Share This Article
NIAID, Nadavspi~commonswiki,
We are living through a horror in New York State and City. There were warnings that were unheeded of a pandemic that would hit our shores. Did we get prepared? No. Instead over the years, particularly in the city, a once proud and forward thinking and planning public health department lost staff and resources.
Despite these losses, the city health department has done an important job of documenting health, social data and other characteristics in the city’s community districts. The disparities and racism (both official and institutional) are clear and outrageous. This has been the case for an exceptionally long time and is the result of thousands of decisions made by local, state, and federal authorities, in both the public and private sectors. Indeed, it is not that difficult to determine the neighborhoods that are most at risk in daily life, and more so when a scourge such as COVID-19 is introduced into the mix.
The other undeniable truth in our diverse city of neighborhoods is that one-size message does not fit all. Social distancing is often not necessarily possible in many communities, especially if it is only spoken in one language.
In addition to losses in the public health infrastructure, a state plan to limit the number of hospitals and hospital beds over the years has contributed to the unfortunate picture in low-income, immigrant, and communities of color. Documentation of the impact of hospital closings in medically underserved communities of color has not slowed this phenomenon. The encouraged consolidations of community institutions into large, powerful networks of hospitals, has deepened it. The public decision-making has moved to healthcare network corporate boardrooms, eliminating any concern on the impact on the effected communities.
The COVID-19 crisis has touched all aspects of infrastructure and economic activity in New York City, but it has not affected all New Yorkers proportionately. Frontline food service, grocery store, and health care workers (i.e. home health aides and homecare workers) are disproportionately people of color, immigrants, uninsured and women. They have allowed most New York residents to stay at home, helping to flatten the curve of new infections. It is not an exaggeration to say that low-income New Yorkers have saved thousands of their neighbors’ lives by allowing them to shelter in place. We also suspect that the unique reach and capacity of NYC Health + Hospitals may have played a role in saving the lives of low-income people on Medicaid and the uninsured that depend on it.
No one who is in the least familiar with neighborhoods in the city is surprised at how the virus started and has spread through the city. The underserved communities in Queens, Brooklyn, and the Bronx were first and hardest hit. Yes, the burden of underlying disease in these communities is high and unmistakable. But that is just a part of the reason for the spread of the disease. The vulnerability of the residents in these communities is very much attributable to the crowded living conditions because of very high rents, the lack of access to good food, the worry over money because salaries are so low, the stress of survival, and more. We used to call these factors “activities of daily living,” but now we have a fancy name: “Social Determinants of Health.”
The inequities in the healthcare system and the disparities in the health of our communities must act as a motivator to change the picture. But this will not happen unless our approach changes dramatically. We need to do things differently than we have in the past both to correct old wrongs and chart a path to avoid future errors.
The governor and mayor are starting on the best path to addressing the pandemic. Both are determined to have programs of testing and contact tracing underway and involved in the determination of how and when to reopen the state and city. This is the scientific and preferred way of making these decisions—so we applaud them for this effort.
Why is this approach wise? It’s clearly important to know the extent of the disease in each community. There are many people who are asymptomatic, meaning they are not showing the symptoms of being ill, yet they are capable of spreading the virus. Knowing who fits in this category and having them isolated until they are cleared of the disease will have an immediate impact on stopping the spread. Knowing the count of illness in each community points the arrow at where resources are needed in order to make a difference. This information is needed to plan appropriately.
The focus during this pandemic has been on hospitals—a focus that was needed, at least initially, although the lack of testing equipment and the stringent criteria to be tested may have contributed to the very sick status of people being hospitalized and later dying. But COVID-19 is a disease and therefore fits into the category of a public health problem. The focus now must be on public health solutions. These are very different than medical solutions.
Through the Fund for Public Health, the city is hiring a thousand contact tracers who will follow up on positive results to reach the people that the infected person came in contact with. We are hearing that the criteria for these positions includes professional backgrounds. But is that necessarily the people who will gain entry and the trust of people in many immigrant and communities of color? No, probably not.
Public health dictates that the persons making the contact must be culturally competent, understand and speak the languages of the communities they are approaching. This is a sensitive endeavor and the persons up front must be trusted and understanding. The preferred way of doing this task, like most public health work, would be community-based organizations that are of, from, and trusted in their communities. This is what works and must be a critical part of what the city initiates. This has got to be the new normal and what the city, working with community organizations that know and understand this importance, must move toward quickly. Otherwise this initiative will be costly, not accomplish its goals in the effected communities, and fail eliminate the spread in the communities most impacted by this disaster.
Do it right now and we will create a model for how to address not just this calamity but other public health concerns and the range of issues that impact our communities.
Judy Wessler is a longtime community health policy advocate. Anthony Feliciano is the director of the Commission on the Public’ Health System.