The Louisville-Jefferson County Metropolitan Government's (LMG) Department of Public Health and Wellness (LMPHW) is an accredited, independent, academic health department. Our mission to achieve health equity and improve the health and well-being of all Louisville residents and visitors is realized by our 265 employees, led by Dr. Sarah Moyer, a board-certified physician and Mayor Greg Fischer’s Chief Health Strategist. As of 2017, Metro Louisville’s population was 770,517 and is the Commonwealth of Kentucky’s most populous city and urban center.  

In response to early data indicating likely health inequities in outcomes due to the pandemic, the Louisville Metro Incident Management Team (IMT) established an incident objective to, “Reduce COVID-19 health inequities.” This led the response team to recruit planners from Public Health and Wellness’ Center for Health Equity (CHE) and to create an Equity Officer role within the IMT structure. The Equity Officer worked collaboratively with the Planning section to ensure the pandemic response addressed the diverse needs of our community. Several plans were created and implemented specifically around providing for the essential needs of people in isolation or quarantine using an equity lens, and other plans were reviewed for potential equity implications. Robust community networks were activated to provide culturally responsive testing, tracing, and direct support to our immigrant and refugee communities, people who are unhoused, and people who are incarcerated.

Essential needs delivery plan: From the beginning, one of the key domains identified as having considerable equity considerations was the challenge posed by isolation and quarantine. A centralized isolation/quarantine site was opened, initially for unhoused people. When it became apparent people were living in crowded conditions or with someone at high risk for complications from COVID-19, this program was expanded to a 100-room hotel to ensure a safe place was available to any resident who wanted it. For people isolating or quarantining at home, our team quickly identified a need to provide culturally responsive food, household cleaning supplies, and durable goods like personal protective equipment (PPE) and prescription medication delivery. Additionally, we worked with a local provider and pharmacy to provide Medication-Assisted Treatment to those who were either in a similar program currently or wanted to be initiated into an MAT program. 

Lastly, a plan to send care kits to people with positive test results to support isolating at home, including items like a pulse oximeter and thermometer to provide data points for case callers, as well as herbal tea and coloring books to promote a relaxing, recuperative environment. 

Testing, tracing, and direct support to high-risk communities: Due to their disproportionate representation in essential employment and disproportionately crowded housing, Louisville’s immigrant and refugee communities were at high-risk for COVID-19. Quickly leveraging existing relationships through the Louisville Metro Government’s Office of Globalization and local community-based organizations, the response team created targeted messaging and special testing events. When contract tracers later had difficulty engaging non-English speaking residents for contact tracing, the team worked with trusted non-profits to visit people in person. Lastly, the city was able to use Coronavirus Aid, Relief, and Economic Security (CARES) Act funds to provide direct financial assistance to immigrant and refugee households affected by the pandemic through embedded community organizations.  

Additionally, an early round of surveillance testing in our unhoused population helped us understand the prevalence of COVID-19 in this community (out of thousands tested, less than a hundred were positive). Restrooms and handwashing stations were installed early to enable residents to follow public health guidance to prevent spread.  

The response team also worked early on with our Corrections department to support the health and safety of staff and incarcerated persons. This included providing information on cleaning and disinfecting, supplying at least 2 cloth masks per person incarcerated, advocating for the quarantine of newly arrested persons, cohorting residents in the jail dorms, and providing both testing for symptomatic individuals as well as surveillance testing of both staff and persons incarcerated. LMPHW’s response team has continued an ongoing relationship with Corrections, our Criminal Justice Commission, and their Jail Policy Committee to advocate for policies that will better protect those incarcerated such as eliminating cash bail and reducing the number of people in pre-trial detention. 

Initial Results: As of December, the racial demographics of Louisville residents who have died of COVID-19 nearly match the racial demographic of the city’s general population.  Hispanic and Latinx residents make up a disproportionately high number of people with confirmed COVID-19 infections and disproportionately low number of deaths. The higher rates of infection have been attributed to an overrepresentation in essential jobs while the lower rates of death are attributed to a significantly lower average age than the general population. 

Innovation: The target population for our equity crisis response interventions were people with limited income, people experiencing homelessness, people with an opioid use disorder, people incarcerated, and people in our immigrant and refugee communities. The response team aimed to reduce community spread by supporting all essential needs for residents to safely isolate and quarantine. Resources were prioritized for the city’s immigrant and refugee residents due to an identified gap in support programs available for them during the pandemic alongside a reluctance to participate in existing programs. Immigrant and refugee workers are also disproportionately employed in essential sectors, especially meatpacking and processing plants that were sites of early outbreaks. While emergency responses have attempted to proactively address potential health inequities in the past, the concerted approach of centering equity in the planning of all Incident Management Team plans was an innovative response to a pandemic that has worsened inequity worldwide.   

The Incident Management Team was able to target initiatives to underserved members of our community by focusing on identifying unmet needs. The program offering a safe, comfortable hotel room for people to stay during their isolation or quarantine period was overwhelmingly utilized by people experiencing homelessness or living in crowded settings including multi-generational households and congregate settings. Food delivery was available to anyone in quarantine or isolation who reported needing assistance, with no means-testing to ensure that there were as few barriers to service as possible.  The Medication Assisted Treatment plan directly addressed the needs of people with opioid use disorder.  Resources were efficiently targeted for the immigrant and refugee communities through partnerships with trusted community organizations. 

This objective was planned and implemented through the Incident Management Team structure of both the city and Louisville Metro Public Health and Wellness. The plans were developed within the Planning Section, submitted to Incident Command for approval, and implemented by the Operations Section and contracted partners. By partnering with the city’s Office of Globalization and working directly with community-based organizations, the response team had direct input from partners at all stages of planning and implementation. In August, community members were recruited for a Community Advisory Board that provided ongoing input into the planning and implementation of the city’s crisis response.   

Partners for the Unable to Contact plan included Catholic Charities of Louisville, Kentucky Refugee Ministries, La Casita Center, and Family Health Centers a Federally Qualified Health Center (FQHC). A local hotel and the Salvation Army partnered to provide isolation and quarantine housing. On-site medical services were provided by a contractor. The Medication Assisted Treatment partner was NuLease Medical Solutions. Essential needs deliveries of food and durable goods were handled by Salvation Army and local government employees, and medication was delivered by the Greater Louisville Medical Society. Care kits were created and delivered by a contractor. Partners for the direct assistance to immigrant and refugee communities included the Bhutanese Society of Louisville, Catholic Charities of Louisville, Colectivo Esperanza, Kentucky Refugee Ministries, The Somali Community of Louisville, and South Louisville Community Ministries. 

Partners in the incarceration work included Corrections, Criminal Justice Commission, and members of the Jail Policy Committee including prosecutors, public defenders, and Judges. Partners in the homelessness work included the Office of Resilience and Community Services, the Coalition for the Homeless, Family Health Centers – Phoenix, and numerous shelters throughout the city. 

The response team was continually adapting and creating new plans to address emergent needs and equity concerns. After an early patient in our isolation site was resistant to maintaining isolation due to opioid withdrawal, the Planning Section created a partnership with a local treatment provider to offer Medication Assisted Treatment (MAT) to anyone with an opioid use disorder for the duration of their isolation or quarantine, while at home or in our centralized site. When it became clear the contact tracing team was struggling to reach immigrant and refugee residents, the planning section quickly convened local stakeholders to develop a more effective way to contact people. As federal and local relief programs were implemented and community members highlighted the ways these programs failed to serve the needs of immigrants and refugees, the response team designated funds for direct financial assistance for households not reached by other programs. The programs and partnerships together increased the likelihood that residents could remain safely at home regardless of their income, nation of origin, immigration status, behavioral health needs, or language spoken. 

Although Louisville has seen a disparate impact of the pandemic on communities of color, immigrant communities, and refugee communities, these inequities have not translated to the disproportionate number of deaths seen in communities of color in many other cities. Integrating an equity lens into the response efforts from the first week contributed to a sustained focus on how resources could best be allocated to support all members of our community.