Abstract
This commentary was difficult to start. It is always a little challenging to write something in April that will be relevant when published in July. This April, we were in the first weeks of what felt like a sudden onset pandemic and, in the United States, witnessing a pandemic response that seemed to get worse every day. As my deadline approached, I struggled to find a point of entry. I am not an epidemiologist who could add to what we were learning from our constantly updating news feeds. I am not a futurist who sees patterns across unfamiliar data points to predict what is ahead. I am not a frontline provider, first responder, or caregiver witnessing the tragedy with my own body and soul. I wasn’t sure of my lane when the corona virus commentary space was already so full.
But then, I remembered the power of health promotion practice, and our lane was suddenly clear.
We are the interstitial space in public health, where, in the words of Canadian poet and songwriter Ferron Foisy, “the lines connect but the points are free” (Foisy, 1980). We are interdisciplinary, crossing borders and social contexts, working in every sector and setting, bringing heart, intelligence, insight, outrage, and hope to the issues of our time and the communities we serve. This is our responsibility in a pandemic. This is our lane.
The Pulse of Health Promotion
To illustrate what goes on in our lane, I invited the Health Promotion Practice (HPP) Editorial Board to share their experiences of March and April 2020, our first weeks of COVID-19. You can read their commentaries in full at https://www.sophe.org/journals/health-promotion-practice/. The accounts reveal their readiness to act and the tenacity of people who will not look away. To share just a few examples:
Armando De Alba, a Mexican physician working in Nebraska, was immediately called into action as the regional Spanish-speaking health care expert for the news media. At the same time, he took on coordination of rapidly developing, tailoring, and disseminating culturally and linguistically appropriate materials for clinical patient management and community outreach.
In Perú, where the government closed the borders, shut down the schools, and imposed a strict curfew on March 11th after only the 10th case was diagnosed, public health social scientist Valerie Paz-Soldán used social media to meet public shock with informed communication in Spanish and English. She then convened informal social media chat groups whose members took on projects such as developing personal protective equipment prototypes and delivering masks to isolated areas.
At the U.S.–Mexico border, Jacob Martinez had to quickly identify new ways for his final semester community health nursing students to complete their clinical hours when they were removed from their clinical placements in order to limit exposure to the virus. He notes the bitter irony of needing to keep students out of local facilities despite major shortages of health care providers in areas hardest hit by the pandemic, and the challenge of securing emergency placements without straining local community agencies.
With their physical operations shut down, Lilian Ferrer’s university in Chile became immediately involved in four initiatives: developing testing strategies and technology, contributing to vaccine development, building ventilation bag compressors, and coordinating an interprofessional response across five Chilean universities.
From Washington, the first COVID-19 epicenter in the United States, Robin Evans-Agnew recalls the way that “the pandemic caught hold in our state with breathless rapidity,” and the sudden death of a friend and colleague. He describes widespread and immediate decentering as “things were starting to come adrift in other parts of my universe.” A weekly writing group he leads used the action inquiry prompts vemos, juzgamos, actuamos (think, judge, act) to examine the immediate impacts of lost work, lost income, fear, and isolation on participants’ families and then to begin to develop coping and organizing strategies to confront their concerns.
Jean Breny, then President of the Society for Public Health Education (SOPHE), was part of the SOPHE staff and leadership team that had to transform a complex annual conference to a completely online format in just 6 days. These demands coincided with urgent and unprecedented responsibilities in her role as department chair upon the physical shut-down of her university in the New York tri-state area, another early epicenter. She writes of “the head spinning rush of change, the daily challenges, and the constant stress and worry about not knowing what the next day will bring.” In that charged atmosphere, she also notes the blatant reveal of long-existing disparities and privilege, including the privileged assumptions of social distancing.
Reading these accounts, I could feel the interstitial pulse of health promotion practice. I invite you to explore their stories and, if you are not doing so yet, begin writing your own. We are living history.
The History of this History
The course of my own family was forever changed by the 1918 pandemic flu. The story I heard growing up seemed as incomprehensible as a tornado to a child from California—a virus that came out of nowhere ripping through their Midwestern town, nothing and no one who could help, the relatives who survived nearly destroyed by grief. For my family and their contemporaries, quarantines and masks, sudden and devastating illness, and confounding patterns of community spread must have taken them by surprise. But we knew better this time. By 2020, the possibility of a virus like this and its impact, particularly on differently resourced communities, could be no surprise.
In the words of Indian author and activist Arundhati Roy (2020), “The tragedy is immediate, real, epic, and unfolding before our eyes. But it isn’t new.” HPP Board member Carlos Rodríguez-Díaz, “a Puerto Rican and a community health scientist in the diaspora,” notes the already urgent public health crisis brought on by the colonial relationship of Puerto Rico to the United States, resulting in “the lack of autonomy, the very inconsistent practices implemented by the government[s], the mismanagement of resources, and the lack of proper risk communication.” This was the preexisting context in which Puerto Rico was thrust into competition with the states for tests and medical equipment, prohibited the local government from making autonomous decisions about the arrival of commercial flights, and frequently erased information on Puerto Rico from national data on the epidemic.
Needed at an emergency call center in El Paso, Texas, across the border from Ciudad Juarez in Mexico, Mexican physician Juan Aguilera was stunned by how many people were without resources or guidance, did not know how to access services, did not have health care, and, due to border closures, could not see a physician on the other side. Francisco Soto Mas and his colleague Laura Nervi document the preexisting disparities in the state of New Mexico, where “small, rural, isolated communities lack resources and adequate health and public health infrastructure, resulting in disproportioned rates of morbidity and mortality from almost all causes.” They warn of the “tremendous stress that an easily transmitted virus can place on [already inadequate] public health and health care systems,” as well as “the collateral damage caused by the critical difficulties in maintaining essential services during the current crisis.”
Nowhere is the history of this history more evident and heartbreaking than in the U.S. city of St. Louis, Missouri. When Board members Keon Gilbert, Darrell Hudson, and LaNita Wright wrote their commentary in early April, all of the COVID-19 deaths in St. Louis were among African Americans; as of April 28, 2020, African Americans were 68% of the deaths yet only 46% of the population (Cyphers, 2020). Suddenly, health disparities were portrayed in national headlines as if this was a breaking story. Yet my colleagues note that many have long understood “that considering the legacies of racism, St. Louis and many cities like it have been structured by deeply entrenched racial segregation, limited health promotive resources, and greater levels of stress and trauma experienced over the life course.” The downstream effects of systemic disinvestment in communities and neighborhoods, and the subsequent and socially constructed impossibility of adhering to social distancing guidelines have had “catastrophic consequences for vulnerable communities.” Arundhati Roy (2020) was right, “the tragedy is the wreckage of a train that has been careening down the track for years.”
We have seen this before
Throughout this spring, I have found myself reflecting on the early days of another pandemic within my lifetime. Others will analyze the critical differences between the global experience of AIDS and COVID-19, but I keep coming back to is what is so familiar. In the early 1980s, a virus took hold in communities already marginalized and stigmatized. We lived for so long with the bone-chilling reality that a diagnosis meant fast and certain death. Many feared entering the hospital and likely dying alone. Then, as now, the health care system was completely unprepared, yet courageous providers, but only in pockets of the country, stepped up to provide care and comfort when others would or could not. The American president was callous and cowardly for too long, while the losses mounted and communities mourned. I remember the unrelenting sadness of the years before there was any hope of medical intervention. And I must not forget the blaming and shaming—too often from our own profession—when prescribed preventive behaviors were not sustained or sustainable.
But what else happened? A new generation of leaders was forged from that fire. Participatory community planning was required to determine the Centers for Disease Control and Prevention’s state and local HIV resource allocation, with mandated protection of the principles of parity, inclusion, and representation at the planning table. Bold activism and advocacy challenged tradition and health-related bureaucracies, systems changed in small but crucial ways. New voices demanded attention, new space was claimed in the margins and the center, new allies were engaged when they proved trustworthy, and a weathered but fire-forged resilience emerged among many who survived and among those who would listen and learn.
HPP Board member Aditi Srivastav sees the lively possibility in the current moment: COVID-19 provides us an opportunity to see structural racism in real time through the disproportionate rates of early mortality caused by the virus among people of color. As a result, the public is making connections to how socio-environmental and historical factors are inextricably linked to racial health disparities. New faces are championing equity. Decision makers are questioning the status quo. Public health must harness this momentum and have hard conversations about racism to build support toward systemic and structural solutions.
In our divided social ecological landscape, Danielle Brittain sees core health promotion principles as essential to the way forward—“collaboration, openness/transparency, flexibility, accountability, communication, cultural competency, self and collective efficacy, and, above all, the structures and resources that nurture resiliency.” Robert Strack writes that “putting the public into public health means we value and fund those things that we did not prioritize in the pre-COVID world.”
The Task at Hand
“We see two things happening: COVID-19 does not discriminate and it impacts individuals and communities differently.” This summary by Melissa Valerio directs our attention to the dual nature of the tasks at hand: compassion for those affected and strategically channeled action to right the deeply entrenched wrongs this shared crisis has laid bare. Last year, in “A message to the graduates,” I suggested that new professionals will need two languages to be effective: a vocabulary of outrage and injustice and a deep and nuanced lexicon of hope (Roe, 2019). We need that sentient framework now more than ever.
There is a place for us in the COVID-19 response, but to do our part in this interstitial space of public health, we must be thoughtful, true, and ready. This is a time for eyes wide open, cultural humility and structural competency, for freedom of confident action without telling someone else’s story. We have another opportunity to be real allies and co-creators, not opportunists or contemporary carpetbaggers eager to claim a piece of the inevitable career-building opportunities. Our lived experiences and professional competencies will serve us well, especially if we stay true to the bedrock of health promotion practice.
We don’t know yet how or when this will end. But we know the power of our lane.
