‘Hard to Reach’ Transcript

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein: We know that COVID-19 is not affecting all communities the same.

Black Americans are more than two-and-a-half times as likely to die from COVID-19 as white Americans.

Hispanics make up 18% of the population but more than 30% of COVID cases where ethnicity is reported.

Public health officials are struggling to connect with many of the people who are at the highest risk of getting sick.

Today from the Annenberg Studio at the University of Pennsylvania, helping the people who are hardest to reach. I’m Dan Gorenstein and this is Tradeoffs.

Matt Notowidigdo had seen the stories.

He knew that people of color — especially Black people — were contracting and dying from COVID-19 at a much higher rate than whites.

But he and a few other economists at the University of Chicago’s Poverty Lab thought there may be more to the story. 

Matt Notowidigdo: Something that wasn’t getting as much attention was the number of tests that turn out to be positive. The positive test rate.

DG: The higher the percentage of positive tests, the more likely it is that you’re only testing the sickest people and missing others who could be spreading the virus undetected.

So Matt and his colleagues mapped out the positive test rate by zip code. 

What they saw surprised them. 

MN: We expected to see a lot of the Black neighborhoods on the south side of Chicago to look really bad in terms of the positive test rate. And we did not see that. Instead, we saw neighborhoods with a high share Hispanic, those neighborhoods had very high positive test rates.

DG: Eye-popping high.

MN: We documented about 30 or 40 zip codes that had positive test rates as high as 30% to 40%.

DG: Let’s put Matt’s numbers in context. 

In mid-May Illinois statewide was at 16%. The World Health Organization says before a community relaxes social distancing, that number should be below 5. 

To be clear, the toll of COVID-19 on Black communities in Illinois is profound.  

Black people make up 30% of the state’s COVID deaths, twice their share of the population.

But on this metric — the percentage of positive tests — Black neighborhoods were more in line with white ones.

Matt and the team had a hunch why Hispanic neighborhoods stuck out. 

MN: We know in Chicago that Hispanics are more likely to be uninsured than whites and they’re also more likely to be undocumented. And so maybe what we’re seeing, it’s really not something about the Hispanic-ness of the neighborhoods, but maybe instead it’s just picking up the fact that if you’re uninsured or if you’re undocumented, that those might be reasons why you’d be less likely to get tested.

DG: The team plugged in the best estimates available for the uninsured rates and the undocumented population for each zip code.

The result?

A neighborhood’s percentage of undocumented and uninsured residents was the strongest predictor of a high positive test rate.

MN: Our expectation was that what would have mattered more was race or income or education. We didn’t expect to see in the data as strong of a relationship with undocumented immigration. And so when we saw that kind of jump out to us, it really surprised us. 

DG: Since May, positivity rates across the board in Illinois have dropped. That’s good news, but Matt says they’re still twice as high in undocumented communities compared to the rest of the state.

This told Matt these neighborhoods should be targeted for more testing. 

But Matt can only see numbers. He can’t see people. 

To understand why these communities could be hot spots, it helps to talk to people like Ana.  

Ana: ¡Hola!

DG: ¿Como está?

Ana: Bien, gracias.

DG: Muchas gracias, Ana.

Ana is undocumented, which is why we are only using her first name.

She’s lived in Denver for 20 years. She works as a cleaner at a school.

Ana (translated from Spanish): I’ve been working there for many years. So at this point, I make more than the minimum wage because I’ve been there for a long time.

DG: “More than minimum wage” means less than $40,000 a year.

Ana: I have to cover rent, all the bills, lights, telephone, rent, food, and it’s very little money considering everything you have to pay for.

DG: In March, Ana watched people in Denver start to get sick. 

And she got scared. 

Ana: What made me the most afraid, even more than the virus was losing my job.

DG: Ana says she couldn’t afford to get sick. 

She works in a job where you are expected to show up every day.

And at 50, with asthma and diabetes, finding another job seemed like a long shot. 

But later that month, Ana started to feel terrible.

Ana: My head hurt a lot. I felt that I couldn’t breathe. I felt that something was being nailed into me. I felt like I was going to burst inside.

DG: It went like that for two weeks.

Things ended up getting so bad, she called a clinic to ask about getting tested. 

Ana: They said I had to call another number, and then they gave me a different number. And then on the other number, they said that I had to go back to the first number. And since I felt so bad, I couldn’t be on the phone all of the time.

DG: Eventually, doctors told Ana she couldn’t get tested but should assume she was positive and isolate for two weeks.

Staying home for 10 days most likely would mean losing her job.

Better to tough it out, she thought, than risk that. 

So she went back to work. 

Public health officials are grappling with the best way to connect testing and tracing with hard-to-reach communities — potential hot spots that are a threat to the people who live there and a barrier to slowing the virus’ spread to safely reopen. 

About 11 million undocumented immigrants live in the United States.

More than half are estimated to be in 20 of the country’s largest cities.

Advocates and medical providers in Houston, Denver, Chicago and Los Angeles told us three primary reasons are keeping many undocumented people from getting tested: fears over job loss, fears that they can’t afford medical care, and fears that getting treatment will lead to deportation. 

The threat of deportation has been exacerbated by a recent change in immigration policy from the Trump administration.

News clip: The Trump Administration’s new public charge policy went into effect on Monday.
News clip: 
The public charge rule will make it more difficult for low-income immigrants to become permanent U.S. residents.
News clip:
It gives officials more power to deny visas and green card applications from immigrants who the government determined rely or could rely on certain public benefits.

DG: The public charge rule historically prevented immigrants from staying in the country if they relied on cash assistance.

The new policy — announced last August — expanded the rule to include things like adult Medicaid, food support and housing assistance.

Samantha Artiga works at the Kaiser Family Foundation. 

She says the public charge rule has pushed many immigrants even further underground.

Samantha Artiga: Families are increasingly fearful and we do have some data from community health centers indicating that they’ve seen increasing shares of their patients, turning away from accessing services and enrolling in programs. 

DG: Federal immigration officials have said that COVID-related care will not count toward a public charge determination.

And public health departments have said they are not sharing information with immigration.

SA: But even with those assurances, I think there are still a lot of fears and uncertainties among the community. And I think it will be challenging to overcome those fears because they are so profound.

DG: None of this is a surprise to federally qualified health centers, where many undocumented immigrants already get care.

In places like Milwaukee and New York they’re calling patients urging them to get tested. Some clinics even run their own contact tracing programs.

We reached out to the health departments in the 20 cities and counties with the largest undocumented populations.

Of the 15 who responded, all are translating basic information about the virus and guaranteeing people’s immigration status will not be shared if they get tested. 

San Francisco is working closely with small businesses.

Houston is spending $2 million on an outreach campaign.

But this is not just a big city problem.

News clip: A local fruit company is the site of a major coronavirus outbreak.
News clip: State health officials confirmed that 48 seasonal workers with the fruit processing plant tested positive for COVID-19.

DG: Dawn Mautner knows rural parts of the country are facing the same challenges. 

In Oregon, where she works, many of the state’s outbreaks have been among migrant farmworkers.

Dawn Mautner: We have already been trying to get them that information through every channel we can figure out. But the people we’re missing are still the people who are at highest risk.

DG: Dawn is a senior advisor to the Oregon Health Authority’s COVID-19 Response Team.

She says the state recognizes earning the trust of people who are often fearful of the government is both difficult and essential.

Dawn speaks fluent Spanish and has been working with low-income and undocumented populations for 20 years.

But she says developing the relationships necessary to increase testing and to do contact tracing, takes some situational awareness and some humility. 

DM: The languages are only one form of the interpretation that needs to happen. At the end of the day, I am a white woman doctor. 

DG: That’s where Monica Juarez comes in.

Monica is an immigrant from Mexico herself and an outreach coordinator for the state health department.

Monica Juarez: It’s easier for me to connect with these communities because I belong to these communities. And so I really want to make sure that they understand that this is a public health method, and it is not to monitor anyone

DG: But Monica is only one person. 

Oregon is working with community-based organizations to hire 600 contact tracers by the end of the summer.

600 Monicas who, on paper, should make it easier to deliver the state’s message. 

MJ: Whether it’s a community health worker, a health navigator, someone who is from that specific community, who speaks the language is super important.

DG: A culturally-fluent contact tracing army can only do so much on its own.

Dawn says the state is also spending $10 million to help support workers who test positive.

DM: It can’t cost them their jobs or their food or their shelter. Because if we don’t provide those supports, then folks won’t be able to adhere to the precautions that can stop COVID.

DG: And that brings us back to Ana in Denver where she had been sick for two weeks. 

But she kept going to work, terrified she’d lose her job. 

Ana: I went to a work very sick a few times. I couldn’t not show up because if the owner of the company was there and saw I wasn’t there, I would lose my job and they would hire someone else.

DG: Some days Ana was in so much pain, her supervisor told her to stay home, said he’d cover for her.

Five weeks after starting to feel sick, Ana finally was able to get a test.

Ana: They told me that I had had it, but it was now out of my system, that I had COVID about two weeks before.

DG: Do you think there’s a chance that maybe you infected somebody else? Do you worry about that?

Ana: I think that, yes, I infected people just like I was infected by others.

DG: The big question — at least from a public health standpoint — is what would it have taken Ana to stay home.

Ana: It’s not as important to me if I lose a week’s salary. But I would have had to be sure that I wasn’t going to lose my job if I stayed home for a week with the virus.

DG: Denver and Boston have announced relief funds for residents who’ve lost their jobs but don’t qualify for state or federal assistance.

California is spending $75 million to offer one-time payments of $500 to undocumented immigrants.

Money that will certainly help people living in the hot spots. Enough to reduce the spread? It’s hard to say. 

But many of the public health officials have at least ID’d the problems that make people hard to reach: language, access, money, fear.

Dealing with those will make all of us a little safer.

I’m Dan Gorenstein, this is Tradeoffs