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June 2021 (Volume 99)
Quarterly Article
Alan B. Cohen
March 2024
Mar 11, 2024
Feb 27, 2024
Back to The Milbank Quarterly
In my introduction to the March 2021 issue of the Quarterly, I referred to 2020 as a “perfect storm” of public health emergency, economic upheaval, long-simmering racial tensions, and civil unrest. George Floyd’s murder by convicted former police officer Derek Chauvin helped spark the Black Lives Matter movement, and forced many white Americans to confront the fact that racism permeates American society. However, despite this growing realization, violent hate crimes against Asian Americans1 and other minorities have escalated, and the health consequences of systemic racism continue to threaten Black communities.2 Even if one did not personally experience the ravages of acute COVID-19, the loss of a loved one, the desperation of financial hardship, or acts of racial hatred, hardly anyone came through last year untouched or unmoved by these events.
Throughout 2020, our daily existence was often unnerving and dangerous. How one coped with COVID-19 and other challenges depended on one’s relative wealth, access to resources, and personal inclinations. Fear of infection drove many into seclusion and caused others to tread cautiously outside their homes, but seemed to have little effect on those who intrepidly risked danger. If one could afford it, contactless home delivery of groceries and almost everything else became the norm. Zoom and other internet platforms served as common media for maintaining contact with family members, friends, and co-workers. Avoiding large gatherings and observing discreet social distance in enclosed spaces became accepted rules of conduct, except for libertarian-minded folks who rebelled against infringement of individual rights. There was no middle ground, though, when it came to state-imposed mask mandates – people either embraced or abhorred them. For some, 2020 also will be remembered as the year of apocalyptic hoarding of critical food staples, hand sanitizer, and toilet paper at the expense of our neighbors’ access to those goods.
Yet, despite the months of deprivation and sacrifice, some “good” emerged from this experience. Mask wearing and other mitigation methods proved effective in cutting down transmission of the virus. Zoom meetings liberated work routines and education from the confines of the office and the classroom, respectively. Health care providers and payers belatedly discovered the value of telehealth as a legitimate means of enabling patients to receive health care services safely and effectively outside physicians’ offices and hospitals. While these unexpected benefits clearly did not offset the harms and challenges we faced, they arguably represented a “silver lining” in the storm clouds that engulfed us over the past year.
In 2020, the United States accomplished the unprecedented feat of bringing multiple effective vaccines to market faster than at any time in history. After a slow start, the rollout and distribution of COVID-19 vaccines in the US gained speed in early 2021, leading to a high rate of vaccination nationally. However, vaccine rates have varied considerably across states, and minority groups have not enjoyed equitable access to vaccines despite the pandemic’s disproportionate effects on these communities.3 In addition, vaccine hesitancy and distrust remain significant problems, and the federal government’s acquisition of millions of vaccine doses, while benefiting Americans, has blocked other nations from obtaining adequate supplies of vaccine, particularly as the pandemic continues to wreak havoc across the globe.4 Few nations have remained unscathed, and even those that were able to control the spread of the virus early on (e.g., Taiwan, New Zealand) are now seeing spikes in infection rates. Most others (e.g., Spain) have experienced recurring waves of infection, and still others (e.g., India, Brazil) are grappling with widespread transmission of COVID-19 variants. In the United States, conditions fortunately have been improving daily, and the American Rescue Plan Act of 2021 is bringing needed insurance coverage and financial relief to citizens facing loss of insurance, income insecurity, and eviction. The Biden administration’s legislative plans for building infrastructure and for supporting American families give rise to hope for a return to normal routines within the coming year. For most other nations, though, the past year of living dangerously unfortunately is likely to continue for some time.
One year ago in June 2020, we issued a call for papers regarding national or state-level policies and strategies that could benefit population health and strengthen the public health infrastructure in the United States post-pandemic. Our goal was to invite original research and thoughtful Perspectives that could directly inform policy makers in health and social sectors. In response to the call, we received more than 80 submissions, from which we culled 11 manuscripts, all related to the COVID-19 pandemic or its aftermath. Two items were published in 2020 – an opinion piece by Charley Willison and Iris Holmes5 regarding the perils of perverse incentives for disaster preparedness, and a research article by Robert Handfield and colleagues6 outlining plans for a reformed National Stockpile for emergency medical materials.
In this issue of the Quarterly, we are pleased to present several original scholarship articles and Perspectives that cover a broad range of COVID-related topics. In addition, the issue contains an original research article that examines the challenges of data exchange between hospitals and public health agencies. Although the study period preceded the pandemic, the research findings have policy implications for the post-COVID-19 era.
In “Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post-COVID Era,” Ji Chang and colleagues surveyed small primary care practices regarding their telehealth use in New York City from mid-April through mid-June 2020. These practices, which represented 40% of primary care providers, were disproportionately located in low-income, minority or immigrant areas severely impacted by COVID-19. Using the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high-SVI or low-SVI areas, the authors found that all providers had rapidly shifted to telehealth, but that they differed based on community characteristics in the primary mode of telehealth used and the types of barriers encountered. Providers in high-SVI areas were more likely to use telephones as their primary telehealth modality, while video was the primary telehealth modality used by providers in low-SVI areas. Providers in high-SVI areas also faced more patient-related barriers and fewer provider-related barriers than those in low-SVI areas. To ensure greater telehealth equity, they advocate policy changes to address barriers faced by marginalized patient populations and those who serve them.
The use of mandated lockdowns has been the subject of contentious debate and sometimes-violent reaction in parts of the United States. Although lockdowns may slow the spread of COVID-19, policymakers worry that they also may reduce citizens’ trust in authorities and compliance with future health mandates. In “Effects of COVID-19 Emergency and National Lockdown on Italian Citizens’ Economic Concerns, Government Trust, and Health Engagement: Evidence From a Two-Wave Panel Study,” Guendalina Graffigna and colleagues analyzed the effects of Italy’s national lockdown on citizens’ personal, psychological, and economic well-being. In a two-wave survey of Italian adults, they found that, while social responsibility had increased between the two waves, and trust toward authorities had remained substantially unchanged, trust in science, consumer sentiment, and health engagement all had decreased. They recommend coupling preventive measures with collaborative educational plans to promote people’s health engagement as partners in such endeavors.
The COVID-19 pandemic highlighted substantial barriers (technological, organizational, and environmental) in the exchange of essential information between hospitals and local public health agencies. In “Identifying Opportunities to Strengthen the Public Health Informatics Infrastructure: Exploring Hospitals’ Challenges with Data Exchange,” Daniel Walker and colleagues used cross-sectional data of acute care, nonfederal hospitals from the 2017 American Hospital Association Annual Survey and Information Technology supplement to identify characteristics of hospitals associated with these types of challenges. Of the 2,794 hospitals in the sample, 61% reported experiencing at least one challenge in reporting health data to a public health agency, with organizational issues being the most commonly reported challenge. Their policy recommendations call for improving data standards, increasing funding for public health agencies to improve their technological capabilities, offering workforce training programs, and increasing clarity of policy specifications and reporting.
Many public health experts believe that our collective recovery from COVID-19 rests on ensuring equity in global vaccine distribution, but the history of previous pandemics suggests that access to vaccines for developing countries will be limited. The COVAX Facility, an international collaboration, seeks to promote equitable access, but the prevalence of vaccine nationalism threatens to limit its effectiveness. In “International Collaboration to Ensure Equitable Access to Vaccines for COVID-19: The ACT-Accelerator and the COVAX Facility,” Mark Eccleston-Turner and Harry Upton analyzed the academic literature regarding access to vaccines during the H1N1 pandemic, and assessed the WHO principles guiding COVAX vaccine deployment. They concluded that, although current efforts through COVAX have greatly accelerated the development of COVID vaccines, these benefits are unlikely to flow to low- and middle-income countries.
In a Perspective that also addresses international collaboration, “Allocating a COVID-19 Vaccine: Balancing National and International Responsibilities,” Reidar Lie and Franklin Miller recognize the pitfalls of vaccine nationalism and propose a middle-ground policy for effective COVID vaccine distribution. Their strategy lies between a fully egalitarian approach that rejects nation-state priority and unbridled vaccine nationalism that disregards equitable global allocation. They contend that features of the COVAX partnership make it an appropriate framework for implementing such a middle-ground policy.
In “Our Postpandemic World: What Will It Take to Build a Better Future for People and Planet?,” May van Schalkwyk and colleagues paint an optimistic portrait of opportunity in the current crisis that could produce strengthened democratic, research, and educational institutions, supported by transparent ideas that challenge the status quo and the existing inequitable distribution of power among actors. They caution, however, that powerful self-interested individuals and industries (many of whom had acted to worsen the COVID-19 crisis) will work to ensure that the future aligns with their personal interests. Nevertheless, they believe that true transformational change is possible, but will require new ways of working together to build a better, more just and sustainable world.
The confluence of the COVID-19 pandemic, the economic crisis, and civic reactions to structural racism in the United States greatly challenged policymakers in 2020. While scholars have analyzed and debated public sector responses to these challenges, little attention has been paid to the commercial determinants of these crises. In “The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect with the COVID-19 Pandemic, Economic Downturn, and Racial Inequity,” Nason Maani and colleagues examine how corporate actors contributed to the conditions underpinning these crises through their market and nonmarket activities. The authors make recommendations regarding the role of governance and civil society in relation to commercial actors in a post-COVID-19 world.
An estimated 700,000 people in the United States have “long COVID” in which symptoms persist beyond three weeks. The long-term effects of COVID-19 are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination. In “Long COVID and Health Inequities: The Role of Primary Care,” Zackary Berger and colleagues assert that primary care providers are in a unique position to provide and coordinate care for vulnerable patients with long COVID. They recommend that policy measures include strengthening primary care, optimizing data quality, and addressing the multiple nested domains of inequity.
In “The Structure and Financing of Health Care Systems Affected How Providers Coped with COVID-19,” Ruth Waitzberg and colleagues compare the financial effects of the COVID-19 pandemic on health care providers in the United States, England, Germany, and Israel. The authors find that US health care providers have experienced greater negative effects than elsewhere, owing to the prevalence of activity-based payment systems, limited direct governmental control over provider capacity, and the structure of government financial relief. They observe that, in a pandemic, activity-based payment reverses the conventional financial positions of payers and providers, and may prevent providers from prioritizing public health because of the desire to avoid revenue loss caused by declines in patient visits.
The need to restructure long-term services and supports (LTSS) in the United States has long been recognized, but the high rates of COVID-19 infections and deaths in nursing home residents, particularly during the early stages of the pandemic, brought the failings of those institutions and the public health system into sharper focus. In “COVID-19: The Time for Collaboration between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now,” Walter Dawson and colleagues analyze the pandemic’s economic toll on state budgets and its direct impact on Medicaid, the primary funder of LTSS. Based on their analysis, they recommend substantive reform of the LTSS system to include required uniform public reporting of COVID-19 cases in all LTSS settings, support of unpaid caregivers, stronger protections for the direct care workforce, increased coordination between public health departments and LTSS agencies and providers, and reduced barriers to telehealth in LTSS.
In the seventh installment of our Milbank Classics series, Georges Benjamin reflects on Thomas McKeown’s 1961 seminal article, “The Next Forty Years in Public Health.” Writing in “On Planning for an Unimaginable Future,” he notes that McKeown had the foresight to recognize that we are limited in our ability to predict and prepare for disruptive health events, such as the COVID-19 pandemic, because we cannot imagine them. He also observes that, even when we do our best planning, we fail to conceive of all factors that can influence far-reaching societal impact. Although McKeown was remarkably accurate in his predictions regarding future mortality and morbidity, his greatest contribution was to focus our attention solidly on the social determinants of health. Looking to the future, Benjamin opines that the “best way to predict—and protect—the future is to make sure everyone has a hand in inventing it.”
In closing, we invite readers to explore recent opinions by John McDonough, Dalton Conley, Rashawn Ray, Lawrence Gostin, and Gail Wilensky on a host of topics that may be found on the Quarterly’s website (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/) as well as recent posts in our Building Back Better series at https://www.milbank.org/quarterly/building-back-better/.
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.
