COVID-19 Research at the Community Level

What investments, priorities and values are shared by communities that are faring better in the COVID-19 pandemic?

Fifteen years ago the Robert Wood Johnson Foundation (RWJF) confronted a puzzling question that still resonates today: Why can some communities rebound after disasters, while others are unable to recover? We first studied this in the aftermath of Hurricane Katrina. Some parts of the Gulf Coast were irreparably damaged, while others were able to recover. Researchers at the RAND Corporation, with RWJF support, sought to identify the qualities that resilient communities shared after a natural disaster, such as the strength of collaborations among government and non-governmental organizations pre-disaster and robust plans to support those most affected. The same team later built on that research by examining community well-being after other types of disasters, including economic downturns and community violence. The researchers partnered with local governments and—time and again—found that prioritizing equity and building collaborative networks bolstered communities under extreme stress.

Today, this team is studying how communities are faring during a global pandemic. The patterns that are starting to emerge align with earlier research findings: Communities that practice health equity principles before disasters fare better afterward.

How Research Supports and Promotes Healthier, More Equitable Communities

It has been several years since the Robert Wood Johnson Foundation made a commitment to build a Culture of Health in America—where every person has a fair and just opportunity to live the healthiest life possible, regardless of where they live, how much they are paid, or the color of their skin. As part of this work, RWJF introduced a Culture of Health Action Framework and measures to help track the nation’s progress toward becoming a country that values health everywhere, for everyone.

Our Action Framework includes 35 exemplary measures that, taken together, can create meaningful change and provide useful signals of progress for the nation. We invite communities to use the framework as a starting point for discussion and recognize that each community will find its own path to a Culture of Health depending on its unique situation and context. We have been working with the RAND Corporation to continuously refine and update these measures, which include access to health insurance, substance abuse treatment, family and medical leave, voting, public libraries, reducing incarceration rates, and more. We believe that highlighting these measures as examples of areas needing focused attention and action will help to catalyze health equity. RWJF and RAND are continuously updating the Culture of Health measures to reflect new realities and to place greater emphasis on reducing collective trauma and racism.

To inform and complement this work, RWJF is using the Sentinel Communities Surveillance Project, which we launched in 2015, to better understand how the Action Framework can propel health equity and well-being in 29 diverse communities across the country. We are studying each community through the lens of the Action Framework to examine whether and how different sectors, organizations and local leadership in each community are working together; how priorities, policies, and investments strengthen health equity; and how each community is engaged in these processes. This surveillance project turns research into concrete, meaningful evidence about what communities are doing to improve population health, well-being, and equity. 

The Urgent Imperative COVID-19 Created

Then, everything changed this year when the COVID-19 pandemic hit. It has been the ultimate stress test for our health care and public health systems, our communities, and our country. It has cost us dearly in lives diminished and lost, not just due to the pandemic, but also to health care system gaps and inequities we’ve failed to erase. The pandemic makes the work to promote health equity and build a Culture of Health even more crucial and the consequences of not doing so excruciatingly clear.

Faced with this new challenge, RWJF leaders realized that, with surveillance already underway, the Sentinel Communities Project could provide a window into the impact and consequences of pre-pandemic investments. It could yield valuable data about which responses to the pandemic mitigate its impact and which exacerbate the harm and the health inequities it causes. Given the likelihood that many health care and social service systems will be re-built, often with greater attention to racial justice, after the COVID-19 crisis ends, the insights gleaned from this study can help communities rebuild stronger than before. So RWJF decided to closely monitor nine of the 29 Sentinel communities as they try to mitigate and recover from the pandemic in order to share and compare real-time information about the impact of these communities’ responses.

A Closer Look at Community Response to COVID-19

This project will report findings every few months on the following nine Sentinel Communities: Finney County, Kan.; Harris County, Texas; Milwaukee; Mobile, Ala.; San Juan County, N.M.; Sanilac County, Mich.; Tacoma, Wash.; Tampa, Fla.; and White Plains, N.Y. The first report (July 2020), available on COVID-19 Community Response: Emerging Themes Across Sentinel Communities, covers activities from March through early June of this year.

It concludes that pre-pandemic investments in holistic approaches to health, cross-sector collaborations, investments in data systems, and actions to promote health equity are key. It identifies four themes that differentiate community response:

• Value of a community’s interest and focus on health and well-being before COVID-19;
• Role of cross-sector collaborations for health and well-being in responses to the pandemic;
• Use of data and systems to effectively monitor and track the course of the disease; and
• Role of a community’s perspective on and actions to address health equity and meet the needs of historically underserved populations.

In Milwaukee, city and county governments responded swiftly to COVID-19, directing support to vulnerable populations, the report finds, even though the city was forced to furlough some employees. Governments posted a crisis hotline, offered resources to prevent infection spread in dementia care, and offered free meals and Chromebooks to students in need. Milwaukee is one of the most racially segregated cities in the country, and it has long experienced significant income disparities based on race. Nonprofits addressing health and economic challenges before the pandemic were able to ramp up by providing housing guidance, information on teleconferencing options for some court appearances, and emergency funds for food, housing, and health during it. Strong neighborhood revitalization programs already in place pivoted to tracking COVID-19 cases and deaths by race/ethnicity, and members of the Black community mobilized to address differential access to health care. Still, there are gaps in community response and many in Milwaukee are struggling.

In San Juan County, environmental damage, poverty, and lack of medical care have long been pervasive, and County residents have high rates of diabetes, alcohol-related injuries, and mental health problems. The County’s population is largely American Indian and Hispanic; oppressive policies have long stoked tensions with the Navajo Nation and anti-immigrant sentiments with the Latino community. COVID-19 hit this County hard, with the Navajo Nation surpassing New York City’s infection rate in May. The County’s unemployment rate more than doubled. Even when the state lifted parts of its stay-at-home orders, San Juan County was excluded from the relief because it was designated a “hot spot.” The County consolidated COVID-19 information and resources on one website, and worked with assisted living centers, hospitals, schools, and detention centers to help control the virus. The San Juan Safe and Healthy Communities Initiative (SJSCI) and other nonprofits have shared resources with residents and businesses.

In Tampa, the report finds, the pandemic has taken a toll not just on residents’ physical health, but also on their economic well-being and mental health. The community is in a state that has become one of the country’s worst “hot spots” for COVID-19. Florida has not expanded its Medicaid program and has a high uninsured rate. Still, Tampa-area officials adopted several policies to provide relief to those affected by the pandemic, including blocking evictions and suspending mortgage payments, providing food and housing assistance, and assembling an Economic Relief Task Force to identify business relief efforts. Hospital and health care systems formed a new collaborative to give health care leaders access to real-time data and help patients find care, but whether this and other collaborations can be sustained is unclear. Although the county has made strides to advance health equity, this work is new and the leaders have not issued specific equity guidance during the pandemic.

COVID-19 Community Response provides many more details on the pandemic’s impact in these and six other communities and looks at how these communities are responding. The next report on these nine communities, Collaboration in Communities to Address COVID-19, will be posted later this month. In both of these reports, we examine how community collaborations that existed before the pandemic are being leveraged to meet emerging needs and describe how health and equity concerns in communities are catalyzing new partnerships and cross-sector collaborations. Over time, this information is designed to inform a stronger, healthier, and more equitable recovery from the pandemic within communities.