Many Americans continue to shrug off prevention (masks, social distancing, hygiene) to instead focus their hopes on a cure, whether that be a vaccine, new treatments, or the distant promise of herd immunity. States rushed to reopen the economy before hitting safety benchmarks, and the ravages of that haste have resulted in 1,000 deaths a day. And we failed to stitch together a system of testing, adequate protective gear, and life-saving equipment early in the pandemic, when we had the chance.
“We keep looking for a silver bullet,” said Dr. Ashish Jha of Harvard’s Chan School of Public Health in a virtual discussion earlier this month. Rather, he said, consistent mask-wearing, rapid testing, contact tracing, and social distancing — all prevention strategies — can form the equivalent of a cure. “You put them all together and that’s the silver bullet,” Jha said. Unfortunately, after six months of deadly pandemic, that’s not where the nation’s energies have been. It’s so much more attractive to aim for a COVID-19 “moonshot” than to make the effort to do the long, slow, annoying work of preventing and containing the disease.
None of this should come as a surprise, because the US response to the pandemic is a microcosm of the nation’s upside-down health care system. It dismisses and disinvests in preventive measures and focuses far more on treatments and cures. These misplaced priorities are especially clear in the funding disparities between public health measures and health care, better known as “sick care” — hospitalizations, surgeries, and drugs. In 2017, public health represented just 2.5 percent of all health care spending in the United States.
Even in Massachusetts, the growth in health care spending consumes so much of the state budget that little is left for preventive public health measures such as nutrition, smoking cessation, substance use disorder counseling, lead-paint inspections, recreation, screenings for disease, and the like. The fiscal 2020 budget allocates $18.5 billion for health care and just $768 million for public health. In 2015, the Boston Foundation produced a five-year study concluding that the state’s world-class medical system produced “lots of health care, not enough health.”
The coronavirus pandemic has made this imbalance even more obvious, as lower-income communities, immigrants, people of color, and those without the flexibility to work at home have borne the brunt of the devastation, both physical and economic. It’s not an accident that Lynn, Everett, Chelsea, and Revere have the highest proportion of COVID-19 cases in the state.
“Your zip code should not be the determining factor of your health,” said Carlene Pavlos, director of the Massachusetts Public Health Association. When we consider the social determinants of health — safe housing and workplaces, access to fresh air and nutritious food — and why they are lacking in certain communities, Pavlos says, “we cannot avoid naming some of it structural racism.” Indeed, economic and racial injustice underlie each of these vulnerabilities, another way in which COVID-19 provides a window into the larger society.
On June 7, Governor Charlie Baker signed a law requiring the state’s hospitals to collect data on COVID-19 patients by race, ethnicity, occupation, and disability. Baker has relied on data to guide the state’s pandemic response, to mostly good effect. But he needs to look more closely at what the numbers are telling him. When he pronounces the vast majority of the state’s communities safe for school reopenings because their virus count is low, he must also address the compounding injustices for the communities that can’t reopen.
Of course, everyone is hoping for a safe, effective, universally available vaccine as soon as possible. But that shouldn’t come at the expense of public health measures that can be implemented today. Beyond masks and handwashing, broader prevention strategies need to be adopted that support the well-being of families and neighborhoods, from fresher food to fairer wages. These will make all Massachusetts communities safer and healthier long after the COVID-19 crisis has passed — and more resilient when the next crisis hits.
Renée Loth’s column appears regularly in the Globe.