America spends $3.8 trillion on health care annually, more than any other country. Yet when it comes to creating a more equitable public health system, it could learn a thing or two from some of the world's poorest nations, says Katie Bollbach, executive director of Partners in Health-U.S.
Partners in Health is best known for providing health care in some of the most under-resourced places on Earth. The charity has responded to epidemics like HIV in Haiti and Ebola in West Africa. But when the coronavirus pandemic struck, the nonprofit saw that its expertise was also desperately needed in one of the world's richest countries.
Early on in the pandemic, PIH began working with partners in various U.S. communities, including Newark, N.J., Fulton County, Ga., the Navajo Nation and the state of Massachusetts, to train contact tracers and set up other public health interventions for America's most vulnerable. Low-income communities of color have been disproportionately hard hit throughout the pandemic — and that's made long-standing racial and ethnic health disparities glaringly obvious.
Those disparities aren't going away anytime soon. This fall, PIH stated that it would make its U.S. operations permanent. In November, the charity announced it had won $11.1 million in federal funding to help community-based outreach workers in hard-hit communities get people vaccinated. We spoke with Bollbach about what the U.S. public health system can learn from best practices in low-income countries, and the different — sometimes tougher — challenges of doing this work in America. Here are some of the points we discussed.
In the U.S., public health systems aren't always good about talking to each other. And that's a problem.
In the U.S., Bollbach says, public health systems are fragmented and don't necessarily speak to each other or coordinate even in the best of times. Each state operates its own public health system — and even systems within a single state can operate independently from each other. For example, "in a place like Massachusetts, we've got 351 local boards of health in one state, versus one statewide health department or ministry of health," she says.
By contrast, building partnerships is at the heart of Partners in Health's approach to public health — hence, the group's name.
Part of PIH's work in the U.S. has focused on helping public health departments and other agencies deepen their collaborations with each other and with community groups, similar to the work they do in low-income countries. In Chicago during the pandemic, for instance, PIH-U.S. helped grow a coalition of 160 grassroots organizations, philanthropists, public health experts and government officials. The coalition worked with trusted local organizations, including social services agencies, food pantries and groups that address youth violence, to spread the word about vaccines, transport people to get their shots and train community members on vaccine outreach. Now, says Bollbach, that coalition is looking beyond the pandemic, working on a project with the Chicago Department of Public Health to improve health equity neighborhood by neighborhood.
The culture wars are making everyone's job harder.
One challenge that makes the situation in the U.S. unique is the ferocity of the country's misinformation problem, says Bollbach. While there's misinformation and vaccine resistance everywhere to some extent, "the kind of culture war that has developed around basic public health guidance in the U.S. — the fierceness of that — has taken me by surprise, maybe naively," says Bollbach. "We have protesters outside of [the homes of] directors of departments of health — that has been a real distinguishing factor of some of the challenges here. The politicization of really basic public health interventions like masking in schools or vaccine mandates — that does stand out here as unique."
Money, money, money. From Sierra Leone to New Jersey, no one has enough.
Even though the U.S. health system overall is rich in resources, that money isn't necessarily reaching public health departments, Bollbach says. "We've found some exceptional leaders with deep commitments to their communities and to health equity who have just been operating in systems that have been systematically under-resourced or disinvested in over many decades." As a result, she says, they "are fighting with two hands tied behind their backs, in some cases even pre-COVID, in terms of keeping essential functions running." That experience of visionary leaders without the resources they need to do their work "feels fairly shared between the Directorate of Primary Care in Sierra Leone as it does in the department of health in Essex County, New Jersey, in some ways."
The demonization of poverty in the U.S. isn't helping anyone.
In America, there's a cultural perception that everyone can pull themselves up by their bootstraps. That can lead discussions about poverty to take on darker dimensions, she says. It can also help fuel resistance to cash assistance programs that give money directly to individuals. "It's a battle we didn't know we would have to fight quite so vigorously," she says.
Bollbach says that attitude stems from the racism built into U.S. systems. While other countries also have a history of colonialism and racism, she says here in the U.S., it's led to a "demonization of poverty as a sort of individual or household problem rather than a societal and policy problem."
PIH's partners in other countries have long embraced a more generous definition of public health interventions, she says. In the early days in Haiti, for instance, tuberculosis patients would get prescribed medications, "but also we'd have doctors write prescriptions for a new roof or shoes or whatever a patient needed to stay healthy."
The pandemic has helped move the needle somewhat in the U.S. In Florida, for example, PIH-US teamed up with the Coalition of Immokalee Workers, a local community health center and a local faith-based group to give cash assistance to migrant farm workers so they could stay home and isolate themselves when infected with COVID-19 — without worrying where their next meal was coming from. And other U.S. communities have also been experimenting with cash assistance to improve health outcomes.
If there's one big takeaway from other nations, it's the importance of community health workers.
"One lesson that has stood out from day one is how essential it is to bring care and services to people where they are," says Bollbach. A key piece of that is community health workers — a workforce made up of people from the community who are trained to connect people to services and help them navigate access to health care.
"Health workers are the foundation and the heart of health systems in most of the places we work, from Haiti to Rwanda to Peru," she says — and they've been essential to the success of PIH's public health interventions over the last three decades. That's true in emergency situations, such as the Ebola outbreak in Sierra Leone, when community health workers went door to door screening people, delivering groceries to those in isolation and even "helping to literally walk side by side or get an ambulance or a bike or whatever was needed to get that person to a clinic," she says.
But this same workforce also helps promote health longer term — for example, by making sure someone living with HIV takes their medications regularly and goes for routine checkups.
Part of PIH's work in the U.S. has focused on building out the community health workforce here. (Currently there are about 60,000 community health workers.)
Early on in the pandemic, these community health workers were trained not only to do contact tracing but also to steer people to resources that would be helpful in this current crisis, including sources of rent assistance and grocery deliveries to help them isolate better.
PIH hopes America's newfound interest in community health workers will last beyond immediate pandemic needs. In North Carolina, for example, PIH-US has partnered with the state department of health and human services to expand an existing community health worker program to all 100 counties statewide.
"I think this is a real inflection point for us as a country to really double down on this commitment to community health workers in a different, more transformational way," Bollbach says.
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