How Fear Induced Messaging Worsened the Response to COVID

How Did Mayor Bill de Blasio’s COVID Lockdowns Affect Access to Healthcare for the Minority Population in Tremont?

Chapter 1

Introduction

The panic regarding the 2020 COVID-19 pandemic led to new administrative challenges regarding protecting and serving communities at the same time. Many cities across America reacted to COVID by trying to curb the virus's spread through the implementation of lockdowns. Local governments implemented drastic measures that changed daily life overnight and exposed the vulnerabilities of already underserved and marginalized communities.

In New York City, the epicenter of the pandemic in the United States, Mayor Bill de Blasio's office issued a series of lockdown policies starting in March 2020 (NYC, 2020) These policies included the closure of non-essential businesses, the implementation of remote learning, the restriction of public gatherings, and the enforcement of social distancing in essential services (NYC, 2020). The media by and large reported on these measures as necessary to contain the public health crisis; however, for the public affected by these measures, there were far-reaching consequences—particularly for the population of Tremont in the Bronx.

Tremont is a predominantly minority community in the Bronx. It has long been characterized by socio-economic disparities, such as high poverty rates and inadequate access to healthcare (NYC, 2020). There are 28,095 residents in Tremont, with a median age of 32. 46.46% are males and 53.54% are females. US-born citizens make up 54.9% of the residents in Tremont, and non-US-born citizens account for 25.36%. 19.74% of the population consists of non-citizens. The neighborhood's residents are mostly African American (11%), Asian (23%), and Hispanic (57%), all groups that have historically dealt with systemic barriers to economic mobility and healthcare equity (Census Reporter, 2024; Gilbert et al., 2022). The COVID-19 pandemic lockdown response essentially aggravated already existing challenges for this population by further limiting access to critical services. The purpose of this dissertation is to explore the specific impact of the lockdown policies implemented between March 2020 and September 2020 on the socio-economic conditions of low-income residents in the Tremont neighborhood. In particular, the research will focus on how these policies affected access to healthcare for the minority population in this community.

Contextualizing the Tremont Neighborhood in the Bronx

It is important to understand the pre-pandemic socio-economic condition of Tremont. Like many other neighborhoods in the South Bronx, Tremont is home to a low-income, minority population that has experienced continual challenges related to poverty, healthcare access, and environmental racism (Brennan, 2021; Estevez, 2020). Indeed, the Bronx has one of the highest poverty rates in New York City, with many residents relying on public assistance and living in overcrowded housing (Clark & Shabsigh, 2022). These socio-economic conditions have long contributed to health disparities in the borough, as minority communities experiencing higher rates of chronic diseases compared to other parts of the city (Shiman, 2021).

The social determinants of health also include environmental factors which have certainly impacted the health of Tremont residents. The South Bronx, including Tremont, has been disproportionately affected by environmental hazards, such as poor air quality and high levels of pollution. Estevez (2020) notes that the South Bronx has historically been subject to political practices that have allowed hazardous industrial activities in the area, which have in turn contributed to high rates of respiratory illnesses among residents. These pre-existing conditions made the Tremont community particularly vulnerable.

Additionally, Tremont residents have faced systemic barriers to accessing quality healthcare (Shiman et al., 2021). The Bronx is home to several public hospitals and community health clinics, but many of these facilities are underfunded and understaffed due to structural racism within the healthcare system, which has contributed to disparities in healthcare access, with minority communities in neighborhoods like Tremont receiving lower-quality care compared to wealthier, predominantly white areas (Shiman et al., 2021).

Research Significance

In Tremont, many residents work in low-wage, essential jobs, often without the luxury of working from home, which increased their vulnerability during the pandemic lockdowns. The area has long faced systemic inequities in housing, healthcare, and employment opportunities, making it one of the most vulnerable communities in the city. Residents were already at higher risk for poor health outcomes due to underlying conditions such as asthma, diabetes, and hypertension (Clark & Shabsigh, 2022; Estevez, 2020).

The importance of researching the impact of Mayor Bill de Blasio's COVID-19 lockdown policies on Tremont lies in understanding how these public health measures worsened existing social and economic disparities. The argument at the time was that lockdowns would help to slow the spread of the virus (Hammond, 2021). However, little attention was given to the potential problem of inequalities in healthcare access worsening for low-income, minority communities like Tremont. Tremont residents already faced barriers to accessing healthcare, and in 2020, due to clinic closures, overwhelmed hospital systems, and the lack of technology for telehealth services, the health situation of the community worsened. Economically, the shutdown of service industry jobs hit the community hard, leading to unemployment, food insecurity, and difficulties in obtaining unemployment benefits, all of which affected the social determinants of health for poor communities like Tremont (Shiman et al., 2021).

Researching these issues is important because it allows for gaining insights into the unintended consequences of pandemic policies on marginalized populations. There is a need to know and understand the specific challenges faced by communities like Tremont, so that policymakers in the future can develop and adopt more equitable approaches to public health crises in the future, and so that low-income and minority populations are not disproportionately affected by similar measures?.

COVID-19 Lockdown Policies in New York City

In response to the COVID crisis, Mayor de Blasio’s office ushered in a policy of lockdown that lasted for months. Essential businesses like grocery stores and healthcare providers were allowed to remain open but were required to implement strict social distancing and hygiene protocols to protect both employees and customers (NYC, 2020). Many Tremont residents were employed in these sectors and were unable to work remotely. Helmreich (2023) notes that the economic impact of the lockdown was particularly severe in the Bronx, where a large proportion of residents rely on hourly wages and do not have the financial safety nets that wealthier individuals might possess.

Moreover, the closure of schools and the shift to remote learning posed additional challenges for low-income families in Tremont due to the pre-existing digital divide. The long-term effects of this educational disruption are still being studied, but early research suggests that students from low-income households experienced significant learning loss during the pandemic (Friedman et al., 2023).

Perhaps one of the most critical areas affected by the COVID-19 lockdown policies was healthcare access. For residents of Tremont, who already faced significant barriers to healthcare, the lockdown policies further limited their ability to access medical services (Roldós et al., 2024). The closure of non-essential medical facilities, such as primary care clinics and dental offices, meant that many people were unable to receive routine care—not to mention the fact that the policies of the mayor’s office supported a social stigma already introduced by non-stop media hype of the dangers of going out in public. People were scared and hesitant to seek medical care due to concerns about exposure to the virus. As a result, conditions that might have been manageable under normal circumstances worsened during the lockdown period. Huang and Li (2022) point out for instance that spatial health disparities were worsened during the pandemic, with low-income and minority communities experiencing higher rates of severe illness and death due to delayed care and reduced access to healthcare resources.

The pandemic also revealed long-standing issues related to health equity in New York City. COVID-19 mortality rates were disproportionately high in neighborhoods with large minority populations, such as the South Bronx (Friedman & Lee, 2023). Factors such as overcrowded housing, a need to rely on public transportation, and limited access to healthcare contributed to the higher rates of infection and death in these communities (Friedman et al., 2023). The lockdown policies showed little consideration for the underlying structural issues and may have worsened existing disparities. Is this how policy serves a community?

Problem Statement

The core problem this research seeks to address is to understand how the COVID-19 lockdown policies implemented by the New York City government impacted healthcare access and socio-economic conditions in Tremont. The policies were intended to mitigate the public health crisis, but they may have actually worsened the situation for low-income, minority populations. Understanding the specific socio-economic and healthcare challenges faced by these communities is crucial for developing more equitable public health policies in the future.

The Bronx has consistently exhibited high poverty rates and unemployment, particularly in low-income neighborhoods such as Tremont. Prior to the pandemic, the Bronx had a poverty rate of nearly 27%, the highest of all New York City boroughs (Clark & Shabsigh, 2022). This is an important point because of the social determinants of health, which affect health outcomes in big ways for communities like Tremont. When healthcare access is restricted, and the social determinants of health are worsened due to restrictive policies like lockdowns, it can create a perfect storm that wreaks havoc on community health.

According to Shiman et al. (2021), structural racism and inadequate healthcare infrastructure have long affected minority communities in the Bronx, and have already contributed to poor health of the population. The COVID-19 pandemic further strained these already limited healthcare resources.

Tremont and other parts of the South Bronx have also suffered from poor air quality and other environmental hazards, which have contributed to higher rates of asthma and other respiratory diseases (Estevez, 2020). This point just goes to show that residents in Tremont were already in a poor health posture before the lockdowns.

Helmreich (2023) shows that the lockdown measures significantly increased unemployment rates in the Bronx, where many residents worked in sectors hardest hit by the pandemic, such as retail and hospitality. Without economic support and stability, social determinants of health can quickly disappear leaving residents without health support.

Research Objectives

The main objective of this dissertation is to examine the socio-economic and healthcare impacts of the COVID-19 lockdown policies on the Tremont neighborhood in the Bronx. Specifically, the research aims to answer the following questions: How did the lockdown policies affect access to healthcare for the minority population in Tremont? What were the broader consequences of these policies, particularly in terms of public health? Through an exploration of these questions, this dissertation looks to contribute to a deeper understanding of how emergency public health measures can impact vulnerable communities and to provide insights into how future policies can be designed to consider such effects.

In doing so, this research will draw on a range of primary and secondary sources, including public health data, government reports, and academic studies. It will also consider the perspectives of community members and healthcare providers in Tremont, who can offer valuable insights into the lived experiences of residents during the pandemic. Ultimately, the goal of this dissertation is to shed light on the specific challenges faced by low-income, minority communities during the COVID-19 pandemic and to provide recommendations for addressing these challenges in future public health emergencies.

To achieve its objective, this study uses a qualitative research methodology, which is suited because this research requires in-depth exploration of the lived experiences of residents and stakeholders during the pandemic (Crabtree & Miller, 2023). A focus on subjective experiences and community-specific issues can be applied by way of the qualitative methodology, which supports deep understanding of how the lockdown policies influenced healthcare access and socio-economic conditions in this low-income, minority neighborhood (Crabtree & Miller, 2023).

Data will be collected primarily through semi-structured interviews with residents of Tremont, healthcare professionals, local business owners, and educators. These interviews will explore their perceptions of the lockdown policies, focusing on their effects on access to healthcare. The semi-structured nature of the interviews allows for flexibility, enabling participants to share personal experiences while ensuring that key research questions are addressed (Crabtree & Miller, 2023). Additionally, focus groups will be conducted with community-based organizations to gather collective insights into how the pandemic affected the broader neighborhood.

Document analysis will also be employed, reviewing local government reports, public health data, and news articles that document the implementation of COVID-19 policies in New York City. This will provide contextual background and help triangulate the findings from interviews.

Thematic analysis will be used to identify patterns and themes emerging from the qualitative data. This approach allows the researcher to categorize and interpret the data based on recurring concepts, such as barriers to healthcare or economic hardships. The use of qualitative methods will offer rich, detailed insights into the social and healthcare inequalities exacerbated by the COVID-19 lockdown, contributing to a deeper understanding of its impact on vulnerable communities.

Chapter 2: Impact of COVID-19 Lockdown Policies on Healthcare Access in Tremont

Introduction to Tremont

Tremont is an overwhelmingly low-income, minority neighborhood located in the South Bronx, New York City. Like many neighborhoods in the Bronx, Tremont has a poor track record when it comes to the social determinants of health, due to high poverty rates, environmental hazards, and inadequate access to healthcare services. The community is primarily composed of African American and Hispanic populations, many of whom have historically faced systemic barriers to healthcare. These existing disparities made Tremont particularly vulnerable during the COVID-19 pandemic, as residents were already at higher risk for poor health outcomes because of underlying pre-existing health conditions like asthma, diabetes, and hypertension (Clark & Shabsigh, 2022; Estevez, 2020).

This research focuses specifically on the healthcare implications of the COVID-19 lockdown policies implemented by Mayor Bill de Blasio’s office between March 2020 and September 2020. Through the closing of non-essential businesses and mandating social distancing and remote learning, the mayor’s policies had far-reaching effects on access to healthcare for minority populations in the neighborhood of Tremont. Tremont could stand in as representative, in fact, of low-income, marginalized minority neighborhoods. Thus, understanding how the mayor’s policies affected healthcare access in Tremont is helpful from a public administration standpoint because it can shed light on the structural vulnerabilities of marginalized communities during public health crises and the extent to which public administrators’ policies and actions worsen or help alleviate those vulnerabilities. Furthermore, it can provide important insights into how future emergency measures can be designed to protect and support low-income, minority populations more effectively.

COVID-19 Lockdown Policies and Their Relevance to Healthcare in NYC and Tremont

In 2020, in the two zip code areas in which Tremont is located, COVID-19 cases were between 39,000 and 44,000 per 100,000 people (NYC COVID-19 Data, 2024). Total death count of the two zip codes for COVID-related deaths was 688 (NYC COVID-19 Data, 2024). The Bronx overall was the hardest hit area of NYC with 3,556 hospitalizations per 100,000 (NYC COVID-19 Data, 2024). Likewise, the Black and Latino communities were the most affected, which is what makes up the majority of the Tremont population (NYC COVID-19 Data, 2024). Per 100,000 Blacks and Latinos in all of NYC, 3,000 of each were hospitalized due to COVID (NYC COVID-19 Data, 2024). Furthermore, people in very high poverty were hospitalized the most, with 3,539 hospitalizations of the very high poverty demographic per 100,000 residents occurring citywide (NYC COVID-19 Data, 2024).

On March 15, 2020, the Office of the Mayor issued a press release that covered a variety of actions that the residents of the city were expected to follow regarding COVID. Action pertaining to healthcare included the following under the headline “New Guidance for Health Providers”: “To minimize possible exposures to healthcare workers, vulnerable patients and reduce the demand for personal protective equipment, the Department of Health and Mental Hygiene will advise patients with mild to moderate illnesses to stay home.” (NYC, 2020b). This directive, while seeming perhaps mild in intention, carried a great deal of gravity in light of the ensuing press releases and notices that followed over the course of 2020—all of which carried an intensifying tone of worry, concern, cause for alarm, and overall fear for the spread of COVID. Essentially, it laid the groundwork for residents to begin pulling back from a life of normalcy; the suggestion appeared to be that—unless one has a health emergency—do not try to access healthcare. Intentional or not, that message is conveyed in the sub-text of this press release of March 15, and reinforced by the numerous notices that followed.

Perhaps the most important press release from the Mayor’s Office came on March 22nd, 2020, when alarm bells began to be rung by city officials in earnest.

Mayor’s Office Press Release:

New Guidance for New Yorkers

“Effective Sunday, March 22nd, at 8:00 PM, all non-essential businesses in New York City will be closed. Only businesses with essential functions will be permitted to operate, such as grocery stores, pharmacies, internet providers, food delivery, banks, financial institutions and mass transit. Businesses that provide essential services must implement rules that help facilitate social distancing. The NYPD will be out in neighborhoods across the City to ensure compliance with the policies.

“The City will also enforce the following rules for non-vulnerable individuals with fines and mandatory closures:

· No non-essential gatherings; any concentration of people outside their home must be limited to workers providing essential services

· Practice social distancing in public (6 feet or more)

· Individuals should limit outdoor recreational activities to non-contact.

· Limit use of public transportation to only when absolutely necessary.

· Sick individuals should not leave home except to receive medical care.

“The City will also enforce “Matilda’s Law,” which sets the following restrictions for vulnerable New Yorkers who are over the age of 70 and/or immune-compromised:

o   Remain indoors

o   Limit outdoor activity to solitary exercise

o   Pre-screen all visitors and aides by taking temperature

o   Wear a mask when in company of others

o   Do not visit households with multiple people

o   Everyone in presence of vulnerable people should wear a mask

o   Stay six feet from other people

o   Do not take public transportation unless absolutely necessary” (De Blasio, 2020).

The message was clear: people should not be out and about, should not be going about their lives normally as they would otherwise; and by extension they should not try to access healthcare as they normally would. Mayor de Blasio’s guidance was followed three weeks later by the following health alert:

“April 11, 2020 Dear Colleagues: It has been more than five weeks since New York City reported its first person diagnosed with COVID-19. We continue to see an increasing number of persons diagnosed with COVID-19, including those who require hospitalization. As of April 11, 2020, there were 96,522 COVID-19 cases reported in New York City, with 27% hospitalized, and 5,463 confirmed deaths. To continue to flatten the curve of this pandemic and to protect health care delivery systems, it is critical to continue to enforce and adhere to existing mitigation measures, including all social (physical) distancing interventions” (2020 Health Alert #10, 2020).

Again, the message to residents was clear and ominous: socially distance, and do not go out or be near others. Fear continued to be amplified and New Yorkers continued to be warned that they must adhere to Mayor de Blasio’s lockdown protocols to “flatten the curve.” In such a heightened state of alarm, all normalcy could be expected to be abandoned—including the reception of regular healthcare services. These may well indeed have remained available, technically, but the Mayor’s Office was clearly warning residents that they should hide.

The following month (May 4, 2020) Health Alert #13 went out alerting residents of another infectious disease spreading: “a pediatric multi-system inflammatory syndrome” which ratcheted up fears still further, as though New Yorkers needed more fuel for their worry (2020 Health Alert #13, 2020).

By October 2020, the strategy meant to slow the spread and flatten the curve was not only still being implemented it was also becoming more draconian, as the city issued yet another NOTICE to New Yorkers:

October 9, 2020 NOTICE:

New York City’s Localized COVID-19 Restrictions To all licensees and registrants:

“The City of New York has taken action in response to the increased spread of COVID-19 cases in particular neighborhoods by implementing restrictions in three zones identified by the State— designated red, orange, and yellow. Visit nyc.gov/COVIDZone to identify the areas in each zone and familiarize yourself with the restrictions relating to: • Public and non-public schools • Businesses • Food service establishments including indoor and outdoor dining • Houses of worship • Non-essential gatherings

Restaurants located in the red zones are prohibited from indoor and outdoor dining and may only offer carryout and delivery options. Restaurants located in the orange zones can offer outdoor dining and takeout and delivery service only. There is a four-person maximum per table; no indoor dining is allowed. Only essential businesses as designated by New York State Empire State Development Corporation can remain open in the red zones. All nonessential businesses located in the red zones must close. Licensees and registrants should communicate with their customers to ensure waste is collected promptly and safely. Business Integrity Commission enforcement agents will be patrolling the affected areas” (NYC, 2020c).

By December 2020, the city essentially announced that there would be no return to the pre-COVID normal—life was now changed forever from here on out: “The COVID-19 pandemic has changed how we live and work in New York City in many ways…” the press release began (NYC, 2020d). It pertained primarily to road safety—but the ominous tone told far more than the text on the statement did. Mayor de Blasio’s COVID response had altered the way the people of New York lived their lives—and, to some extent, how they cared for them.

Finally, on May 1, 2021, a little over one year after the initial press release given by the Mayor, a notice entitled “Managing the Return to the Office in the Age of COVID-19” was issued. Not only was all pretense to slowing the spread gone for good but the Office was now using the tragic-sounding “Age of COVID-19” to define the times in which people now found themselves living. Among the requirements of people returning to work one year after the attempt by the Mayor to begin flattening the curve with lockdowns were the following:

· Public areas are being cleaned in accordance with DOHMH’s guidance

· 6 ft. markers have been implemented and poste for enforcing the City’s health assessment requirements for employers, visitors, and clients.

· Occupancy limitations for shared spaces (e.g., conference rooms, huddle spaces, pantries, break rooms, copy rooms) have been posted.

· Signage has been posted throughout all workspaces reminding individuals to adhere to proper hygiene, physical distancing rules, face covering requirements, and cleaning and disinfecting protocols.

· Workspaces that do not allow for physical distancing have been blocked off (NYC, 2021).

In case anyone had failed to realize, Mayor de Blasio’s Office had, to put it colloquially, doubled, tripled, and quadrupled down on his initial COVID response strategy. Whatever sense New Yorkers had of being part of a community in which they could live, breathe, and mingle as one people without fear or worry was effectively all but gone. Surely, this approach to a public health crisis had an effect on the extent to which the people of Tremont enjoyed access to regular healthcare.

Other Considerations

New York City’s lockdowns in 2020 delayed serious healthcare procedures for many in the Bronx. Cancer and mental health treatments were postponed during 2020 at alarmingly high rates (Dorvil et al., 2023). Indeed, Dorvil et al. (2023) found that “more than half of participants (54%) reported disruption to either routine physical healthcare or mental health services. Concern about getting COVID-19 (61%), stay-at-home policies (40%), belief that care could safely be postponed (35%), and appointment challenges (34%) were among reasons for delaying routine healthcare. Concern about getting COVID-19 (38%) and reduced hours of service (36%) were primary reasons for delaying mental healthcare. Reported reasons for the sustained delay of care past 18?months involved COVID concerns, appointment, and insurance challenges” (p. 1).

Ultimately, Hammond (2021) boiled it down to a few points:

· “The state’s early response was undermined by flawed guidance from the federal government, inadequate planning and stockpiling, limited consultation with experts, exaggerated projections and poor cooperation between federal, state and local officials, among other issues.

· “To date, none of the Legislature’s pandemic-related hearings has focused on the critical missteps of the state’s early response.

· “Better-controlled outbreaks in countries such as South Korea demonstrate the value of public health preparedness and could serve as a model for New York” (p. 1).

Clearly, the COVID-19 lockdowns had big consequences for low-income communities. The effects were particularly severe in terms of access to healthcare for the people of Tremont, however.

Tremont experienced new barriers to healthcare during the lockdown. The closure of clinics and restricted public transportation options made it difficult for residents to access essential medical services, as Dorvil et al. (2023) pointed out, if they even wanted to try in the face of the Mayor’s Office’s warnings. The shift to telemedicine also likely affected disparities, as many low-income households lacked access to stable internet or the necessary technology to participate in virtual healthcare visits (Office of the State Comptroller, 2021). This digital divide was a major issue for the community of Tremont, where residents already faced systemic barriers to healthcare before the pandemic.

In Tremont, as elsewhere in the US, there was reduced access to preventive care, chronic disease management, and even necessary mental health services (Irimata et al., 2023). The lockdown orders essentially exposed healthcare inequities for those dealing with diabetes and other chronic conditions that require consistent, regular management. The closure of non-essential businesses and healthcare facilities limited residents’ access to routine medical services, preventive care, and management of chronic conditions. This was particularly problematic for Tremont’s minority population, many of whom rely on local community health centers and public hospitals for affordable healthcare. These facilities, already underfunded and strained before the pandemic, were further overwhelmed by the surge of COVID-19 cases, making it difficult for residents to receive timely and adequate medical care (Shiman et al., 2021).

Healthcare Access Challenges During the Lockdown

One of the most significant consequences of the lockdown policies was the disruption of healthcare services in Tremont, as in the other low-income communities of the Bronx (Office of the Comptroller). The citywide shutdown of non-essential services included many healthcare providers, such as primary care clinics and specialists, which played an important part in managing chronic conditions for residents of low-income neighborhoods like Tremont. Chronic conditions, including asthma, diabetes, and cardiovascular disease, are prevalent in the Bronx and disproportionately affect minority populations (Clark & Shabsigh, 2022). With limited access to healthcare providers during the lockdown, many residents were unable to receive essential care, leading to a deterioration in their health. The Office of the Comptroller (2023) concluded:

“According to the most recent New York City Community Health Profiles, each of the 10 neighborhoods in the borough had rates of diabetes, obesity and hypertension that were similar or higher than the citywide average, with none experiencing rates below the average. The New York City Department of Health and Mental Hygiene has noted the prevalence of these poorer health outcomes in low-income, minority communities where economic stress and discrimination can limit access to quality health care.

“Analysis of the correspondence between COVID-19 health outcomes in the Bronx and median household income and share of minority residents found an association with more severe health impacts. In general, throughout the pandemic, the six neighborhoods with the lowest household incomes in the Bronx, among the lowest citywide, have been among those with the highest hospitalization rates from COVID-19. Most ZIP codes associated with these neighborhoods fell within the top third of hospitalization rates citywide. The four Bronx neighborhoods that had more moderate median household incomes also had lower hospitalization rates.

“Neighborhoods in the City that had a higher share of minority residents generally experienced higher cumulative case rates and death rates. Eighteen of the City’s 55 Census-defined neighborhoods had a minority population in the top third in 2019, greater than 83 percent. Of these 18 City neighborhoods, eight were in the Bronx. The 20 ZIP codes covering these eight Bronx neighborhoods all had cumulative death rates within the top half of all City ZIP codes, and 11 were in the top third. The results are very similar for case rates.

“While similar neighborhoods are also located in other boroughs (and were affected similarly to those in the Bronx), those boroughs also include more middle- and high-income areas, which were affected less severely and generally suffered from lower rates of hospitalizations and deaths.”

Additionally, the healthcare system in the Bronx was overwhelmed by the pandemic, with hospitals inundated by COVID-19 patients (Office of the Comptroller, 2023). This strain on the system resulted in delays in treatment for non-COVID conditions, further exacerbating healthcare disparities in Tremont. Residents faced longer wait times for medical appointments, reduced access to testing and treatment for chronic conditions, and limited availability of healthcare professionals due to the reallocation of resources toward COVID-19 care (Friedman & Lee, 2023). The lack of accessible healthcare during this critical period may have contributed to worsened health outcomes in Tremont, as residents were unable to manage their existing health issues effectively.

Disproportionate Impact on Minority Populations in Tremont

The COVID-19 pandemic disproportionately affected minority populations across New York City, with African American and Hispanic communities experiencing higher rates of infection, hospitalization, and death (Office of the Comptroller, 2023). In Tremont, where the majority of residents belong to these minority groups, the lockdown policies compounded existing healthcare disparities. Structural factors included overcrowded housing, reliance on public transportation, lower access to healthcare, and lower rates of health insurance coverage, all of which increased residents’ vulnerability and limited their ability to access healthcare services safely during the lockdown (Friedman et al., 2023).

Moreover, many Tremont residents faced language barriers, lack of internet access, and limited health literacy, which further hindered their ability to navigate the healthcare system during the pandemic (Office of the Comptroller, 2023). The transition to telemedicine services, which became more prevalent during the lockdown, posed additional challenges for low-income residents who lacked reliable internet access or the digital literacy needed to participate in virtual healthcare appointments (Roldós, Jones, & Rajaballey, 2024). As a result, many residents were unable to receive timely medical advice or follow-up care, further exacerbating health disparities in the community.

The Role of Public Hospitals and Community Health Centers

Public hospitals and community health centers are essential in providing healthcare to low-income residents in neighborhoods like Tremont. However, these institutions were severely impacted by the pandemic, as there were resource shortages, staff burnout, and an overwhelming influx of COVID-19 patients. According to Huang and Li (2022), hospitals in the Bronx, including those serving Tremont, were among the hardest hit during the early months of the pandemic, with many reaching capacity and struggling to provide adequate care.

Community health centers, which provide essential services such as primary care, dental care, and mental health support, were forced to reduce services or close temporarily due to the lockdown policies. This left many Tremont residents without access to basic healthcare services, which are critical for managing chronic conditions and maintaining overall health. The reduced availability of these services during the lockdown may have contributed to the deterioration of health outcomes in the neighborhood, particularly for vulnerable populations who rely on affordable, accessible healthcare (Shiman et al., 2021).

The Consequences of Delayed and Reduced Healthcare Access

The delayed and reduced access to healthcare during the lockdown had significant consequences for the health and well-being of Tremont residents. For individuals with chronic conditions, such as diabetes or hypertension, regular medical visits are essential for monitoring and managing their health. The inability to access these services during the lockdown likely led to the worsening of these conditions, increasing the risk of complications and hospitalizations (Clark & Shabsigh, 2022).

Furthermore, the delay in seeking care due to fear of contracting COVID-19 in healthcare settings contributed to poorer health outcomes. Many residents were hesitant to visit hospitals or clinics during the pandemic, even for urgent health issues, due to concerns about exposure to the virus. This fear, combined with the overwhelmed healthcare system, resulted in many individuals delaying or forgoing necessary medical care, leading to preventable health complications (Huang & Li, 2022).

Addressing the Healthcare Disparities Exacerbated by the Lockdown

The COVID-19 pandemic underscored the deep-rooted healthcare disparities that exist in low-income, minority neighborhoods like Tremont. The lockdown policies, while necessary to control the spread of the virus, further limited access to healthcare for vulnerable populations and exacerbated existing inequalities. Moving forward, it is essential for policymakers to consider the unique needs of marginalized communities when designing public health interventions. Ensuring equitable access to healthcare, particularly during public health emergencies, is critical to preventing further harm to these communities.

Policy recommendations for future public health crises should include increased funding for public hospitals and community health centers, expanded access to telemedicine services with support for digital literacy and internet access, and targeted outreach efforts to ensure that minority populations receive timely and accurate health information. By addressing these systemic issues, policymakers can help reduce healthcare disparities and improve health outcomes for low-income, minority communities like Tremont during future crises (Shiman et al., 2021; Friedman & Lee, 2023).

Conclusion

The COVID-19 pandemic and the subsequent lockdown policies enacted by Mayor Bill de Blasio’s office between March 2020 and September 2020 had serious effects on low-income communities across New York City, particularly in neighborhoods like Tremont in the Bronx. As this research has shown, Tremont is home to a predominantly minority and low-income area, and was already grappling with significant socio-economic challenges, including inadequate access to healthcare, high rates of chronic illnesses, and environmental injustices, all of which contribute to the social determinants of health and disease. These pre-existing vulnerabilities were especially worsened by the public health measures of the mayor’s office.

The lockdown policies resulted in the temporary closure or limitation of many healthcare facilities that residents of Tremont relied on for essential services. Community clinics and public hospitals, which provide care to uninsured and underinsured residents, were also overwhelmed by the surge of COVID-19 patients. This led to delays in care for non-COVID-related health issues and a reduction in routine medical services, such as chronic disease management and preventive healthcare, worsening health outcomes for many in the community.

Furthermore, the healthcare disparities that were already present in Tremont became more pronounced as access to care diminished during the lockdown. Factors such as overcrowded living conditions, reliance on public transportation, and limited access to digital resources for telemedicine further exacerbated these challenges, placing Tremont’s residents at a higher risk of severe illness and death from both COVID-19 and untreated pre-existing conditions.

Chapter 3: Methodology

This chapter discusses the research methods used to explore how Mayor de Blasio’s COVID-19 lockdown policies affected access to healthcare for the minority population in Tremont. As this study’s intention is to explore and better understand the lived experiences of a marginalized community, a qualitative research methodology is utilized. This approach allows for a detailed investigation into the perceptions and healthcare-related experiences and realities faced by residents during the pandemic.

Research Design

The study uses a case study approach to focus on Tremont, a low-income, predominantly minority neighborhood in the Bronx. The qualitative methodology is chosen because it provides an in-depth examination of personal experiences, as described by Crabtree and Miller (2023). This approach enables the researcher to explore the consequences of lockdown policies on healthcare access, employment, and education by gathering primary data from the affected community.

The two primary methods of data collection used were semi-structured interviews, conducted with residents of Tremont and local healthcare professionals; and document analysis, reviewing local government notices and press releases, public health data, and media articles documenting the implementation of COVID-19 policies.

Sampling

A purposive snowball sampling method was used to ensure that participants reflect diverse perspectives within the Tremont community. The interview sample included residents of Tremont, i.e., low-income individuals and families affected by the city’s policies. It also included healthcare professionals, i.e., workers from clinics and hospitals serving Tremont.

Residents of Tremont

Efforts were made to include individuals from various age groups, genders, and ethnic backgrounds to capture true demographic representation of residents within the full range of healthcare access experiences. This group of participants overall encompassed individuals with chronic health conditions, who had a more urgent need for healthcare, as well as generally healthy residents who still encountered barriers to healthcare access.

Priority was given to low-income residents, as economic limitations often compounded barriers to accessing healthcare during the pandemic. Residents with direct experiences of either delayed or denied care due to facility closures, transportation restrictions, or lack of telehealth resources were specifically targeted.

Healthcare Professionals Serving Tremont:

This subgroup consisted of doctors, nurses, and administrative staff from healthcare facilities in or near Tremont. These professionals were selected for their firsthand insights into the systemic strain placed on local healthcare resources and the challenges of adapting to telemedicine, facility restrictions, and other pandemic-related adjustments.

Including various healthcare roles allowed the study to capture a multi-layered perspective on how different functions within healthcare facilities responded to the increased demand and limitations imposed by lockdown policies. For example, physicians could describe treatment delays, while administrative staff could speak to challenges in scheduling and communicating with patients.

This sampling approach was structured to achieve data saturation, so that recurring themes and issues could be captured across different participant groups. With a focus on residents with varied experiences and roles within the healthcare and resident sectors of Tremont, the sample was deemed likely sufficient to address the study’s research questions comprehensively, to gain insights into the lived experiences of healthcare access and the community impact of lockdown policies.

Data Collection

Semi-structured Interviews

The interviews are semi-structured, allowing flexibility to capture detailed personal narratives while ensuring key research questions are addressed. Each interview lasted approximately 45 minutes to one hour.

The interviews were conducted in person, with audio recordings of each. The audio recordings were transcribed verbatim for analysis.

Document Analysis

To provide a broader context, the study incorporates an analysis of secondary data sources, including:

· Public health records from the New York City Department of Health.

· Reports issued by the Mayor’s office on lockdown regulations.

· Local news and media articles documenting the implementation of the lockdown in the city. These documents were analyzed to triangulate interview findings and provide insights into broader policy impacts.

Data Analysis

The data were analyzed using thematic analysis, which involves identifying recurring patterns and themes from the interview transcripts and documents. Thematic analysis is well-suited for this study as it allows for the categorization of common issues such as barriers to healthcare access, economic hardship, and social inequalities exacerbated by the lockdown. Important steps in the analysis process included familiarization, coding, and theme development. Familiarization involved reading through transcripts and documents to gain a complete understanding of the data. Coding involved labeling segments of text with codes that represent key ideas or concepts (e.g., "healthcare barriers," "economic impact"). Theme development involved grouping related codes into themes that reflect the primary issues affecting Tremont residents.

Ethical Considerations

This research adheres to strict ethical guidelines to ensure the confidentiality and well-being of participants. Participants provided informed consent, and all data were anonymized to protect their identities. The interviews were conducted with sensitivity to participants' experiences during the pandemic, and they were offered emotional support resources if needed.

Semi-Structured Interview Questions: Healthcare Access

The semi-structured interview process was supported the by the following interview questions:

For Residents

1. Access to Healthcare Services

· How did the COVID-19 lockdown affect your ability to access healthcare services (e.g., doctor’s appointments, medications)?

· Were there any specific health services that became harder or impossible to access during the lockdown?

· How did the closure of non-essential healthcare facilities impact your ability to manage chronic health conditions, if applicable?

2. Telemedicine and Digital Access

· Were you able to use telemedicine during the lockdown? If so, how was your experience with accessing virtual healthcare services?

· Did you encounter any issues related to technology or internet access when trying to use telemedicine?

· How do you feel about the shift from in-person to virtual healthcare during the lockdown? Was it sufficient for your needs?

3. Delayed or Forgone Care

· Did you delay or avoid seeking medical care during the lockdown due to COVID-19 concerns? If yes, why?

· How did any delays in care affect your health or the health of family members?

· Were there any specific treatments or procedures you had to postpone? How did the postponements impact your condition?

4. Health Outcomes and Concerns

· In what ways did the lockdown policies influence your overall health and well-being?

· Were there any health issues that worsened due to the reduced access to healthcare during the lockdown?

· What were your biggest concerns regarding healthcare access during the pandemic?

5. Perception of Healthcare System Response

· How would you describe the response of local healthcare facilities during the lockdown? Did you feel supported or abandoned by the healthcare system?

· In your opinion, how could the healthcare system have responded better to meet the needs of people in your community during the lockdown?

6. Barriers to Access

· What were the primary barriers you faced in accessing healthcare during the lockdown (e.g., transportation, fear of exposure, facility closures)?

· Did you encounter any financial barriers to receiving healthcare during this period?

7. General Reflection

· Looking back, what would you say were the biggest challenges related to healthcare access during the lockdown?

· If another public health crisis were to happen, what improvements in healthcare access would you like to see for your community?

For Healthcare Professionals

1. What were some of the biggest challenges your facility faced in providing healthcare to non-COVID patients during the lockdown, especially those with chronic conditions?

2. How did the lockdown impact your ability to communicate with and support patients who had limited access to technology or internet for telemedicine services?

These questions were designed to elicit detailed and personal accounts of the experiences people faced regarding healthcare access during the lockdown, so that key themes such as barriers, delays, and telemedicine use were covered.

Piloting of the Research Questions

Before conducting the full series of interviews for the study, a pilot test of the interview questions was conducted with two interviewees. This preliminary step aimed to evaluate the clarity, relevance, and effectiveness of the questions in capturing the desired data on healthcare access during the COVID-19 lockdown. The two participants selected for the pilot were:

1. Participant A: A local resident with a chronic health condition (asthma) that required regular medical care.

2. Participant B: A healthcare professional working in a community clinic in Tremont during the pandemic.

The piloting process provided valuable insights into the suitability of the interview questions and allowed for adjustments to be made before the full data collection.

Clarity of Questions

Both participants found the questions generally clear and easy to understand. However, Participant A expressed some confusion about the phrasing of the question regarding telemedicine access, particularly when asked about “digital barriers.” They requested more specific prompts related to internet access or device usage, which led to the rewording of this question to include examples such as "Did you have trouble with internet access or using telemedicine apps?"

Relevance to Research Objectives

The questions effectively elicited detailed responses from both interviewees. Participant A shared personal experiences about postponing medical appointments and the emotional stress caused by lack of healthcare access. This helped confirm that the questions were well-aligned with the research objective of understanding the lived experiences of residents during the lockdown.

Participant B offered insights from a healthcare provider’s perspective, particularly on the strain faced by clinics and the challenges of transitioning to telemedicine. The questions about healthcare system responses and delayed care provided rich data on the healthcare system's limitations and the barriers that patients faced. However, Participant B suggested including a follow-up question about the availability of resources or support during the telemedicine shift, which was later added to the interview guide.

Ability to Produce In-depth Responses

Both participants provided extensive responses to most questions, indicating that the semi-structured format encouraged them to share their experiences without feeling restricted by overly rigid questioning. Participant A gave detailed accounts of their inability to access asthma medication, and how they attempted to self-manage the condition. Participant B explained the overwhelming demand for healthcare services during the lockdown, coupled with limited resources, illustrating the challenges healthcare providers faced.

However, the pilot test revealed that some questions, particularly those on delayed or forgone care, could benefit from additional probing. For instance, when Participant A mentioned delays in care, a follow-up question on the specific health impacts of those delays elicited more nuanced responses. This insight led to the addition of prompts like “How did these delays impact your health or well-being?”

Emotional Sensitivity and Ethical Considerations

The pilot interviews demonstrated the importance of emotional sensitivity, especially for residents who faced significant health challenges. Participant A became emotional when discussing the stress of managing a chronic condition during the lockdown, which highlighted the need for empathetic interviewing techniques. This prompted the inclusion of more supportive language in the final interviews, such as offering participants a chance to take a break or skip questions if they felt uncomfortable.

Adjustments Made Based on Pilot Feedback

Terms were clarified and questions reworded about telemedicine and digital barriers for better clarity. Also, more prompts were added, including more follow-up questions to elicit detailed accounts, especially related to the consequences of delayed care. Some more empathy was also given to phrasing by adjusting the language to be more sensitive, so that participants felt comfortable sharing emotionally charged experiences.

Overall, the pilot interviews confirmed that the research questions were effective in generating the desired data on healthcare access, while also providing an opportunity to refine the interview guide for the full study. These adjustments helped ensure that the interviews would not only produce rich, detailed data but also allow participants to express their experiences in a safe and supportive environment.

Chapter 4: Findings

The findings of this study are organized around the major themes identified through thematic analysis of interview data and relevant documents. These themes are derived from the responses of Tremont residents and healthcare professionals. They reveal the challenges residents faced in accessing healthcare during the COVID-19 lockdown. They also show the compounded effects of socio-economic factors, technology access disparities, the response of local healthcare, and the messaging of the Office of the Mayor. First presented are answers to the questions, and second are the themes as they appear.

For Residents

1. Access to Healthcare Services

· How did the COVID-19 lockdown affect your ability to access healthcare services (e.g., doctor’s appointments, medications)?

· "They shut everything down. My regular spot was closed. I couldn’t get meds like I used to. I’d call, they say, ‘Sorry, we full up’ or they don’t answer. I just deal with it on my own."

· "Forget about it. I tried getting an appointment, but they keep push back. I miss whole month blood pressure pills ‘cause nobody is help."

· "It was nearly impossible to see my doctor during the lockdown. My regular clinic was either closed or had such long waiting times that I gave up. I went without my medication for a while because getting a refill felt like such a challenge."

· "Total mess. My doctor’s office closed, and when I called they just said ‘try again next week’ or some nonsense like that. I was left just tryna hold it together on my own."

· "It was real hard…My mom got check-ups, but all that got put on hold. I was worried every day ‘cause we couldn’t see the doctor like usual."

· "Appointments were canceled. It was just hard. Said they could only offer virtual consultations, like what the ---- is that?"

· Were there any specific health services that became harder or impossible to access during the lockdown?

· "Yeah, I was supposed to get my knee checked out, but every place told me, ‘Nah, we only takin’ emergencies right now.’ By time I got appointment, it was way worse. Couldn’t barely walk by then."

· "I needed a dentist bad ‘cause my tooth was killin’ me, but they wasn’t takin’ nobody unless it was an emergency. Had to live with that pain for months."

· "I needed physical therapy. Nope, nothin’ open, too bad. When they finally open, there’s a wait list a mile long."

· "Can’t even get no dentist! I had a tooth infection, man! Nope! They ain’t even gonna open up."

· "For real, I needed some dental work, but they wouldn’t even let me in the door."

· "I couldn’t get to my regular asthma appointments. I was just out here. I had to just hope I didn’t get worse."

· How did the closure of non-essential healthcare facilities impact your ability to manage chronic health conditions, if applicable?

· "I have diabetes, so I need regular check-ups to manage my blood sugar levels. When the clinic closed, I couldn’t get the support or monitoring I needed, which led to a few emergency visits."

· "The lockdown meant I couldn’t go in for my asthma checks, which usually help me manage my symptoms. Without those visits, I ended up in the ER more than once because I couldn’t keep it under control."

· "I got asthma, I got diabetes, I got it all. I got high blood pressure. I usually see my doctor every few weeks to keep me in check. But I couldn’t get no help, couldn’t get no inhaler on time. Nothin’. I was strugglin’ bad, and there was no one around to help."

· "My sister got asthma, and she couldn’t see her specialist. She started wheezing real bad, and we had nowhere to go. It’s like they just forgot about everybody who wasn’t dealing with COVID."

· "The diabetes got rough. My numbers was all over the place ‘cause I couldn’t see my doc. They kept tellin’ me to call back, but no one would pick up, and I didn’t know what to do."

2. Telemedicine and Digital Access

· Were you able to use telemedicine during the lockdown? If so, how was your experience with accessing virtual healthcare services?

· "Nah, I ain’t got no laptop or fancy phone. They talkin’ ‘bout video calls, but I could barely get a phone call to go through without droppin’. Ain’t no way that was workin’ for me."

· "I tried it once, but the doctor couldn’t hear me half the time. Plus, I got a prepaid phone, and the minutes run out quick with video. Just wasn’t made for folks like us, you know?"

· "Telemedicine was all they offered, but I don’t have good internet. I tried to use it a couple of times, but it was difficult. I was hanging up out of frustration because I couldn’t hear what the doctor was saying."

· "Yes, I used telemedicine, but it wasn’t very effective for what I needed. The doctor couldn’t examine me physically, so they just prescribed medication based on what I described. It felt very impersonal."

· "Yeah, I tried, but it was weird. I couldn’t get a good signal half the time, and I just kept sayin’, ‘Hello? You hear me?’ It wasn’t workin’ right. Felt like they was just rushin’ me off the phone, you know?"

· Did you encounter any issues related to technology or internet access when trying to use telemedicine?

· "Absolutely. I don’t have a smartphone or a laptop, and the internet connection in my area isn’t reliable. I ended up missing a few appointments just because the call kept dropping."

· "I don’t got Wi-Fi, so I was just tryna do it off my data. But the video kept freezing up, and then I’d get kicked off. I had to give up ‘cause it was just too stressful tryna make it work."

· "I had to borrow my cousin’s phone just to make it work, and even then, it was rough. I don’t got no computer, and my old phone kept freezin’ up. I felt like they was speakin’ another language."

· "I was using my phone, and it was frustrating because I couldn’t get clear instructions on my condition, and I felt lost most of the time."

· How do you feel about the shift from in-person to virtual healthcare during the lockdown? Was it sufficient for your needs?

· "Not at all. I prefer face-to-face consultations because my doctor can actually see what’s wrong. Virtual care doesn’t give the same level of attention, and it felt like they were just trying to rush through the call."

· "Telemedicine might be okay for some things, but it didn’t work for me. My needs weren’t met because it’s hard to explain certain symptoms over the phone without the doctor seeing me."

· "It ain’t help. They actin’ like it’s all the same, but it’s not. Sometimes you need someone to look at you, not just talk on some screen."

3. Delayed or Forgone Care

· Did you delay or avoid seeking medical care during the lockdown due to COVID-19 concerns? If yes, why?

· "Oh yeah, I stayed home. Everyone was sayin’ how dangerous it was out there, so I just tried to handle it myself. Had a lotta fear about catchin’ somethin’ if I went to the clinic."

· "I didn’t even think about goin’ nowhere ‘cause they made it sound like if you step outside, you gon’ get sick. Didn’t wanna end up in the hospital, so I kept puttin’ it off."

· "I was worried about catching COVID at the clinic. I decided to wait out my symptoms, but that probably made things worse."

· "Absolutely. With all the fear, I just didn’t want to go near any healthcare. Even when I felt really sick, I stayed home, thought I could manage on my own."

· How did any delays in care affect your health or the health of family members?

· "By the time I went to get help, my condition was way worse. Couldn’t hardly breathe some days. I ended up in the ER ‘cause I couldn’t manage it no more. And felt like they just about killed me in there with all their crazy COVID protocols—feel like I’m lucky to be alive! Definitely feel like I would have been better just staying home, man."

· "My diabetes went outta control. I knew I needed help, but I kept waitin’ and waitin’. Now I got more issues than I did before all this started. Ended up passin’ out one day, and they had to call an ambulance. Scared my family."

· "The delays took a toll. My blood pressure spiked because I wasn’t monitored, all could have been avoided with regular check-ups."

· "I delayed going to the doctor, and my condition worsened. What would have been a simple treatment turned into a more serious issue because I wasn’t able to get help right away."

· Were there any specific treatments or procedures you had to postpone? How did the postponements impact your condition?

· "I was supposed to get some kinda scan done on my back. Had to cancel it, though, ‘cause they weren’t seein’ nobody. Now I got more pain than before, and it’s like they just don’t care."

· "I was scheduled for a minor surgery that got postponed indefinitely. Without it, my symptoms worsened, and I experienced a lot of pain that could have been avoided."

· "Had an appointment to fix a bad tooth, but they canceled it. When I finally got seen, they had to pull it out. All that pain, just to lose the tooth."

· "I was supposed to get some tests done for my heart, but they shut it down. I don’t even know what’s goin’ on with me ‘cause I ain’t been able to see nobody."

· "I had to delay a dental procedure for a cavity. Ended up I needed a root canal instead of a filling, what should have been a filling, I mean."

4. Health Outcomes and Concerns

· In what ways did the lockdown policies influence your overall health and well-being?

· "The lockdown added so much stress to my life. Financial struggles. Not being able to see my doctor. Depression got worse."

· "Stress, straight up. I was stressed out all the time, worried about gettin’ sick, and my health got worse. Bein’ stuck inside, not seein’ my doctor, it all stacks up. I felt drained every day."

· "I was scared, honestly. Health was already shaky, and with no doctor around, I was just prayin’ I didn’t get worse. My anxiety went through the roof."

· "It made me more anxious and isolated. My physical health went downhill too, especially because I couldn’t manage my chronic conditions as well without regular healthcare access."

· Were there any health issues that worsened due to the reduced access to healthcare during the lockdown?

· "Yeah, my asthma was way worse. I couldn’t get my refills on time, so I was usin’ what I had sparingly. Had a lot more attacks, and it scared me to go to the ER."

· "My sugar levels went up bad. I didn’t have the usual check-ups, couldn’t go out and get exercise, just eatin’ bad, couldn’t keep things under control. My doctor couldn’t see me, so I just got bad."

· "My diabetes got out of control, and I had other complications because I couldn’t get adjustments."

· "My asthma was worse. Was a struggle to breathe at times. I couldn’t get help easily."

· What were your biggest concerns regarding healthcare access during the pandemic?

· "I was most worried about my condition worsening to a point where it would be hard to recover, simply because I couldn’t get the care I needed in time."

· "I worried that I would end up with serious complications from my untreated issues. Not knowing when I could get help again made me very anxious."

· "The biggest thing was not knowin’ what was gonna happen next. I needed help, but every door was shut. Felt like I was on my own, like nobody cared."

5. Perception of Healthcare System Response

· How would you describe the response of local healthcare facilities during the lockdown? Did you feel supported or abandoned by the healthcare system?

· "I felt like we was forgotten. Like they only cared ‘bout COVID patients and left the rest of us to deal on our own. They sayin’ to stay home, but what if stayin’ home is makin’ us worse?"

· "I felt abandoned. The system was so focused on COVID-19 that it felt like they forgot about people with other health issues. There was no guidance on what to do for people like us."

· "It seemed like the system didn’t care about us. We were on our own. I needed help, but everything was either closed or overwhelmed. It was a difficult time."

· In your opinion, how could the healthcare system have responded better to meet the needs of people in your community during the lockdown?

· "They coulda set up something, so we ain’t mixed with the COVID. Separate spots, I don’t know. It woulda made a difference."

· "They shoulda thought ‘bout people with no internet, no tech. If they really cared, they’d make sure everyone had access, not just the ones who can go online."

· "There should have been more resources for non-COVID conditions, even if that meant setting up for chronic patients."

· "The system could have done more to support people who needed regular care. Keeping things open would have made a big difference."

6. Barriers to Access

· What were the primary barriers you faced in accessing healthcare during the lockdown (e.g., transportation, fear of exposure, facility closures)?

· "The biggest thing was fear. Every time I thought about goin’ out, I’d remember how they said stay home or you’ll get sick. That stuck with me, so I didn’t wanna go nowhere."

· "The main barrier was that my usual clinic was closed. I couldn’t get there without reliable transportation, and I didn’t feel safe taking public transit during COVID."

· "Fear of exposure was a big one for me. I didn’t want to risk going into a clinic where COVID might be spreading, so I stayed away."

· Did you encounter any financial barriers to receiving healthcare during this period?

· "Yes, the lockdown affected my job, so I was worried about the costs. I delayed some care because I wasn’t sure if I could afford it with my reduced income."

· "Absolutely. I lost hours at work and was afraid I couldn’t pay for medications, so I skipped some of my regular medications to save money."

· "Money was tight, yeah. I lost hours at work, and payin’ for meds got hard. I started rationin’ my pills ‘cause I didn’t know when I could afford more."

· "For sure. Lost hours, couldn’t afford my meds. Had to skip doses ‘cause I couldn’t pay, and I knew it wasn’t good for me, but I ain’t got no choice."

7. General Reflection

· Looking back, what would you say were the biggest challenges related to healthcare access during the lockdown?

· "Not bein’ able to go see my doctor, that was number one. Felt like all the healthcare doors was closed to us, like we didn’t count."

· "The hardest part was gettin’ help. Every time I called, they was closed or booked up. I was just on my own for months."

· "The biggest challenge was the lack of in-person healthcare. Virtual appointments didn’t feel like enough, especially for people with chronic issues."

· "Access was the biggest issue. Everything was either closed or restricted. We felt left out and helpless, especially since the system seemed so focused on COVID cases."

· If another public health crisis were to happen, what improvements in healthcare access would you like to see for your community?

· "There should be designated clinics for non-COVID patients so we can still get the care we need."

· "Better telemedicine options, more support for low-income patients, and a plan to keep chronic care clinics open would be essential. We need a healthcare system that considers all health issues, not just the crisis at hand."

For Healthcare Professionals

1. "What were some of the biggest challenges your facility faced in providing healthcare to non-COVID patients during the lockdown, especially those with chronic conditions?"

· "The hardest part was having to turn away patients who needed regular care. Our focus was shifted almost entirely to COVID patients, so managing chronic cases was pushed to the back burner. We didn’t have the staff or resources to handle both COVID and our regular patient load, so people with chronic conditions were left to wait, sometimes for months."

· "Balancing COVID care with everything else was nearly impossible. A lot of our non-COVID patients relied on frequent visits for things like diabetes and hypertension. Asthma, things like that. But PPE and staff shortage—it got so that we could only see emergencies. We wanted to help, but so many restrictions, there wasn’t much we could do. It was heartbreaking because we knew the situation for a lot of people was probably declining."

· "We were short on almost everything—staff, equipment, time. Chronic patients need routine management, but every time we tried to arrange appointments, we had to consider the risk of exposure. For a lot of them, the visits they needed to stay stable just didn’t happen, and it was frustrating for us, too."

2. "How did the lockdown impact your ability to communicate with and support patients who had limited access to technology or internet for telemedicine services?"