Health Advisory: Prioritizing Populations with Structural Barriers to Health in COVID-19 Care Response (SFDPH)


Public health advisory concerning COVID-19 has been posted on the San Francisco Department of Public Health, Disease Prevention & Control Website at:  

Copied from advisory: 
Emerging data indicates populations experiencing structural oppression bear a disproportionate burden of COVID-19 disease and death, have a higher prevalence of predisposing co-morbidities, and are more likely to experience conditions that may facilitate the spread of infection. SFDPH aims to provide additional support and resources, particularly to vulnerable populations, to prevent COVID-19 infections and hospitalizations, and slow transmission within the community.

Keeping individuals and families healthy is essential to the City’s resilience during our COVID-19 response and recovery. The Centers for Disease Control and Prevention (CDC) describes “people at higher risk for severe illness” only along clinical parameters. This approach risks under-investment in populations that need greater focus and resources due to structural oppression. San Francisco must prioritize access and quality care for people with structural barriers to healthy outcomes in order to achieve more equitable outcomes and prevent death among the populations most susceptible to death from COVID-19.This is the right thing to do at any time and more so during this pandemic when our health is connected to the health of each person and community in San Francisco.

[For a discussion on structural barriers and local health inequities, see References below.]


Clinicians are encouraged to identify patients at risk of (1) severe illness and (2) increased transmission of COVID-19 that incorporates consideration of structural oppression. In addition to medical vulnerability (see San Francisco’s definition at:, there are structural conditions which put some individuals and groups at higher risk. The following populations are at higher risk because of structural inequities (i.e. experiences of racism, poverty, housing insecurity, etc.).

  1. Severe Illness: Populations at increased risk of severe illness and death from COVID-19 due to structural inequities
    People experiencing marginalization, systemic inequity, and health inequities:

o   Racial and ethnic groups (see:
Black/African American Community
Latina/o/x Community
Native Americans/Indigenous Community
Pacific Islander Community
Immigrant and undocumented people
People with disabilities
People experiencing homelessness

  1. Increased Transmission: The following populations experience conditions that facilitate the spread of infection and may be at higher risk of developing COVID-19.
  •     People Living in High Density Situations

o   Congregate care settings, such long-term care facilities

o   Congregate living settings, such as shelters, navigation centers, single room occupancy (SRO) hotels, or correctional facilities

o   Homelessness and unstable housing

o   Low-income housing

o   Multi-generational households where isolation is difficult

o   Racially segregated and/or densely populated neighborhoods

  •     People with High-Risk Economic/Work Conditions

o   Essential Workers who have extensive contact with the public

o   People without paid sick leave and/or health insurance

o   Sex Workers

o   Low-income people who must go out in public for resources frequently


Healthcare providers and systems of care are encouraged to increase monitoring and support for individuals from vulnerable populations in the following ways:

  •   Focused outreach. Engage in focused outreach to link vulnerable communities with necessary health services
  • Encourage testing.
    • Provide multilingual printouts and flyers on COVID-19 and testing:
    • Have high index of suspicion for COVID-19 when assessing symptoms
    • Ensure testing for identified populations is easily accessible and non-coercive. SFDPH encourages clinicians to test individuals with any one symptom concerning for COVID-19, asymptomatic close contacts of lab-confirmed COVID-19 cases, and asymptomatic frontline or essential workers.
  •     Increased vigilance. Maintain close monitoring of such patients to alert to disease progression.
  •     Partner with community. Partner with community-based organizations (CBOs) and faith-based organizations (FBOs) to reduce cultural barriers to care for patients in identified populations
  • Support isolation and quarantine.
    • Refer and link patients to community resources, especially for patients who require Isolation and Quarantine. See “Isolation and Quarantine Directives: Frequently Asked Questions for Healthcare Providers:”
    • Encourage patients to call 311 or go to SF.GOV to get connected to resources
  • Support contact tracing.
    • When disclosing results to a new positive case, ask about who else lives in the household and link household members to immediate testing resources.
    • Encourage patients to talk with case investigators and contact tracers, if called. Explain how this work to keeps their neighbors and friends safer.
  • Fill out the demographics sections of the CMR. Providers are the sole source for many of these data that help us understand which populations are at higher risk and may need additional resources and support to stay healthy
  • Contextualize data. Include context when highlighting disparity data to avoid inadvertently perpetuating harmful myths and stereotypes.
    • Data on socioeconomic status (SES) could be reported alongside racial data. Complementary SES information will clarify how racial and class forces are intertwined
    • Explanations for how discrimination and marginalization impact health should be offered alongside any racial disparity data
  • Partner with SFDPH. SFDPH welcomes feedback on how we can continue to work with providers to improve support for vulnerable patients. Contact:

Categories of urgency levels
Health Alert:  conveys the highest level of importance; warrants immediate action or attention 
Health Advisory:  provides important information for a specific incident or situation; may not require immediate action
Health Update:  provides updated information regarding an incident or situation; unlikely to require immediate action
CD:   Tel (415) 554-2830   Fax (415) 554-2848
STD: Tel (415) 487-5530   Fax (415) 431-4628
TB: Tel (415) 206-8524   Fax (415) 206-4565


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