A Memorial Day Pandemic Prescription:
Remembering who we are as Americans will move us beyond this crisis
special edition
This Memorial Day the front lines are in our front yards…
By Robert Pestronk, MPH
Pestronk is a past executive director for the National Association of County and City Health Officials, and former health officer and director for the Genesee County Health Department with headquarters in Flint, Michigan. The opinions he expresses here are his own and should not be attributed to any organizations where he has worked.
Despite the majority of communities beginning to re-open, many of us not already infected continue to remain at risk. Nothing has changed that personal vulnerability. The pandemic continues to work its way insidiously, predictably, and unevenly through our communities, and much remains to be known about the novel coronavirus and its effects while we await the development of safe and effective vaccines and curative therapies.
More of us and those we love will get sick and needlessly die from the coronavirus without renewed public confidence and compliance based on visible, permanent, and more equitable conditions and outcomes. However, unnecessary family tragedies of early death and serious illness and, perhaps, lifetimes of disability from the coronavirus still can be prevented by returning to our roots as Americans. By applying the fundamentals of leadership, public health, and democracy, we can move forward.
Reliable leadership
Everything in this nation begins with effective leadership, but leadership starts with our individual vote. We must have elected officials who are tolerant and respectful of those who know more and have different life experiences than they do. We need officials we can trust, who will tell us the truth, and who are honest about what they know to be true, what is science-based, and who surround themselves with, and rely upon, people of the same ilk. This pandemic will not end soon; this is why the upcoming elections are an opportunity to ensure we have leaders who are truly up to the task of guiding us through it.
Our elected officials should also trust our public health leaders whose decisions are based upon what is known about improving our individual and collective health, and supportive of competent medical leadership.
Lastly, we need other leaders from the business, religious, and media communities to help create conditions which enable us to be healthy and prosper safely in ways we choose. Careful business owners know they must operate differently upon opening for the health and future of their business and employees.
Trustworthy communication
Not everyone uses and believes the same sources of information yet it is vital that our leaders use and reinforce consistent, reliable information in the marketplace of ideas to counteract myth and fiction and to provide a basis for evidence-based action. This also helps quell the remaining fear and anxiety about both the chance for infection and the ability of the economy to recover.
A good example of such an effective campaign occurred recently in New York State where the governor ran an open competition to create public service videos urging New Yorkers to wear person protect equipment such as masks. Public engagement was further enhanced by asking the public to choose the winning videos. This kind of publicity and interpretation of public health goals helps us understand the underlying assumptions and rationale for governmental response to the pandemic, and the strengths and weaknesses of models on which public health and elected officials base their decisions.
Data about the coronavirus and our understanding of it will continue to change, shifting our models and projections. This will of course cause our official guidance to also change. We must demand our media use up to date information and call out and discard dangerous misinformation. We must do the same in our conversations with one another, and while encouraging participation in elections to ensure we have leaders who not only promote and adhere to reliable information, but also have the resolve to learn what has and has not worked to limit the impact of the pandemic in other communities.
Solid evidence
Unfortunately, largely due to weak federal and executive leadership, pandemic data collection in the US has been sketchy, gathered in different forms and with different definitions of disease, and with gaps in the demographic characteristics of those infected. Our digital medical record keeping systems have not performed as we had hoped to best inform us despite billions of dollars spent on them. And as we now know, many who are infected show no symptoms and may not even think to be tested or take stricter precautions to protect others. They do not appear in our statistics.
We are a diverse nation that has taken different state and local approaches to the pandemic. This may be essential as the pandemic progresses because “hot spots” and downward curves will suggest shifting allocations of resources. National leadership will become essential, again, to assist with this transfer. To date, we have not consistently benefited from sensible and science-based national leadership as as one might have hoped. At the national level, for example, states and localities should never have had to compete against one another for supplies and equipment to protect essential workers. This should not happen again, ever.
Trust and cooperation
This pandemic is not the first time many of our public health professionals have had to work with such a wild and wide range of unknowns while providing counsel to elected officials. These are public servants, not rogue individuals bent on ruining our lives and freedoms. Their lives and careers are devoted to protecting us, promoting our health and preventing disease. It’s helpful to keep in mind that public health officials live among us and share our risks. We don’t appreciate or typically understand their efforts and commitment because when they are successful, as they usually are, their work is invisible to us. We take it for granted. Now is the time to support them well and thoroughly and to continue this support over time. We should not let that support erode once the pandemic is controlled.
Effective strategies
We’ll have to be careful with strategies adopted going forward. Some public health experts have suggested one way to confidently re-open the economy is to offer antibody “certificates”. While this sounds innovative, it is too impractical to be of use. “Good” tests with adequate sensitivity and specificity for detection of the virus are not widely available or equitably employed.
We don’t know enough about what level of antibody presence is protective for those who have had the disease. We don’t know for what period of time antibody presence is protective. We lack information about what level of virus produces infection or under what conditions. We also lack the ability to interpret current testing data in such a way as to make certificates helpful. All of this would add up to the likelihood of a black market for high quality fraudulent certificates, allowing those who purchase them to re-enter the economy at risk of exposure and exposing others at work, at home and at play.
Other bad ideas include promoting cures or preventive measures based on “feelings”, such as the president has done with hydroxychloroquine, despite mounting evidence that it is harmful and even lethal as a treatment, and with virtually no evidence that it is an effective prophylactic.
Better strategies to make re-opening the economy safer include rapid and accurate testing made widely available, and deployed in an informed manner, along with allocating the proper resources to monitor for, and identify, new outbreak “hotspots” and waves, hospitalizations, and deaths. These data can be leveraged for rapid responses such as targeted community closures and other evidence-based actions such as contact-tracing.
When paired with consistent public information campaigns that explain the importance of finding people who are infected and who have been in contact with others, and of the steps they can take such as quarantine or isolation, we can minimize the spread of infection. Although not perfect and with hesitancies about data and privacy protection measures, digital methods to alert us to contacts with those infected and used in contact tracing, and are constantly being improved.
Current and existing efforts to promote and protect public health are grounded in Constitutional law. These enable us to live among, work, and play in a large, complicated, heterogeneous society of people and nations.
Sadly, the current president’s tendency to fan the flames of irrationality by promoting dubious treatments, his failure to model responsible behavior such as refusing to wear personal protective equipment, and his public undermining of top public health officials, weakens our national momentum for a safe return to disease control and further progress on the road to a more fair and equitable society.
Return to democracy
We’ve seen our neighbors in many communities take responsible steps recently, deeply changing their habits, canceling visits to see loved ones to protect themselves and others and recognizing the important social responsibility to protect and support others. This generosity of spirit is not surprising. It is deeply engrained in us as Americans, if not always visible. Still, some may wish to risk their health by choice. Unfortunately, those decisions heighten the risk of disease for others.
Those of us who feel our freedom infringed by current recommendations and orders are often the same people who will want public health and clinic workers to take care of them when they become seriously ill or injured. This is why the pandemic gives us an opportunity to remember that we are dependent both nationally and internationally on each other. The path forward will undoubtedly be strewn with moral hazards, extreme differences of opinion, and outcries over various camps’ cries of infringement.
We’ve been here before in this country, and we have many historical examples of civil discontent, even violence, but our unique, Constitutional form of government was meant to address such extremes through its deliberate balancing of powers, the exercise of those powers, and through our votes when conditions become too extreme or harmful.
We can do better. As the wealthiest nation in the history of the world, there is no excuse for our rates of death from this pandemic and other diseases of the body and mind which are as high and inequitable as data show and higher than many of our Western economic peers and of some of those we label, unfortunately, as “less-developed nations”.
A Way Forward
Here are some specific suggestions, based on decades of my own public health career experience, to enable a more sensible, cohesive and effective response to prevent and address this and future outbreaks of disease and pandemic and to help us be healthier:
Assure current and future local and state decision-making around opening and closing businesses is effectively explained recognizing that the disease will affect us and our communities differently until effective therapy and vaccine is universally available
Assure we benefit from the expertise of, and coordination among, federal agencies, state, and local governing authorities and assure independent action by each, when necessary to address local conditions and protect the public’s health.
Support continuous research and knowledge about this and other diseases
Design more effective ways to enable best practice by individuals and organizations in public, private, and non-profit settings recognizing that these practices will change as more is learned and that we should expect them to change and for us to adapt.
Provide sufficient resources for universal, if not widespread, efficacious and repetitive testing for virus and disease in local communities to identify hot spots, better allocate a wide range of resources, and understand the effectiveness of our prevention and mitigation efforts and adapt them as necessary.
Offer treatment for any one now infected and when modalities become available vaccination and treatment make them universally available.
Produce an effective counterforce to presidential and social media hype which creates an echo chamber for unproven cures and treatments
Begin now to strategize a vaccination program that can be implemented immediately once a vaccine is available, ensuring it is offered equitably to everyone who hasn’t been infected in a sensible order of delivery, for example first protecting those who care for us and who labor to support us
Continue implementation of protocols that protect public health and medical professionals, as well as the legions of low wage non-health workers on whom society depends and better recognize through salary and benefits those who perform these essential roles
Develop and implement strategies to better prevent the spread of infection in “communities” such as nursing homes and incarceration facilities where people must be isolated
Move constantly to enable universal national “health” coverage and a “reasonable” reimbursement rate for any preventive measure and clinical treatment for which there is evidence of efficacy for the period of time necessary to achieve outcomes deemed reasonable by a panel of experts and lay people. These people could be appointed by the president and Congress and be recommended from a list provided by the National Academy of Medicine, Engineering, and Science to whom the nation looks for guidance and expert opinion in so many areas
Adequately staff local health departments nationwide for immediate and thorough screening, tracking, and contact tracing and provide annual Congressional, state, and local appropriations to cover the cost of the diverse staff and equipment needed to perform this work well so that in addition to the regulatory role we count on them to play, and filling gaps in clinical and health services others choose not to perform, and they have the resources to be our communities’ highly valued chief health strategists by design
Offer loan forgiveness for educational expenses in public health related domains for those who contract on acceptance to work five years post-graduation in a national, state, or local health department
Provide annual financial resources for local health department to purchase and use electronic/digital systems to maintain up-to-date data, staff and equipment which enables partnerships with other local clinical, educational, and social service data systems
Assure safe places to house and isolate the ill if home settings are not suitable
Assure no one is made homeless through loss of income during the pandemic with lessons learned about how to do this translated into future social policy during non-pandemic times
Assure access to nutritious foods for those isolated or quarantined and for those who are now socially isolated but might otherwise not have easy access to food or be dislocated in the future
Require unemployment payments and benefits at a living wage for those out of work due to the virus or any other future condition or economic dislocation which has the potential to shut down large segments of the economy or create unemployment. Provide useful work for them to do while they retrain
Adopt federal law requiring ample paid sick leave for any employee full, part time, or gig to discourage people from coming to work sick
Adopt federal reimbursement sufficient to reimburse families for day care expenses for those who need and choose it and to incentivize a greater supply of safe sources of day care and the staff needed for that care. Protect and grow safely our youngest cohort.
If businesses choose to open, until an effective vaccine is universally available and accessible:
Require staff be provided with personal protective equipment and adaptations to their work environments which prevent their risk to infectious disease from other employees
Require temperature testing at entry to the workplace, social distancing at worksites, and sanitized air exchange in the workplace, i.e., OSHA-like protections for obvious workplace hazards.
Encourage telework where practical
Pay current minimum wage workers a true living wage. Without them we could not continue to live in a hunkered down state. Enable them to better enjoy the fruits of our national wealth since their labor is essential to generate it. .
Before efficacious treatment and vaccine become available:
If any of us must or chooses to go back to our “normal” non-hunkered lives, we will have to assume some of the risk of infection. Legal systems exist to identify, fairly judge and, if necessary criminally or civilly punish “bad actors” be they employees, employers, well-schooled and professionally recognized people, and organizations. These systems should be improved through adoption of better practice recognizing nonetheless that they are by their nature cumbersome, time consuming, and risky to those who use them. Fair and effective systems of adjudication are essential. People may need to be helped to understand how to use them and be supported in their use.
If one chooses to stay hunkered at home, living wages and benefits should continue for the “long term” through some combination of public and private support for the period of time science and experience tells us is necessary to be safe. No one’s life and health should be sacrificed by design.
Let us emerge from this current challenge with increased confidence in our individual abilities to make a difference, with governments that make life and health easier for us all and that serve us well, and living in a nation of which we can be proud and a model for others to emulate.
~Robert Pestronk, MPH