A year ago, few could have predicted that the richest nation on earth would soon be in the midst of the greatest public health crisis in its history, with hundreds of thousands of deaths and millions of people having been infected in a matter of months by a new virus that emerged from a faraway place. But we were warned. As far back as 1992, the US Institute of Medicine issued a report called “Emerging Infections: Microbial Threats to Health in the United States.” Just two years later, Pulitzer Prize–winning journalist Laurie Garrett wrote her best seller The Coming Plague: Newly Emerging Diseases in a World Out of Balance. Democratic and Republican administrations since then have pursued pandemic preparedness plans in revolving cycles of enthusiasm and ennui, with SARS, avian flu, H1N1, and Ebola lighting periodic fires under Presidents George W. Bush and Barack Obama in the 2000s.
It’s all well and good to have high-level plans and resources, like the Strategic National Stockpile of protective equipment, vaccines, and drugs that President Bill Clinton set up in 1999. But public health crises play out at the state and local level; it’s not the feds who are on the front lines. And here again we were warned. In 2018, the Trust for America’s Health’s annual report stated that “Budget cuts have occurred at all levels of the public health system from the smallest town to the most populous city as well as at the federal level. The country needs a long-term commitment to rebuild the nation’s public health capabilities—not just to plug some of the more dangerous gaps but to make sure each community will be prepared, responsive and resilient when the unexpected occurs.” Last winter, the unexpected hit—and we were not prepared, responsive, or resilient.
While the failures of the Trump administration on Covid-19 are deservedly well known, Trump alone did not set us up for this catastrophe. Since 2002, during the Bush and Obama presidencies, key funding for state and local health departments dropped by a third, from $940 million in fiscal year 2002 to $667 million in fiscal year 2017. And as the Trust for America’s Health documented in 2018, of the $3.36 trillion we spend on health care annually, only 3 percent goes to public health.
However, public health is not just about preparedness. We went into this pandemic sicker than our peers among the industrialized nations, burdened by, as another Institute of Medicine report summarized in its title, “Shorter Lives, Poorer Health.” The reason for the sorry state of Americans’ health, as Elizabeth H. Bradley and Lauren A. Taylor explained in their 2013 book, The American Health Care Paradox: Why Spending More Is Getting Us Less, isn’t that we don’t spend enough on health care in the United States. It’s that we spend too little on the social services that undergird a population’s health.
Last April, my colleague Amy Kapczynski and I started advocating for a New Deal for Public Health in the larger context of what we call a new politics of care. As we said in a piece in Boston Review, “We must build for a better future, not just climb out of the rubble of this pandemic, brush ourselves off, and start up in the same place we found ourselves in January 2020.” This New Deal begins not just with a massive investment in our communities to combat the pandemic but also by confronting the social, environmental, and behavioral determinants of disease and death that Bradley and Taylor describe in their book. We’re asking for a huge new jobs program focused on sending 2 million new community health workers into the places hardest hit by Covid-19, as well as those places that were already struggling with poor health long before this virus hit.
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The idea is almost mainstream. A group of Democratic members of Congress has called for a new health corps, and Joe Biden’s Covid-19 plan has a health force as part of its response to the pandemic. However, the people behind some of these plans seem to think that what we need now is just to focus on the virus and mobilize people to test and trace. But as contact tracers head out into the field, they are running into communities in crisis, which need more than a diagnosis and a warning to stay home. Contact tracers are becoming “part disease detective, part social work[er], part therapist,” as Dr. Emily Gurley told ProPublica; some, wrote John A. Schneider and Harold A. Pollack in the JAMA Health Forum, are serving communities “as a gateway to meet their basic needs.”
Such efforts could be the start of something remarkable: a real focus on this country’s community health, a collective realization that the pandemic is a symptom of what has ailed us as a nation. For too long, we have thought our health begins and ends with the sophisticated procedures on offer at our nation’s teaching hospitals and other major medical centers. We marvel that those who can afford it come to the United States from all around the world to get the best care they can—except those who can expect to live longer by staying in their own countries. In life expectancy, according to the latest United Nations report, Americans rank 37th.
A genuine New Deal for Public Health—one that lifts up social welfare as key to our nation’s post-pandemic future—will be a struggle to achieve. Senate majority leader Mitch McConnell and the GOP will summarily dismiss it as socialism, because doing anything that helps the incoming administration is not in their political interest, even if it’s a matter of life and death for their constituents. The temptation in Congress, too, will be to settle for less by compromising from the start. But if the Democrats embrace an austerity politics now—by claiming, as Ted Kaufman, one of Biden’s chief advisers, did in August, that “when we get in, the pantry is going to be bare”—we will limp out of this pandemic far worse off than when we began. When the prescription is for a full dose of medicine to cure a disease, getting a few pills isn’t a victory; it’s a recipe for the next disaster.
We can deny the importance of bringing America’s public health and social welfare up to code, and we can declare it un-American, unaffordable, unrealistic, and unachievable. However, the next virus won’t care about our excuses. In the words of James Baldwin (quoting an old hymn): “God gave Noah the rainbow sign, / No more water, the fire next time!”
