Health Justice & Public Health in the Age of COVID-19

​With the COVID-19 epidemic spreading across the globe, people everywhere are getting a crash course in public health. Terms like “flattening the curve” and “herd immunity” are daily being added to our vocabularies. Since its beginnings during a cholera epidemic in the 1850s in London, the field of public health has evolved dramatically, yet some of the advances that are particularly germane to COVID-19 are not getting much attention. That includes public health’s focus on social justice.

​During London’s cholera outbreak, a physician, John Snow, noticed that a lot of his sick patients got their water from the same well on Broad Street. Suspecting that there was a link between the well and the disease, he went door to door to find out who was sick and where they got their water from. When it became clear that those who used the pump were more likely to contract the disease, he removed the pump handle, thereby stopping the outbreak. While his actions may not sound earth-shattering today, Snow was essentially pioneering epidemiology, the research methodology now associated with public health. Epidemiologists track illnesses (surveillance) to identify “risk factors” (conditions, behaviors, or traits that increase the likelihood of contracting diseases). The implications for social justice were also clear. Instead of just treating those who could afford care, he prevented everyone in the community, rich and poor alike, from getting sick in the first place.

Epidemiologists went on to explore other threats to the public’s health—everything from car crashes to domestic violence to climate change. In recent decades, they’ve also tried to explain the dramatically lower life expectancies and higher rates of disease and disability for certain groups. Study after study has affirmed that these disparities are linked to “social determinants,” which include race, ethnicity, social support, culture, language, access to care, and where people live and work. Social determinants affect the risk for conditions ranging from diabetes to dementia to elder abuse. 

​While many were saying that COVID-19 doesn’t discriminate, just the opposite is becoming increasingly apparent. Epidemiologists have, in fact, long known that viral outbreaks disproportionately affect the poor. ​Flu-related hospitalizations in poor neighborhoods, for example, are double those in higher-income areas. Today, the Centers for Disease Control and Prevention (CDC) is predicting that people with conditions like diabetes, hypertension,  and coronary artery disease—conditions that are more common in certain racial and ethnic minorities—are more likely to get critically ill or die from Covid-19. The crisis is also revealing glaring disparities in access to information, screening, protective gear, treatment, and communication technology.

While many  were saying that COVID-19 doesn’t discriminate, the opposite is becoming increasingly apparent. Epidemiologists have, in fact, long known that viral outbreaks disproportionately affect the poor.

Healthy People 2020, CDC’s master plan for the decade, acknowledges that protecting the public’s health cannot be accomplished without addressing five social determinants:

1. Economic stability, which requires addressing poverty, employment, and food and housing security;
2. Education, which requires addressing barriers related to language and literacy;
3. Social and community, which includes social cohesion, civic participation, discrimination, and incarceration;
4. Access to health care; and
5. Neighborhoods and built environments, which encompasses access to healthy food, quality of housing, crime and violence, and environmental conditions.

One way to reduce health disparities and extend the reach of the health care system is with community health workers ... During epidemics like COVID-19, CHWs are particularly vital because they are likely to know what people in their communities actually believe and understand about the virus and they are likely to be more trusted than the medical establishment.

One way to reduce health disparities and extend the reach of the health care system is with community health workers (CHWs). These front-line public health workers (also called navigators or promotores) speak the languages of the communities they serve and are trained in proactive communication, health literacy, motivational interviewing, advocacy, and chronic care management. During epidemics like COVID-19, CHWs are particularly vital because they are likely to know what people in their communities actually believe and understand about the virus, and they are likely to be more trusted than the medical establishment. In addition, they help to combat confusion, misinformation, and stigmas that stand in the way of accessing life-saving services. But even when there’s not an epidemic, CHWs can help prevent and manage diseases and chromic conditions and help clients stay safe.  ​

Clearly, it will take years to unpack what we’ve learned from the current epidemic. Understandably, much of the attention will remain on emergency interventions and ensuring that livelihoods and security are restored.
 
But as we emerge from this crisis and plan for the future, it’s critical to not lose sight of the fact that epidemics are exacerbated by inequality. And the reverse is also true--health disparities are exacerbated by epidemics as those affected have fewer resources to help themselves recover.
 
Advocates can play an active role in promoting equity as we move forward, in both crises and everyday life, for old and young, through the following:

• Advocate for public health programs and policy that not only focus on emergency responses but address the social determinants of health;
• Promote the use of CHWs*;
• Take steps to eliminate barriers to health for all, including undocumented or recent immigrants; and
• Increase the public’s understanding of public health goals and methods; including its role in achieving social justice.

... as we emerge from this crisis and plan for the future, it’s critical to not lose sight of the fact that epidemics are exacerbated by inequality. And the reverse is also true--health disparities are exacerbated by epidemics as those affected have fewer resources to help themselves recover.

COVID-19 demonstrates in no uncertain terms that protecting the public requires that every member of society has access to information, screening, shelter, and the resources they need to keep themselves and their families safe. There is no denying that we’re in this together.

*For more on CHWs and their potential role in aging and elder abuse prevention, see CEJC’s webinar Improving Access to Aging Services with Community Health Workers

​Lisa Nerenberg is CEJC's executive director and author of Elder Justice, Ageism, and Elder Abuse (Springer, 2019).