COVID-19 has exposed health disparities. How do we address them before the next pandemic?

Prof. Harold Pollack on what we can learn from the COVID-19 crisis

The impact of COVID-19 has been felt unevenly across America, with some communities suffering more than others. In Chicago, for example, Black and Latinx residents have accounted for a disproportionate percentage of the known fatalities so far, while those living and working in nursing homes and incarcerated people have been infected at higher rates across the country.

University of Chicago scholar Harold Pollack, an expert on the intersection of public health and poverty, says that finding equitable public health solutions means acknowledging our obligations to one another. Pollack recently authored an article in the Journal of Health Politics, Policy and Law on the subject of COVID-19 and social justice, and why preparing for health crises requires greater and more sustained attention.

“One of my greatest fears is that public health is boring until it’s not—and then it becomes boring again,” said Pollack, the Helen Ross Professor at the Crown Family School of Social Work, Policy, and Practice.

In the following Q&A, Pollack examines what the U.S. has done right (and wrong) during the pandemic, and makes policy recommendations to prevent a public health catastrophe of this scale from unfolding in the future.

Why did you decide to write about COVID-19 and social justice?

The major reason is because we’re all bearing witness to a public health catastrophe. And it’s a catastrophe that has had a disproportionate impact on disadvantaged groups, making tensions and institutional failures that already existed in society more visible by their tragic consequences.

I’m talking about people who are living and working in nursing homes, African Americans, undocumented individuals, essential workers and others who may be in greater danger by virtue of their situations, with few choices when it comes to protecting themselves. The same people may have few resources at their disposal to advocate for changes that would keep them safer.

So, who is stepping up for them? The combination of 1) a profound threat, 2) inequality and 3) disparities in political influence makes this a social justice issue. And that’s what motivated me to write the piece. We who are more privileged can’t have a sense of impunity about this.

What policies could help address future public health threats, while reducing the disparities you describe?

One of my greatest fears is that public health is boring until it’s not—and then it becomes boring again. This happened with H1N1 and Ebola: In the moment, people said, ‘We have to make sure this never happens again’—but then the threat passed and no institutional changes were made.

Given how much COVID-19 has strained our systems, I do think we’ll make some changes this time. We’ll figure out how to stockpile personal protective equipment and improve the supply chain for critical public health activities going forward. But whether or not we will actually improve our public health and social service infrastructure in a more profound way is unclear.

One thing I would like to see is for Medicaid—which serves more than 70 million people—and similar programs to take on population health as a part of their mission. Under our current system, state-of-the-art hospitals treating Medicaid patients can exist alongside overcrowded homeless shelters where the risk of COVID exposure is high. How can that be?

The federal government should consider paying for public health initiatives with a matching arrangement, the same way state Medicare funds are matched. We need to give policymakers an incentive to spend more on preventative outreach that keeps people safer and healthier, and matching would be a great way to accomplish that. I hope the Biden administration embraces this challenge.

What has the U.S. done right in its response to the pandemic?

There’s no question that we did two things right during COVID. The first was that the Trump administration indicated to vaccine manufacturers that if they developed a successful vaccine, the federal government would buy millions of doses. The market responded to that in a very impressive way. We now have multiple protective vaccines, less than a year after scientific priorities shifted to focus on COVID-19.

The second thing we did right was providing economic resources to people so that they could get over the temporary hurdles posed by the initial lockdown. But the danger of a stimulus is that there’s a zero-sum aspect to it politically: Because a stimulus gives money from the government to people directly, it tends to give a polling boost to those who are in office at the time it passes, which can make their opponents ambivalent about it.

We need a better safety net system. Such a system would trigger payments automatically when a sharp spike in the unemployment rate occurred, providing sustained support to people—especially those in industries that were directly impacted, like the restaurant industry in the case of COVID-19—without being subject to the politics of the moment.

The U.S. spends a lot on scientific research—think rapid vaccine development—but less on public health. What are the consequences, and how can we rebalance our priorities?

When we underfund public health departments, we make it more difficult for them to serve us. We also end up spending money on treatments and experience the social harms associated with illnesses that could have been avoided in the first place. Public health departments shouldn’t be transmitting data on fax machines, and they shouldn’t be ridiculed for having to do their jobs with outdated technology.

Instead, we should be looking at our epidemiological surveillance systems and asking ourselves how to make them better. Improved technology is certainly a big part of that. But a lot of what needs to happen in public health is not high tech: It’s about communities.

How can social workers win people’s trust, while ensuring that they have the ability to actually follow through on public health guidance without jeopardizing their livelihoods? To do so, they need to be both culturally competent and capable of giving people access to resources they might need to act. We need leaders from both sides of the political aisle and across every segment of American society unified behind a vaccine. And we need to be willing to meet people where they are, building trust rather than deepening their skepticism.

This is a huge challenge given the diversity that exists in our society. And it’s an increasing challenge given political polarization, as the public health enterprise itself encounters more distrust within politically and culturally conservative communities across America. We need greater cultural competence and more credible local messengers to cross these divides.

Contract tracing for COVID-19 in the U.S. has not been very successful. How can we improve it?

I think there are two reasons why contact tracing has been unsuccessful here so far. The first is institutional and cultural competence. We tried to begin building institutional capacity after the catastrophe was upon us, which is not an effective way to meet a challenge. And when contact tracers called people, they weren’t always able to establish trust.

Imagine if you were a U.S. citizen living in a household with undocumented individuals. Would you be fully forthcoming with someone from the government who called you out of the blue, asking you to report all your contacts and stop going to work? Even if you recognized their good intentions, you might feel unsure.

Finally, as a country we’re not providing people with the resources they need to take the protective behaviors we say are necessary. If we want someone to physically isolate, we need to figure out how we can make that work for them personally. Do they need a free hotel room? What about groceries or other necessities while they are separated from their families? Just by changing our framing from a statement (Do this!) to a question (How do I help you do this?), we’re going to get much more receptive reactions.

You’ve written about harm reduction in public health. How does it apply here?

Harm reduction is an important principle that’s relevant to contract tracing and COVID-19 guidance generally. As we’ve learned from HIV, educating people about harm reduction and giving them the knowledge they need to evaluate risk and make safer choices can be an effective strategy.

If someone you know is taking unnecessary COVID risks, for example, a helpful approach can be to tell them what social activities are low risk and what makes them low risk, rather than chastising them. If they must see others, they should be doing it outside, with masks on, at a distance. Public health isn’t about finger-wagging. It’s about working with people to reduce risk.

The bottom line is that we shouldn’t define ourselves in opposition to certain behaviors, but rather as partners working together on solutions that keep people safe. It’s about compassion, humility, and bringing to bear all the social services tools that we have available.