A., Bristow, B., Fielding, J., et al. (2011). Pandemics and Health Equity: Lessons Learned from the H1N1 Response in Los Angeles County. (Abstract only.) Journal of Public Health Management and Practice. 17(1): 20-7.

The authors examine data from an H1N1 mass vaccination clinic provided by the Los Angeles County Department of Public Health in 2009. African American residents reported the lowest vaccination rate, followed by white residents. The authors note that informal community messaging was running counter to “official” messaging that was highlighting equity in vaccination access.

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Quinn, C.S. and Kumar, S. (2014). Health Inequalities and Infectious Disease Epidemics: A Challenge for Global Health Security. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 12(5):263-273.

The authors advocate for addressing health inequalities and social determinants of health to improve global health security.

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Santana, M.P. (2020). Community Mobilization as a Model for Preparedness with Equity. Migrant Clinicians Network.

This blog post describes a “community mobilization” model used in Puerto Rico to incorporate equity into emergency preparedness and response. In this model, community health centers build connections between their patients and government agencies before an emergency happens, and then leverage those connections to have government support communities, which define barriers to preparedness and response for themselves.

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Smiley, K., Noy, I., Wehner, M., et al. (2022). Social Inequalities in Climate Change-Attributed Impacts of Hurricane Harvey. Nature Communications. 13, 3418. .

Using land-parcel and census tract socio-economic data, the authors examine the relationship between social inequalities and climate change-related (specifically due to Hurricane Harvey) extreme weather event effects. They found that Latina/x/o neighborhoods--specifically those that were low-income and located outside of FEMA’s 100-year floodplain--were disproportionately affected. They emphasize the need to address the impact climate change is already disproportionately having on certain populations in addition to planning for future events.

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* The National Academies of Sciences, Engineering, and Medicine. (2021). Contact Tracing and the Challenges of Health Equity in Vulnerable Latino and Native American Communities.

This resource summarizes the discussion from a July 2020 workshop that was focused on the role of contact tracing for vulnerable groups, specifically Latino and Native American communities. Considerations related to distrust in government, cultural competency, and identifying case contacts without health care access or insurance, are included.

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The RISK Project. (n.d.). The Resilience in Survivors of Katrina (“RISK”) Project. (Accessed 11/16/2021.)

This longitudinal research project followed low-income parents who lived in New Orleans to better understand the role of different variables on educational attainment. The study began before Hurricane Katrina struck the area; the researchers were able to also examine consequences related to the disaster, including physical and mental health outcomes.

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Trust for America’s Health. (2021). Ready or Not: 2021 Protecting The Public’s Health from Diseases, Disasters, and Bioterrorism.

Included in the 2021 issue of this annual report that serves as a “scorecard” of states’ preparedness, is an interview with public health professionals about barriers to vaccination in communities of color entitled, “Earning Vaccine Confidence in Communities of Color” (see p. 12). Practical communication strategies for addressing barriers, such as misinformation and distrust of government, are discussed.

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Wahowiak, L. (2018). Climate Change, Health Equity ‘Inextricably Linked’: Vulnerable Populations Most at Risk from Harmful Effects. The Nation’s Health.

This article discusses how climate change and health equity are linked and includes examples of work by public health departments to support equity in response and help vulnerable communities build resilience.

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Lessons Learned: COVID-19

Alberti, P., Lantz, P., and Wilkins, C. (2020). Equitable Pandemic Preparedness and Rapid Response: Lessons from COVID-19 for Pandemic Health Equity. Journal of Health Politics Policy and Law. 45(6).

The authors discuss how COVID-19 highlighted systemic disparities, and how the U.S. is “ill equipped to realize health equity in prevention and control efforts for any type of health outcome, including an infectious disease pandemic.” They propose a health equity-focused framework for pandemic preparedness planning that actively involves the community.

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Cox, H., Gebru, Y., Horter, L., et al. (2023). New York State, New York City, New Jersey, Puerto Rico, and the US Virgin Islands' Health Department Experiences Promoting Health Equity During the Initial COVID-19 Omicron Variant Period, 2021-2022. Health Security. 51(S1).

The authors explain how five different U.S. jurisdictions provided outreach to populations disproportionately affected by COVID-19 via strategies including working with trusted community leaders, maximizing established (pre-pandemic) relationships, and addressing mistrust and misinformation. They emphasize the need for equity-centered approaches to improve future health outcomes.

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Ezell, J., Griswold, D., Chase, E., and Carver, E. (2021). The Blueprint of Disaster: COVID-19, the Flint Water Crisis, and Unequal Ecological Impacts. The Lancet Planetary Health. 5(5):E309-E315.

This resource describes how the 2015 Flint Water Crisis developed, how officials responded, and how residents responded to guidance and information (or lack thereof) from officials, in the context of institutionalized and ongoing racial and ethnic disparities. The authors note this information may be used as a case study for improving how COVID-19 mitigation activities are presented and implemented in historically marginalized communities.

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Honolulu Civil Beat Inc. (2020). How One Pacific Islander Community Is Responding To The Pandemic *.

This article describes how a local Marshallese community COVID-19 task force team worked to mitigate the spread of COVID-19.

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Infectious Disease Society of America and HIV Medicine Association. (2020). COVID-19 and Health Disparities in the United States. (Added 6/29/2020)

This document highlights the disproportionate effect COVID-19 has had on African American, Latinx, and Native American populations and other underserved communities. The authors recommend five actions in response: improve access to healthcare coverage and healthcare services; ensure the collection of COVID-19 data by race, ethnicity, and disability by zip code; provide access to affordable COVID-19 testing, prevention, care, and treatment; protect frontline workers; and address social and economic determinants of health.

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Levine, C. and Jansson, D. (2021). Concepts and Terms for Addressing Disparities in Public Health Emergencies: Accounting for the COVID-19 Pandemic and the Social Determinants of Health in the United States. Disaster Medicine and Public Health Preparedness. June 8:1–7.

This article “reviews the historic use of concepts and terms to describe populations disproportionately impacted by emergencies” due to existing disparities. The authors recommend that emergency-related activities target social determinants of health (SDOH) and attributes from the Community Resilience Assessment Measure (CRAM) to mitigate inequities, which are exacerbated in emergencies.

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* National Academy for State Health Policy. (2020). States Launch Initiatives to Address Racial Inequities Highlighted by COVID-19 *.

This article highlights how some states are approaching high rates of COVID-19 cases and deaths in communities of color. There are recommendations from state task forces that target response efforts and address inequities in communities most impacted.

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Ndumbe-Eyoh, S., Muzumdar, P., Betker, C. and Oickle, D. (2021). ‘Back to Better’: Amplifying Health Equity, and Determinants of Health Perspectives During the COVID-19 Pandemic. Global Health Promotion. 28(2): 7-16.

The authors conducted a series of virtual discussions among 13 practice, policy, research, and community leaders focused on how social and structural determinants of health were impacted by COVID-19, and how emergency preparedness plans could be improved to account for health equity.

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Office of Minority Health. (2020). Advancing the Response to COVID-19: Sharing Promising Programs and Practices for Racial and Ethnic Minority Communities. U.S. Department of Health and Human Services.

These recordings of the September 2020 event hosted by the HHS Office of Minority Health highlight state, tribal, territorial, and community-based efforts to address COVID-19 among racial and ethnic minority and American Indian and Alaska Native populations. The virtual symposium featured experts and public health leaders who shared efforts and promising practices for confronting the pandemic.

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Office of Minority Health. (2021). The Impact of COVID-19 in Latinos: What Can We Do to Move Forward? U.S. Department of Health and Human Services.

This blog about the impact of COVID-19 in Latinos and includes reliable resources to disperse misinformation and increase COVID-19 prevention measures.

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Servick, K. (2020). ‘Huge hole’ in Testing Data Blurs Racial, Ethnic Disparities. Science. 369(6501): 237-238.

Using data collection from the first wave of the COVID-19 pandemic in 2020 as an example, the author discusses how missing ethnicity data from testing prevented a complete understanding of racial and ethnic disparities in morbidity and mortality, and how this information is needed for devising strategies to mitigate disparities.

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Sivashanker, K., Duong, T., Ford, S., et al. (2020). A Data-Driven Approach to Addressing Racial Disparities in Health Care Outcomes. Harvard Business Review.

The authors discuss lessons learned in the development of a data collection, analysis, and reporting system used by Brigham Health during the COVID-19 pandemic “to understand the differential impact of Covid-19 on our patients and staff.” They note how understanding of inequities is limited by the lack of demographic data collected and describe how this data was used “to design high-impact strategies to reduce harm” caused by racial disparities.

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* The National Academies of Sciences, Engineering, and Medicine. (2021). Contact Tracing and the Challenges of Health Equity in Vulnerable Latino and Native American Communities.

This resource summarizes the discussion from a July 2020 workshop that was focused on the role of contact tracing for vulnerable groups, specifically Latino and Native American communities. Considerations related to distrust in government, cultural competency, and identifying case contacts without health care access or insurance, are included.

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United Nations. (2020). Policy Brief: The Impact of COVID-19 on Women.

This document discusses the “shadow pandemic” of the COVID-19 pandemic affecting women and girls. Quarantine orders forced women and girls to be trapped at home with their abusers, leading to a spike in domestic violence; loss of employment and health insurance kept women from accessing care; and healthcare professionals and support staff in medical facilities are predominantly women, putting them at greater risk of direct exposure to infection.

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* University of Minnesota, National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM). (2021). Embedding Equity throughout the COVID-19 Response Organizational Structure.

This resource describes how the Minnesota Department of Health (MDH) proactively incorporated equity considerations into its Incident Command System (ICS) during the response to COVID-19. The placement of equity-focused staff within the MDH ICS, and position descriptions, are included.

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Plans, Tools, and Templates

Administration for Strategic Preparedness and Response. (2021). HHS Maternal-Child Emergency Planning Toolkit. U.S. Department of Health and Human Services.

This toolkit outlines basic planning steps, highlights key resources and promising practices, and explains critical data and information to be integrated into emergency planning for maternal-child health populations. It provides guidance and advice to address the needs of people who are pregnant, postpartum, and/or lactating and typically developing infants and young children in emergencies.

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* Administration for Strategic Preparedness and Response. (2023). Equitable Disaster Recovery Assessment Guide & Checklist.

In disaster events, many of the existing health disparities and inequities faced by underserved communities, particularly those residing in communities with high social vulnerability indices, are exacerbated. This tool can help state, local, or tribal partners create or implement disaster recovery plans by highlighting data sources, metrics, outcomes, and key stakeholders engaged in supporting whole-of-community approaches for disaster recovery (e.g., disaster equity or health equity training, review of inequitable practices, an equitable community engagement process).

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Agency for Toxic Substances and Disease Registry. (2024). CDC/ATSDR Social Vulnerability Index. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

The CDC/ATSDR Social Vulnerability Index (CDC/ATSDR SVI) uses 15 U.S. census variables to help local public health officials and emergency response planners meet the needs of socially vulnerable populations in emergency response and recovery efforts.

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* ASPR TRACIE. (2023). Health Equity Officer Job Action Sheet (PDF).

This job action sheet (JAS) is modeled after the Hospital Incident Command System (HICS) JAS. It was initially developed by Hennepin Healthcare in Minneapolis, MN and was reviewed and modified by national experts. While not an official HICS component, health care planners may tailor it to their systems interested in incorporating a dedicated health equity officer position. Access the Word version here: https://files.asprtracie.hhs.gov/documents/health-equity-officer-job-action-sheet.docx

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Center for Care Innovations. (2021). Telemedicine for Health Equity Toolkit.

This toolkit provides information and guidance for safety-net healthcare systems seeking to initiate, expand, or improve their telemedicine programs in equitable ways.

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Flanagan, B., Gregory, E., Hallisey, E., et al. (2011). A Social Vulnerability Index for Disaster Management. Journal of Homeland Security and Emergency Management. 8(1):Article 3.

This resource describes the development of a social vulnerability index (SVI) for emergency management based on 15 census variables at the census tract level. It includes a case study where the SVI is used to “explore the impact of Hurricane Katrina on local populations.”

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Listos California. (2021). Innovations for Equity in Disaster Resilience.

This resource briefly reviews the ideas applied “to increase equity by deploying culturally and linguistically appropriate messages, messengers, and mediums” through the “Listos California” program, began in 2019. This program used a grassroots field strategy in partnership with 300+ community-based organizations and volunteer and service teams to reach vulnerable populations and enhance community resilience. The full report may be downloaded at https://www.phi.org/thought-leadership/listos-california-impact-report-a-people-centered-movement-to-build-disaster-resilience/.

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National Consensus Panel on Emergency Preparedness and Cultural Diversity. (2011). Guidance for Integrating Culturally Diverse Communities into Planning for and Responding to Emergencies: A Toolkit. American Hospital Association.

This toolkit was developed to provide preparedness planning and response agencies, organizations, and professionals with practical strategies, resources and examples of models for improving existing activities and developing new programs to meet the needs of racially and ethnically diverse populations.

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* Office of Minority Health. (n.d.). National Culturally and Linguistically Appropriate Services Standards. (Accessed 11/16/2021.) U.S. Department of Health and Human Services.

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care are a set of 15 action steps that provide guidance for providing health care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.

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* Office of Minority Health. (2021). Minority Health Social Vulnerability Index (SVI). U.S. Department of Health and Human Services.

This tool can be used to apply a health equity lens to research, strategic planning, program design, and evaluation related to response and recovery for COVID-19 and other public health emergencies.

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U.S. Census Bureau. (2021). Community Resilience Estimates Equity Supplement.

This dataset combines information from the Community Resilience Estimates, the American Community Survey, and the Census Bureau’s Planning Database to allow users access to data on equity and social vulnerability.

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U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response. (2023). Cultural and Linguistic Competency for Disaster Preparedness Planning and Crisis Response.

This webpage includes links to resources and tools that enhance and address cultural and linguistic competency to help mitigate the impact of disasters and emergency events.

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U.S. Food and Drug Administration. (2021). #VaccineReady Social Media Toolkit. U.S. Department of Health and Human Services.

This web page includes various social media resources to encourage members of diverse communities to be vaccinated. Resources include graphics and messages for Twitter and Facebook and links to videos.

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University of Wisconsin School of Medicine and Public Health. (n.d.). Neighborhood Atlas. (Accessed 11/16/2021.)

This webpage provides a description of the Area Deprivation Index (ADI), which uses data from the American Community Survey to assess income, education, employment, and housing quality for each census block tract in the United States and Puerto Rico. The ADI provides each neighborhood a score representing level of socioeconomic disadvantage that may be used to inform emergency planning.

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Plans, Tools, and Templates: COVID-19

Morehouse School of Medicine. (2021). National COVID-19 Resiliency Network (NCRN). Office of Minority Health, U.S. Department of Health and Human Services.

This website developed through a cooperative agreement between the HHS Office of Minority Health and the Morehouse School of Medicine shares important messages and linkages to healthcare and social services in communities across the nation and in areas hardest hit by the pandemic.

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National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM). (2022). Vaccine Central. University of Minnesota.

This webpage includes various resources for vaccine providers working with refugee, immigrant, and migrant communities to increase COVID-19 vaccination rates.

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* Office of Minority Health. (2021). Minority Health Social Vulnerability Index (SVI). U.S. Department of Health and Human Services.

This tool can be used to apply a health equity lens to research, strategic planning, program design, and evaluation related to response and recovery for COVID-19 and other public health emergencies.

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Seattle Office for Civil Rights. (2020). Racially Equitable Decision-Making Data Tools for COVID-19 Responses *.

This resource list is intended to support city staff in centering racial equity in quick decision-making where deep community engagement may not be possible.

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U.S. Department of Housing and Urban Development and U.S. Department of Health and Human Services. (2021). COVID-19 Vaccinations and Testing Toolkit. (Added 6/15/2021.)

This toolkit assists community health centers and U.S. Housing and Urban Development (HUD)-assisted housing and homeless programs interested in partnering to provide public and low-income housing residents and people experiencing homelessness with COVID-19 testing, vaccination, and health care.

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Virginia Association of Counties. (2020). COVID-19 Unified Command Task Force.

This resource contains the organizational chart of the structure used by Virginia to manage its COVID-19 response. While used by a state government, it may be referenced in the development of state and local emergency management or public health incident command structures.

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Virginia Emergency Support Team (Virginia Department of Emergency Management & Virginia Department of Health). (2020). COVID-19 Health Equity Guidebook.

This resource provides guidance for “planning and executing inclusive and accessible COVID-19 testing events and contact tracing efforts with a health equity lens.” It may be referenced by other public health agencies or healthcare organizations in developing similar plans for future public health emergencies.

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Research

Adams, R.M., Evans, C.M., Mathews, M., et al. (2020). Mortality From Forces of Nature Among Older Adults by Race/Ethnicity and Gender. Journal of Applied Gerontology.

The authors compared mortality rates among older adults (60+ years) in the United States across gender, race/ethnicity, and hazard type to assess mortality risk from “forces of nature.” In addition to reporting the data, they provide recommendations for targeting messaging and programs by hazard.

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Andrulis, D., Siddiqui, N., and Purtle, J. (2009). California’s Emergency Preparedness Efforts for Culturally Diverse Communities: Status, Challenges and Directions for the Future. Drexel University school of Public Health, Center for Health Equity.

The authors of this report examine the challenges and barriers to meeting the emergency preparedness needs of culturally diverse communities. The report also highlights gaps in programs and policies and provides promising practices and strategies to guide efforts at 5 the state, regional, and local levels. Although it focuses on California, the overall framework may be relevant to other states and jurisdictions.

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Andrulis, D., Siddiqui, N., Purtle, J. and Cooper, M. (2012). H1N1 Influenza Pandemic and Racially and Ethnically Diverse Communities in the United States: Assessing the Evidence and Charting Opportunities for Advancing Health Equity. Texas Health Institute.

This report was prepared by the National Consensus Panel on Emergency Preparedness and Cultural Diversity, established by the U.S. Department of Health and Human Services’ Office of Minority Health after Hurricane Katrina in 2005. It examines the peer-reviewed evidence of racial and ethnic disparities in morbidity and mortality during the 2009-2010 H1N1 pandemic and reasons for the observed disparities and offers “recommendations for integrating diversity and equity into pandemic influenza planning and response.”

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Andrulis, D.P., Siddiqui, N.J., and Purtle, J.P. (2011). Integrating Racially and Ethnically Diverse Communities into Planning for Disasters: The California Experience. (Abstract only.) Disaster Medicine and Public Health Preparedness. 5(3): 227-34.

The authors of this study conducted a literature review, environmental scan of organizational website providing preparedness materials for diverse communities, and key informant interviews with public health and emergency management professionals. Using California as a locus of study, the objective was to identify challenges and barriers to meeting the preparedness needs of racially and ethnically diverse communities, and highlight promising strategies, gaps in the programs, and future priorities. Impact: Results identified at least four intervention priorities for California and across the United States: engaging diverse communities in all aspects of emergency planning, implementation, and evaluation; mitigating fear and stigma; building organizational cultural competence; and enhancing coordination of information and resources.

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Bethel, J., Burke, S., and Britt, A. (2013). Disparity in Disaster Preparedness Between Racial/Ethnic Groups. Disaster Health. 1(2): 110-116.

Behavioral Risk Factor Surveillance System survey respondent data was examined to determine the relationship between race/ethnicity (independent variable) and disaster preparedness (three dependent variables). The authors found that people from racial/ethnic minority groups were less likely to have three days’ worth of medical supplies. Only Spanish-speaking Hispanics were less likely to have an emergency evacuation plan than white respondents.

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Brite, J., Alper, H., Friedman, S., et al. (2020). Association Between Socioeconomic Status and Asthma-Related Emergency Department Visits Among World Trade Center Rescue and Recovery Workers and Survivors. JAMA Network Open. 3(3): e201600.

The authors sought to examine the relationship between barriers to care (in this case, race, education, and income) and asthma-related emergency department visits among responders and survivors of the 9/11 World Trade Center bombing. Of the 448 subjects who had at least one ED visit during the study period, 28% (p < .001). The authors highlight other associations and suggest there may be additional variables (e.g., lower health literacy and gaps in asthma-specific knowledge) at play.

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Burger, A.E., Reither, E.N., Hofmann, E.T. and Mamelund, S.E. (2017). The Influence of Hispanic Ethnicity and Nativity Status on 2009 H1N1 Pandemic Vaccination Uptake in the United States. Journal of Immigrant and Minority Health. 20:561–568.

The authors examined data from the 2010 National Health Interview Survey to estimate rates of 2009 H1N1 vaccination among Hispanics. They concluded that foreign-born Hispanics were least likely to be vaccinated compared with native-born Hispanics and Whites, due to “insufficient access to flexible resources and healthcare coverage among foreign-born Hispanics.”

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Cox, K. and Kim, B. (2017). Race and Income Disparities in Disaster Preparedness in Old Age. (Abstract only.) Journal of Gerontological Social Work. 61(7):719-734.

The authors used data from the 2010 Health and Retirement Study to explore race and income disparities in preparedness in old age. They concluded that their data analysis “suggests that preparedness programs should target minority and low income elders.”

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* Crimmins, A.R., C.W. Avery, D.R. Easterling, K.E., et al. (Eds). (2023). Fifth National Climate Assessment. U.S. Global Change Research Program.

This report highlights observed and projected vulnerabilities, risks, and impacts associated with climate change across the country. It includes sections on physical science, national topics (e.g., air quality, indigenous peoples, agriculture, and social systems and justice), and concerns by region. Examples of response actions that focus on community mitigation and adaptation are also included.

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Crouse Quinn, S. (2008). Crisis and Emergency Risk Communication in a Pandemic: A Model for Building Capacity and Resilience of Minority Communities. (Abstract only.) Health Promotion Practice 9(4 Suppl):18S-25S.

The author addresses the challenges public health agencies have when communicating risk to certain populations during a pandemic (e.g., distrust of government, existing health disparities). The author also suggests the use of a risk communication strategy based on community engagement, disaster risk education, and crisis and emergency risk communication to help prepare minority communities and government agencies to prepare, respond, and work together in a pandemic.

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Davis, J., Wilson, S., Brock-Martin, A., et al. (2010). The Impact of Disasters on Populations With Health and Health Care Disparities. Disaster Medical Public Health Preparedness. 4(1): 3038.

The authors performed an extensive literature review to examine the effects of a disaster and living in an area with existing health or healthcare disparities on a community’s overall health and quality of life and access to health resources.

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Dee, D.L., Bensyl, D.M., Gindler, J., et al. (2011). Racial and Ethnic Disparities in Hospitalizations and Deaths Associated with 2009 Pandemic Influenza A (H1N1) Virus Infections in the United States. (Abstract only.) Annals of Epidemiology. (8):623-30.

The authors used various data sources to examine racial-ethnic disparities in the 2009 pandemic influenza A (H1N1) illness severity and health consequences for U.S. minority populations. The authors noted racial-ethnic disparities in H1N1-associated healthcare seeking behavior, hospitalizations, and pediatric deaths.

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Evidence Aid. (2024). Humanitarian Impact of Climate Change.

This evidence collection contains summaries of research related to the global humanitarian impact of climate change.

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Gabe, T., Falk, G., McCarty, M., et al. (2005). Hurricane Katrina: Social-Demographic Characteristics of Impacted Areas. Congressional Research Service.

This document provides data about areas impacted by Hurricane Katrina in 2005, including estimates of the population who were most affected and most likely displaced by the storm, in total and in each of the three affected states: Louisiana, Mississippi, and Alabama. It presents a social-demographic profile of the affected population, looking at characteristics such as poverty and race/ ethnicity status, homeownership, and housing status. Separate topics are also addressed for the elderly, children, and working-age adults.

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Hahn, M., Van Wyck, R., Lessard, L., and Fried, R. (2021). Compounding Effects of Social Vulnerability and Recurring Natural Disasters on Mental and Physical Health. Disaster Medicine and Public Health Preparedness. March 24: 1-9..

The authors used census tract level data from 500 U.S. cities to model “self-reported, poor mental and physical health, or a clinical diagnosis of high blood pressure or asthma” in those that had experienced recent or recurring natural disasters from 2001-2015. They controlled for social and environmental risk factors in the study and found that communities that experienced a disaster within 5 years had poorer health outcomes compared to communities that did not.

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Henkel, P. and Marvanova, M. (2019). Basic Disaster Preparedness of Rural Community Pharmacies in 5 States. (Free registration required; request full text from authors.) Disaster Medicine and Public Health Preparedness. 14(3):329-334.

Community pharmacies in rural areas in North and South Dakota, West Virginia, Southern Oregon and Northern California were surveyed via telephone to determine their levels of disaster preparedness. The authors concluded that “being in a rural, low-income, or high-elderly area was associated with lower likelihood” of basic community pharmacy disaster preparedness.

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Icenogle, M., Eastburn, S., and Arrieta, M. (2016). Katrina's Legacy: Processes for Patient Disaster Preparation Have Improved but Important Gaps Remain. American Journal of Medical Science. 352(5): 455–465.

The authors present findings from a qualitative study of participants representing healthcare and social services organizations serving health disparate residents of the Mississippi and Alabama Gulf Coast. They note that participant organizations have implemented changes to ensure continuity of care for the chronically ill in case of disasters (e.g., evacuation planning and assistance; support to find resources in evacuation destinations; equipping patients with prescription information, diagnoses, treatment plans, and advance medications when a disaster is imminent), but that additional solutions are necessary to meet the needs of disparate populations more fully.

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Institute for Healthcare Improvement. (2021). Health Equity.

This webpage includes links to resources on health equity (e.g., publications, podcasts, and videos), accessible via free registration.

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Marmot, M., Allen, J., Boyce, T., et al. (2020). Health Equity in England: The Marmot Review 10 Years on. Institute of Health Equity.

The authors review what has happened in England in the 10 years since the first report was published. Findings are presented based on five social determinants of health and followed by a section on governance for health equity. The authors emphasize the need to address “the twin problems of social inequalities and climate change…at the same time.”

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National Healthcare Quality Report and National Healthcare Disaprities Report. (2020). National Healthcare Quality Report and National Healthcare Disparities Report.

AHRQ has produced the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) annually since 2003. These reports measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness and efficiency of care. Chapter topics include care coordination of health system infrastructure. The reports present, in chart form, the latest available findings on quality of and access to health care.

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Niles, S. and Contreras, S. (2019). Social Vulnerability and the Role of Puerto Rico’s Healthcare Workers after Hurricane Maria. Natural Hazards Center, University of Colorado.

The authors used observation data and health worker interviews after Hurricane Maria to understand how the storm impacted health, and how healthcare workers reached those who were most impacted. They describe who was most vulnerable to the health impacts of the storm and extended disruptions to infrastructure after the storm and note that healthcare worker flexibility, local knowledge, and collaboration within affected communities supported successful medical outreach through existing clinics, mobile clinics, and by traveling door-to-door.

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Nkechi, C., Gagliardi, J., McGahee, S., et al. (2022). Medical Mistrust in Perinatal Mental Health. (Abstract only.) Harvard Review of Psychiatry. 30(4):238-247.

Community health centers (CHCs) can improve disparities by addressing mistrust of the health system among historically marginalized populations. CHCs can commit to financing, let people in the community lead, and learn from past obstacles to reach marginalized groups.

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Pettit Cornelius, A., Char, D., Doyle, C., et al. (2022). Disparities in Disaster Healthcare: A Review of Past Disasters. (Abstract only.) American Journal of Disaster Medicine. 17(2):171-184.

The authors reviewed the literature to understand how social determinants of health affected outcomes after disasters. They found that disaster plans did not sufficiently prepare marginalized communities for these events and emphasize the need for further research.

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Pettit Cornelius, A., Char, D., Gustafson Ista, L., et al. (2024). Disaster Healthcare Disparities Solutions: Part 1-Preparation. (Abstract only.) American Journal of Disaster Medicine. 19(2):91-100.

As part of a series of three articles on understanding and addressing disparity in disasters, the authors focused this article on inequities in the preparedness phase of disasters. While some solutions identified have been implemented, others remain theoretical; both types could have a positive effect on disaster healthcare. Access the authors’ Part 2-Response here: https://pubmed.ncbi.nlm.nih.gov/38698508/ and Part 3-Recovery and Mitigation here: https://pubmed.ncbi.nlm.nih.gov/38698509/

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Quinn, S.C., Kumar, S., Freimuth, V.S., et al. (2011). Racial Disparities in Exposure, Susceptibility, and Access to Health Care in the US H1N1 Influenza Pandemic. American Journal of Public Health. 101(2):285-93 .

The authors of this study examined racial disparities in H1N1 exposure, susceptibility to H1N1 complications, and access to healthcare during the 2009 H1N1 influenza pandemic. They noted disparities in the risks of exposure, susceptibility (particularly to severe disease), and access to healthcare.

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Raker, E., Arcaya, M., Lowe, S., et al. (2020). Mitigating Health Disparities After Natural Disasters: Lessons from The RISK Project. Health Affairs. 39(12).

The Resilience in Survivors of Katrina (RISK) project examined 15 years of data specific to 1,109 low-income, primarily Black parents to determine the short- and long-term effects of disasters on vulnerable populations. The study authors categorized their findings into five priorities: primary prevention of disaster exposure (and associated trauma); improve post-disaster health care; integrate social services; aid survivors in social support and community building; and provide targeted, long-term services for highly affected survivors.

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Rubenson Wahlin, R., Ponzer, S. Lövbrand, H., et al. (2016). Do Male and Female Trauma Patients Receive the Same Prehospital Care?: An Observational Follow-up Study. BMC Emergency Medicine. 16(6).

The authors retrospectively analyzed data from 383 records obtained from local trauma registries and hospital and ambulance records in Stockholm County, Sweden. They found that males were more likely to be transported directly to a trauma center than females, and hypothesize that this may be due to gender differences in symptom presentation that physiologic criteria for triage do not account for. There were no differences in total on-scene time or on-scene interventions provided between genders.

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Runkle, J., Brock-Martin, A., Karmaus, W., and Svendsen, E. (2012). Secondary Surge Capacity: A Framework for Understanding Long-Term Access to Primary Care for Medically Vulnerable Populations in Disaster Recovery. American Journal of Public Health. 102(12):e24-32.

The authors advocate for the expansion of surge capacity plans to meet the chronic health care needs of vulnerable populations that increase following the acute phase of disaster response. They use a health services model to identify factors that perpetuate health disparities following disasters. To address these disparities, the authors recommend a baseline assessment of needs, with the expectation that such health care needs will expand post-disaster.

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Substance Abuse and Mental Health Services Administration. (2022). National Network to Eliminate Disparities in Behavioral Health. U.S. Department of Health and Human Services.

This network is comprised of community-based organizations focused on issues that impact diverse populations. This network provides information, training, and technical assistance to increase equity in behavioral health service distribution.

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Toldson, I., Ray, K., Hatcher, S.S., and Louis, L.S. (2011). Examining the Long-Term Racial Disparities in Health and Economic Conditions Among Hurricane Katrina Survivors: Policy Implications for Gulf Coast Recovery. (Abstract only.) Journal of Black Studies. 42(3):360-78.

This article reviews findings from a 2006 survey of Hurricane Katrina survivors to evaluate health and economic disparities one year after the storm. Based on self-reported data, black survivors were found to have more hurricane-related problems with personal health, emotional well-being, and finances.

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Uscher-Pines, L., Maurer, J., and Harris, K.M. (2011). Racial and Ethnic Disparities in Uptake and Location of Vaccination for 2009-H1N1 and Seasonal Influenza.

The authors analyzed nationally representative survey data of US adults collected in March 2010 to “learn more about racial and ethnic disparities in influenza vaccination during the 2009-H1N1 pandemic.” The concluded that Blacks were significantly less likely to be vaccinated against seasonal influenza and 2009-H1N1 than were Whites, and advocate for additional study of how communication and vaccine distribution methods affect vaccine uptake within minority communities.

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Various Authors. (2021). Structural Racism and Discrimination: Impact on Minority Health and Health Disparities. Ethnicity and Disease. Volume 31, Supplement 1.

This supplemental issue of Ethnicity & Disease features research articles dedicated to the study of the impact of structural racism and discrimination on minority health. Authors highlight findings and make recommendations for studying the impact and designing interventions.

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Williams, D., Lawrence, J., and Davis, B. (2019). Racism and Health: Evidence and Needed Research. Annual Review of Public Health. 40:105-125.

The authors summarize the evidence linking the primary domains of racism (structural, cultural, and individual-level discrimination) to various health outcomes. They also highlight key findings, priorities for future research, and areas that still need more research.

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Research: COVID-19

Adhikari, S., Pantaleo, N., Feldman, J. et al. (2020). Assessment of Community-Level Disparities in Coronavirus Disease 2019 (COVID-19) Infections and Deaths in Large US Metropolitan Areas. JAMA Network Open. 3(7):e2016938.

This article discusses results from a cross-sectional study conducted in May 2020 that used census data aggregated at the county level to explore the relationships between income, race, and COVID-19 infections and deaths. The authors concluded that “racial and ethnic disparities in COVID-19 infections and deaths existed beyond those explained by differences in income.”

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Alsan, M., Stanford, F.C., Banerjee, A. et al. (2021). Comparison of Knowledge and Information-Seeking Behavior After General COVID-19 Public Health Messages and Messages Tailored for Black and Latinx Communities: A Randomized Controlled Trial. Annals of Internal Medicine. April.

This study found that physician-delivered messaging for Black and Latinx participants increased their knowledge about COVID-19 symptoms and prevention methods, and that race-concordant messages modestly increased knowledge-seeking behavior among Black participants, but not among Latinx participants.

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Centers for Disease Control and Prevention. (2021). County-Level COVID-19 Vaccination Coverage and Social Vulnerability — United States, December 14, 2020–March 1, 2021. Morbidity and Mortality Weekly Report. 70(12);431–436.

This report discusses how high social vulnerability counties had lower COVID-19 vaccination coverage than did low social vulnerability counties during the first 2.5 months of the U.S. vaccination program. The authors note the importance of this data for developing local vaccine administration and outreach efforts to reduce COVID-19 vaccination inequities.

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Chan, S.B., Smith-Garcia, J., and Collier, C. (2020). Racial Disparity and Covid-19 Outcomes: An Emergency Department Study. (Abstract only.) Annals of Emergency Medicine. 76(4): S16-S17.

The authors collected data on individuals tested for COVID-19 in three Emergency Departments that are all part of an emergency medicine residency program. They found that non-whites were more likely to test positive for COVID-19, require intubation, and die from COVID-19 compared with whites, regardless of co-morbidities.

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County of Los Angeles Public Health. (2020). Racial, Ethnic & Socioeconomic Data & Strategies Report *.

This report disaggregates COVID-19 data by race/ethnicity and socioeconomic status in LA County and reviews strategies to address COVID-19 inequities.

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Gross, C., Essien, U., Pasha, S. et al.. (2020). Racial and Ethnic Disparities in Population Level Covid-19 Mortality. Journal of General Internal Medicine. 35: 3097–3099.

The authors conducted a cross-sectional study using publicly reported Covid-19 mortality data from state websites as of April 21, 2020, to evaluate the completeness of race and ethnicity reporting in Covid-19 mortality data across states. They found “substantial variation in the completeness of race data across states” and advocate for improved data collection to better evaluate disparities and target public health and clinical interventions.

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Infectious Diseases Society of America, HIV Medicine Association, and the Society for Healthcare Epidemiology of America. (2020). COVID-19 Initial Lessons Learned: Recommendations to Prepare for a Fall Surge of COVID-19 Cases. (Added 6/22/2020.)

This document offers recommendations on the following issues to prepare for additional waves of COVID-19: personal protective equipment and other medical supplies, testing capacity, physical distancing and wearing masks/face coverings, contact tracing, telehealth, workforce capacity, access to care and treatment, health disparities, antimicrobial resistance, increasing immunization rates, preparing for a COVID-19 vaccine, minimizing viral spread during large gatherings, safe elections, comprehensive data collection, protections for frontline workers, and global cooperation.

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Iyanda, A.E., Boakye, K.A., Lu, Y. and Oppong, J. (2021). Racial/Ethnic Heterogeneity and Rural-Urban Disparity of COVID-19 Case Fatality Ratio in the USA: a Negative Binomial and GIS-Based Analysis. Journal of Racial and Ethnic Health Disparities. DOI: 10.1007/s40615-021-01006-7.

This article discusses results of a cross-sectional study that examined determinants of COVID-19 case fatality ratio (CFR) based on publicly sourced data from January 1 to December 18, 2020. The authors concluded that “rural counties have a COVID-19 case fatality ratio higher than the national rate,” with minority populations experiencing the greatest impact.

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Kabarriti, R., Brodin, N.P., Maron, M.I., et al. (2020). Association of Race and Ethnicity With Comorbidities and Survival Among Patients With COVID-19 at an Urban Medical Center in New York. JAMA Network Open. 3(9):e2019795.

The authors conducted a cohort study of 5,902 patients who presented for care to a large urban academic medical center in New York between March 14 and April 15, 2020 to determine if race/ethnicity resulted in differences in comorbidities in patients with COVID-19, or in “case fatality rates among ethnic and racial groups when controlling for key risk factors.” The authors concluded that Hispanic and non-Hispanic Black patients had a greater proportion of comorbidities vs. non-Hispanic Whites but did not experience higher case fatality rates when controlling for age, sex, socioeconomic status and comorbidities.

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Karaye, I. and Horney, J. (2020). The Impact of Social Vulnerability on COVID-19 in the U.S.: An Analysis of Spatially Varying Relationships. American Journal of Preventive Medicine. 59(3):P317-325.

This study used Social Vulnerability Index (SVI) and COVID-19 case count data to identify counties at increased risk of infection. Results showed that “minority status and language, household composition and transportation, and housing and disability predicted COVID-19 case counts in the U.S.”

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Lowe, J., Brown, I., Duriseti, R. et al. (2021). Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income. Western Journal of Emergency Medicine. 22(3): 552–560.

The authors reviewed electronic health records (EHR) for a two-ED healthcare system in Northern California from March–June 2020 to compare weekly absolute number of visits and proportional change in visits in 2019 focusing on race/ethnicity, insurance, household income, and acuity. They found that those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups while stay-at-home orders were in place and presented with higher acuity illness than other groups as the pandemic went on.

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Mackey, K., Ayers, C.K., Kondo, K.K. et al. (2021). Racial and Ethnic Disparities in COVID-19–Related Infections, Hospitalizations, and Deaths. Annals of Internal Medicine .

The authors conducted a review of cohort and cross-sectional studies, ecological studies, and data from the Centers for Disease Control and Prevention and APM Research Lab “to evaluate racial/ethnic disparities in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates and COVID-19 outcomes, factors contributing to disparities, and interventions to reduce them.” They found higher rates of SARS-CoV-2 infection and COVID-19–related mortality among black and Hispanic populations, but similar rates of case fatality across racial and ethnic groups.

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Muñoz-Price, L.S., Nattinger, A.B., Rivera, F., et al. (2020). Racial Disparities in Incidence and Outcomes Among Patients With COVID-19. JAMA Network Open. e2021892.

The authors conducted a cross-sectional study of 2,595 patients that presented to a large academic medical center in Milwaukee, WI from March 12 to March 31, 2020 to determine if there is “an association between race and coronavirus disease 2019 (COVID-19) after controlling for age, sex, socioeconomic status, and comorbidities.” They concluded that race was associated with COVID-19 infections and with a higher risk of hospitalization (in conjunction with poverty).

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National Alliance to End Homelessness. (2020). Racial Disparities During COVID-19 *.

This spreadsheet tool helps homelessness systems streamline data collection to identify and address racial inequities in testing, treatment, and appropriate service delivery.

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Nayak, A., Islam, S.J., Mehta, A. et al. (2020). Impact of Social Vulnerability on COVID-19 Incidence and Outcomes in the United States. medRxiv.

The authors examined the association between COVID-19 incidence and case fatality rate (CFR) and social vulnerability using population-based county level data collected early in the pandemic. They concluded that “socioeconomic status and minority status were both predictors of higher incidence and CFR.”

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Substance Abuse and Mental Health Services Administration. (n.d.). Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S.. (Accessed 11/9/2021.) U.S. Department of Health and Human Services.

This resource uses data and charts to illustrate “deep-seated inequities” faced by communities of color during the COVID-19 pandemic, specific to physical and behavioral health. Suggested policy efforts, communication strategies, partnerships, and healthcare efforts are listed to help address challenges associated with lower access to behavioral health and substance abuse treatment opportunities, particularly during a public health emergency.

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* The National Academies of Sciences, Engineering, and Medicine. (2020). Framework for Equitable Allocation of COVID-19 Vaccine. The National Academies Press.

This consensus study report offers a phased framework based on ethical and procedural principles for equitable allocation of COVID-19 vaccine that reduces severe morbidity and mortality and negative societal effects of the pandemic. In addition to the framework, the authors addressed implementation challenges related to program administration, risk communication and community engagement, vaccine acceptance, and global equity in allocation.

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Thomas, D., Jang, S., and Scandlyn, J. (2020). The CHASMS Conceptual Model of Cascading Disasters and Social Vulnerability: The COVID-19 Case Example. International Journal of Disaster Risk Reduction. 51. .

The “Cascading Hazards to disAsters that are Socially constructed eMerging out of Social Vulnerability” (CHASMS) model examines the relationship between health disparity, social vulnerability, and environmental justice and how these variables contribute to cascading disasters. The authors apply CHASMS to COVID-19 as an example “of how underlying inequities give rise to foreseeable inequitable outcomes.”

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Yehia, B.R., Winegar, A., Fogel, R. et al. (2020). Association of Race With Mortality Among Patients Hospitalized With Coronavirus Disease 2019 (COVID-19) at 92 US Hospitals. JAMA Network Open. 3(8):e2018039.

The authors conducted a cohort study of 11,210 adult patients hospitalized with confirmed severe acute respiratory coronavirus 2 (SARS-CoV-2) between February 19, 2020, and May 31, 2020, in 92 hospitals in 12 states to examine the effect of race on mortality. The authors concluded that “mortality for those able to access hospital care did not differ between Black and White patients after adjusting for sociodemographic factors and comorbidities.”

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Agencies and Organizations

Centers for Disease Control and Prevention. Health Equity.

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Drexel University School of Public Health. Diversity Preparedness.

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Healthy People 2030. Social Determinants of Health.

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Institute for Healthcare Improvement. Health Equity.

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National Health Council. Addressing Discrimination & Health Disparities.

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Rural Info Hub. Rural Health Disparities.

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Society for Academic Emergency Medicine (SAEM). Diversity, Equity, and Inclusion Library.

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U.S. Department of Health and Human Services. Office of Minority Health.

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U.S. Department of Health and Human Services, Office of Civil Rights. Emergency Preparedness.

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US. Department of Health and Human Services. Office of Climate Change and Health Equity.

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This ASPR TRACIE Topic Collection was comprehensively reviewed in October and November 2021 by the following subject matter experts (listed in alphabetical order): Dianna Havner Bryant, PhD, CIH, CSP, Institute for Rural Emergency Management, University of Central Missouri; John Hick, MD, Hennepin Healthcare; Roslyn Holliday Moore, MS, Deputy Director for Programs, HHS Office of Minority Health; Maggie Jarry, M.Div., MS, Emergency Coordinator, Substance Abuse and Mental Health Services Administration; Rachel Kaul, LCSW, CTS, Senior Program Analyst, Behavioral Health Lead, HHS ASPR; Cheryl Levine, PhD, At-Risk Individuals Program Director, HHS ASPR; Kayla Siviy, MSW, Behavioral Health Program Analyst, HHS ASPR; members of the HHS Office of Climate Change and Health Equity; and Kandra Strauss-Riggs, MPH, Senior Advisor, Division of Community Mitigation & Recovery, HHS ASPR.

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