The COVID pandemic: Testing and disparities
Providing access to diagnostic COVID testing has been a primary focus of the national response to the pandemic, with approximately $25 billion allocated by the U.S. government in April 2020 to support testing and contact tracing at the federal and state levels. The Families First Coronavirus Response Act passed in March 2020 included specific measures to provide coverage for testing the uninsured and, to date, more than 560 million COVID tests have been performed in the United States, more than any other country.
In 2018 there were approximately 28 million uninsured non-elderly people in the United States, most of whom were in low-income service jobs without the opportunity for remote work. The majority of the non-elderly uninsured are U.S. citizens, and although 41% of these individuals are white, people of color are at an increased risk of being uninsured. Taking these factors into consideration, there have been numerous efforts to provide universal access to testing, with local efforts such as ad hoc community-based testing services having some positive impact. Despite these efforts, there have been both perceived and actual differences in access to testing in different communities across our country. Not surprisingly, the socioeconomic and ethnic groups hit hardest by the ravages of COVID-19 appear to have the most difficulty in getting the tests [ Lieberman-Cribbin et al (Am J Prev Med, 2020 59(3): 326-332) and Maroko et al (J Urban Health, 2020 97(4): 461-470)].
Socioeconomic disparities, and the resulting inequities in both the social determinants of health (such as high-risk occupations and poor living conditions) and health care access and outcomes was described by the father of modern pathology, Rudolf Virchow, over a century and a half ago in his report on a typhus outbreak in Upper Silesia (now Poland) [Ruffin (Am J Public Health, 2010 100 Suppl 1:8-9)]. The COVID-19 pandemic serves as a recent and regrettable example of this issue in our own country. A number of studies published during the pandemic have documented the disproportionate impact of infections on lower socioeconomic groups and communities of color [Munoz-Price et al (JAMA Netw Open 2020, 3(9) e2021892 and Owen et al (JAMA 2020, 323(19): 1905-1906)]. The data indicates that those in communities of color have been anywhere from 2 to 9 times more likely to become infected by SARS-Co-V2 when compared to people who are predominantly white or have higher mean socioeconomic status. In addition people in communities of color are 2.5 to 3.5 times less likely to be tested. In addition, these people are also more likely to be hospitalized and have universally worse outcomes when compared to whites across all age groups. Beyond the statistics, the personal stories behind these disparities and the challenges they create are heartbreaking and serve as a call for change [Maxmen (Nature 2021, 592(7856): 674-680)].
As with many other diseases, the reasons behind the disparities in COVID-19 are complex and multifactorial. To help unravel this difficult problem, one element that deserves specific consideration is the role of SARS-CoV-2 diagnostic testing. Throughout the pandemic, access to COVID testing has been a mainstay in guiding public health measures aimed at curbing the spread of the illness and guiding the care of individual patients. COVID testing and isolation of infected individuals is particularly effective in poorer households; research by the International Monetary Fund indicates that isolating half of asymptomatic COVID infections in this group would reduce deaths by 75% in one year [IMFBlog]. And yet, as we have seen, the barriers to providing diagnostic testing in lower socioeconomic groups persist, including lack of a reliable community source of care, lack of access to a health care professional to speak with, and concerns around the cost of care for a positive result.
Conquering infectious disease can only be achieved if measures are applied to every group and subgroup in the population: The testing that is needed to detect and diagnose diseases must be universally available. Working to manage, and eventually defeat, the COVID-19 pandemic will require screening technologies that can be used in a variety of group settings, rapid and affordable point-of-care tests that can be widely deployed and readily interpreted, and accessible care facilities with the technologies needed to confirm infection and deliver effective treatment. To meet these challenges, we must continue to innovate to expand the number of tools available and invest in the infrastructure required for their delivery. As we strive to improve health for all people, these same principles must be applied to other communicable diseases and chronic illnesses that also disproportionately affect economically disadvantaged members of our society.