(Illustration by Anna Gusella)
The debate over what a “return to normal” from COVID-19 should look like can strike you as coming simultaneously much too late and far too soon. Many of our reactions to post-pandemic life already seem baked in: Offices have laid out plans to reopen, switched to hybrid, or gone entirely remote; outdoor dining appears to be here to stay; the economy is recovering. Meanwhile, new variants of the virus are leading to higher hospitalization rates and, in some places, taking the United States back to the darkest days of the winter 2020 surge. It feels premature to talk about lessons learned from a pandemic that isn’t over, but decisions are being made at this moment that will shape what will come after.
COVID-19 has exposed profound and perpetual inequities in our society. The impacts of systemic racism on the social determinants of health and health-care access put many racial and ethnic groups at a higher risk of getting sick and dying from COVID-19. As vaccines and boosters become available, myriad impediments, including lack of access and trust, lead to lower vaccination rates among communities of color. To defeat the pandemic, society can no longer ignore these problems.
Government leaders, public health authorities, and nonprofits have come together to stem the tide. Taking an early and deep interest in combating COVID-19, The Rockefeller Foundation formed a Pandemic Solutions Group (PSG), aligning with the Centre for Public Impact to design and manage the day-to-day operations of this learning network for public officials. We are now advocating to transfer the gains of the 41 US cities, states, and tribal nations we’ve worked with to the post-pandemic world.
Of the public health advancements made by those in our network, community health workers, community clinics, and genomic sequencing have proven particularly impactful. These initiatives have expanded access to care and prioritized hard-to-reach communities by focusing on relationships, trust, and smart data. While some pre-pandemic practices should return to normal, promising adaptations in health care can make our society work better for all on a more permanent basis. Rather than rolling back these approaches as the pandemic subsides, we should continue to develop them into sustainable systems to address enduring health disparities.
Three Principles of Public Health
Specifically, we observed three interrelated principles at work in successful public health efforts during COVID-19 that should be embraced and applied more broadly. First, they designed solutions with people and human relationships in mind. Second, they considered everything through the lens of trust and legitimacy. And third, they used data and technology to learn, innovate, and adapt in real time. Let us consider them in turn.
Effective programs center people in everything they do. By cultivating authentic relationships with the individuals and communities most impacted by COVID-19, public health practitioners were able to understand the unique contexts of their patients’ lives. This emphasis on local connections and conditions also enabled programs to adapt their approach from one area to another, in line with the cultural intricacies of the community in question.
Similarly, successful COVID-19 outreach demonstrated thoughtfulness in working with and relying on existing community-trusted partners that had already earned the confidence of residents, leveraging rather than undermining that inherent legitimacy. When people view an organization as a credible source of positive change, they are more likely to follow its recommendations and benefit from its services.
Lastly, the disruptions of the pandemic highlighted how technology can enable adaptation and innovation in response to rapid, unpredictable changes on the ground. Public health practitioners used technology to better listen to, learn from, and adapt to communities and their dynamic environments. This culture of continuous learning and improvement, a necessity during the pandemic, must become a mainstay, with technology a central element.
Workers, Clinics, Data
Public health efforts connect with people and gain legitimacy through the right intermediaries. Community health workers (CHWs) are frontline providers who are trusted members of the community or who have developed a close understanding. Personal knowledge of the places they work and established relationships with residents help CHWs facilitate access to services and improve the cultural competence of service delivery. This relationship-based approach increases community confidence in health care and leads to greater usage of local services.
Since different communities have different needs and different cultures, CHWs will not look the same from one area to another. For example, the Health Advocates In-Reach and Research (HAIR) Campaign in Maryland trains barbers to work as CHWs, while CORE (Community Organized Relief Effort), an organization dedicated to supporting local crisis response, partnered with a pastor in Oakland, California, who led door-knocking and phone campaigns to spread awareness about COVID-19 testing. In June 2021, the White House acknowledged the success of HAIR’s work and moved to replicate the initiative nationwide, while CORE has increased testing in the Oakland area from 60 to 500-1,000 tests per day.
In addition to building trust in public health systems, initiatives such as the Baltimore Health Corps (BHC) demonstrate the potential economic impact of CHWs by creating career pathways for them. During the pandemic, BHC has recruited, trained, and employed 275 new CHWs who were unemployed, furloughed, or underemployed. Focusing on neighborhoods hit hardest by COVID-19, BHC uses racially equitable recruitment and hiring practices to employ contact tracers, care coordinators, and support staff, providing them with good jobs, fair pay, training, and skills, as well as ongoing support to improve professional trajectories.
Like CHWs, community clinics have risen in prominence during the pandemic as trusted vaccination sites and critical components of local health care. The most effective are staffed with a mix of familiar faces and approachable health workers who can provide trustworthy information and medical services. These clinics have also taken on a role as an early warning system for which specific communities are not being reached.
“Even though our walk-up sites are located in low-income neighborhoods that have high COVID positivity rates, it doesn’t mean you’re still getting the right people onto the sites,” CORE’s Ann Lee says. “It’s not just the messaging; we have a team of community mobilizers who are working with trusted community-based organizations to get the message out to make it more accessible.”
Critical to the success of community clinics is their ability to draw on an existing reservoir of trust and legitimacy with residents. Long-standing skepticism of public health systems, backed by a history of racist, discriminatory, unethical, and abusive conduct, has dissuaded communities of color from seeking support when experiencing COVID-19 symptoms or considering vaccination. Community clinics can customize their approaches to what works best in an individual neighborhood, thereby validating public health outreach that residents may not have otherwise accepted. As the pandemic fades, local public health departments must strengthen these neighborhood-based clinics as anchors of public health ecosystems.
Public health efforts must also be guided by accurate information. Throughout the pandemic, we’ve seen how real-time, reliable data supports continuous learning and improvement. Data can tell us whether masks work, how far to socially distance, whether lockdowns are necessary, and who is more vulnerable. Data is what moves communities from reactive, panic-driven responses to proactive, science-driven ones.
Genomic sequencing, which identifies patterns of infectious disease transmission, helps public health officials recognize potential transmission sources—including “super-spreader” events—and rapidly detect new variants before they can circulate widely. Paired with epidemiological tools, such as testing and contact tracing, this data provides a detailed look at the development and transmission of COVID-19 to better guide public health decisions.
Genomic sequencing is one step in the surveillance process and requires coordination with public health departments on sample collection, linking with metadata, analysis, interpretation, and subsequent decision-making. Yet genomic surveillance systems in the United States are largely ad hoc and siloed and have proven inadequate to meet the demands of the ever-evolving pandemic. Even worse, our current data does not adequately track based on race, ethnicity, zip code, health status and history, and other factors that can identify which populations are disproportionately impacted.
The American Rescue Plan, signed into law on March 11, 2021, provides $1.75 billion for genomic sequencing and surveillance. This funding follows $200 million allocated for genomic surveillance in February 2021. Such investment will help build out our public health infrastructure and has massive potential well beyond COVID-19. Laying the groundwork for a national system that amplifies warning signals and proactively shares information will help forestall the next pandemic, saving countless lives and billions of dollars.
Achieving Health Equity
COVID-19 has produced, for the first time in many of our lives, a situation where every person’s health holds consequences for those around them. If and when the pandemic abates, so too will the driving force behind our awareness. Yet this relatively brief period is producing notable advances in the ways we provide public health services. It is imperative that we not revert to pre-pandemic mindsets, but rather expand on approaches developed during the pandemic to better serve vulnerable communities and tackle complex challenges.
More broadly, the principles underlying advancements in public health during COVID-19 represent exciting possibilities for society and how it can be restructured for the benefit of everyone. We must strive to reimagine ourselves such that power sits with those closest to the issues and the solutions, human relationships are valued and intentionally supported to flourish, existing social relational networks are cherished and respected, and governments prioritize listening to and learning from those who don’t feel heard.
Read more stories by Otis Rolley & Dan Vogel.