Spatial Inequities in COVID-19 Testing, Positivity, Confirmed Cases, and Mortality in Three U.S. Cities
An Ecological Study
Table of Contents
Table of Contents
Report Publish Date: March 30, 2021
This journal article explores inequities in COVID-19 testing, positivity, confirmed cases, and deaths in the pandemic’s first six months, based on where people lived in New York, Philadelphia, and Chicago.
Primary Takeaways
“[W]e found large spatial inequities in COVID-19 testing, positivity, confirmed cases, and mortality in 3 large U.S. cities and strong associations of COVID-19 positivity, confirmed cases, and mortality with higher neighborhood social vulnerability,” the authors write. “These within-city neighborhood differences in COVID-19 outcomes emerge from differences across neighborhoods generated and reinforced by residential segregation linked to income inequality and structural racism, coupled with decades of systematic disinvestment in segregated neighborhoods.”
Overview and Objectives
Evidence at the start of the COVID-19 pandemic pointed to racial and ethnic inequities in infections and deaths. The authors wanted to know whether these differences showed up among neighborhoods of different socioeconomic statuses in three major U.S. cities.
Hypothesis or Approach
“We used data on the total numbers of tests, confirmed cases, and deaths by ZIP code tabulation area (ZCTA) of residence from Chicago, New York, and Philadelphia,” the authors write. Data came from the Chicago Department of Public Health, the New York Department of Health and Mental Hygiene, and the Philadelphia Department of Public Health. The authors looked at four indicators: total tests per 10,000 people, positivity rates, confirmed case rates per 1,000 people, and deaths per 1,000 people. They used the Centers for Disease Control and Prevention's Social Vulnerability Index to determine the social vulnerability—factors like poverty, crowded housing, and poor access to transportation—of each ZIP code area. They conducted a three-step statistical analysis to examine the distribution of the indicators across each city’s neighborhoods.
How This Influences Change
“Addressing ... structural factors linked to income inequality, racism, and segregation will be fundamental to minimizing the toll of the pandemic and to promoting population health and health equity across many other health conditions,” the authors write.
Research: Go Deeper
Background: Preliminary evidence shows inequities in COVID-19–related cases and deaths in the United States.
Objective: To explore the emergence of spatial inequities in COVID-19 testing, positivity, confirmed cases, and mortality in New York, Philadelphia, and Chicago during the first six months of the pandemic.
Design: Ecological, observational study at the ZIP code tabulation area (ZCTA) level from March to September 2020.
Settings: Chicago, New York, and Philadelphia
Participants: All populated ZCTAs in the 3 cities
Measurements: The study looked at COVID-19 testing rates, test positivity rates, confirmed cases, and deaths in ZIP Code Tabulation Areas (ZCTAs) through September 2020. It used the CDC's Social Vulnerability Index (SVI), which measures how vulnerable communities are based on social and economic factors, using data from the 2014–2018 American Community Survey. The researchers analyzed whether COVID-19 outcomes and social vulnerability were geographically clustered and examined the relationship between social vulnerability and COVID-19 outcomes.
Results: The researchers found geographic clusters of neighborhoods with high and low COVID-19 positivity rates, case rates, and death rates. These clusters often matched areas with high or low levels of social vulnerability in all three cities studied. The results showed clear inequities: neighborhoods with higher social vulnerability had lower COVID-19 testing rates but higher test positivity rates, more confirmed cases, and more deaths than neighborhoods with lower social vulnerability.
Limitations: The ZCTAs are imperfect and heterogeneous geographic units of analysis. Surveillance data were used, which may be incomplete.
Conclusion: Spatial inequities exist in COVID-19 testing, positivity, confirmed cases, and mortality in 3 large U.S. cities.
Ann Intern Med. 2021. doi:10.7326/M20-3936
Research Team
This study and report was conducted and created by the following people.
- Usama Bilal
- Loni P. Tabb
- Sharrelle Barber
- Ana V. Diez Roux
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