While climate change has dropped out of the news in our new corona-verse, in this column I argue that the COVID crisis is indeed a climate crisis, and that the United States needs a Green New Deal approach if we are to reopen our economy safely, without incurring waves of new COVID-19 infections that will force future lockdowns.
Unlike China, Hong Kong, Singapore and South Korea where new infectious cases fell dramatically after aggressive health efforts to contain the disease, the United States must follow a different model. Our laggard scale-up of testing and lack of a coordinated response by the US government has resulted, as of April 20, in 760,000 cases of viral infections in all 50 states, with over 40,600 deaths.
Robert Redfield, the director of the Centers for Disease Control and Prevention (CDC), predicted last week that to reopen, we need to ramp up not only COVID-19 testing, but “very aggressive” contact tracing of new cases. A recent Kaiser health policy editorial noted that while the detective work of finding cases is a key measure epidemiologists see as vital to control the pandemic, contact tracing has gotten little attention by politicians or the media. The labor-intensive nature of the task is probably why. At present between the CDC and local health departments, the United States has only about 2200 such “disease detectives.” Former CDC Director Tom Frieden estimates that, based on experiences in Asia, 300,000 such workers will likely be needed across the country. The problem is that chronically underfunded, and now overwhelmed, municipal and state health departments have no capacity for such a massive scale up.
This is where the Green New Deal strategy comes in. This much debated proposal to link job creation to a just energy/climate transition, emulates FDR’s depression-era Work Progress Administration jobs program, and could offer a win-win solution to our two acute (and simultaneous) dilemmas: record levels of unemployment and a vital need for more feet-on-the-ground to reduce our viral case load.
The GND environmental strategy is, in fact, on point, given that emerging evidence shows that the pandemic is a product of the same globalizing, fossil-fueled capitalist practices that are ravaging earth’s climate. Scientists investigating origins of coronavirus find evidence it almost surely came from bats, and likely passed through an intermediary wild animal before infecting humans, as have other recent emerging infectious diseases like SARS and Ebola. Rapid urban development, as existed in Wuhan, China, and the environmental degradation that accompanies land clearing for oil palm plantations or mining, flushes wild animals into the open bringing them in contact with humans. Through vendors in urban wildlife markets conditions are created for “spillover” of dangerous viruses to dense human populations. This unleashed viral genie has gone global, and we cannot return to the original GND agenda of a just energy transition [still urgently needed] until we solve the problem in front of us of containing the novel coronavirus’s spread.
As a medical anthropologist who has studied prior emerging disease epidemics and national health systems, my argument for ramping up health staffing derives from the same system thinking behind the GND proposal (eg. hitting multiple birds with one stone). To treat the crush of sick patients in Wuhan, China sent 42,000 health workers to the city from other parts of the country. Despite the likelihood that many new hot spots will crop up here, the United States lacks a mobile medical corps that can be deployed rapidly to assist local hospitals. Also, many political observers predict that after the pandemic, citizens are likely to demand more investment in access to care and public health surveillance. One analogue might be the underfunded “National Health Service Corps” which ties medical school loan forgiveness to commitments by new doctors to practice for two years in an underserved area. So a plan to strengthen health staffing could address future needs as well as our current emergency. And besides containing new infections and providing vital paychecks to our unemployed, like other “essential” workers, the new health corps would spend their funds into the economy boosting demand for goods and services.
That Dr. Frieden, who directed the CDC from 2009 to 2017, endorsed this approach is not surprising. Years ago Frieden implemented a similar program in New York City. I did a post-doctoral research project in 1999 comparing two recent epidemics of resurgent multi-drug-resistant tuberculosis (MDR-TB) – one in New York City and one in Lima, Peru. I learned that while working in the CDC’s Epidemic Intelligence Service in 1991 Frieden helped demonstrate that MDR-TB was widespread in many poor neighborhoods of New York, a finding that spurred the city to replace its health leadership which had ignored mounting signs of the epidemic. Frieden was appointed to lead the city’s tuberculosis division and later credited for innovative policies that brought the outbreak under control. [In 2002 he was appointed Health Commissioner for the city.] One key initiative was the hiring and training of community health workers to do outreach, track cases and administered doses of anti-TB drugs in a regimen known as Directly Observed Therapy (DOT) – designed to solve the problem of non-compliance once TB patients felt better and tended to discontinue their drugs leading to resistance. Frieden, who I first met in the 1980s when we both volunteered with a network of US committees advocating for health rights in Central America, had edited a newsletter that detailed the success of community health approaches in that region.
Community health workers were also the key to controlling MDR-TB in the Peruvian field site I studied during that 1999 post-doc. Drug resistance was first identified in a barrio of Lima in the late 1990s by the Boston-based non-profit Partners in Health (PIH) –led by Drs. Paul Farmer and Jim Yong Kim. PIH built a program at an urban clinic there to address the deadly outbreak using a similar strategy of outreach and treatment with lay workers doing home visits and social programming with patients. In both the New York and Lima epidemics, a training staple for successful community outreach was cultural sensitivity and a willingness to establish relationships and trust with patients and their families. PIH’s Peru work helped established a model for treating MDR-TB outbreaks in low-income countries. PIH went on to help expand rural health training, infrastructure and use of community health workers in Africa in recent decades.
The non-profit is now applying that experience to COVID-19 in Massachusetts where the health department just contracted with PIH to hire 1000 fulltime community health workers who will do contact tracing statewide. New York State health officials are also discussing hiring ”a legion” of health workers to do contact tracing of COVID-19 cases, with the initial focus in New York City which has only 150 “disease detectives;” a preliminary plan is to scale up to 1000. To reach a level of effectiveness needed to re-open the economy, federal funding for such workers will be needed in every state.
The main job initially for this new health service corps, which I would argue should have both professional and community-based contingents, would be contact tracing – the painstaking work of finding people exposed to the virus and assisting them with treatment and isolation plans to prevent further spread. Since April 1 the country has seen 25,000 to 30,000 new COVID cases a day. Given COVID-19’s high level of asymptomatic contagion, epidemic models predict the infection will continue to spread across the country in the months (possibly years) ahead, potentially producing not hundreds of thousands, but millions of new infections, especially in places where existing “shelter in place” rules are lifted early or in states where they were never fully implemented; not to mention arrivals of infected passengers through a gradual opening of international air travel. Drawing on the Asian experience, epidemiologists predict that most likely contact tracers would be aided by data from an electronic tracing system using cell phones, given the enormous scale and scope of such a project in the US. Several tech companies are working on such apps at present, but the prospect is raising many concerns about privacy and risks of laying the basis for a surveillance state.
Each case of an infected person found can prevent a potential new hot spot for an outbreak, and the contact tracers, ideally hired from the same communities or regions where they would serve, would assist patients with testing, treatment, and quarantine options – an essential step to remove them from family members in crowded households that have immune-compromised or elderly members. When locally based and trained well, community health workers are also the ideal outreach personnel to aid in community education on COVID-19 prevention and treatment, including advice and on chronic problems that contribute to a high COVID mortality in Latino and Black families.
How to pay for such a program? The same way the federal government pays for military hardware, fossil fuel subsidies or bank bailouts. Or better still, eliminate some of the above in favor of keeping tens of thousands more Americans from dying of COVID-19 [as I write this mortality just topped 40,600]. Did anyone notice the $425 billion in the last stimulus bill of taxpayer funds to leverage $4.25 trillion of Federal Reserve sweetheart loans for large corporations that critics dubbed a “robbery in progress” since it will benefit mainly CEOs and shareholders? And close to another billion went to a Pentagon handout to Boeing –nevermind that Boeing and scores of other corporations spent huge portions of their profits on stock buybacks to benefit those same parties in recent years.
There are other things the United States needs to do in order to re-open, such as (at minimum) triple the current rate of testing and develop a humane program for quarantining infected patients away from family members. But as policymakers scramble for aid packages to keep the working class afloat, they would do well to consider hiring some of them. Until we have an army of disease detectives, the virus will continue its massive crime wave. Mother Nature is very angry.
Teaser photo: Contact tracing during a Cholera outbreak in Bangladesh (2014): FETP investigators interview the mother of an index case patient.