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JAMA Forum
July 15, 2021

Commonality and Continuity in Responses to Pandemic and Endemic COVID-19

Author Affiliations
  • 1New York City Department of Health and Mental Hygiene, New York, New York
JAMA Health Forum. 2021;2(7):e212474. doi:10.1001/jamahealthforum.2021.2474

The etiology and trajectory of COVID-19 have led many infectious disease experts to posit that the virus, to one extent or another, is here to stay. It may become endemic with illness that is less severe, it may become like seasonal influenza, or it may persist with an ongoing threat of a mass outbreak. Our best conjectures are constrained by the fact that the pandemic is not over—and we ignore current global outbreaks and vaccine shortages at physical and moral peril. But even if the novel coronavirus becomes endemic, it should not mark the end of our response.

History remains a guide, including the lessons of prior health crises such as the 1918 influenza pandemic. But even as we improve our ability to swiftly contain infectious diseases, we must heed the broader warnings of COVID-19. Perhaps most important among these is the catastrophic combustibility of historical patterns of injustice, such as structural racism, intersecting with disease. There are slower-moving crises and faster-moving crises, but the suffering associated with both have common cause and often common solutions.

Ischemic heart disease can provide a clinical analogy. Like pandemics, major heart attacks are uniquely shattering; survivors must contend with a new sense of vulnerability and ideally commit to minimizing future risk. On the other hand, nearly half of heart attacks are “silent,” occurring with few if any recognizable symptoms. Yet both types can lead to heart failure. The slower-moving diseases of poverty, racism, food and housing insecurity, domestic and public violence, and other disasters similarly place futures in peril by presenting as quotidian, and thus all too easy to overlook.

The COVID-19 pandemic should serve as a wake-up call, not just for respiratory viruses, but also for the need to build more fundamental public health protection. Four essential elements of this protection are public health messaging, earning the trust of marginalized communities, tearing down walls between physical and behavioral health, and massive investment in public health.

Protective Public Health Messaging

In the midst of the 2009 H1N1 epidemic, Historian Nancy Tomes, PhD, laid out lessons learned from the 1918 influenza pandemic, many of which could have served as a predictive guidepost for COVID-19.1 She noted that, during and after 1918, experts promoted public education around personal hygiene, even when evidence or observation suggested that handwashing had relatively little containment effect. Perhaps such guidance was seductively easy to fall back on. But the routinization of science-based public health messaging can trigger its expansion, and orient the public to a wider range of practices to ramp up when the next emergency arrives.

If, for example, social distancing had been broadly normalized as needed in the everyday spread of infection prior to COVID-19, then calls to self-isolate may have seemed less novel or threatening. Policy shifts as straightforward as mandatory paid sick days would bolster the basic axiom that we should keep away from others when we are unwell.

Earning the Trust of Marginalized People and Communities

Before individual measures are widely adopted, health officials and clinicians must prove worthy of the trust of the communities most affected. Responses to the H1N1 influenza pandemic in 2009 demonstrated that the most effective way to do this is to create stronger, neighborhood-centered public health infrastructures.2

During the COVID-19 pandemic, communication incorporating social, emotional, and cultural context frequently resulted in the most effective vaccination strategies. New York City’s “Vaccine Talks” campaign—aimed at empowering clinicians’ communication with patients about COVID-19 vaccination—focused on listening, acknowledgment, and motivational interviewing.

Generating broader social trust is the longer arc of this work. Social mistrust may develop among those who have suffered acute loss, and it may even pass to later generations.3 For instance, a child’s first—and traumatic—association with visiting a hospital may be the loss of a loved one.

Social cohesion should be assessed as a key public health indicator. To that end, the New York City health department has incorporated such measurements, from civic participation to levels of trust in one’s neighbors, into its annual Community Health Survey. Measurement of social cohesion and connection forces us to think about interventions to improve those indicators as public health priorities.

Tearing Down Barriers Between Physical Health, Behavioral Health, and Social Needs

The behavioral consequences of the pandemic are staggering. Reports of symptoms of anxiety or depression have hovered consistently around 40% throughout the pandemic, a rate roughly 4 times greater than the first half of 2019. Delayed effects should also be expected; historical evidence suggests that catastrophic grief, stress, and trauma lead to higher rates of suicide. Already on the rise are opioid overdoses, a tragic but unsurprising finding given self-reported increases in substance use concomitant with increases in fentanyl in the drug supply.

The traditional care divide between physical health and behavioral health services belies their mutually dependent relationship. Integration also requires acting upon the link between emotional distress and social needs; during the pandemic, clinicians bore witness to the stress that so many experienced related to food, housing, and financial hardship—particularly essential workers and people of color. The architecture of societal safety nets should be further centered around a holistic approach to physical health, behavioral health, and social needs.

Massive Investment in Public Health

To be effective at scale, these and other proposals demand reallocation of resources, directed in ways informed by historical trajectories and more near-term lessons of COVID-19. We can start with the clear conclusion that economic recovery is not possible without public health investment, particularly in vaccine delivery. The cost-effectiveness of longer-term public health investment is also beyond contention.4 More to the point, if health expenditures were apportioned according to how people in the US across the political spectrum would choose, two-thirds to three-quarters of our health budget would be applied to the fundamental drivers of health, such as food and housing.

Public health leaders have a unique opportunity to call for and shape those solutions in this moment because of the seismic shifts in society wrought by COVID-19. Massive investment in public health and the reallocation of health spending are needed so they are more in line with both science and lived experience. And to build widespread societal support, leaders in public health and health care also need to shine a critical light on ourselves, thinking hard about how we allocate and use the resources we already have; how to be more worthy of the trust of those whom we serve; what language we use to communicate with those whom we serve; and how to more seamlessly collaborate with partners who also contribute to the production of health.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Chokshi DA. JAMA Health Forum.

Corresponding Author: Dave A. Chokshi, MD, MSc, New York City Department of Health and Mental Hygiene, 42-09 28th St, New York, NY 11101 (dave.chokshi@alumni.duke.edu).

Conflict of Interest Disclosures: Dr Chokshi reported receiving personal fees from the Institute for Healthcare Improvement, the Aspen Institute, RubiconMD, and ASAPP Inc.

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Rust  G, Melbourne  M, Truman  BI, Daniels  E, Fry-Johnson  Y, Curtin  T.  Role of the primary care safety net in pandemic influenza.   Am J Public Health. 2009;99(suppl 2):S316-S323. doi:10.2105/AJPH.2009.161125PubMedGoogle ScholarCrossref
Aassve  A, Alfani  G, Gandolfi  F, Le Moglie  M.  Epidemics and trust: the case of the Spanish flu.   Health Econ. 2021;30(4):840-857. doi:10.1002/hec.4218PubMedGoogle ScholarCrossref
Masters  R, Anwar  E, Collins  B, Cookson  R, Capewell  S.  Return on investment of public health interventions: a systematic review.   J Epidemiol Community Health. 2017;71(8):827-834. doi:10.1136/jech-2016-208141PubMedGoogle ScholarCrossref
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