Population Health in the Midst of a Pandemic
Monica L. Wang, ScD, MS
To all the physicians (including my husband), nurses, and health care workers on the front line. Thank you for putting yourself at risk while others are lowering theirs.
To all the other essential workers and schoolteachers — we see and appreciate you. You deserve more.
To the alumni and students of the Harvard Master’s in Health Care Management program — we need your leadership now more than ever. You’ve got this.
Hey there. How are you all doing? Really.
Like many of you, I am reeling from the events of the past month. As a public health expert, researcher, and educator, a wife of a primary care physician, and a mother of a 5 year-old and a 3 year-old who are at home, I am not “working from home” but “trying to work and parent while at home during a crisis.” Here are some of my thoughts on the unfolding COVID-19 pandemic from a population and social determinants health perspective (please take this with a grain of salt, since I am not on the frontlines or working directly in health care).
First, many of the U.S.’s current efforts on managing COVID-19 represent Dr. Geoffrey Rose’s Prevention Paradox at its ugliest. The lack of prioritization on systematic and widespread testing from the highest level of government is astounding. What the U.S. is currently doing is mitigating, rather than suppressing the virus. We have a lot to learn from how other countries and dealing with this. Taiwan used big data analytics, new technology, and proactive testing. Singapore is using high tech surveillance and an app, keeping schools and businesses open.
We have a rapidly narrowing window of opportunity to partner with industry, big data, and technology to roll out proactive nationwide free testing and make taking the test a requirement for anyone who wishes to go back to school or work. IF we can systematically know who is infected, we may be able to open up large parts of our society sooner rather than later. Other countries show us this is possible. The political and social milieu of the U.S. make accomplishing this difficult for a country of its size and for regions who are staunchly opposed to any whiff of authoritarianism.
Second, we must remember that while we are in the same boat, we are weathering different storms depending on our privilege, resources, constraints, barriers, networks, and our professional and personal demands. The effects of shutting down schools, businesses, offices, and other venues indefinitely are going to have major adverse health and non-health repercussions, particularly for vulnerable populations including the homeless and soon-to-be homeless, those who are low-income, unemployed, and the 10 million individuals who recently filed for unemployment benefits, single parents, children and adolescents who rely on school food and other resources, people who experience domestic abuse at home, and the imprisoned. This “tradeoff” should not be taken lightly.
The takeaway: the elderly, the immunocompromised, and those with underlying conditions/comorbidities (note: low-income groups and racial/ethnic minorities are at disproportionately higher risk for the latter, thus placing them at higher risk for COVID-19 related complications and morbidity) are not the only high risk groups of this long-haul pandemic. Many millions more than COVID-19 infected more will experience the “collateral” effects of social distancing. We cannot separate the health of the economy from the health of the population, particularly when the majority of the population is insured through their employers as in the U.S. This means that decision makers should proactively think about and have a plan in place for vulnerable populations. Some cities and states are doing this well; others are not.
A country’s infrastructure is only as strong as what it can do for its most vulnerable and weak. We should always be thinking about public health and health equity, pandemic or not. While the virus may be blind to income, insurance status, and race/ethnicity, the U.S. and its health care system are not. We must remember that the populations who are going to be most at risk in general for negative health outcomes are also going to be at higher risk of contracting it and doing poorly if infected (e.g., low-income and racial/ethnic minorities tend to live in more crowded spaces in poorer neighborhoods, have poorer health access, face higher job insecurity, experience elevated stress levels, shorter telomeres, and poorer immune systems).
This means that prioritization of the above-referenced populations is directly related to and paramount to virus suppression. I fear that health inequities will be exacerbated in many ways related to COVID-19 outcomes, with socioeconomically disadvantaged and racial/ethnic minorities at greater risk for getting triaged for treatment because of the disproportionately higher prevalence of these pre-existing conditions in these populations, which are due in part to institutionalized discriminatory policies such as redlining and residential segregation. We are already seeing this play out in Boston, Chicago, Detroit, Michigan, and Philadelphia.
Third, if the imperative for cross-sector collaboration is not yet crystal clear, I don’t know what is. Certain industries outside of health care such as retail, automobile, and essential services are stepping up to address the critical needs during this time, as well as the economic fallout. Brands like Christian Siriano, American Apparel, and Hanes are making masks and other protective gear for health care workers, while Target and Apple are donating masks. GM, Ford, and Tesla are moving switching gears to produce ventilators. A number of essential service companies, such as Amazon, Walmart, Kroger, Trader Joe’s, Dollar General, and CVS Health are hiring employees. These examples can serve as a model for widespread dissemination.
Fourth, the spread of misinformation is deadly. I have received disturbing reports from colleagues in Atlanta (ironically headquarters of the CDC) that some of their neighbors think COVID-19 is fake news and are hosting “COVID-19 is a hoax” parties. State variation in adherence to social distancing guidelines widely and woefully varies. Physicians, scientists, and public health experts need to engage in science communication now more than ever, which requires us to think about how to best frame our messages to different audiences. Sometimes it’s not about what you said, it’s what they heard. Educating the public remains critical. Strategically thinking about the pitch and who is delivering will be essential to getting the message across. This means that while the core message needs to be consistent, the delivery, tone, and messenger may need to be different across different regions of the U.S. in order to achieve the intended impact of recommendations for social distancing and testing.
Lastly, in the words of Harvard Business School Professor Rosbeth Moss Kanter, “When national is ugly, local can be beautiful.” I’ve heard countless stories from many physician leaders, whose teams are finding creative ways to innovate and strategize with the little that they have. Now is also the time to engage and persuade decisionmakers. If you are feeling frustrated at the state and national level (and if you have the time and the bandwidth), mayors can be a good place to start at the local level, given over half (~60%) of them identify as Democratic (cities tend to be more liberal). COVID-19 has made it starkly clear that public health and medicine are political. And while I am not usually a fan of binary positions, a pandemic really is the time to think about are you in this moment making the world a better place or not? And if you want to make the world a better place, how are you uniquely positioned to do so?
It’s overwhelming the sheer tsunami of change that has upended nearly every aspect of our lives in just one month. What did working parents do before TV?
Hang in there everyone. We are all in this together, even if we are weathering different storms.
Monica L. Wang, ScD, MS is an Assistant Professor at the Boston University School of Public Health and an Adjunct Assistant Professor at the Harvard T.H. Chan School of Public Health.
Twitter: @DrMonicaWang
