The CDC issued a new eviction moratorium order to prevent further spread of COVID-19. The looming evictions for people who have not been able to pay rent are a public health crisis that may disproportionately affect people of color. The time is right to address systemic racism and repeal barriers that lead to income and housing inequities.

We know that where people live is an important social determinant of health. Stable and affordable housing, safe neighborhoods, and homes that do not expose people to toxins or injury all contribute to healthy outcomes. Systemic racism, including redlining, has contributed to disparities in where people live and what they can afford. Black, Native American, and Hispanic households are more likely than white households to be low-income renters.

The pandemic contributed to unstable housing for many low-wage workers who have been out of work. Non-essential businesses were shut down in March 2020, with low-wage workers in restaurants and bars the most affected by shutdowns. Unemployment status reached levels not seen since the Great Depression. According to census bureau data, Black and Latino workers were more likely to lose income or employment during the pandemic.

In late January 2021, 21% of renters reported being behind on rent payments. Renters of color are more likely to be behind on rent, with 29% of Latino renters and 36% of Black renters  behind on rent, compared to 12% of White renters. The Eviction Lab reports that landlords have filed for over 450,000 evictions during the pandemic, and those affected will be the same communities and individuals who were at risk of eviction prior to the pandemic – disproportionately Black and Latino. There is already a severe shortage of affordable rental homes in the United States, and the upcoming evictions will result in homelessness for many of those evicted and make it more difficult for them to obtain housing in the future.

After the previous order expired on July 31, the CDC issued a new eviction moratorium order for tenants who fail to make rent or housing payments, limited to counties reporting substantial and high levels of community transmission levels of COVID-19. This order ensures tenants do not have to relocate to congregate settings such as shelters or shared housing situations where it is not possible to maintain safe social distancing. The CDC asserts that mass evictions could be detrimental to public health control measures to slow the spread of COVID-19. A study in 2020 found an association between the expiration of eviction moratoriums and increased COVID-19 incidence and mortality.

The CDC order remains at risk, as the Supreme Court ruled in June that the CDC had “exceeded its statutory authority by issuing a nationwide eviction moratorium”, but ruled to leave the moratorium in place until July 31 as initially planned. It is expected that this new CDC order will be challenged.

The question is what will happen when the new eviction order expires. This looming public health crisis further exposes the lack of affordable housing for low-income workers and the importance of rental assistance. There are still billions of dollars available for emergency rental assistance that have not been distributed. We need additional emergency rental assistance covering past and future months of rent to prevent mass evictions.

The American Public Health Association has reported on how structural racism has led to disparities in health and housing equity and offers the following solutions:

1. Prevent structural racism
2. Increase affordability
3. Advance quality & safety
4. Support neighborhoods
5. Ensure stability

As the threat of COVID-19 continues, the time is right to address systemic racism and repeal barriers that lead to income and housing inequities.

The COVID-19 pandemic highlighted how the social determinants of health directly impact the health of communities. Unsafe or unstable housing, income insecurity, lack of transportation, and underlying health inequities put some populations at higher risk during the pandemic. Systemic inequities resulted in a higher burden on racial and ethnic minority communities, especially during the first wave of the pandemic.

The Social Vulnerability Index (SVI) was initially developed by the CDC in 2011 to help government officials identify communities that may need support during public health emergencies. The standard SVI incorporates 15 social factors based on census data such as socioeconomic status, minority and language status, disability status, housing type and transportation.

The new Minority Health SVI launched in 2021 adds additional factors known to be associated with COVID-19 outcomes and include two new themes. Health care infrastructure and access now also consider the number of hospitals and urgent care clinics per 100,000 residents. Medical vulnerability now includes variables such as the obesity rate and cardiovascular disease mortality per 100,000 residents. The dataset is also broken down into specific race and ethnicity categories and languages. Data is included for five racial and ethnic minority groups: American Indian and Alaska Native, Asian, African American or Black, Native Hawaiian/Pacific Islander, and Hispanic or Latino/a. The data also include the top five languages spoken by populations with limited English proficiency (LEP) at the county level, described in variables such as “Spanish speakers who speak English less than ‘very well’ ”.

We all have a responsibility in public health to address the inequities that persist across the social determinants of health. In order to understand and address racial and ethnic health disparities, we need quality disaggregated data. We are excited to see the new Minority Health SVI offer greater disaggregation of its data by factoring in more languages and racial and ethnic minority groups.

Short term, the data and dashboards can help with planning COVID-19 testing, and improving access to treatment and vaccine distribution for specific communities. The data can also be used to help identify communities that need improved health care infrastructure and access, language assistance, and other community-level efforts to address systemic factors related to the social determinants of health.

The Minority Health SVI is a critical tool for applying a health equity lens to public health. We look forward to exploring the data and incorporating it into our work.

Read the Minority Health Social Vulnerability Index Fact Sheet and search the data using the Minority Health Social Vulnerability Index Explorer.

Health inequities have been a major issue in the US throughout our history, but have drawn new attention over the past year due to the heightened focus on systemic racism and the disparate impacts of the COVID-19 pandemic. These twin crises are bringing new awareness to inequities in our communities and their sometimes-dire effects on health.

It’s well known at this point that communities of color have been hardest-hit by COVID-19. The COVID Tracking Project found that COVID-19-related death rates are twice as high among Black Americans as among white Americans. As we move closer to approval of the first COVID-19 vaccine, this cruel reality has led to new conversations around who should be prioritized in receiving vaccines.

The Advisory Committee on Immunization Practices (ACIP), which advises the Centers for Disease Control and Prevention (CDC) on vaccine schedules, is in the process of preparing its recommendations for how COVID-19 vaccines should be allocated. Health equity is being considered in these discussions for perhaps the first time. ACIP has received multiple proposals that will inform their plan, one of the most influential of which is the National Academy of Sciences’ Framework for Equitable Allocation of COVID-19 Vaccine, which includes equity as a cross-cutting consideration in its recommendations.

Recommendations for vaccine allocation using the Social Vulnerability Index

In particular, the National Academy’s framework recommends incorporating a metric of social disadvantage such as the CDC’s Social Vulnerability Index into its priorities for vaccine allocation. Their framework proposes that state and local authorities “ensure that special efforts are made to deliver vaccine to residents of high-vulnerability areas (defined as 25 percent highest in the state).”

The Social Vulnerability Index (SVI) was developed by the CDC to help government officials identify communities that may need support around hazardous events such as natural disasters, chemical spills or infectious disease outbreaks. It incorporates 15 social factors which are grouped into four themes: Socioeconomic Status, Household Composition, Race/Ethnicity/Language, and Housing/Transportation. These factors come together to comprise an overall ranking for each US census tract as well individual rankings for each theme.

Given its focus on resource and response planning around events such as disease outbreaks, the SVI seems ideally suited to the question of COVID-19 vaccine allocation. The National Academy’s proposal says that the use of such an index allows them to “incorporate the variables that the committee believes are most linked to the disproportionate impact of COVID-19 on people of color” without directly targeting racial and ethnic categories.

How the SVI has already been used during COVID-19

The SVI has already been utilized to help in other ways in the fight against COVID-19. The CDC published a research report in October investigating the association between social vulnerability and the risk of a county becoming a COVID-19 hotspot in June and July 2020. The study found that counties with higher social vulnerability were more likely to be identified as hotspots. Among its findings was that the risk for becoming a hotspot was over 37 times higher in areas with the highest levels of vulnerability around racial/ethnic minority status and English proficiency than in areas with the lowest levels of those vulnerabilities. This strong association between aspects of social vulnerability and COVID-19 hotspot status suggests that high SVI rankings may be a strong predictor of disproportionate COVID-19 impact and thus well suited to play a larger role in the pandemic response.

The SVI has also been modified to include health-specific factors in order to better inform COVID-19 planning and estimate COVID-19 risk at a local level. The COVID-19 Community Vulnerability Index (CCVI) extends the SVI by adding COVID-19-specific epidemiologic risk factors and variables measuring public health system capacity, resulting in a total of six themes and 34 factors as shown below. The CCVI has been featured by the CDC and is also mentioned in the National Academy’s framework as a potential metric to use in vaccine allocation.

Estimating COVID-19 risk at a local level

Lastly, City Health Dashboard, a project that provides key health data at the city and community level has created a COVID Local Risk Index, which extends the SVI in a similar way as the CCVI but for a slightly different purpose, to estimate COVID-19 risk at a local level. The COVID Local Risk Index incorporates three themes: social vulnerability as determined by the SVI; COVID-related chronic health conditions such as obesity and diabetes; and COVID-related demographics such as age and minority status. Since the COVID Local Risk Index is embedded into the larger City Health Dashboard framework, it also compares cities and neighborhoods to others in the Dashboard’s 500 largest cities.

It’s clear that social vulnerability is a measure that can be useful across a number of different contexts, and one that can play an important role in incorporating health equity into our efforts to control the pandemic. In addition, as a tool to highlight the effects of systemic racism and broad inequities, it can likely also contribute to the larger multi-sector movement to increase awareness and bring about societal-level change in the US.

Photo by CDC on Unsplash.

In our work understanding tobacco at the point of sale, we know that Native Americans have long been targeted by the tobacco industry, with smoking disparities at one of the highest in the United States. The tobacco industry has exploited Native American images, strategically and opportunistically taking advantage of a long history of some Native Tribes growing and using tobacco for sacred and medicinal purposes. The use of Native images on commercial tobacco products is a manipulation of a cultural history and practice for the sake of cigarette sales. Research has found disparities in tobacco advertising with Non-Hispanic American Indians and Alaska Natives being more exposed than Non-Hispanic Whites. The CDC reports that 43.8% of Native American adults have reported current use of commercial tobacco and have the highest prevalence of cigarette smoking among all racial/ethnic groups in the U.S. We invite you to learn more about Native Americans and POS tobacco at our CounterTobacco resource.

Tribes are aware of the health and community impacts of commercial tobacco and have created campaigns such as Keep It Sacred – National Native Network. This public health resource helps refocus Native American tobacco use back to cultural tradition rather than harmful commercial tobacco use.

Our nation has long been problematic in its telling of history and the narrative around Native Americans. Data published in 2015 showed that 87 percent of the references to Native Americans in U.S. curricula are in the context of American history before 1900, which the authors say teaches students that Native Americans are a “long since forgotten episode in the country’s development.”

To change this narrative, we can look to projects like Reclaiming Native Truth, A Project to Dispel America’s Myths and Misconceptions. They describe it as a “national effort to foster cultural, social and policy change by empowering Native Americans to counter discrimination, invisibility and the dominant narratives that limit Native opportunity, access to justice, health and self-determination.” They have published a helpful messaging guide for allies that works to change the narrative about Native Americans, shares success stories, and describes steps you can take to make change in your own community.

We have also found helpful the resource Native Land which displays a map of North America with an eye-catching overlay of where tribes were originally located or are located today. This is a great tool for learning whose Indigenous land you live on and exploring the history of your community. The site offers a Teacher’s Guide for helping understand how to use the map and foster discussions.

In this pandemic, CDC data show a disproportionate COVID-19 impact in American Indian/Alaska Native populations. In response to this, the CDC has provided funding and other resources to tribal communities such as contract tracing, epidemiological support, and more.

We look forward to continuing to learn about Native Americans, the issues around their historical narrative and current inequities, and how to be strong allies and supporters of change.

Photo by Dulcey Lima on Unsplash of Tohono Indian Women leading the Tucson 2019 Women’s March.

The idea that exposure to secondhand smoke is dangerous is certainly not a new one. In fact, we’ve known this risk since the first Surgeon General’s Report on Smoking and Health was issued in 1964. Today, more than 50 years later, we also know that the deaths of at least 2.5 million nonsmokers can be attributed to secondhand smoke exposure. Over the years, there has been significant progress in the smoke-free movement. What started as policies to create nonsmoking sections in places like restaurants and airplanes has evolved into comprehensive smoke-free laws covering all public places and workspaces in 27 states and more than 1,500 localities.

Unfortunately, despite this success, these laws still aren’t protecting all of us. In fact, 39% of Americans live in a place that is not fully protected by 100% smoke-free laws. Like many health equity issues, we see that where people live and other sociodemographic factors make a big difference in terms of exposure to secondhand smoke. Communities with higher income and education are more likely to be covered by smoke-free laws than communities with a greater African American population or more residents living under the poverty level.

Additional gaps in smoke-free protections exist, even within individual communities. Many jurisdictions with smoke-free regulations offer exemptions for certain types of businesses. Generally, these exemptions apply to venues such as factories, casinos or bars that are employing primarily low-wage workers, further harming people who are already burdened with other health and social inequalities. Interestingly, evidence from peer-reviewed studies across the country show that smoke-free policies and regulations do not have an adverse economic impact on the hospitality industry.

As another example of the link between income and secondhand smoke exposure, the CDC reports that renters, especially those who live in multi-unit housing, also face higher rates of exposure. Thankfully, in 2018, the U.S. Department of Housing and Urban Development adopted a rule requiring all their public housing properties to implement a smoke-free policy, but there are plenty of other multi-unit housing locations across the country without a policy in place.

As we aim to advance social justice in the world of tobacco prevention and control, it’s important to work towards guaranteeing smokefree protections for all, regardless of geographic region, race, ethnicity, occupation, or economic status. The American Nonsmokers’ Rights Foundation has several recommendations for closing this gap, including:

1. Making all workplaces smokefree– with no exceptions.
2. Giving local communities back their power to create stronger smokefree policies. This involves repealing preemption where it exists.
3. Prioritizing smokefree protections in health equity initiatives– and vice versa.

We’ve come a long way since 1964, but it’s clear the work isn’t done yet. This time, let’s be sure not to leave anyone behind.

This post was originally published as a feature article for The Geographic Health Equity Alliance (GHEA), a CADCA initiative. GHEA is a CDC funded National Network dedicated to reducing geographic health disparities related to tobacco and cancer. 

I grew up in Fresno, CA—the center of San Joaquin Valley and, really, the state. While Fresno is home to a great deal of large-scale agricultural production, it’s not all farm land; it’s the 34th most populous city in the US, ranking between Tuscon, AZ and Sacramento. Cher went to high school in Fresno…so there’s that.

Fresno’s also the poorest big city in California. You may have heard the word, “ghetto” used as slang for something that associated with being poor, budget-friendly, or sub-par. But in Fresno high schools in the early aughts, “ghetto” was replaced with “south of Shaw.”

“Shaw” refers to Shaw Avenue, which runs east/west and divides the city in half—racially and economically—thanks to the railroad tracks Shaw replaced, Depression-era redlining, and suburban sprawl.

When hearing—or, admittedly, using—the term “south of Shaw” in high school, I didn’t think much of it. With the exception of a couple historic neighborhoods like Fig Garden, home to North Van Ness Blvd, which transforms into the spectacular Christmas Tree Lane every December, the phrase held up: south Fresno was depressed, disadvantaged, and dangerous; and Shaw was the border. (By the way, my high school was literally south of Shaw—way south—with a student body that was a combination of neighborhood students and magnet students from all over the city but largely from neighborhoods north of Shaw.)

It wasn’t until I learned, sometime in college, that Fresno’s wealth gap was the largest in the nation that I reflected on how loaded of a phrase “south of Shaw” is. It tells us something about the impact “place” has on the people in and around it. (Fresno is now ranked second in the nation for income inequality, just behind Bakersfield, which is about two hours south of Fresno and also in the San Joaquin Valley.)

I found a 2013 dissertation from a PhD student in City and Regional Planning at UC Berkeley called Health Equity in a New Urbanist Environment: Land Use Planning and Community Capacity Building in Fresno, CA (I hope she got that PhD!). In it, I learned that Fresno’s racial and social segregation is due in large part to historic and sustained land use, which can have major health implications on the populations in those neighborhoods.

For example, the majority of the city’s industrial areas are located—you guessed it—south of Shaw. In 2005, the lifetime cancer risk for people living in neighborhoods south of Shaw was 27% higher than those living north of Shaw, likely due in part to there being three times as many tons of toxic chemicals emitted in South Fresno compared to North Fresno.

And in 2011, neighborhoods north of Shaw had nearly three times as many acres of parks per capita than neighborhoods south of Shaw. And we know that 1) people are more physically active when they have access to safe, affordable, high-quality space for recreation; and 2) physical activity is critical to prevent and control chronic disease.

So to bring it all home (so to speak), in 2011, the average life expectancy for those living south of Shaw was 2 years less than those living north of it.

Turns out, the term “South of Shaw” isn’t just slang. It’s a term infused with data and history about the systems of power and (dis)advantage that allowed certain groups of people to settle north of Shaw while it was made virtually impossible for others to do the same.

Who knew that a high school student’s go-to insult would become the basis of the work I do now? It shouldn’t matter if you live south of Shaw or in the southern states of the US; everyone deserves the opportunity to live a healthy life in a healthy place. Even Cher.

This post was originally published on Nina’s blog.