America’s public health experts must engage communities in the covid-19 response – The BMJ

The incoming administration has to help Americans understand that their survival—both economic and physical—depends on individual actions, write Krutika Kuppalli and colleagues

On 3 November, voters in the US cast ballots in a general election that had the highest voter turnout in over a century. They did so against the backdrop of a surging covid-19 pandemic that has killed over 250 000 Americans, and which has set records since the election with case counts surpassing 100 000 new infections and averaging more than 1000 fatalities per day. Despite these indicators of a poorly controlled pandemic, more than 70 million Americans voted for Donald Trump, and most of his supporters believe that the coronavirus pandemic is under control.

As covid-19 surges across this country, the incoming administration faces the challenge of bringing together a divided country, containing the pandemic, and rolling out a vaccine. The covid-19 taskforce headed by president elect Joe Biden must contend with the failed leadership of the current administration, the lack of cohesive messaging, and public mistrust. They must also help Americans understand that their survival—both economic and physical—depends on individual actions. 

Discontent with covid-19 in the US stems from a vacuum of national leadership, poor communication, and misinformation, which escalated into three overlapping problems. 

Firstly, the federal government’s failure to create a unifying message about the threat of covid-19 led to it becoming a partisan issue. State and local government officials were left to interpret rapidly evolving data, develop their own strategies and plans, and counter misinformation without federal guidance. The ensuing politicization of the pandemic has undermined public buy-in for mitigation measures including face masks, resulting in state level mask mandates and curfews. 

Secondly, rapidly evolving knowledge about this coronavirus, combined with suboptimal messaging, misinformation, and a lack of community engagement, has exacerbated confusion and mistrust. Scientific knowledge has evolved and been published at an unprecedented rate, requiring clear and direct messaging from public health leadership about what the data mean and how they will be used. Instead, government scientists and public health experts have been sidelined and silenced, leaving the public to interpret data on their own. As a result, members of the public have turned to unreliable sources such as social media, which is replete with misinformation campaigns, anti-science rhetoric, and conspiracy theories—often from the White House itself. Looking ahead, the public health community can expect to encounter similar challenges with the rollout of a covid-19 vaccine. 

Thirdly, disinformation campaigns have created a false dichotomy between lives and livelihoods when, in fact, the health of the population determines the strength of the economy. Without control of the pandemic, we will have cycles of re-openings and lockdowns that exacerbate economic devastation. Many political leaders have cast public health restrictions as foes to economic survival, leading many to believe that they had to choose between pandemic control or economic survival. Poor management of lockdowns and other restrictive measures, which have both failed to control the pandemic and have had significant economic and social impacts, may have further contributed to an erosion of support for public health. 

How can we dispel disinformation and find our path back towards united action to combat this threat? 

Distrust and public health denialism are not new challenges for infectious disease control efforts. Healthcare and public health professionals have faced these thorny problems in other epidemics—from polio to HIV to Ebola. Lessons from these outbreaks can be applied to the current pandemic. For example, during the 2013-16 west African Ebola epidemic, the distrust of aid workers, widespread disbelief, and conspiracy theories surrounding the existence of Ebola hampered efforts to control the epidemic. It took months of public health workers collaborating with local specialists who understood cultural norms and developed partnerships with communities to make inroads and gain trust with citizens. Efforts to engage and educate communities were instrumental in controlling the Ebola outbreak and eventually declaring it over in the region. This basic principle of grassroots community engagement can work for the coronavirus pandemic as well.

The guiding philosophy of community based public health interventions is that we work “with” communities to meet them “where they are,” not “where they need to be.” Practically speaking, there are at least three necessary components for success. 

Firstly, public health leadership must adapt public health responses to diverse local contexts. This requires an understanding of a community’s cultural demographics, the number of people at risk for severe illness, the landscape of vulnerability, and challenges faced by the local healthcare systems. Local and state public health leaders must develop collaborations through coalitions with advisory boards, non-governmental organizations, businesses, faith based institutions, and ethnic groups to determine how evidence based interventions can be adapted to fit the local context. For example, while isolation space may be needed in a number of communities, how those spaces take shape should vary. Isolation spaces for communities with large nursing home populations, for example, need to include services specific to that group.  

Secondly, public health leaders must build trust at the community level by empowering local leadership as equal partners in the public health response. Trusted community leaders such as religious figures, athletes, and business professionals can provide a bridge to communities, relaying information about implementation strategies, risk communication, outreach, messaging, and dispelling misinformation campaigns. Successful lessons from rural America can be applied to the greater population as a whole. Specifically, local trusted leaders can help develop transparent policies while acknowledging the hardships associated with restrictive measures.  

Lastly, public health responses must be aligned both across local, state, and federal public health levels as well as sectors. Community health requires the collaboration of multiple sectors across society that influence population health, including education, business, healthcare, and hospitality. Public health leaders must support coordinated community action plans across multiple systems and sectors to help with overall community mitigation measures. Furthermore, a coordinated response must focus on economic and social impacts of the pandemic, and frame public health measures as tools for protecting the economy and achieving other meaningful goals.  

It is evident to the scientific community that controlling the covid-19 pandemic is critical to mitigating human, economic, and social costs to our society. The recent presidential election must be a wake-up call for scientists, epidemiologists, and public health experts, particularly as the country heads into winter with cases, hospitalizations, and fatalities rising at record pace. Our guidance and plans must be context- and community specific, and give people a sense of empowerment so that we can adjust the course of the pandemic in this country. 

Krutika Kuppalli is an assistant professor of medicine in the Division of Infectious Diseases at the Medical University of South Carolina in Charleston, South Carolina. Krutika is also an emerging leader in biosecurity fellow at the Johns Hopkins Center for Health Security. Twitter @KrutikaKuppalli

Anne N Sosin is the program director for the Center for Global Health Equity at Dartmouth College and the co-lead on Dartmouth research on covid-19 and rural health equity in northern New England. Twitter @asosin

Syra Madad is an infectious disease epidemiologist and serves as the senior director of the System-wide Special Pathogens Program at NYC Health + Hospitals. Syra is also the health and safety lead of the Enhanced Special Investigations Unit of NYC Test & Trace Corp and fellow at the Harvard Kennedy School Belfer Center for Science and International Affairs. Twitter @syramadad

Nahid Bhadelia is the medical director of the Special Pathogens Unit at the Boston Medical Center, an associate professor in the Section of Infectious Diseases at the Boston University School of Medicine, and infectious diseases physician at Boston Medical Center. Twitter @BhadeliaMD

Joshua A Barocas is an assistant professor of medicine at the Boston University School of Medicine and infectious diseases physician at Boston Medical Center. Twitter @jabarocas

Competing interests: KK is a consultant for GSK and JAB receives funding from NIDA. AS, SM, and NB have no disclosures.

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