Contact Tracing Could Exacerbate COVID-19 Health Disparities: The Role of Economic Precarity and Stigma

Recent research on COVID-19 contact tracing programs, including the essay by Schneider et al. in this issue of AJPH (p. 917), highlights the enormous challenges and opportunities presented by such interventions.^1–4 The efficacy of contact tracing to reduce COVID-19 transmission hinges not only on a well-resourced public health infrastructure, but also on the public’s willingness and ability to participate. Against a backdrop of rising inequality and pandemic-induced economic hardship, public health interventions have the potential to reduce racial and socioeconomic gaps in morbidity and mortality. Alternatively, if interventions primarily prevent transmission and save lives among the most privileged, they will exacerbate health disparities.

Here, I discuss two major challenges to implementing effective and inclusive contact tracing programs in underserved communities. First, economic hardship and marginality present difficult choices that make testing, treatment, and isolation intractable for many American families. Second, the COVID-19 stigma that prevents disclosure and access to index persons’ social networks is more pronounced in marginalized communities. In making these arguments, I draw on preliminary findings from two ongoing cohort studies that track social behavior and attitudes related to the pandemic.

DATA SOURCES

The state representative, probability-based Person to Person Health Interview Study (principal investigator: Bernice Pescosolido) was fielded face-to-face in Indiana in 2019 and early 2020 prior to the pandemic, and again in April and May 2020 via phone (n = 994); it is currently in the field for additional follow-up (Russell Sage Foundation, grant no. 2005–24212; principal investigator: Brea Perry). VidaSana is a longitudinal cohort study of social determinants of health among new and established Latinx immigrants in Indiana, many of whom are undocumented and thus not represented in traditional survey designs (R01DE025836; principal investigator: Gerardo Maupome). A supplemental COVID-19 wave was collected from the VidaSana cohort in the summer of 2020 (n = 400). These data sets were harmonized using poststratification survey weights to match the census demographic characteristics of the Latinx and general populations in Indiana. Estimates were generated using predicted probabilities from survey weighted logistic regression models, controlling for gender, education, and age.

PANDEMIC PRECARITY

As Schneider et al. note, “COVID-19 is penetrating the most vulnerable networks in poor, underserved, stigmatized, and marginalized communities,”^{3(p. 918)} with consequences extending far beyond morbidity and mortality. Elsewhere, my colleagues and I have documented unprecedented material deprivation and economic anxiety resulting from the COVID-19 pandemic, which we refer to as “pandemic precarity.”⁵ Economic shutdowns have sent shock waves through vulnerable communities, weakening economic resiliency and reinforcing disadvantage among groups that had not yet recovered from the Great Recession.

Social and economic insecurity disincentivizes participation in contact tracing efforts. In our survey data, adults with higher levels of pandemic precarity (operationalized using an index of food, housing, and financial insecurity indicators; Cronbach α = 0.76) were significantly more likely to agree that inability to work if COVID-19 positive is a barrier to participating in testing programs (Figure 1). Similar patterns were observed for Black and Latinx adults, and especially for recent immigrants, 89% of whom agreed that work disruption is a barrier. In other words, the basic survival needs of individuals and families likely outweigh prosocial motivations to comply with contact tracing programs. These same minority and underserved groups also cited as important in testing decisions their inability to afford treatment or to access hospitals that had sufficient resources to care for COVID-19 patients (Figure 1).

FIGURE 1—

Predicted Probabilities of Factors Affecting (a) Willingness to Participate in COVID-19 Testing Programs and (b) Indicators of Perceived Stigma as a Function of Pandemic-Related Economic Insecurity: Person to Person Health Interview Study, Indiana, April–May 2020

Note. Predicted probabilities are estimated using multivariate regression models with postestimation survey weights adjusting for gender, age, and educational attainment. All coefficients are statistically significant at P < .05 or better. Data are from the COVID-19 follow-up wave of the Person to Person Health Interview Study (principal investigator: Brea Perry). The same size was n = 994.

Along the same lines, Schneider et al. observe that immigrant communities have been reluctant to access health or social services during the pandemic for fear that doing so would affect their ability to gain permanent residency.³ In particular, immigrants who are undocumented may avoid interactions with authorities for fear of being detained or deported. For the most vulnerable and marginalized, who do not have insurance or are otherwise unable to access health care, having knowledge of one’s COVID-19 status does not improve their ability to achieve a better outcome. Facing constrained choices, participation in contact tracing programs may in fact be an irrational decision for many in the United States.

COVID-19 STIGMA

Stigma is another major threat to the efficacy of COVID-19 contact tracing efforts. Stigmatizing attitudes are most pronounced for diseases that are perceived to be controllable (indicating personal responsibility), when the diseases pose a risk of injury or harm to others (e.g., through contagion), and when uncertainty and unpredictability regarding prognosis create fear—all conditions that apply to COVID-19.⁶ The mark of shame associated with COVID-19 positivity provides powerful motivation to refuse testing following exposure, and to avoid disclosing COVID-19 status to others. Stigma may underlie the finding that only 50% of index patients in the Howard Brown Health program provided the name of at least one contact partner.³

The organization of personal social networks is likely to exacerbate the challenges of COVID-19 stigma, because people engage in more regular and intimate contact with a core network of family and close friends (i.e., those typically inside a person’s COVID-19 “bubble”). Disclosure of COVID-19 status within these core networks is apt to initiate a supportive response, and is often unavoidable at any rate.⁷ However, to reduce the chances of an outbreak, it is critical for contact tracing programs to accurately identify and intervene with those contacts that provide a bridge to other networks.³ An index person is likely to be especially reticent to name these weak, bridging ties as potential vectors of transmission since they pose a greater threat of stigma and widespread disclosure of COVID-19 status relative to trusted core network ties.

Additionally, there is preliminary evidence that COVID-19 stigma may be more pronounced in marginalized and underserved communities. Schneider et al. note anecdotally that a majority of patients reporting COVID-19 stigma were Black or Latinx.³ Our survey data support this contention, revealing similar patterns across racial and ethnic groups and immigration status. For example, recent immigrants (30%) were nearly four times as likely as nonimmigrants (9%) to report that a person should be afraid to tell other people if they test positive for COVID-19, and were also significantly more likely to report that being COVID-19 positive would make you an outsider in your community (51% vs 36%) and would cause you to lose friends (41% vs 29%). Significantly higher levels of perceived stigma across all items were also reported among adults without a college degree and those experiencing more severe pandemic precarity (Figure 1). To the degree that stigmatizing attitudes circulate disproportionately in the social networks of people of color and those facing economic hardship, contact tracing programs will face greater resistance and be less effective in these communities.

CONCLUSION

Contact tracing may be a viable strategy for reducing COVID-19 transmission rates in the underserved communities where hospitalization and mortality rates are disproportionately high.^8,9 However, history has demonstrated that interventions that are less effective or less accessible to lower-status groups will widen health disparities.^10,11 Where having more knowledge or resources improves the outcomes of a treatment or intervention, the privileged will derive the greatest benefit. Moreover, pervasive racial and socioeconomic segregation in the United States ensures that any such programs that are successful among the advantaged are unlikely to have spillover benefits for the rest of the population.

To avoid widening disparities, it is critical to invest in public health infrastructure that engages marginalized communities, reduces barriers to participation, and redistributes resources. The contact tracing program at Howard Brown Health appears to be an excellent model in this regard, strategically targeting index patients in underserved communities and offering critical social services (e.g., meal delivery, rent and utility assistance) that incentivize participation and foster trust in local institutions.^2,3 Equally important is a robust set of policy initiatives that addresses longstanding health and economic inequalities and strengthens the social safety net for individuals and families in crisis.