The novel coronavirus disease 2019 (COVID-19) pandemic dramatically impacted life across the world and amplified inequities in both economic and health outcomes. In the United States, communities of color historically most impacted by disasters also experienced disproportionate burden of COVID-19.1–3 These inequities highlighted centuries of discrimination and racism deeply embedded in the systems and structures meant to protect the public. Oregon's unique oppression of Black, Indigenous, and People of Color (BIPOC), centered in the history that it was the only state founded with an exclusionary clause,4 had far-reaching impacts on the state's racial diversity and health disparities. Washington County (WC), the second most populous county and among the most diverse in Oregon,5 had the first confirmed case of COVID-19 in the state a few weeks before the World Health Organization declared COVID-19 a pandemic.6
Approach and Transformation
To address COVID-19, WC activated the Emergency Operations Center (EOC) and centralized its response efforts following the National Incident Management System (NIMS).7 The EOC relied on an Incident Command System (ICS) approach that created clear decision-making hierarchy and standardized procedures that provided efficiency in the ambiguous and rapidly changing emergency. The EOC structure included membership from across multiple departments, including public health leadership, to mitigate health inequities and support communities. These leaders quickly recognized that the ICS structure was not designed to deliberately include the voices of people most impacted by an emergency in the decision-making process and advocated to develop an equity framework for the EOC. Early county-level surveillance data indicated a disproportionate burden of disease in communities of color, especially among Hispanic/Latino/a/x/e residents. These disparities confirmed the importance of expanded engagement with BIPOC communities and reinforced the need for the structural change in the EOC response.
The revised structure, adapted from Washington state,8 included an Equity Officer (EO), a Language Access Coordinator (LAC), an Equity Technical Advisor (ETA), and an Equity Team (ET) (Figure 1). The EO reported directly to the Incident Commander and was responsible for policy and system-level decisions. The LAC was deployed to the Incident Command team to develop language access policies and procedures to facilitate an effective and timely translation of materials in the EOC efforts. The ETA functioned at the Operations level, advising staff who were collaborating with community leaders and organizations. The ET was supported by the ETA and the LAC, all of whom reported to the EO. The ET comprised culturally specific subject matter experts, technical advisors, and community liaisons. It was intentionally designed to overcome the strict functionality of the EOC and incorporate community voice in the response efforts.9
The ET developed communication tools and implemented a decision-making lens to embed equity into the rapid decisions made in the EOC (see Figure 2, Supplemental Digital Content, available at https://links.lww.com/JPHMP/A856). This lens along with other tools and resources developed by the EO and the ET provided the foundation to address critical equity issues and ensure inclusive action. In addition to these tools, harnessing the power of community relationships was critical to elevate equity concerns and priority issues as they arise. An integral member to the EOC in strengthening this community connection was Vision Action Network (VAN), a nonprofit with more than 20 years of experience as an impartial convener of people, organizations, and sectors. VAN bridged the gap between the EOC and community by developing communication strategies to reach the most impacted communities. As part of the communications effort, VAN conducted interviews with WC staff, community-based organizations (CBOs), and subject matter experts on the impacts and responses to COVID-19. These interviews were recorded and posted or live streamed on social media each week and many of them were conducted in Spanish, reaching thousands of people in the community. VAN also worked alongside WC to coordinate responses to food insecurity, shelter, and mental health needs. VAN used its network of 2500 people to disseminate information and worked with the ET on weekly bilingual resource bulletins to CBOs. Bringing together community partners and county staff with expertise in using an equity lens in their work strengthened the communications efforts with partners and led to increased engagement across the EOC.
The new equity-focused structure of the EOC led to more intentional engagement with communities and facilitated connections between WC leadership and BIPOC-centered organizations in the region. The EO and county leadership, including the County Chair, Sheriff, and Director of Health and Human Services, hosted a forum with community leaders of color to acknowledge their shared stories of COVID-19 impacts on their communities and an opportunity to advise county leadership on how best to respond. With the support of a robust network of community partners, the ET members and WC staff were able to identify critical barriers impacting residents. These were addressed through a variety of strategies including the prioritization for hiring bilingual/bicultural staff for COVID response programs and services. Furthermore, WC contracted with culturally specific CBOs to create a culturally and linguistically responsive program to provide financial support for households in isolation or quarantine.
An EOC structure embedded with equity provided infrastructure for WC to intentionally expand collaborative community relationships within an emergency response. WC extended its community reach by leveraging its long-standing relationship with VAN. Absent having such a convener, an EOC can rely on existing relationships with prominent CBOs, especially those providing culturally specific services, to reach communities most impacted. Building a robust community partnership with CBOs, health systems, and trusted community leaders and elders will facilitate strong allyship and infrastructure to address equity issues in an emergency. A crisis can be an opportunity to form new partnerships, particularly with smaller CBOs, and the integration of equity into the EOC can accelerate this process. In WC, the relationships with community partners strengthened coordination across systems and silos, improved communication and resource allocation, and resulted in the development of culturally specific strategies for COVID-19 prevention and mitigation. A key lesson that was highlighted during the pandemic was the importance of intentionally building trust and relationships with community partners before the onset of an emergency. Financial and technical resources are essential to strengthen partners' capacity and readiness to engage in an emergency response. Engaging partners and constructing formal pathways for input and feedback are a continued priority for this work.
It is also valuable to note some challenges experienced during the process of embedding equity in the EOC structure and in partnering with communities. Although leadership was supportive of equity and inclusion and the development of new positions, the system and those supporting the response were not well-prepared for change. Staff were redeployed across the organization to work in the EOC and arrived with varying levels of understanding of racial equity and equity work. Team members assumed new roles that were developed within a short time frame and with limited institutional support. To better prepare emergency operation systems to integrate equity throughout the operations, all staff members involved in the response effort should be trained in core equity principles prior to the activation. In addition to the lack of formal training in core equity principles, individuals and communities involved in the emergency response experienced novel personal and professional stress that impacted their tolerance for change and adoption of new strategies. While the EO successfully created and shared equity tools and resources, they were underutilized, partly due to limited capacity and competing demands.
Bringing partners together at the speed at which decisions were being made was also challenging. Partners often felt left out of conversations regarding the disparities observed and the decisions that were made. CBOs were also in a precarious position during this time as many of them were responding to incredibly high levels of community need, including provision of necessities such as food. Although many partners made time for meetings and conversations with the county, some had very little capacity to prioritize this work. Thus, creating collaborative efforts, active listening, and shared power structures allow for expanded capacity, mutual trust, and effective execution of inclusive responsive strategies during a disaster.
Public health emergencies are complex, dynamic, and resource-intensive and can rapidly overwhelm often lean government systems designed for routine operations. It is easy to sideline the voices of people most impacted by the emergency if a focus on equity is not intentionally embedded. In an emergency, local governments must act quickly to address community needs that may limit opportunities for collaborative equity-based approaches. Equity should be incorporated into the regular command structure of emergency management centers to accelerate solutions and prevent harm to impacted communities. Jurisdictions can adjust their emergency response plans before the onset of a crisis to embed equity to ensure members gain knowledge and skills and develop community partnerships prior to an event. WC's experience of integrating equity into the EOC during a pandemic offers lessons for how to approach these structural changes intentionally even during an emergency response. Intentionally embedding equity within the EOC structure for all emergencies, not just communicable disease, is a key step forward in stopping the perpetuation of structural racism.
Implications for Policy & Practice
- Decision-making groups should have standard membership that includes public health professionals with an equity lens.
- EOC centers, while not equity-focused by design, can be organized to prioritize equity and collaboration with external partners and to better serve communities most impacted in an emergency.
- To be most prepared, training, tools, frameworks, and charters centered in equity should be incorporated into EOC operations and policies prior to the onset of an emergency.
- Roles within the EOC should regularly be reviewed and updated to ensure a focus on equity, inclusion, and collaboration at all levels of the response, including leadership.
- Engagement with community partners should include a strong foundation of trust, formal feedback loops, and financial and technical resources to strengthen partners' capacity and readiness to engage in an emergency response.
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2. Bambra C, Riordan R, Ford J, Matthews F. The COVID-19 pandemic and health inequalities. J Epidemiol Community Health. 2020;74(11):964–968.
3. Lichtveld M. Disasters through the lens of disparities: elevate community resilience as an essential public health service. Am J Public Health. 2018;108(1):28–30.
5. US Census Bureau. Table DP05, demographic and housing estimates, 2015-2019 American Community Survey 5-year estimates. https://data.census.gov/cedsci/table?q=DP05&g=0500000US41067&tid=ACSDP1Y2019.DP05&hidePreview=false
. Published 2020. Accessed June 14, 2021.
6. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed. 2020;91(1):157–160.
7. Federal Emergency Management Agency. National Incident Management System. https://www.fema.gov/emergency-managers/nims
. Accessed June 7, 2021.
9. Nelson J, Spokane L, Ross L, Deng N. Advancing racial equity and transforming government: a resource guide to put ideas into action. https://racialequityalliance.org/wp-content/uploads/2015/02/GARE-Resource_Guide.pdf
. Accessed June 14, 2021.