A 35yo immigrant from El Salvador calls a hotline in May 2020 w 5d cough, aches, fever, chills. Offered covid testing -but declines. Why? Our paper in @AMJPublicHealth answers. First auth A Egelko, incl @amaoutleen, @cjstreed, @joshgaroon, me
https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2020.305964 #phethics /1

First: public health in the US (and elsewhere) works in tandem with systemic racism, so that covid neither creates new patterns of inequity nor reveals hidden equities. It's always been out in plain sight. We can't understand reluctance to test w/o acknowledging that./2

We propose categories of phenomena to help understand how reluctance to be tested for covid might reflect ongoing systemic issues. Ideally this discussion will help providers, caregivers, and neighbors understand the variety of decision making around covid./3

We point out that *mandatory* testing often does not have technical force of law, but might be required by schools or employers -- and this requirement might be enforced differently among different groups (eg, at a university, faculty vs students vs staff) /4

Covid testing involves a financial burden. If you test positive, and your company does not pay for leave, you must stay home without the means to pay for food and shelter. This is an ethical conflict (no trolleys needed). /5

Immigration status: Immigrants comprise a significant proportion of frontline and essential workers, unable to access most social services in the US, worried about the Public Charge rule which actively discourages self-/other-care, and fear deportation if they test positive./6

#CovidStigma is real. Many in the US have been stigmatized, including black people, Chasidic/Charedi Jews, Asians, and others. They have been the victims of violence and denied care & employment). Stereotype threat might imply that members of these groups avoid testing./7

Research aversion: the history of research in the US is replete with racist exploitation. Covid testing occurring in the context of clinical trials (or covid vaccine trials, for example) will face justified mistrust from exploited populations. /8

The most complicated reason, perhaps, has to do with misinformation. Black communities and other non-white groups do not lack information or ways to access it, but the relationships between health care institutions and these communities have been exploitative and malignant. /9

If scientific information depends on access to accredited institutions, but these institutions and non-white communities are at cross-purposes, misinformation might be more easily accepted& worsen existing estrangement. Merely condemning it might be counterproductive./10

These issues are deep-seated. This manuscript was written in August and is posted in November (pretty fast actually). Nothing has changed with regard to what must happen. Our conclusion:/11

It is unwise to assume that vulnerable communities do
not have facts about COVID-19, insufficient to ensure simply that they do have those facts, especially
when they are excluded from the processes through
which these facts are discovered and disseminated./12

If such communities are to be fully and effectively
included in public health efforts, the social and political
structures that harm them, and lead to recurring harmful
consequences, must be dismantled and remade, with the
most-affected communities in the lead.