In the year since novel coronavirus emerged and became a global public health crisis, the United States has been reckoning with the staggering consequences of uncontrolled spread, inconsistent quarantine practices, and disparate infection mitigation policies. In addition to the impact of COVID-19 on individuals’ health and the nation’s economy, the pandemic has revealed and worsened long-standing inequities that threaten the health and survival of many communities. Communities of color, low-wage workers, those living in poverty, incarcerated persons, unhoused populations, and those with chronic illnesses have borne the brunt of COVID-19-related morbidity and mortality. All the while, the nation struggles to enact incremental changes that are unlikely to reach those who need them most. Largely unseen, however, has been a rapid expansion of community-driven practices that prioritize effective and timely solutions for individuals and families with the greatest need. This article explores three of these practices and highlights how the country’s path forward must include the support and expansion of similar approaches to close the health equity gap, ensuring the health of all.

Mutual Aid Networks
Mutual aid networks are generally organized around the philosophy that everyone within a community has something to contribute, and everyone has a need. Through these networks, community members identify their own needs and develop strategies to meet them. Social media and web-based resources have provided inexpensive and readily available opportunities for mutual aid groups to organize, plan, develop, and regularly refine the provision of services, goods, and resources to those in need. At the start of the pandemic, an estimated 50 mutual aid groups were documented across the country. By May 2020, the number grew to over 800 and could be found in nearly every U.S. state. 1 Through these volunteer-run mutual aid groups, community members gather and distribute food, medical supplies and PPE, housing information, childcare resources, transportation, wellness checks, money, and a host of other services – rapidly, locally, and responsively. Mutual aid is guided by the needs of the specific community these groups serve and a shared purpose, which is a powerful force, particularly in marginalized communities for whom the consequences of the pandemic have been most dire. 

Community Fridges
As COVID-19’s economic impact continues to threaten the livelihood of millions, the number of families facing food insecurity continues to rise. An estimated one in six, or 50 million people—including one in four (17 million) children—are food insecure. A reported 20% of grocery shoppers have used a food bank, pantry, or community food distribution service since the beginning of the pandemic—half of whom had not used any of these services in the previous year.3  Black workers are more likely than Whites to be at risk for pandemic-related layoffs.4 It is unsurprising, then, that food insecurity has escalated to be a significant threat among communities of color, with 35% of Blacks and 22% of Hispanics becoming reliant on free food support as a result of the pandemic.

Community refrigerators have emerged as one mutual-aid strategy to combat food insecurity, mitigate food waste, and reduce stigma around their use. Unlike traditional services, community fridges allow anyone to secure food, without restriction on quantity or type, and are often more accepting of commercial food surpluses. In addition to canned and dry-goods staples, these public stations intentionally stock fresh produce, as well as ready-to-eat foods that are critical for supporting individuals who are unhoused or have limited kitchen access. While not sufficient to address the enormity of the nation’s nutritional needs, community fridges represent an important and hyper-local strategy to meet ongoing food access challenges.

Out-of-Hospital Births
At the start of the pandemic, health care facilities almost immediately began to restrict access only to those receiving emergent and essential care as a strategy to reduce onsite exposures to COVID-19. In some instances, pregnant and laboring persons were not permitted to have a support person with them during labor and delivery.  As expectant families faced concerns of potential COVID-19 exposures while in the hospital, many began seeking non-hospital options for delivery. Prior to the pandemic, the maternal mortality rate for non-Hispanic Whites in the United States was 13.4 deaths per 100,000 live births; however, among non-Hispanic Blacks, the rate was an astounding 41.7.5  Systemic racism and marginalization by the health care system are leading causes of this disparity and have led to a host of initiatives aimed at providing safer options for expectant Black families – including promotion of non-hospital births and the use of birth support from doulas.

Taken together, there has been an increase in the number of families seeking midwives to support out-of-hospital births – either at home or in birth centers. For context, 98% of all U.S. births take place in a hospital, a figure that is in stark contrast to the early 1900s when most births took place at home and were facilitated by midwives and support team members.  Out-of-hospital births are an attractive option for some families seeking a safe labor and delivery; however, they often are not available to those seeking them, as private insurance coverage for midwifery care and homebirth varies widely. Additionally, 42% of all births (21% to 70%, depending on the state) are covered by Medicaid 7,8, a number that has likely increased as newly unemployed pregnant persons have become Medicaid eligible. However, out-of-hospital birth coverage under Medicaid programs remains inconsistent and, for many, inaccessible due to low reimbursement rates for Medicaid-eligible providers and lack of coverage for licensed professional midwives who support most home births. 

Doulas, non-clinical birth support professionals, have also seen increased demand as families seek help navigating the birth experience, regardless of birthing location. Studies have shown that the use of doulas can significantly reduce the rates of medical interventions that often lead to negative birth outcomes. However, a subset of private insurers and only four state Medicaid programs provide coverage for doula services. 10, 11, 12  

Towards A New Normal: The Path to Health Equity

As the world looks to a “return to normal,” particularly in light of increasing COVID-19 vaccination efforts, it is critical that we move forward with an intentional focus on eliminating the pre-existing disparities that have only worsened in the pandemic. Innovative systems-level solutions are needed at national, regional, local, and community levels that do not require us to reinvent the wheel. We will need to prioritize robust and sustained funding for the public promotion of effective community-based and “alternative” strategies, many of which have re-emerged during the pandemic yet are often overlooked in favor of novel and expensive approaches. COVID-19 has forced our collective hands to implement a host of unconventional solutions for survival; however, at current levels, these approaches merely scratch the surface of fully addressing the needs. 

Efforts to stabilize our nation that include strategies such as those noted above and address the root causes of social, health, and economic injustice, will propel our nation towards a path to true health equity and ensure we achieve it.


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This article was published in the Winter 2021 edition of PSC's Service Contractor Magazine.