What follows is an open letter offered by the investigators and partners of the Healthy Neighborhoods Study (HNS) on March 23, 2020. In it, we provide data and recommendations from communities in the study to guide decision-makers and communities as they work together to respond to the threat and impact of COVID-19 in ways that equitably and effectively meet the needs of vulnerable populations and places.
HNS is a community-based, longitudinal study of the effect of neighborhoods on the health and well-being of residents in nine urban communities in metro Boston. Our data centers residents and communities most impacted by changes brought on by transit-oriented development, gentrification, and climate change. Our analysis shows that many residents of Massachusetts are at risk of food, money, and healthcare shortages and do not always have the means to practice social distancing measures to fight the spread of COVID-19.
Since 2015, we have surveyed over 3,000 residents across the nine HNS communities.
- Four percent of people reported living in transient housing (shelter or half-way house); 6% live in public housing, and 62% are renters.
- In total, 37% rely on some type of housing assistance, which means they cannot afford to be without income or have limited incomes.
- 33% were born outside the U.S.
- 44% earn less than $1,250 per month.
- 27% of respondents are older than 55 years: 15% are 55–64, 12% are 65+.
This diverse sample, inclusive of people living in senior homes, helps us better understand how COVID-19 risk and protection policies will impact vulnerable communities.
View executive summary here:
As of late March, the COVID-19 pandemic is far from peaking in Massachusetts. We expect to see enormous growth in the number of cases, hospitalizations, and even in the number of deaths over the coming months.
Doctors believe that COVID-19 is particularly dangerous for older adults and those with underlying medical conditions. While people of other ages can contract COVID, younger people and those in overall good health have drastically lower risks of becoming seriously or fatally ill. As such, public officials, agencies, and senior health professionals are working around the clock to form recommendations and deploy strategies to protect these two groups from contracting and spreading COVID-19. In addition to protecting vulnerable groups, public officials must consider and protect entire neighborhoods that face systematic barriers to adopting widespread social distancing and in-home care. As is common in many public planning processes, the recommendations being formulated fail to fully consider, understand, and include the experiences, needs, and voices of people in the groups and places likely to be most impacted by the pandemic.
Social Distancing is Difficult for Our Communities
Recommendations from government officials and public health professionals have advised “social distancing” as the most effective way to prevent infection. Social distancing entails staying home and away from other people as much as possible. Having as many people as possible stay home to avoid contact with others is vital for slowing the spread of the virus in our communities and keeping the health care system from becoming overwhelmed.
Included in social distancing are recommendations to work from home, stay home if people feel sick, and to stock up on supplies. Without support and additional resources, however, these actions are difficult, if not impossible, for many members of our communities, particularly those:
- with fixed incomes,
- the elderly,
- Aid to Families with Dependent Children (AFDC) families using aid to care for children,
- experiencing homelessness,
- struggling with addiction, and
- with mental health challenges.
When Staying Home Means Loss of Income
Many people must show up in person for work every day, often getting there by public transportation, or they will not be paid. Paid sick leave and working from home are not options for all workers across the region, and most people cannot afford to be without income. Without paid sick leave, individuals rely on unemployment benefits to supplement income loss, and it’s unclear when these funds will become available and how many of the lost hours they will cover.
When developing plans to extend these benefits, policymakers must include workers who are not traditionally included, such as:
- undocumented people and others who do not qualify for benefits due to immigration status,
- people who work in the cash or informal economy (e.g., construction, landscaping, restaurants, barbershops, salons, and sex workers), and
- low-income independent contractors such as ride-share drivers.
Stocking Up on Supplies Isn’t Possible When You’re Already Food Insecure
For families who already struggle to afford food each week, stocking up on weeks of extra supplies is not possible. In addition, previous resources for families to secure food are becoming unavailable or unsafe. For example, as schools shut down across the country, children are no longer receiving free/reduced-price meals, and their families are struggling to provide them with food. In some cases, like in Fall River, Massachusetts, local restaurants are feeding children for free while schools are closed for three weeks. While this is a shining example of community support and resilience, it is not enough to fully meet the community need at present, and its sustainability is uncertain. Standing in crowded lines poses an additional health risk for people relying on local food banks and drop-off sites for meals.
Unstable or Crowded Housing Makes Staying Home When Sick Challenging for All
When people get sick with COVID-19, medical experts advise that many mild cases can be cared for at home. Infected people are advised to manage their illness at home and to try to keep from infecting other household members while sick.
For those without stable housing, living in crowded housing, lacking the financial resources to keep a reliable supply of medicine and food in the home, and without social or family support to help care for them, managing illness at home could be extremely challenging, and often impossible. While the situation is still evolving, a neighborhood organization from New Rochelle, New York, has come up with an innovative solution for both helping potentially sick individuals and protecting the larger neighborhood population from exposure to the virus. They set up an errand system for quarantined families, where they can list which supplies or errand they need, and a healthy community member will fulfill their request and drop supplies by their front door. An open-source catalog of other mutual aid efforts around the country can be accessed here.
Community-Level Risk Must Be Considered Alongside Individual Risk
While public officials are aware that COVID-19 poses unique threats to more vulnerable population groups, such as older and sicker people, they must also understand that entire neighborhoods face systematic barriers to adopting widespread social distancing and in-home care. These barriers contribute to place-based vulnerability, as well. Place-based disparities in health, wealth, housing security, neighborhood amenities, public infrastructure, and climate readiness make entire communities more vulnerable to COVID-19 and have serious health and economic consequences at the population level.
In the absence of tailored strategies and support for communities facing these challenges, COVID-19 has the potential to spread widely and overwhelm local capacity for families and neighbors to care for one another, deepening existing health inequities.
Our data illustrate the ways that COVID-19 may pose serious threats in communities. HNS communities are at risk of being more vulnerable to COVID-19 due to several conditions that contribute to increased exposure to dense urban areas, increased sensitivity to the virus because of pre-existing conditions, and limited financial and social resources to care and protect residents. Preliminary analysis of over 3,000 surveys collected between 2016–2020 shows how the different dimensions of vulnerability to health risk interplay at the neighborhood level in HNS communities.
About the Healthy Neighborhood Study
HNS provides critical information on residents’ experiences on the ground in their communities and what matters most for health where they live.
HNS is a Participatory Action Research study that aims to better understand and address the effects of neighborhood change on population health in nine urban communities in metro Boston: the cities of Brockton, Chelsea, Everett, Lynn, Fall River, and New Bedford; and the Boston neighborhoods of Dorchester, Mattapan, and Roxbury. We work together in a consortium of partners from academia, urban planning, environment, and public health, community residents, and grassroots organizations. We ask questions, collect data through community surveys and interviews, and analyze it to understand how complex processes like neighborhood development, gentrification, and climate change shape neighborhood conditions and population health. Together, we use what we learn to advance data-driven recommendations and solutions for healthy places and people.
HNS is participatory, rooted in public participation for the focus and design of research. The study engages people and communities most adversely impacted by ongoing development and neighborhood change. The study provides real-time, critical information to help partners understand local health risks, build resident and community capacity to respond, and inform effective strategies for equitable development and better health. As such, HNS survey topics, questions, and participant samples are designed by a network of 45+ resident researchers who live in HNS communities so that the research reflects their neighborhoods. By design, survey samples emphasize the most vulnerable and adversely impacted people in those communities. The voices and experiences of the most vulnerable are often left out of studies.
Study Insights and Recommendations
Our extensive survey and in-depth interview data suggest that even basic social distancing measures will be difficult for HNS communities.
Transportation
60% of our respondents rely on public transportation to accomplish day-to-day tasks ranging from commuting to grocery shopping to accessing healthcare. It is difficult to keep 6 feet from others at all times when you must take public transportation. Transportation and public health officials should work together to use the best available data on vulnerable populations and places to inform:
- the frequency of buses and trains needed to safely separate riders who still rely on T to get to work;
- the regular intervals at which buses, trains, and stations should be sanitized; and
- the measures that can be taken to protect MBTA worker health.
Public officials should also maintain paratransit service (i.e., The RIDE, Boston), which might be the only transportation connecting people with disabilities and older adults to basic needs.
“I hate taking public transit during the wintertime. It’s so gross… People are so sick, and they’re taking the train, and they’re not covering their mouths. Within two days, I always get sick. I know I’m going to get sick. I just have to embrace it.”
Physical and Mental Health
About a quarter of respondents report poor (4%) or fair (19%) health, putting them at increased risk of severe disease if they become infected with COVID-19. Almost one-fifth (18%) report living with nearly constant stress or nervousness. 6% feel nervous or stressed all of the time, and 12% report feeling this way most of the time. Coping with the financial and health risks created by COVID-19 is extremely difficult for people already struggling with high levels of stress in their lives.
“I think it all relates back to the economic equality. I think that’s the biggest challenge, not only in Dorchester but throughout the city of Boston right now. You have a huge economic disparity. And I want to put that at the forefront because these rents keep going higher. I’ve seen a number of people have to move out of the city. And if you’re not making it, you’re really not making it… I feel like a number of things stress people out, and the money is one of the number one stress focus points. If families aren’t making enough so that they can survive… then you have domestic violence cases. You have children who are running away from home. You have insufficient food supplies… it all stems back to the money.”
Isolation and Social Support
Should COVID-19 begin to spread in our communities, public officials must be aware of how difficult it will become for many households to manage the illness. For example, 27% of our survey respondents report that they do not have anyone they could count on to take care of them if they were confined to bed. Providing community organizations with financial and informational resources to support ailing community members can mitigate the spread of the virus and ensure essential care to those who need it.
“But what can sometimes be challenging is still we are close enough, but sometimes it’s still a little too far. For example, my grandfather, he lived all the way in Hyde Park, and he was going through a lot of health issues. Like he had two strokes. He has dementia, too. And my mom is the one taking care of him, so it’s very hard to go from Chelsea all the way to Hyde Park.”
Employment and Financial Security
Many households will also struggle to cope with the financial costs of missing work and managing illness at home. Under normal circumstances, 59% of respondents find it very hard (19%) or somewhat hard (40%) to cover expenses every month, leading 62% to report that they came up short paying bills at some point in the past 5 years.
“[Money] gets a little bit iffy when my brother gets sick because, when I’m studying, my mom has to call the days off and that just makes it a little bit harder… He’s gotten sick maybe twice, and it lasts like two weeks.”
“My son is collecting unemployment right now, but he is supposed to start work. But because the malls are kind of like closed or whatever because of this [COVID-19]… they told him not to go in just yet. I don’t know what’s gonna happen, but his unemployment is running out, so I don’t know. I’m worried about him.”
When asked how respondents got by when money was short, 10% didn’t buy food, and 12% worked more. 21% of our respondents report that they or family members went hungry in the past month in the past month, and COVID-19 threatens to exacerbate problems of hunger terribly.
“… it’s only one income, so you only get one income, and it’s like you’ve got three, four mouths to feed. How are you supposed to afford it? So then it’s… you need to pick and choose. Got to pay the rent, but like I said, then we need to eat, then we need the lights, and then we need the gas. But it’s kind of makes you juggle your brains”…
Paid sick leave and expanded unemployment benefits are crucial public health measures in our communities. Public officials should also be preparing to provide nutritional support for households as workers are forced to cut back on work hours. Evictions, foreclosures, utility shut-offs, and student loan debt collection should cease until the pandemic has passed.
“This thing came out of nowhere, so none of us have any answers in terms of our work, in terms of our everyday life, in terms of a lot of stuff… The reality of it is that it’s having an effect on all of us in our society. In terms of work there’s a lot of unknowns, there’s a lot of uncertainty.”
Communication and Community Connections
COVID-19 emergency policies disrupted routine channels of communication. Once the state of emergency went into effect, community partners lost the best means of communication with senior and other groups likely to be most affected. All programming in the Boston Housing Authority, churches, and gatherings of more than 25 have been eliminated, which severely limits communication and the delivery of support to those most affected.
“Technology is huge. My mother and them, they use the old flip phones. And a lot of people in our community are not up to the advances of technology, and they’re getting lost in society. They’re sinking because they’re not connected.”
Health Insurance and Access to Health Care
Despite living in a state with one of the nation’s lowest rates of uninsured, 7% of respondents report not having health insurance. Public officials must do more to communicate to communities where to go for testing, that the cost of testing and treatment for COVID-19 will be covered, and that cost should not dissuade people from seeking care.
Only 40% of respondents report that they go to a doctor’s office when they are sick. As a result, advice to “call your doctor” if you feel ill should be expanded to include people who do not have a primary care physician and use drop-in clinics or other sources of care. Public officials must provide clear instructions for getting medical care for people who do not have a primary care provider. This information should be shared not just online, but also through trusted community hubs and networks, such as community organizations, clinics, and shelters.
Vulnerability of Seniors
Many residents face multiple forms of vulnerability. We conducted a targeted analysis for the higher-risk population to better understand how this subgroup within the HNS study may be affected by COVID-19.
Among our respondents over age 60 who are in fair or poor health:
- 56% use public transportation;
- 29% don’t have anyone they could count on to take care of them if they were confined to bed;
- 64% find it very hard (20%) or somewhat hard (44%) to cover expenses every month;
- 56% were short in income in the past 5 years;
- 11% didn’t buy food to get through difficult financial times;
- 2% live in transient housing (shelter or half-way house), 18% live in public housing, and 50% receive housing assistance.
Coping with illness or disruption will be much more difficult for older adults with low incomes. For some, the only care option may be to move in with a family member, putting them at a higher risk of the virus due to overcrowding
Public officials should work with seniors to develop programs that provide care for older adults who are sheltering in their homes to protect themselves from COVID-19 and have underlying health conditions with ongoing medical needs. Separate programs should be developed for older adults who have contracted the virus and have no viable care option at home.
Conclusion
This analysis demonstrates the multiple and intersecting factors that can make it harder for people and communities to engage in social distancing, and for the extremely limited financial and caregiving resources many households in our communities have available to them. In addition, we show that COVID-19 has the potential to affect households that are already very precarious in terms of money and food.
We have called for several specific measures:
- more frequent public transportation to thin out population densities for people who must travel,
- paid sick leave,
- help with food,
- messaging that COVID-19 tests and treatment are free, and
- guidance on how to proceed if you are sick but do not have a regular doctor to call.
Public officials should also consider extending the deadlines for federal and state taxes to allow enough time for people to prepare and file taxes, especially if they are relying on assistance that is not available at this time of disruption.
Lastly, especially in this time of emergency, it is essential to include the voice of residents in emergency planning efforts. Community-based organizations are best positioned to understand community needs, share information and provide support, and inform and develop effective solutions.
Submitted by,
Professor Mariana Arcaya and Vedette Gavin on behalf of the Healthy Neighborhoods Research Consortium and partners of the Healthy Neighborhoods Study.
Special Thanks to Contributing Authors:
Mariana Arcaya (MIT Department of Urban Studies and Planning) – Principal Investigator
Arnetta Baty (Rounding the Bases Inc.) – HNS Site Coordinator
Carl Baty (Rounding the Bases Inc.) – HNS Resident Researcher
Andrew Binet (MIT Department of Urban Studies and Planning) – Doctoral Student
Amy Laura Cahn (Conservation Law Foundation – Senior Attorney
Vedette R. Gavin (Conservation Law Foundation) – Co-Principal Investigator
Reann Gibson (Conservation Law Foundation) – Senior Research Fellow
Robyn Gibson (Mattapan Food and Fitness Coalition) – HNS Site Coordinator, Resident Researcher
Isaac Hodes (Lynn United for Change) – HNS Site Coordinator
Yael Nidam (MIT Department of Urban Studies and Planning) – HNS Research Manager, Fullbright Fellow
Gail Rodrigues (Southcoast YMCA) – HNS Site Coordinator
Staci Rubin (Conservation Law Foundation) – Senior Attorney
Andrew Seeder (Conservation Law Foundation) – Senior Associate, Research & Metrics
For questions or requests for more information, please contact Reann Gibson rgibson@clf.org.