COVID Lockdowns and Healthcare Access in Bronx's Tremont

Introduction and Background: Tremont and the COVID-19 Pandemic

The panic surrounding the 2020 COVID-19 pandemic created new administrative challenges around simultaneously protecting and serving communities. Many cities across America reacted to COVID-19 by trying to curb the virus's spread through the implementation of lockdowns. Local governments enacted strict measures that changed daily life overnight and exposed the vulnerabilities of already underserved and marginalized communities.

In New York City, one of the worst-hit cities in the United States, Mayor Bill de Blasio's office issued a series of lockdown policies beginning in March 2020 (NYC, 2020; Tolentino et al., 2021). 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 largely reported on these measures as necessary to contain the public health crisis; however, for the communities affected, the consequences were far-reaching—particularly for the population of Tremont in the Bronx.

Tremont is a predominantly minority community in the Bronx that has long been characterized by socioeconomic 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. Males make up 46.46% of residents and females 53.54%. US-born citizens account for 54.9% of residents, non-US-born citizens for 25.36%, and non-citizens for 19.74%. The neighborhood's residents are mostly African American (11%), Asian (23%), and Hispanic (57%)—all groups that have historically faced systemic barriers to economic mobility and healthcare equity (Census Reporter, 2024; Gilbert et al., 2022).

During the major COVID months of 2020—roughly March through September—the NYC Department of Health reported a cumulative infection rate of over 40,000 per 100,000 residents in certain Bronx zip codes, with the Bronx consistently leading New York City in infection metrics due to the social determinants of health. De Blasio's office responded to this infection rate by restricting the movements and interactions of people whose activities were not deemed essential. In other words, if one was not a frontline worker—such as a healthcare worker—there was little reason to be outdoors. The rationale was that limiting movement would help stop the spread (Erwin et al., 2021).

However, the COVID-19 pandemic lockdown response essentially aggravated already existing challenges for this population by further limiting access to critical services (Tolentino et al., 2021). The purpose of this dissertation is to explore the specific impact of the lockdown policies implemented between March 2020 and September 2020 on the socioeconomic conditions of low-income residents in the Tremont neighborhood, with a particular focus on how these policies affected access to healthcare for the minority population in this community.

It is important to understand the pre-pandemic socioeconomic condition of Tremont. Like many 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). 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 socioeconomic conditions have long contributed to health disparities in the borough, as minority communities experience higher rates of chronic diseases compared to other parts of the city (Shiman, 2021).

The social determinants of health also include environmental factors that have certainly affected the health of Tremont residents. The South Bronx, including Tremont, has been disproportionately affected by environmental hazards such as poor air quality and high pollution levels. Estevez (2020) notes that the South Bronx has historically been subject to political practices that permitted hazardous industrial activities in the area, contributing to high rates of respiratory illness 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. Structural racism within the healthcare system 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).

In Tremont, many residents work in low-wage, essential jobs without the option of working from home, which increased their vulnerability during the pandemic lockdowns. The area has long faced systemic inequities in housing, healthcare, and employment, 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). Indeed, Tremont's residents experience higher rates of these conditions compared to other NYC neighborhoods, meaning they faced elevated risk of severe COVID-19 outcomes (Huang & Li, 2022). Case studies on NYC and the Bronx in particular noted that COVID-19 hospitalizations and mortality were especially high among residents with such pre-existing conditions, highlighting the need for targeted health interventions and resource allocation in these communities (Friedman & Lee, 2023; Huang & Li, 2022).

The importance of researching the impact of Mayor de Blasio's COVID-19 lockdown policies on Tremont lies in understanding how these public health measures worsened existing social and economic disparities for underprivileged populations. The argument at the time was that lockdowns would help slow the spread of the virus (Hammond, 2021). Major cities like NYC followed federal guidelines as most states did, with notable exceptions such as Florida, where the governor pushed to keep businesses open. For the most part, federal guidelines have been accepted as necessary to meet the challenges of the pandemic. However, little attention has been paid to the potential problem of worsening healthcare access inequalities 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 community's health situation worsened. Economically, the shutdown of the service industry hit the community hard, leading to unemployment, food insecurity, and difficulties 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. Understanding the specific challenges faced by communities like Tremont can allow policymakers to develop more equitable approaches to future public health crises, so that low-income and minority populations are not disproportionately harmed by similar measures.

The main objective of this dissertation is to examine the socioeconomic 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 in terms of public health? Through an exploration of these questions, this dissertation aims to contribute to a deeper understanding of how emergency public health measures can affect vulnerable communities and to offer insights into how future policies can account for such effects.

To achieve its objective, this study uses a qualitative research methodology, which is suited to in-depth exploration of the lived experiences of residents and stakeholders during the pandemic (Crabtree & Miller, 2023). A qualitative approach enables focus on subjective experiences and community-specific issues, supporting a deep understanding of how lockdown policies influenced healthcare access and socioeconomic conditions in this low-income, minority neighborhood.

Data were collected primarily through semi-structured interviews with residents of Tremont, healthcare professionals, local business owners, and educators. These interviews explored participants' perceptions of the lockdown policies, focusing on their effects on healthcare access. 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 were conducted with community-based organizations to gather collective insights into how the pandemic affected the broader neighborhood.

Document analysis was also employed, reviewing local government reports, public health data, and news articles documenting the implementation of COVID-19 policies in New York City. This provided contextual background and helped triangulate findings from the interviews. Thematic analysis was used to identify patterns and themes emerging from the qualitative data, allowing the researcher to categorize and interpret data based on recurring concepts such as barriers to healthcare and economic hardship.

NYC Lockdown Policies: Alignment with CDC Guidelines and State Standards

De Blasio's COVID-19 policies in New York City were designed to align with state and federal public health guidelines, particularly those from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Although challenging to implement in a densely populated and transit-reliant city like NYC, these policies mirrored broader state and city efforts across the United States (Erwin et al., 2021). The differences in resources and logistical challenges between NYC and the rest of New York State provide context for the delays and difficulties encountered during the initial response phase (Tolentino et al., 2021).

New York City's first official lockdown order was issued on March 22, 2020—just three days after similar orders in California, where San Francisco and Los Angeles implemented a statewide shelter-in-place order on March 19, 2020. By late March 2020, New York City had already become one of the hardest-hit major US cities of the pandemic, with significantly higher infection and hospitalization rates than many other metropolitan areas (Tolentino et al., 2021). The city's early cases grew rapidly due to high population density, reliance on public transit, and what some critics characterized as a slower lockdown implementation relative to West Coast cities (Tolentino et al., 2021). The NYC Department of Health reported nearly 96,522 confirmed cases and over 5,463 deaths by April 11, 2020.

NYC's policies under de Blasio were intended to align with CDC guidance issued in early 2020, which focused on social distancing, mask mandates, closures of non-essential businesses, and lockdowns. These guidelines served as a blueprint for both state and city-level responses (Erwin et al., 2021). However, NYC faced unique challenges—including high population density and dependence on public transportation—that required stricter enforcement measures compared to other parts of the state.

As one of the worst-hit areas of the pandemic, New York City encountered overwhelming demand for healthcare services and personal protective equipment (PPE), resulting in delayed response times (Tolentino et al., 2021). The city's limited hospital capacity and strained resources affected its ability to meet CDC-recommended guidelines consistently, compared to less populated regions in New York State.

NYC's hospitals in densely populated areas faced severe resource shortages, including ICU beds and ventilators (Jarrett et al., 2022). The rapid surge in COVID-19 cases created significant strain on the healthcare system, with hospitals forced to adapt hurriedly. Jarrett et al. (2022) reported that many hospitals were unable to maintain adequate levels of critical supplies and personnel, frustrating their ability to follow CDC-recommended infection control measures consistently.

As New York City hospitals experienced PPE shortages, frontline healthcare workers faced increased risk. Tolentino et al. (2021) found that PPE rationing was common, causing delayed and inconsistent use of protective gear. These shortages exposed healthcare workers and patients to higher infection risks. Additionally, Hick et al. (2021) found that PPE access disparities were more pronounced in larger cities like NYC compared to smaller regions, due to supply chain constraints and higher demand in urban hospitals.

Compared to rural and suburban areas of New York State, NYC's hospitals also lacked adequate surge capacity. Thakur et al. (2020) highlighted that other regions were better able to maintain PPE supplies and expand bed capacity quickly, partly due to lower patient density and more flexible infrastructure. These disparities revealed the challenges that NYC, as a densely populated urban center, faced in aligning with state and federal pandemic standards. Long (2021) argued that urban areas like NYC should have robust stockpiling policies and rapid-response frameworks to avoid similar shortages in the future, as outlined in CDC pandemic preparedness guidelines.

Unlike many other parts of New York State, NYC's public health policies also needed to account for dense urban living and extensive use of mass transit. This reliance on public transportation made social distancing particularly difficult to enforce. Public health policies had to adapt to balance CDC recommendations with the city's logistical constraints (Park et al., 2020).

COVID-19 Data and the Mayor's Office Policy Directives

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). The total COVID-related death count for those two zip codes was 688 (NYC COVID-19 Data, 2024). The Bronx overall was the hardest-hit area of NYC, with 3,556 hospitalizations per 100,000 residents (NYC COVID-19 Data, 2024). The Black and Latino communities were the most affected—and they make up the majority of Tremont's population. Per 100,000 Black and Latino residents citywide, 3,000 of each group were hospitalized due to COVID-19 (NYC COVID-19 Data, 2024). Furthermore, people in very high poverty were hospitalized at the highest rate, with 3,539 hospitalizations per 100,000 residents in that demographic occurring citywide (NYC COVID-19 Data, 2024).

On March 15, 2020, the Office of the Mayor issued a press release covering a variety of actions that city residents were expected to follow regarding COVID-19. Action pertaining to healthcare appeared 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, though seemingly mild in intention, carried considerable weight in light of the press releases and notices that followed throughout 2020—all carrying an intensifying tone of worry, concern, alarm, and fear about the spread of COVID-19. Essentially, it laid the groundwork for residents to begin pulling back from normal life. The implicit message was that, unless one had a health emergency, one should not try to access healthcare. Intentional or not, that message was conveyed in the subtext of this March 15 press release and was reinforced by the numerous notices that followed.

Perhaps the most important press release from the Mayor's Office came on March 22, 2020, when city officials began sounding alarm bells in earnest:

"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: Remain indoors. Limit outdoor activity to solitary exercise. Pre-screen all visitors and aides by taking temperature. Wear a mask when in the company of others. Do not visit households with multiple people. Everyone in the presence of vulnerable people should wear a mask. Stay six feet from other people. 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, and by extension should not try to access healthcare as they normally would. Mayor de Blasio's guidance was followed three weeks later by a health alert on April 11, 2020:

"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 ominous: socially distance and do not go out or be near others. Fear continued to be amplified, and New Yorkers were 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 routine reception of healthcare services. These services may well have remained technically available, but the Mayor's Office was clearly warning residents to stay home.

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 (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 but was also becoming more restrictive, as the city issued another notice:

"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… 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" (NYC, 2020c).

By December 2020, the city essentially announced that there would be no return to the pre-COVID normal: "The COVID-19 pandemic has changed how we live and work in New York City in many ways…" (NYC, 2020d). Mayor de Blasio's COVID response had fundamentally altered how New Yorkers lived their lives—and, to some extent, how they cared for their health.

Finally, on May 1, 2021, more than one year after the initial press release, a notice entitled "Managing the Return to the Office in the Age of COVID-19" was issued. Among the requirements for people returning to work were the following: public areas cleaned in accordance with DOHMH guidance; six-foot markers posted for enforcing health assessment requirements; occupancy limitations for shared spaces posted; signage posted reminding individuals to adhere to hygiene, physical distancing, face covering requirements, and cleaning protocols; and workspaces that do not allow physical distancing blocked off (NYC, 2021). Mayor de Blasio's office had, in effect, doubled, tripled, and quadrupled down on its initial COVID response strategy. Whatever sense of community life New Yorkers had previously enjoyed was all but gone—and this approach to a public health crisis undeniably affected the extent to which the people of Tremont could access regular healthcare.

New York City's 2020 lockdowns delayed serious healthcare procedures for many in the Bronx. Cancer and mental health treatments were postponed at alarmingly high rates (Dorvil et al., 2023). 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).

Hammond (2021) summarized the state's early response failures as follows: 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 among federal, state, and local officials. Better-controlled outbreaks in countries such as South Korea demonstrated the value of public health preparedness and could serve as a model for New York (Hammond, 2021).

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. The shift to telemedicine also likely worsened 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 Tremont, where residents already faced systemic barriers to healthcare before the pandemic.

In Tremont, as elsewhere in the United States, there was reduced access to preventive care, chronic disease management, and mental health services (Irimata et al., 2023). The lockdown orders exposed healthcare inequities for those dealing with diabetes and other chronic conditions requiring 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).

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Appendix: Semi-Structured Interview Questions

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. Understanding and Awareness of Available Resources

Were you aware of resources like food assistance or healthcare options available to you during the lockdown? If so, how did you find out about them?

8. Sources of Information and Perceived Reliability

How did you primarily receive information about COVID-19 policies and guidelines? Did you feel this information was clear and consistent?

9. Clarity and Consistency of Policy Guidelines

Did you understand the quarantine protocols and when or where to seek medical care if you developed symptoms? Was the guidance on this clear?

10. 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?

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?