ABOUT TH IS PUBL ICAT ION

As part of its mission, the Duke-Margolis Center for Health Policy aims to educateand train the next generation of leaders who will advance health and the value ofhealth care locally, nationally, and globally. The Margolis Scholars programcombines academic and experiential training in health policy and managementfor exceptional students at Duke University. It uniquely brings together studentsfrom different disciplines to learn about and tackle pressing health carechallenges through interdisciplinary, evidence-based approaches.  Each year the Margolis Scholars come together in the spring to organize an eventfocused on a critical health policy issue of their choice. With plans for the eventfirmly underway, the pandemic hit, centering everyone’s attention on COVID-19and upending our usual ways of gathering and learning. With their ingenuity andresolve, the Margolis Scholars quickly pivoted from their original topic – workingwith the Partnership for Healthy Durham to advance student and communitycollaboration to improve health and health care in Durham – to crafting a series ofreflections on COVID-19.  The ethos of the Scholars program shines through in this collection, reflectinginterdisciplinary perspectives and thought leadership on important and diversefacets and impacts of the pandemic. The topics covered include a range of issuesthat have arisen from, or been highlighted or exacerbated by, the COVID-19experience to date, including food and housing insecurity, loneliness and othermental health concerns, structural racism, and inequities in access to care. Topicsclosely related to the pandemic response, such as telehealth, testing and tracing,supply chains, health care workforce, and public health and primary careinfrastructure, are also explored. Aligned with the original event idea, the first fivereflections of this collection examine the impact of the COVID-19 pandemic onDurham’s top five health priorities, as determined by the community through thePartnership for Healthy Durham’s 2017 Community Health Assessment. For moreinformation on the assessment and/or the Partnership for Healthy Durham, pleasevisit https://healthydurham.org/.

Collectively, the reflections critically and boldly outline key actions needed torespond to the challenges and opportunities posed by the pandemic. They alsoexamine the short- and long-term reforms required to modify or strengthen theunderlying structures, practices, and policies that aim to protect population healthlocally, nationally, and globally.  In closing, this collection showcases the tremendous talent, creativity, tenacity,and leadership of the Margolis Scholars. We hope readers will be both inspired andchallenged to “respond and reform” – not only in dealing with this immediatecrisis, but moving forward to reimagine and achieve a more prepared, resilient,and equitable health care system.

ACKNOWLEDGEMENTS

 First and foremost, many thanks to all of the Margolis Scholars for their thoughtleadership, time, and commitment to producing an impactful reflection series inspite of the challenges introduced by the pandemic and juggling multiplepriorities, including graduation for some. We are also grateful to Dr. CorinnaSorenson, Faculty Director of Graduate Education Initiatives and the MargolisScholars program, for her guidance and input – from concept to collection design– as well as to Meril Pothen (Margolis Scholar and MPP ’20) and Duke-Margolissummer intern, Adrianna Williams, for contributing to the design of this book.Finally, a very special thank you to the Partnership for Healthy Durham for theirvaluable insights and support on several of the reflections.

  0 4COVID-19 and

Access toCare: The Need

for HealthReform in

Durham andNorth Carolina

  0 8COVID-19

Exposes theCracks in our

Housing System

  1 2COVID-19 Drives a Vicious CycleBetween FoodInsecurity andChronic Illness

  1 7Mental Health

During andAfter the

COVID-19 Era

  2 1"Our Community,

Our Responsibility”:Community Efforts

to Navigate theIntersection of

COVID-19, Povertyand Structural

Racism in Durham

  2 5Loneliness

DuringCOVID-19

  2 9

COVID-19and theRise of

Telehealth

3 3Engaging

CommunityMedical

Providers in theAge of

COVID-19

3 7Privacy and

Digital Contact-Tracing

  4 1COVID-19 andthe NursingProfession:

Where Must WeGo From Here?

4 7Pandemic

Response is aDefense Game,

the U.S. is PlayingOffense

  5 1What DoesCOVID-19Mean For

ChildWelfare?

TABLE OF

CONTENTS

RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY SRAVYA DURBHA ,

RACHEL HOLTZMAN ,

AND CHUCK MATULA

COV ID - 1 9 AND ACCESS

TO CARE : THE NEED

FOR HEALTH REFORM

IN DURHAM AND

NORTH CAROL INA

Inequitable access to health care isone of the most acute problems ofour time. Here in Durham, a 2018study community health assessmentfound that 70% of residents notedaccess to health care and healthinsurance as a top health issue – andBlack and Latinx Durhamites are twoand seven times more likely thanwhite residents to be uninsured,respectively. Across our state, COVID-19 is only decreasing access to care.From March 15 to April 25, nearly340,000 North Carolinians lost theirjobs, leading to record numbers ofnewly uninsured, low-income peoplewho will fall into the Medicaid gapand struggle to access care.

In fact, because of increased patientvolume nationwide due to COVID-19,15 million adults in the U.S. have beendenied care for themselves or afamily member – and denial rates arefour times higher for low-incomeadults (incomes at or below $40,000)than their peers. It is clear thatracism and other forms of systemic    

oppression around class, immigrationstatus, language and other markers,impacts who has access to healthcare, and who does not. As studentsof health policy, we have learned thatour U.S. health care system needsmeaningful reform – we spend toomuch, for too few people, with poorlyaligned incentives that encouragelow-quality and low-value services –but we now see it in a new light. Thecoronavirus pandemic isexacerbating deeply inequitableaccess to care in a time when weneed equitable access more thanever.

Federal efforts to expand COVID-19testing options for insured patientsare important but not sufficient. TheFamilies First Act and the CARES Actrequire private carriers to cover 100%of the cost of coronavirus testing(including diagnostic and antibodytests). However, affordable testing forthe uninsured remains limited. Acoronavirus test can cost up to $229,which may represent nearly a quarter

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4

of one’s monthly income for NorthCarolinians in the Medicaid gap. Evenfor insured patients, providers cancharge for coronavirus tests by billingpatients directly rather than billinginsurers, which could negotiatediscounted fees for their members.This doesn’t touch on the heftymedical bills patients might face ifthey do fall sick. A recent reportestimated that an uninsured personhospitalized for coronavirus canexpect to pay more than $73,000 inmedical bills, and another found that14% of people with a likely case ofCOVID-19 will avoid care due to cost.The federal government must ensureCOVID-19 testing and treatment isaffordable for everyone, includingpeople with and without insurance.

Recent federal policy increases accessto telehealth for some but not allpeople. Understanding the importantrole of telehealth during thepandemic, the HHS Office of theInspector General is allowingproviders to reduce or waive cost-sharing for telehealth services used byMedicare patients. However, factorssuch as lack of adequate access tobroadband, lack of insurancecoverage, and homelessness hindermeaningful access to telehealth forsome (see Boisvert, Durbha, andNguyen and Brown and Xiereflections).

Research confirms that underservedpopulations, such as uninsured andlow-income people, use telehealthservices less than their peers. This isno surprise in places like Durham,where the majority of DurhamHousing Authority public housingunits do not provide WiFi to their 

residents. Even with recent CMSguidance to expand and standardizeMedicaid reimbursement fortelehealth, more work is needed toensure that underserved populationshave the internet connectivity anddevices necessary to utilizetelehealth. Federal and stategovernments must align incentivesand resources to this end.

The federal government must alsoinvest in the home and community-based services workforce. As morepatients become hospitalized due toCOVID-19, acute care settings willbecome increasingly overwhelmed.While portions of the Cares Act’s$175B in relief funds are allocated toMedicare facilities, providers in ruralareas, and providers in low-incomeareas, simply providing funds toexisting facilities and providers is notenough. Many rural, low-income, orother health professional shortageareas do not have enough of anexisting health care workforce totake advantage of these funds.Investments in building a morerobust home and community-basedservices workforce – especially forvulnerable populations like theelderly and immunocompromised – isvital to ensure that people canreceive care in the communitieswhere they live.

Because of the remaining needs foraccess to care, Durham community-based organizations are stepping upto fill in the gaps. A few of the manyexamples include Project Access ofDurham County, Senior Pharmassist,and Lincoln Community HealthCenter. In addition to its regular workconnecting uninsured patients to 

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5

specialty care, Project Access ofDurham County is part of a coalitionworking to ensure prevention,identification, and medical care forCOVID-19 cases among Durhamitesexperiencing homelessness.Meanwhile, Senior PharmAssist staffreceived free masks from Coveringthe Triangle, typed up instructionsfor how to wear them, and thenbrought the masks and instructionsto the Forest at Duke to be shippedout to each of their 1,400 members so they could safely leave theirhomes. (Talk about a team effort!)Further, Lincoln has created a walk-up or drive-through testing site forsuspected COVID-19 patients, most ofwhom are uninsured and pay for careon a sliding scale. These and othersafety net providers around Durhamare ensuring that vulnerablecommunities have access to theservices they need.

But community and federal effortscannot succeed alone; the NorthCarolina General Assembly mustexpand Medicaid to support NorthCarolinians through this crisis.Citizens in news outlets fromAsheville to Burlington to Greensboroto Robeson have pleaded for statelegislators to expand Medicaid in theface of the pandemic. Harvardresearchers have explained howMedicaid expansion will provideneeded support for health caresystems and state budgets, andnoted the harmful effects that 1115waivers like the Healthy AdultOpportunity Initiative (enablingstates around the country totransition towards Block Grants inMedicaid, not to be confused withNorth Carolina’s

Healthy Opportunities Pilots meantto address Social Drivers of Health inour state), would have in these times.Meanwhile, the NC Justice Center hasnoted that many North Carolinians inthe Medicaid gap are service workers– the very people we rely on for childcare, groceries, and health careduring pandemic. NC Child hasshown that Medicaid coverage isimportant for the financial security ofNC families during the pandemic,and prior research by AAP tells usthat the children of parents withinsurance are more likely to receivenecessary pediatric care. Meanwhile,experts such as Duke professor DonTaylor and attorneys at the NationalHealth Law Program and theCharlotte Center for Legal Advocacyhave long since made the case forhow Medicaid Expansion wouldbenefit our health and economy inNC – which are needed more thanever right now. We must expandMedicaid to ensure that NorthCarolinians can access the care theyneed for us all to weather this stormtogether.

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6

RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY KELBY BROWN

AND JUL IAN X IE

COV ID - 1 9 EXPOSES

THE CRACKS IN OUR

HOUS ING SYSTEM

Every Sunday morning, Mike Harris*drinks his coffee from the same seatin the right corner of church. You cancount on him to ask how you’redoing and tell you to “stay blessed.”His wife, Melanie, bounces aroundthe refreshment table in the backroom, organizing donated food froma local bakery that she picked up thenight before. Their children sitamong friends until the youth aredismissed. While social distancinghas kept most of the family out of thepews, Mr. Harris, a church boardmember and custodian, still showsup to keep the old yet intimatebuilding in order.

The Harrises never advertise thathousing in Durham is unaffordablefor them. Their ever-changingneighbors share their struggle oftrying, and at times failing, to resistthe known consequences of housinginsecurity: chronic stress, mentalillness, poor educational attainment,childhood behavioral problems,physical disease, shorter lifeexpectancy – the list goes on. Whileno one would want to live in thesetoxic conditions, the adage holds truethat the choices one makes aredetermined by the choices one has. 

As such, the Harrises have beenresidents of the Durham HousingAuthority (DHA), Durham’s publichousing agency, for over 12 years.After their son was rushed to thehospital for carbon monoxidepoisoning a decade ago, theyrelocated to a different publichousing facility. In March 2020, theywere forced to relocate again fortheir own safety. Now their choicesare to move into yet another facility,one they know to be even less safethan their prior home, or to cram intoa one-bedroom apartment with theirson and daughter-in-law. They havechosen the latter while they continuetheir search for better options – asearch now far more challengingthanks to COVID-19.

Durham faced a housing crisis longbefore the pandemic reached ourcity’s borders. On January 3rd, 2020,DHA began relocating 270 familiesfrom McDougald Terrace, Durham’slargest public housing venue, afterseveral carbon monoxide poisoningsprompted inspections that revealeddangerous levels of carbon monoxideradiating from outdated appliances.Residents were displaced for fourmonths, staying in hotels or with

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8

family, while DHA worked to addressthe maintenance issues. While theagency fixed the gas leaks with pipewrenches and sealant, DHA’sexecutive director, Anthony Scott,knows he will need far more to repairdecades’ worth of damage caused bya failing support system. In aninterview with a local newspaper onemonth into the McDougald Terracecrisis, Scott highlighted the $57billion in underfunding to DHA by theUS Department of Housing andUrban Development (HUD). “So, yes,there is responsibility at a nationallevel and then is definitelyresponsibility here…” Mr. Scott said.“So, we're trying to take care ofbusiness here.”

Co-chair of the Partnership for aHealthy Durham’s (PHD) Health andHousing Committee, CaressaHarding, compares the nationalattention McDougald Terrace hasreceived to that of the TuskegeeSyphilis Study. Both were simply themost publicized examples of theirrespective failing systems, affordablehousing and biomedical research.

The root causes of Durham’s housingcrisis are multifaceted andinterrelated. Durham’s increasinglyexpensive housing market, caused inpart by other systemic problems likegentrification and housingsegregation, has resulted in 40% ofDurham residents being costburdened (i.e., paying more than 30%of their monthly wages towards rent).To pay less than 30% of monthlyincome for the average two-bedroomapartment in Durham, family mustearn over $20/hr for a full-time job –nearly 3 times the state’s minimum

wage. The resultant financial fragilitymanifested as the worst eviction rateamong NC’s most populous countiesin 2018 (1 in 278 residents) and a 25%increase in homelessness comparedto NC’s 11% decrease from 2011-2015.With over one million unemploymentclaims in the state since March 16thdue to COVID-19, housing has onlybecome more of a burden.

When one experienceshomelessness, the first safety netsare emergency shelters, such asUrban Ministries of Durham. Suchorganizations provide valuableservices, but are struggling to meetthe growing levels of need in thearea, especially while adhering tosocial distancing protocols. Peoplewho need longer-term assistanceapply for public housing throughDHA, but often find the conditions tobe hardly livable due to the systemicproblems described earlier.

Residents have the option to applyfor one of DHA’s 3000 housing choicevouchers (formally known as Section8), which allow them to select theirown housing and pay rent at 30% oftheir monthly incomes. The waitlistfor vouchers is capped at 1500 andless than 50 applicants receivevouchers each month; wait timesoccasionally approach a decade. Evenif the Harris family gets the voucherthey have been patiently waiting for,they would then begin the oftenharder process of finding a landlordwho will accept it in a housingsystem that incentivizesdiscrimination. Many Americans, justlike the Harris family, fall throughthese cracks of our housing system. 

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9

Housing insecurity drives poor healththrough four primary pathways: 1)instability, whether it be chronichomelessness or frequent moves; 2)poor quality housing, with exposuresto lead, mold, pest infestations,carbon monoxide, and crowdinghazards; 3) lack of affordability,causing financial strain onhouseholds; and 4) environmentaltoxicity, stemming from proximity tobusy roads, noise pollution, unkeptbuildings, overgrown lots, and lack ofaccess to fresh foods and safe spaces.And the health consequences ofthese effects, even if experiencedonly in utero, are drastic. For familieslike the Harrises, in which the fathersuffers from diabetes, cardiovasculardisease, and lung disease, the motherfrom chronic pain, and everyone elsefrom asthma, their housing struggleonly exacerbates these issues.

Housing insecurity intersects withfood insecurity and chronic disease(see Xie et al. reflection), mentalillness (see Neptune and Nguyenreflection), health inequities, andpoverty (see Holtzman, Nikpour, andBrown reflection), and the currentpandemic only complicates them.Along with making access to healthcare (see Durbha, Holtzman, andMatula reflection) more difficult,COVID-19 has disproportionatelyaffected already disadvantagedpopulations like those trapped intenuous housing circumstances.

Mr. Harris has lost three familymembers to the virus. While wedgedeight people deep into a tinyapartment, the Harrises arealternating nights on the lonemattress while trying to follow socialdistancing measures.

“I can’t really put it into words,” Mr.Harris said when asked about theimpact of COVID-19 on the family.“It’s been very stressful on all of us.”The Harrises have first-handknowledge of the sinking house thatis Durham’s crisis. For those of uswho had only seen the cracks in thewall, COVID-19 has forced a closerinspection and, indeed, thefoundation is flooding.

As health professionals, mostdiseases we diagnose are actuallyjust the symptoms of larger societalills. We treat the fallout fromDurham’s housing crisis in ouremergency rooms and on ouroperating tables with band-aidsolutions. But to truly stop thebleeding, we need to address theroot problem: the floodedfoundation. When Durham residentsidentified affordable housing as thetop health priority in 2017, PHDestablished the Health and Housingcommittee to coordinate the effortsof dedicated community membersand organizations. Now is the timefor health professionals to join thiswork of building a future wherehousing is a human right, and wherefamilies like the Harrises can expectto feel safe and secure at home.

*The names of some individuals havebeen changed to protect theiridentities.

Acknowledgements

The authors want to thank WillisWong and Tamar Chukrun for theirtime and input, as well as MarissaMortiboy, Caressa Harding, and Dr.Donna Biederman from PHD forcontributing their expertise.

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10

RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY JUL IAN X IE , GEOFF

CR ISANT I , HANNAH MAL IAN ,

AND  NATAL IE WICKENHE ISSER

COV ID - 1 9 DR IVES A

V IC IOUS CYCLE BETWEEN

FOOD INSECUR ITY AND

CHRONIC I L LNESS

“I can’t get enough food because I’mafraid to go out.”

“With COVID-19, I’ve been havingtrouble getting enough food for theweek.”

These are just a couple things we’veheard from food-insecure patients inDurham. Access to nutritious foodhelps people stay at home safely andmaintain their health. But theinterplay of food insecurity andCOVID-19 is a vicious cycle -one thatthe healthcare community needs tohelp break as part of the fightagainst this pandemic. COVID-19 notonly disproportionately impactspatients with chronic disease, butalso drives unemployment andpoverty that will lead to more severefood insecurity. COVID-19 may leadup to 17.1 million additionalAmericans at risk to become foodinsecure and, by insecurity rate hasdoubled to 23%, up from 11% beforethe pandemic. Even more thanbefore, people will face impossiblechoices between paying for food,rent, and medication. This will make

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12

it harder for people to managechronic disease and increase theirfuture risk too. In 2015, 17.9% ofDurham residents were foodinsecure. The history of segregationand economic marginalization havecontributed to food desert and foodswamp conditions, especially forpeople of color in Durham. Foodinsecurity is linked to many commonchronic diseases, including obesity,diabetes, depression, hypertension,and heart disease. Patients withcomorbidities, the most commonbeing high blood pressure, diabetes,and cardiovascular disease, are 71%more likely to be hospitalized and78% more likely to be in intensivecare than those not havingcomorbidities. These impacts areeven higher for people of color, whoare already disproportionatelyaffected by both chronic illnessesand COVID-19 itself. The pandemicwill likely exacerbate theseinequalities.

COVID-19 has also added newobstacles to food assistance. Foodpantries need to find high-quality

provides meals, shelf-stableingredients, and family-stylecasseroles for children and theirfamilies. This program is vital sinceschools are normally a key source offood, with two-thirds of DurhamPublic School students qualifying forfree and reduced school lunches. The Task Force also works with ElCentro Hispano, Lincoln CommunityHealth Center, and other immigrantand refugee organizations to serveDurham’s immigrant population,including refugees andundocumented people. This coalitionis delivering food and providingtranslation and assistance to helppeople get connected to necessaryservices.

End Hunger Durham and the DukeBenefits Enrollment Center havedelivered hot meals to over 900seniors. Several local cateringbusinesses have participated in thiseffort, including the restaurantZweli’s (who also coordinate mealrelief for McDougald Terraceresidents displaced by anenvironmental health crisis). Nowthat nutrition and chronic diseaseeducation must now be virtual, theDurham Innovative NutritionEducation program now sends out arecipe newsletter and plans to holdvirtual cooking demonstrations.

Many of the same organizations thatcompose the Durham Food SecurityTask Force are members ofPartnership for a Healthy Durham(PHD). PHD is a coalition oforganizations and communitymembers who collaborate to improveDurham’s physical, mental, and socialhealth and well-being.

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cold storage for fresh foods, andvolunteers to meet an influx of need.Many pantries have converted to adrive-through model to increasesocial distancing. But there are manymore people whose transportationbarriers and physical mobilitylimitations are now compounded bythe fear that going on a bus couldput them at risk for COVID-19infection. Food-insecure people arealso highly vulnerable to housinginsecurity (see Brown and Xiereflection) and trouble accessinghealthcare (see Durbha, Holtzman,and Matula reflection). This putspeople at risk for even furtherphysical, mental, and economicharm. This vicious cycle of COVID-19and chronic disease requires us to fixthe problem at its source – foodsecurity and economic inequality.

Durham’s response to protect foodsecurity

The Durham County and Citygovernments, and key food securityorganizations have recognized thatsupporting food access will helpsupport our COVID-19 response. TheCounty Commissioners formed theDurham Food Security Task Forceunder the County EmergencyOperations Center. On May 12, theCounty Commissioners allocated$152,000 to support End HungerDurham, Meals on Wheels, and ElCentro Hispano’s food relief efforts.The Task Force offers food deliveryfor individuals who are in isolation forsuspected or confirmed COVID-19.The Task Force created DurhamFEAST (a collaboration of the DPSFoundation, Food Insight Group, andthe Durham Hotel). Durham FEAST

Since April 1st, Root Causes hasdelivered food to 160 patients andtheir families with biweeklydeliveries, totaling over 7500 poundsof fresh fruits, vegetables, and shelf-stable foods. Based on surveys from39 of our patients, we have heardthat half of respondents have hadtrouble with getting adequate foodin a given week. One in five have losttheir jobs. Both before and duringCOVID-19, they report low foodsecurity.

Beyond food, Root Causes partnerswith the Duke Hotspotting Initiativeto procure and deliver non-foodessentials such as protective masks(made by Cover the Triangle), soap(made locally by Fillaree), handsanitizer, disinfecting wipes, papertowels, and toilet paper. We have alsodelivered over 25 grow-it-yourselfhome gardening kits for pediatricpatients. The kits are made ofrecycled wood, soil, seeds, and acolorful gardening guide in Englishand Spanish. We will also soon beprocuring blood pressure cuffs,glucometers, pulse oximeters, andother portable medical devices tohelp our patients manage chronicillness at home.

One patient recently sent us amessage: “Good afternoon, I receivedmy delivery today and I am beyondwords right now!!!! Thank you somuch for the masks, I am stillworking but I didn't get access toany. This was such a big help andthe food as well.” Another said,“We’ve been really enjoying all thetypes of produce, we've never cookedBok Choy before but it has beenfun to look up new recipes and it wasdelicious!" 

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The Partnership’s Obesity, Diabetesand Food Access committee (ODAFA)leads a collaborative approach toimproving food security, andpreventing obesity and chronicillnesses. The ODAFA committee isnow supporting the Food SecurityTask Force and also engaging inongoing work on the DurhamCommunity Health Assessment. Thiswill guide the hard work andcooperation that is needed amongthe health care, government,community, and private sectors tobuild a more resilient and equalDurham food system – one that willmake fewer people vulnerable to apandemic like COVID-19.

The Root Causes Program

We also wanted to highlight the workof one of this paper’s authors,Margolis Scholar Julian Xie, wholeads the Root Causes Fresh ProduceProgram, which is currently home-delivering fresh produce to at-riskpatients. Root Causes is a Dukemedical student organization withcollaborators from multiple healthcare and graduate schools, andfunding from American HeartAssociation and Blue Cross BlueShield Foundation of North Carolina.

Root Causes works with FarmerFoodshare and the Food Bank ofCentral and Eastern North Carolina todeliver locally-sourced produce andshelf-stable items. Patients arereferred from the Duke OutpatientClinic, Duke Healthy Lifestyles Clinic,and Lincoln Community HealthCenter. Many of these patients havemultiple chronic health conditionsthat make them particularlyvulnerable to unstable food access.  

We encourage the health carecommunity to get engaged in theODAFA committee which meetson the 2nd Wednesday of themonth at 9 a.m. The Task Forcecoordinates organizations througha weekly call, and for anyonelooking to volunteer, please checkout the Durham Food SecurityTask Force Feeding TogetherPortal or contact the paper’sauthors.

Acknowledgements

Key input on this paper came fromKelly Warnock (Durham FoodSecurity Task Force and DurhamCounty Health Department),Chelsea Hawkins (Durham CountyHealth Department and ODAFACo-Chair), Jeff Howell (United Wayof the Triangle and ODAFA Co-Chair), and Marissa Mortiboy(Coordinator of PHD). We’d alsolike to thank Tamar Chukrun,Willis Wong, Nila Masha, andmany others on the Root Causesteam.

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15

RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY NATHAN IEL NEPTUNE  

AND  ELA INE NGUYEN

MENTAL HEALTH

DUR ING AND AFTER

THE COV ID - 1 9 ERA

Mental health issues related to theCOVID-19 pandemic are continuingto spread rapidly and invisibly, similarto the coronavirus. The necessarypublic health measures to encouragesocial distancing and reduce thespread of coronavirus have led toincreased social isolation. Ourisolation is also mixed withoverexposure to the unrelentingmedia coverage of the pandemic. The combination of social isolation,information overload, and disruptionsof daily life have caused increasedfeelings of anticipatory grief, worry,and anxiety around the nation.Further, the increased socialdeprivation, unemployment rates,and economic hardship caused bythe pandemic are all linked withincreases in suicide rates.

Public health crises typically exposeand exacerbate weaknesses in thehealth system, and the COVID-19pandemic has done both for mentalhealth support systems. Prior to thepandemic, Cigna’s survey of over10,000 adults revealed 61% ofAmericans reported feelings ofloneliness and 24% reported theirmental health as fair or poor; bothare increases from prior years.Additionally, over 10 million adults

still report an unmet need for mentalhealth care. Locally, survey datacollected by the Partnership for aHealthy Durham revealed that 55% ofDurham residents felt mental healthshould be a “top community priority,”and close to 1 in 3 Durham highschool students reported feelings ofdepression in 2017. The COVID-19pandemic will increase the stress onour fragile mental health systemwhile creating new challenges for abroader swath of Americans leadingto a second-wave pandemic ofmental health crises.

The decreased opportunities forsocial interaction will weakenpeople’s protective factors againstpsychosocial problems. Many willlook to use alcohol, illicit drugs, orother maladaptive coping techniquesto escape feeling out of control,lonely, or anxious about their healthand economic livelihoods. School,work, and other outings often serveas a respite from stressful or abusivehome situations. Since shelter-at-home orders have been issued,countries have reported up to a 50%increase in reports of domesticviolence, and child welfare expertshave expressed concerns ofincreased child abuse and neglect.

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Further, those in most need of help or with the fewest resources aresuffering the most. The socio-economic needs of many adults have forced them to choose betweenpaying bills or seeking support fortheir mental health needs. Peoplewithout adequate internet access areunable to access virtual visits, andfewer people can pay for mentalhealth services due to layoffs (seeBoisvert, Durbha, and Nguyenreflection). Also, those belonging toracial, ethnic, gender, or sexualminority groups, who often faceheightened barriers to care, continueto be more susceptible to poormental health outcomes,discrimination, and a lack of access to services (see Durbha, Holtzman,and Matula reflection).

Our daily lives will not return to whatwe considered normal in the pre-COVID-19 era, but many opportunitiesexist to adequately address themental health needs of thecommunity. This point in time can bethe moment of change for improvedmental health services. Socialdistancing measures have forcedclinicians and counselors to conductvirtual visits and they now have moretools available to reach patientsvirtually. Mental health expertsshould continue to capitalize on thesurge in interest for telehealth andexplore other avenues to conductvirtual visits, especially as a telehealthsession does not have to be limited toa video conference. Other methods ofcommunication, namely textmessages, can also be used asanother telehealth tool. Additionally,services such as the Crisis TextLine can provide anonymous mentalhealth services to anyone with access

to text messaging, at any time of theday. Other virtual counseling tools,including wellness applications,social media, and telephone groups,can help provide support for copingduring this crisis.

The lack of equity in the provision ofmental health services, whethervirtual or in-person, must not beoverlooked, as those who do not haveaccess to the internet or othertelecommunication services anddevices will find these servicesinaccessible. The social drivers ofhealth, mental well-being, andphysical health are all intertwinedand should be assessed and treatedin tandem. Equity-based approachesare required to ensure mental healthservices are universally accessibleregardless of race, income, language,age, physical ability, or technicalknowledge.

Additional recommendationsgathered during listening sessionsheld by the Partnership for a HealthyDurham prior to the pandemicinclude creating an anti-stigmamental health campaign toencourage people to discuss theirmental health concerns and offeringfree mental health screenings for allschool children. Local communityworkers can be a point of contact toinitiate universal screening for ourvulnerable populations whom foodpantries and other supportorganizations are already in frequentcontact with. Future work shouldfocus on developing ways to monitorthe mental health of communitiesand the impact of COVID-19,integrating behavioral health intoprimary care services, and addressingthe social drivers of health alongside 

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mental health services. NorthCarolina is in an advantageousposition to lead the charge forchange. We can address social riskfactors for health by leveraging ourcurrent progress with initiatives suchas the Health Opportunities Pilots tocontinue improving the overallhealth care of vulnerablepopulations.

The COVID-19 pandemic is a blackswan event with profound mentalhealth impacts on all of society. Thedetrimental effects of COVID-19 andsocial distancing on mental healthwill outlast the virus and continue topresent challenges related to socialdistancing, adjusting to new norms,and coping with the trauma ofenduring a pandemic. Now is thetime for policymakers and healthcare organizations to focus ourefforts equally on finding a cure orvaccine for COVID-19 and ensuringthe mental health needs of all peopleare met.

If you or someone you know is inneed of immediate help, please call1-800-273-TALK (8255) any time tospeak to someone and get support.Additional local resources can befound here.

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RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY RACHEL HOLTZMAN ,

JACQUEL INE NIKPOUR ,

AND KELBY BROWN

"OUR COMMUNITY ,

OUR RESPONS IB I L I TY ” :  

COMMUNITY EFFORTS

TO NAV IGATE THE

INTERSECT ION OF

COV ID - 1 9 , POVERTY AND

STRUCTURAL RAC ISM IN

DURHAM

When COVID-19 first began to spreadwidely, experts held their breaths.Tweets to the tune of “the virusdoesn’t care if you’re Black or white,poor or rich” came rolling in. No oneknew for sure who would be mostaffected. As students of health policyand health equity, we held ourbreaths too. We hoped our racial andethnic minority and working-classneighbors would not bedisproportionately impacted, as theyso often are in health care, but fearedthey would. As COVID-19 wreakedhavoc on our communities, it hasuncovered the all too familiar realitythat divisions of race and class arewoven into the fabric of our society.

The reality is that COVID-19 hasn’tcaused new disparities – it’s onlyexacerbated those that already

existed. For example, while Black andLatinx people make up just 22% and10% of the North Carolina population,they account for 36% and 23% ofCOVID-19-related deaths(respectively). This is partially due tooccupational segregation that hasresulted in nearly a quarter of Blackand Latinx workers being serviceindustry workers, compared to just16% of white workers. Therefore,when we are told to stay safe bystaying home, there’s a big racialdivide in who has access to thatprivilege.

Furthermore, while 40% of whiteNorth Carolinians hold collegedegrees, only 30% of Black NorthCarolinians do, perpetuating thedisparity in social mobility that allowsone to endure economic downturns

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like this. Even the Black-ownedbusinesses in Durham, such as BeyuCafe and Empower Dance Studio, arehaving to make severe reductions inhours and staffing that will make ithard for them to recover. The resultof these co-occurring realities is thatlow-income people of color in NorthCarolina – and in Durham specifically– are facing increased physical riskfrom COVID-19, with fewer of theprotections that come from steadyemployment and wealth. The virusmay not discriminate between who itinfects, but structural racism suredoes.

The effects of structural racism oncommunities of color in Durham isnothing new. A clear example is thenear erasing of the Hayti communitythat was once home to Durham’sthriving Black middle class andhundreds of Black-owned businesses– even praised by Dr. W.E.B. Du Boisand Booker T. Washington. This once-bustling community was decimatedby the urban renewal movement inthe 1960’s. Rather than routing thenew NC-147 highway through any ofthe many predominantly whiteneighborhoods in Durham, the stateelected that Hayti should be thescapegoat, and in the process razednearly 200 acres in the heart of“Black Wallstreet” to the ground.

While Black community leadersvoted for urban renewal because ofpromises from the State and Federalgovernment about resources thatwould be provided to the Blackcommunity, those promises werenever realized. Hayti was nearlydestroyed, with most businessesgoing under and many familiespermanently displaced. The list of

minority communities in Durhamthat have endured through decadesof racism goes on and on.

Yet in spite of, or perhaps because of,these systems of oppression,Durhamites have grown incrediblyresilient. This resiliency is embodiedwithin Hayti’s community foodpantry, the nonprofit BelieversUnited for Progress. If you were todrive to the food pantry, you mightalmost miss the small shop entirely.Once you arrive, though, you’d begreeted by the Director, KasibAbdullah, a middle-aged Black manwith laugh lines at the corners of hiseyes. Kasib is well known in theDurham community as a leader, afriendly face, and the owner of thedelicious restaurant, New Visions ofAfrica, out of which Believers Unitedfor Progress is run.

Unlike many businesses, Kasib’spurpose is not to make money, but tofeed and engage with thecommunity. Long before COVID-19,he and his staff served freecommunity meals to children andfamilies, bringing together folks of allnationalities and religions fromwithin and beyond Hayti. Kasib alsosponsors mentorship programs andthe like for kids and families, as wellas a community garden. Theseprograms are taking a new shape inthe face of the pandemic, but arecontinuing to engage and supportthe community.* The nonprofit’s rolein Durham can even be seen onKasib’s business card, with threepairs of brown and white handsclasped in handshakes along the sideand “our community, ourresponsibility” stretched across thetop.

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“Our community, our responsibility”is a motto that holds true throughoutDurham. Now, more than ever,Durahmites are building uponexisting networks and creating newones to support one another duringCOVID-19. At least 15 neighborhoodsare now part of the Durham MutualAid Network, which is organizingsupport within and across neighborhoods using a framework ofsolidarity and collective liberation –the recognition that everyone’sstruggles are interconnected, andthus our liberation is too. Families are building new victory gardens likethat of the Inter-Faith Food Shuttle,using small spaces to harvest freshfood for folks who need it. TheDurham Public Schools (DPS)Foundation has started providingthousands of meals a week to low-income families through the DurhamFEAST program, after the DPSfeeding program was shut down dueto an employee testing positive forCOVID-19 (see Xie et al. reflection). A group of Durham residents andorganizations created The ThrivingCommunity Fund for Durham-basedminority owned businesses thatdemonstrate “transformationalstrategies to end racism andpoverty.” Throughout the manypockets of Durham, residents areshowing their tendency towardscommunity-led resiliency ininstances when we can’t fully rely onthe government for support.

What’s happening in Durham is notunique; instead, it’s connected to abroader movement of people callingfor systemic change. From Rev. Dr.William J. Barber II and the PoorPeople's Campaign, to the more than200 groups that have signed onto the

NC People’s Platform for Social andEconomic Survival and Beyond Us, itis clear that North Carolinians arehungry for reform. They embody along history of progressivemovements by, with, and for workingclass communities and communitiesof color, as well as people who havebecome newly involved in theircommunities in the time of thepandemic. And the need for thesemovements is only growing asCOVID-19’s impact continues toworsen disparities of class and race.

We must collectively look back atwhat led us to this moment andforward to our reimagined future ofinterdependence and mutualflourishing. Only together will wehave the power to withstand thispandemic and pave a new highwaythat bends towards justice.

*Believers United for Progress will beone of the distribution sites for theUSDA Coronavirus Food AssistanceProgram, which will send bulk foodto community food pantries to beredistributed to people in need offood aid over the next six months.Kasib is currently looking forvolunteers to help him repackagefood for around three hours a week.If you’re interested in gettinginvolved, you can email Kasib athumanityone@believersunitedforprogress.org with the head line“Volunteering for the USDACoronavirus Food AssistanceProgram.”

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RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY THA IN S IMON

Most will remember March 2020 asthe month America shut down toflatten the curve. But it meanssomething different to me. The weekbefore social distancing began, myfather was diagnosed with cancer. Assomeone living on my own, Iexperienced the sadness, frustrationand despair of a parent’s illnessacutely, and alone. This experience ofisolation – novel and temporary forme, but familiar and permanent forso many – moved me towards adeeper understanding of lonelinessas both a personal and public healthissue.

My father began chemotherapy inCalifornia on the day I attended myfirst virtual law school class inDurham, after Duke University closedits campus. I had wanted to go home,but the country was shutting down,flights were being cancelled, and therisk of exposure inherent in travelmade such a trip – to visit a soon-to-be immunocompromised parent noless – out of the question. In theweeks that followed, my routineinvolved hours of Zoom lectures anddaily phone calls home. As oftenhappens with chemotherapy, myfather’s treatment grew moredifficult with each additional round. Ibegan listening for – and finding –signs of fatigue in my parents’ voices.I internalized their weariness as if by  

doing so I could carry some of theirburden.

In time, I grew tired of my routineand my apartment. It took more andmore effort to stay focused on myclasswork, which no longer feltimportant. I was turning inward,preoccupied with the uncertaintyahead, shaken, frustrated and sad.

Under normal circumstances, I wouldhave leaned on my friends forsupport. We’d have met for coffee,cooked meals together, shareddinner and drinks at our favoriterestaurants and bars. But socialdistancing made the physicalpresence of friends impossible and Iwas left to process, grieve, and findthe strength I needed on my own.Before I knew it, a month had passedwithout any experience of humanpresence deeper than a passing wavewith my neighbors.

On Easter Sunday, more than amonth into lockdown, a friend andfellow Margolis Scholar reached outto see if I wanted to go for a socially-distanced walk in Duke Forest. I hadbeen politely declining invitationslike this for weeks in an abundanceof caution. But this time, forwhatever reason, I relented. Fresh airand friendly company would do mesome good. We walked and chatted

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LONEL INESS DUR ING

COV ID - 1 9

for two hours, keeping our distanceas best we could, but trusting also inthe sun and the breeze and theopenness of an outdoor space.

After the walk – my first meaningfulin-person human interaction in amonth – I felt lighter and happier. My emotional equilibrium had beenreset and renewed. If I needed anymore proof that I had been deeplylonely, this was it. I’m an introvert,and I usually enjoy living alone. Butchoosing to be alone during certainparts of the day – solitude – isdifferent from loneliness. The formercan be energizing; the latter can bedebilitating.

There is nothing unique about mysituation. The coronavirus pandemichas affected everyone. Nearly twomillion Americans are diagnosedwith cancer each year. And lonelinessis a common experience: a 2019survey found that 60% of Americanadults report feeling lonely. My ownexperience of loneliness has beenmild and temporary. But there’sgrowing recognition that socialisolation is itself a serious publichealth issue. Research suggests thatloneliness can be as harmful tohealth as obesity and may increasethe risk of heart disease, stroke anddementia.

Loneliness sharpens the bite of life’shardships. It makes responding toinevitable experiences of suffering –like a parent’s cancer diagnosis –more difficult. The people I mighthave leaned on for support after myfather’s diagnosis were all still therefor me. But we couldn’t get together,we couldn’t meet for coffee or a

meal, and we couldn’t hug. Thesethings matter.

When we spend less time with otherpeople, our focus shifts to ourselves –our world can’t help but shrink. Thisshift heightens the awareness of ourown problems just as it erodes ourconnection to the concerns of others.Even as the world battled a deadlycontagion, I was concerned mostlywith my own father’s health. And astime went by, my attention shiftedeven further inwards to my own well-being and small hardships: theshortcomings of zoom lectures, thetedium of law school exams – myown petty frustrations. Time spentwith others, especially in person,invites us out of ourselves. Wereconnect with the world, gainperspective on our own lives, andcultivate gratitude for what wealready have – all of which makes ushappier. Through human connectionwe press pause on self-concern andgrow towards the empathy neededto do meaningful work, especially inhealth care.

We knew this before the pandemic,but we are feeling it now, anddifferently. Loneliness doesn’t affecteveryone equally. The elderly, forexample, are distinctly at risk ofexperiencing loneliness – just as they are at greater risk of negativeoutcomes from COVID-19. During thispandemic, however, social distancinghas introduced scores of people likemyself, otherwise fortunate to enjoystrong social support, to theloneliness of isolation. It shouldawaken us to the real suffering of thesocially isolated and compel us toaction.

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Fighting loneliness requires nothingbut our time and intention. Checkingin on people really helps. Those whoare experiencing loneliness may notreach out themselves, so beproactive. As I experienced it, a shortwalk with a friend can make a worldof difference. And when it comes tohuman connection, not allinteraction is created equal. Inperson visits are the best (when wecan). After that, video calls beatphone calls, which are better thantexts.

Loneliness existed before COVID-19and it will exist after. It is emergingas a public health concern of the firstorder. But this is a problem we can alltackle, today, without money ortraining. Who in your life might belonely? Have ten minutes to sayhello?

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RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

B Y S CO T T BO I S V E R T ,

S R A V Y A DUR BHA ,

AND E L A I N E NGU Y EN

COV ID - 1 9 AND THE

R ISE OF TELEHEALTH

With the coronavirus drasticallylimiting in-person contact andappointments, health care providershave turned to a new tool that maychange the health care industry inthe long-term: telemedicine.Physicians are able to use an internetconnection and computers,smartphones, or tablets to conductvirtual visits with their patients. Anadditional advantage of thetelehealth visit is that it allowsdoctors to assess the patient’s homeenvironment and whether it may becontributing to the patient’s healthissue.

Acknowledging the need fortelehealth visits during this time,state and federal regulators havemade accommodations to increaseaccess to this kind of care. TheCenters for Medicare and MedicaidServices issued a waiver in March toexpand he use of federally fundedhealth insurance (Medicare,Medicaid, and the Children’s HealthInsurance Program) to pay fortelehealth visits Before this waiver,Medicare would only cover telehealthvisits on a limited basis, like forpatients who lived in designatedrural areas and had trouble getting

to a medical facility. The Departmentof Health and Human Services alsoannounced that they would relaxHIPAA privacy restrictions so thathealth providers could use morecommon platforms like FaceTimeand Zoom to communicate withpatients. On the state level, NorthCarolina Medicaid similarly expandedits coverage of telehealth visits, asdid Blue Cross Blue Shield of NorthCarolina, the state’s largest insuranceprovider.

While the COVID-19 pandemic canbe seen as the catalyst for the rise oftelehealth tools and utilization,public and private sector systemsmust ensure that these servicesevolve in parallel with the U.S. healthcare system, which is increasinglyemphasizing value-based principles.One characteristic of telehealth thatappeals to many is its ability togenerate cost savings, as costsrelated to traveling to an in-personmedical visit would not be incurred.Some argue that the convenienceand potential accessibility oftelehealth services will lead to theiroveruse by providers and patients,which will increase the total cost ofcare. In contrast, 32 states have

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enacted telehealth “parity laws”,which require insurance companiesto pay health care providers for thesame telehealth services that wouldhave otherwise been covered duringan in-person visit. This regulation isintended to incentivize physicians totake advantage of telehealth servicesover in-person services. NorthCarolina is one of 18 states that donot have a telehealth parity law,claiming that full parity, or equalpayments, for telehealth servicesmay undermine their cost-effectiveness due to overuse. Stateslike North Carolina argue that, totake full advantage of the value oftelehealth services, they must bereimbursed at a lower rate to reflecttheir value. While the U.S. strugglesto resolve questions around paymentfor and the value of telehealthservices, we also continue to facehurdles with respect to variations intelehealth insurance coverage andphysician licensure requirements, aswell as patient privacy andaccessibility to medical data.

Furthermore, a broad and rushedexpansion of telehealth may lead todisparate impacts on communitieslacking sufficient internetconnectivity. According to the PewResearch Center, only 73% ofAmerican households havebroadband access. Broadband accessis the gold-standard of internetconnectivity – representing thefastest download speeds andcorresponding device operability.Even more troubling is that thisfundamental service is especiallylimited in rural communities (63%),low-income households (56% forincomes <$30,000), and among racialminorities (61% of Hispanic adults,

66% of Black adults). Known as the“digital divide", the widening gap ininternet connectivity betweenunderprivileged communities andwealthy, suburban communities hasimplications far beyond Netflixbuffering times. As morefundamental services have movedonline in response to COVID-19 – suchas education – the detrimentalimpact of limited broadband accesshas become increasingly stark.

The digital divide presents analarming picture of the current stateof inequity in the U.S. with respect toaccess to internet services andtelehealth. However, it is also alooming harbinger of the potentialexacerbation of health inequitiesamong underserved communities.The New York City Department ofHealth and Mental Hygiene found asubstantially higher number ofhospitalized and non-hospitalizedCOVID-19 cases among Black andHispanic populations in the city.Furthermore, COVID-19 death ratesamong Black and Hispanicpopulations were 92.3 and 74.3 per100,000 people respectively,compared to 45.2 deaths per 100,000among white populations. Racial andethnic minority groups are also morelikely to experience inadequateeconomic and social infrastructure,underlying health conditions, loweraccess to care. Given theseconditions, the populations deprivedof broadband access and telehealthservices may actually be at thehighest risk for COVID-19.

Tying health care access to internetconnectivity through the rapidadoption of telehealth measures adda further barrier to already 

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underserved communities.Telehealth necessitates base levels ofinternet connectivity to supportproviding services digitally. Lessconnectivity may result in decreasedprovider flexibility in diagnosis tools(such as access to high-definitionvideo) and treatment options (suchas using internet-connected devices)– let alone the 14,551,297 Americansexcluded from telehealth entirely duelack of internet access at any speed.

To overcome the digital divide inhealth care and expand meaningfulaccess to telehealth for all, wepropose the followingrecommendations:

1. Policymakers should prioritizeexpanding digital infrastructure aspart of telehealth rollout. Absent abroader definition of health caredevelopment that includes internetinfrastructure investments, deployingtelehealth broadly risks leavingbeyond some of America’s mostvulnerable populations.

2. Hospitals and policymakers mustwork together to incorporate value-based care principles into utilization of and reimbursement for telehealthservices. Although telehealth mayafford considerable cost-savings,stakeholders must fully consider thecosts and benefits of telehealth overin-person visits when makingdecisions regarding parity laws andreimbursement rates.

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RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY YUN BOYLSTON

ENGAG ING

COMMUNITY MEDICAL

PROV IDERS IN THE

AGE OF COV ID - 1 9

Do what you can, with what you’vegot, where you are.

In his autobiography, TheodoreRoosevelt imparts the wisdom of BillWidener to sum up what heconsiders to be one’s duty in life.More than a century later, thisphilosophy aptly describes theoutlook of U.S. health care workersborn out of necessity in the age ofCOVID-19. Faced with a scarcity ofboth supplies and knowledge to fightthe virus, we seem to be collectivelywitnessing a game of Concentrationin which tile pieces are laboriouslymatched and removed to reveal thedetailed picture underneath.

As a community physician, it’ssobering to see the fragmentedresponse at the federal and statelevels, leaving community healthsystems and providers to face thereality that they are essentially ontheir own for the time-being. Dowhat you can, with what you’ve got.My independent medical practice hasleaned into the rapid pace of change.Attending Zoom webinars withpublic health, medical, and businessexperts has become a part-time

profession. Now a few months intoimplementing and scaling telehealth,virtual encounters comprise over 25%of our practice’s visit volume. Wehave also benefited from thegenerosity and ingenuity of ourcommunity. This includes donationsof N95 masks from lawn servicecompanies and homemade clothmasks. But good fortune has itslimitations. Our PPE supply is still tooscarce to be able to safely andsustainably provide communityCOVID-19 testing in any capacity.While our IDNow machines sit idle,we do not expect point-of-care teststo be made available to us anytime inthe foreseeable future.

While the pandemic has laid bare theglaring disconnects in supply anddemand across economic sectors,this is also true in healthcare. Ashospitals and emergencydepartments post record censusnumbers, inundated with demand,the majority of communityphysicians and surgeons have seen asignificant decline in patient care.The Commonwealth Fund notes thatthe volume of ambulatory office visitsin the U.S. dropped steeply by almost

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60% in mid-March of this year. Whydoes this matter? Medical practicesare no different from the millions ofsmall businesses across the countryand our fate should be no different.Yet there is opportunity here. Asstates roll out strategies for re-opening, community medicalproviders may yet play a critical rolethat seems to be overlooked thus farin the national discourse.

In National Coronavirus Response: ARoad Map to Reopening, MarkMcClellan, Director of the Duke-Margolis Center, and his colleaguescomprehensively outline the fourphases of action needed to eliminatethe current threat and to prepare forfuture pandemics. Essential steps inPhase 1 include increasingnationwide testing capacity,implementing a COVID-19surveillance system, and mass scalingof contact tracing.

In order to implement an effectivecontact tracing system across thenation, a recent Johns HopkinsCenter for Health Security reportestimates that an initial 100,000contact tracers will be required.Forperspective on the scale of thisworkforce mobilization, the U.S.Census employed under 42,000 inApril. State and local public healthentities that are already strapped forfunds and resources are assigned thedaunting task of building thisinfrastructure. How about as a firststep, do what you can with whatyou’ve got?

Engage the Medical Home

For a national test and trace programto be successful, engendering trust

and confidence is critical. Thisrequires partnership with medicalproviders who have establishedrelationships with their patients andcommunities. According to the CDC,84% of American adults in 2018 hadan encounter with a health careprofessional in the preceding year.For children, this figure was almost94%.As noted by the CDC’sexpanding list of COVID-19-relatedsymptoms, the presentation can bevaried, especially for mild cases thatdo not require hospitalization. Thesesymptoms could potentially be dueto a number of illnesses orconditions, not just COVID-19.Seeking care and evaluation from amedical provider, who knows yourhistory and risk factors and will guideyou through your illness, isfundamental to good medical care.

Leverage Existing Public HealthPartnerships

Community medical providers have alongstanding history of evaluating,testing, and reporting communicablediseases in partnership with localhealth departments and the CDC.These relationships and workflowsalready exist. From seasonal flu, tochlamydia and Hepatitis A,community medical providersprovide essential frontline diagnosticand reporting services on a dailybasis to protect the public’s health.

Rely on Available Expertise

While COVID-19 is very much a publichealth crisis, we must not overlookthe need to safeguard the privacyrights of individuals, as with anyother medical condition. Communitymedical providers and their staff are

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already trained in HIPAA compliantpractices. Primary care providers andmedical homes also possessexperience in patient education andcare management needed to helpcare management needed to helpindividuals navigate the course ofillness.

Support Community-Driven Actionto Address Disparities

Socioeconomic and racial disparitiesare clearly coming to light as thepandemic evolves. The CDC reportsthat racial and ethnic minoritiesdisproportionately bear the burdenof illness and death from COVID-19.Social determinants of health arecomplex and challenging torecognize or understand for thosenot familiar with affectedcommunities. For this reason, it isimperative that public healthmeasures to implement an effectivetest and trace strategy be rooted inpartnership with community-basedorganizations and medical providerswho are of the community. Whereyou are.

While community medical providerscan by no means be expected to fillthe gap for all test and trace needs,they can be a powerful ally in quicklyscaling and complementing theendeavors of public healthdepartments. Empower us to dowhat we do best – care for ourpatients and communities. Thiscollaboration will require clearcommunication from public healthleaders and prioritized access toresources such as testing suppliesand PPE in order for communityproviders to implement widescaletesting and reporting. For medical

clinics that have the capacity anddesire to contribute to contacttracing, they should be recruited inthis effort. In order for thispartnership to be successful, trainingwill be required, as well as a creativepayment model that captures thevalue of the work being performed.

As a nation, we have more reservesthan we realize in combatting thispandemic. Do what you can, withwhat you’ve got, where you are.Effectively deploying these resourcesto where they are needed as we buildand expand capabilities will be key.We are here.

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RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY M . BENNETT WRIGHT

PR IVACY AND DIG I TAL

CONTACT TRAC ING

Privacy policy is a balancing act.Bigger threats warrant bigger privacysacrifices. The greatest privacy lossesspawn from threats with no clearend-dates. For example, when theevents of 9/11 initiated the PATRIOTAct, Americans accepted someprivacy invasions in order to counterterrorism. By nature, terrorism neverfully dies, so the privacy decisions arehere to stay. Similarly, privacyinvasions made to counter thecoronavirus could easily becomepermanent, because the threat ofdisease never truly ends. Currently,leaders are investigating digitalcontact-tracing: phone apps thatwarn users when their phones havebeen near infected individuals. Whilethis may be key to counteringCOVID-19, leaders should carefullyweigh such efforts againstimmediate and long-term privacyimpacts. Here, I consider ome issuesthat leaders should balance inevaluating contact-tracing methods,and briefly discuss current efforts byApple and Google to establishcontact-tracing software.

Privacy Values

Fully outlining the value of privacy isbeyond my scope, but some in-depthcommentary can be found here.Sometimes, governments andcompanies have misused surveillance

information to discriminate and tocurtail civil rights. Even withoutmisuse, surveillance limits citizens’ability to choose what portions oftheir lives are public. Moreover, anyform of personal data collection riskssecurity breaches and exposure tounintended parties. Leaders shouldweigh these concerns in consideringnew contact-tracing methods.

Efficacy

Efficacy is essential – if it won’t work,it isn’t worth a decrease in privacy.Low adoption rates, insufficienttesting capabilities, high infectionrates, or technological challengescould derail contact-tracing efforts.Unless we have confidence in thoseareas, we shouldn’t implementdigital measures that significantlyintrude on privacy.

Contact-tracing apps operate bywarning users when their phoneshave been near the phones ofinfected individuals, so the systemonly functions if adoption rates arehigh. If the infected person doesn’thave the app, their contacts aren’tprotected. Some estimates say thatin order to be useful, around 80% ofsmartphone users would need toinstall the app. However, PewResearch indicates that Americansare split on the acceptability of the

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government tracking their cellphones to deal with COVID-19, soassuaging privacy concerns may beessential to high adoption andefficacy of the app.

To warn app users, we need to knowthat their contacts are infected, andthat requires readily accessibletesting. Though testing capabilitiescontinue to improve, they have beeninadequate thus far. Until those thatneed tests can easily receive them,digital measures will be ineffective.If people regularly come in contactwith infected individuals, digitalcontact-tracing apps notify almosteveryone to quarantine, and then thesystem is little better than a generalstay-at-home order. For contact-tracing to enable the economy toremain open, infections must besufficiently low.

Finally, the technology has to work. Ifthese elements are not in place, thenleaders should hesitate to implementdigital contact-tracing, because itmight violate privacy interestswithout any positive effect.

Consent

Voluntary systems are more ethical,useful, and likely to be downloaded.Because high adoption rates area key to success, it may be temptingto require all smart-phone users todownload a contact-tracing app. Butverifying whether individuals havethe app requires that information onthe app be personally identifiable,which raises significant privacyconcerns. Moreover, with citizensalready questioning the ethics ofcontact-tracing, trust will beessential, so greater levels of

voluntariness may actually increaseadoption.

Limited Government Access

As the Supreme Court has noted,location tracking can reveal intenselypersonal information about anindividual’s life, including “familial,political, professional, religious, andsexual associations.” If you knowwhere someone has been, you canlearn almost anything about them. Assuch, American law recognizes thatgovernment access to suchinformation should be limited.Because it can reveal so much abouta person’s beliefs and lifestyle,intrusive surveillance has historicallyenabled governments to curtailreligious freedoms, civil rights, andlifestyle choices. Citizens’ justifiedhesitation to provide suchinformation may reduce adoptionrates.

Even legitimate uses by lawenforcement might dissuade manyfrom downloading the app. Thus,limited (or even zero) directgovernment access to the data wouldenhance both privacy and efficacy.Likely the only way to prevent suchaccess is to avoid storing the data inone place, and giving only individualusers control over their data.governments to curtail religiousfreedoms, civil rights, and lifestylechoices. Citizens’ justified hesitationto provide such information mayreduce adoption rates. Evenlegitimate uses by law enforcementmight dissuade many fromdownloading the app. Thus, limited(or even zero) direct governmentaccess to the data would enhanceboth privacy and efficacy. 

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Likely the only way to prevent suchaccess is to avoid storing the data inone place, and giving only individualusers control over their data.

Minimal Data Collection

Because certain data may be morehelpful than anticipated, appdevelopers may want to collect manytypes of data over long swaths oftime. However, developers shouldavoid this temptation. Not only doesgreater data collection further invadeprivacy, but it can be less effective.Minimized data collection simplifiesapps, which both streamlinesdevelopment and makes it easier tosecure the data. Getting the appsooner would increase its impact,and data security would increaseadoption.

Apple & Google Contact-TracingUsing Bluetooth

Apple and Google have entered intoa rare partnership to enable contact-tracing apps to work on both Androidand iOS (thereby covering essentially100% of smartphones). A goodsummary is here. Decentralizing datacollection, this effort reduces some ofthe major privacy concerns. Ratherthan amassing everyone’s locationinformation in a government-accessible database, each individualphone maintains a record of whichphones it has been near. Users thenchoose to notify those phones if theyreceive a positive diagnosis.Moreover, the data is not personallyidentified, and the identifiers forphones regularly change. Sometechnical issues remain (Bluetoothwas not designed for precise distancemeasurements), but the Google and

Apple partnership seemsencouraging and privacy consciousoverall.

Digital contact tracing could be animportant part of our response toCOVID-19. However, beforeimplementing any privacy-invasivepolicy, leaders should ensure thatelements necessary for efficacy are inplace. As specific features develop,governments also should considerissues like voluntariness, dataminimization and decentralization,and security. The Apple and Googlepartnership is promising, but leadersshould carefully weigh each of theseconcerns, and more, throughoutdevelopment. The privacy sacrificeswe make in this crisis will likelyestablish our new normal for years tocome.

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RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY JACQUEL INE NIKPOUR ,

LAUREN ARR INGTON ,

ALLYSON MICHELS ,

AND MICHELLE FRANKL IN

COV ID - 1 9 AND THE

NURS ING PROFESS ION :

WHERE MUST WE GO

FROM HERE ?

The COVID-19 pandemic highlightsmany of the fractures in our healthcare delivery systems. Shortages oftesting and a lack of contact tracinghave created an inadequate publichealth response to this crisis, leadingto overwhelmed hospitals and healthcare workers, who are simultaneouslymanaging shortages of personalprotective equipment (PPE).Extended stay at home orders, whilenecessary to prevent diseasetransmission, may have severeimpacts on access to needed care,such as specialty care and behavioralhealth services. Historicallymarginalized populations, such asBlack and working-classcommunities may experience adisproportionate impact, both interms of case numbers and thelonger-term societal impact due tolong-extant health disparities. Whilethe importance of a strong publichealth infrastructure and caredelivery systems that promotepopulation health outcomes havelong been known, the COVID-19 crisishas added a sense of urgency to

these needed reforms. As we work toheal and transform our fracturedhealth care delivery systems, nursesmust be at the helm.

Nurses are well-suited to makepopulation health decisions, addresssocial drivers, and provide leadershipin health crises such as COVID-19.Situated at the intersection of medicaland social expertise, nurses provideholistic, patient- and community-centered services to promoteaffordable, high-quality care. Nurseshave been frontline in caring forCOVID-19 patients, as well as inprevention, education, and otherpreventative health measures to slowthe spread of disease. The currentpandemic has immeasurablytransformed the profession –impacting the available workforce,highlighting inequities in healthoutcomes, and opening newopportunities in care delivery. As webegin to move forward past thepandemic and into its aftermath, thenursing profession must grapple withits future, and understand how we as

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the nation’s most trustedprofession – now, more than ever –can be part of the solution to thelong existing societal healthchallenges highlighted by thepandemic.

Addressing Inequities

There is a clear understanding that,across the country Black, Latinx andAmerican Indian populations areexperiencing a disproportionate levelof suffering and death during theCOVID-19 pandemic. Racial andethnic inequities in access to highquality health care services existedbefore the pandemic and havecarried over into disparities in accessto COVID-19 testing and treatment(see Durbha, Holtzman, and Matulareflection). Black and Latinxcommunities find it harder topractice social distancing at homeand at work and often faceemployers that do not prioritize theirsafety and health.  Whileunemployment related to COVID-19has devastated all communities,Black and Latinx workers areexperiencing the highest rates.Additionally, the stress of racismpredisposes many nonwhitecommunities higher rates ofmorbidity and mortality during thepandemic.

Nurses must recognize and helpaddress the ways in which societalinequities perpetuate disparatehealth outcomes. While nursingeducation focuses predominantly onproviding acute care in hospitalsettings, COVID-19 has shown theimportance of educating current andfuture nurses to address healthoutcomes at a population level.

As systematic bias plays a large rolein perpetuating these disparities, wemust prepare a nursing workforceeducated to provide culturallyrelevant care and address structuraldeterminants of health. Populationhealth competencies, includingadvocating for social justice; makingdata-based, culturally relevantdecisions in care; and, promotinghigh-quality outcomes for diversepopulations are necessary at all levelsof education. Furthermore, clinicaltraining should prepare nurses forroles in diverse settings, and fundingpriorities should align withpopulation health management andrelated measures.

Expanded Nursing Workforce Roles

Currently, most workforcediscussions have been centeredaround hospital-based care, and littleattention has been paid to the publichealth nursing workforce. This isdesperately needed to mitigate thecurrent pandemic, address thesocietal health consequences thathave resulted, and manage futureacute and chronic population healthcrises. Indeed, since the H1N1pandemic in 2009, the nation lostnearly a quarter of the entire publichealth workforce with no plan forrefunding. Given that the majority ofhealth department employees arenurses, it is likely that many of thoseeliminated were nursing positions.

Despite its importance in managingthe current outbreak, and its crucialrole in health promotion, education,and prevention of chronic disease,public health funding accounts forjust 3% of all health expenditures. Inits current state, the public health

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infrastructure and workforce arecritically underfunded, limiting theircapacity to drive an effectiveresponse of surveillance, contacttracing, and data sharing, andcontributing to the pandemic’scatastrophic societal effects (seePothen reflection). Issues such aspersonal protective equipment andventilator shortages may very wellhave been significantly lessened ifthe “upstream” preventativeapproach of a strong public healthsystem were implemented in theearly days of the pandemic.

COVID-19 may be the impetus torevive funding for a strong publichealth workforce. The pandemic hashighlighted the need to addresshealth needs at a population level,make timely, evidence-baseddecisions, and provide a unified voicein educating the public – roles thatpublic health nurses have long beenexperts in. Furthermore, the societalhealth impacts of COVID-19 willpersist long after the initial outbreak,particularly in areas of health equity.Diversion of the population healthworkforce to focus on COVID-19needs has led to cuts in services suchthe Nurse-Family Partnership, whichdelivers maternal and infant care tohigh-risk, low-income mothers.Investments in these nurse-ledservices going forward will be criticalto mitigating these long-lastinginequities.

Other areas exist for expansion of thenursing workforce into community-based settings. Caregivers may bemore reluctant to place their lovedones in a long-term care facility, asresidents are unable to leave or have

visitors, and as COVID-19 outbreaksare staggeringly high. For elderlyindividuals who need care, thedemand for home health servicescould thus rise exponentially.Furthermore, as many behavioralhealth treatments have been delayedand group-based therapies sociallydistanced, the demand for mentalhealth care (see Neptune andNguyen reflection) could also createmore opportunities for nurses. Lastly,as the Centers for Medicare andMedicaid have expanded flexibilityfor telehealth services, the number ofindividuals able to access primarycare and specialty services is likely toincrease. This may open up new rolesfor nurses in connecting individualsto social services, coordinating care,and serving as the first point ofcontact for greater numbers ofpatients and families.

The COVID-19 pandemic has alsoheightened the need to transformperinatal health care with nurses atthe forefront of innovative strategiesto improve care and outcomes. Priorto the pandemic, there were effortsunderway to reduce the U.S.maternal mortality rate, which is thehighest among similarly wealthycountries. During the pandemic,pregnant women have faced extrememeasures, including giving birthalone, and restrictions on doulaservices, hydrotherapy andambulation during labor.Increasingly, childbearing familieshave sought care in the communityto avoid hospital exposure to COVID-19. Nurse-midwives and public healthnurses are experts in providingintegrated care between home andhospital that meets the needs of

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childbearing families and improvesoutcomes. Moving forward, nursingmust grow opportunities forintegration of nurse-led programsand services into perinatal healthcare, as has been done in manycountries with far better perinataloutcomes.

Primary Care and Telehealth

The importance of primary care andoutpatient management (e.g., homehealth) and nurses’ role in caredelivery and coordination withinthese settings are well established.However, COVID-19 caused a collisionwith a surge of patients needingtesting and treatment for COVID-19in addition to baseline care needs.COVID-19 has taught us the need tokeep people in the community andsave hospitalizations for only thosewho have the most critical needs ashospitals become more dangerousfor patients and health care workers.The risk of COVID-19 exposure inhospital and clinic settingsaccelerated the uptake of virtualprovision of such services (seeBoylston and Boisvert, Durbha, andNguyen reflections). For example,telehealth use has surged butunprecedented demand hasoverwhelmed telehealth services.Nurses have provided valuableimprovements to telehealth as wellas evidence-based solutions torespond to this demand.

Nurse- and advanced practiceregistered nurse-provided telehealthhas the potential to greatly expandaccess and quality of care. Telehealthis one way nurses can address criticalunmet health needs post COVID-19 –from basic primary care to virtual

hospitals for more intense treatment.In order to realize this potential,innovation on the part of nurses,public health departments, healthsystems, and policy makers areneeded. This will also requirestrategic investment in nursingeducation to address the nursing shortage that is present andintensifying. By 2022, more than500,000 experienced nurses areexpected to retire and this is nottaking into account changes to thefrontline RN (registered nurse)workforce as a result of COVID-19.With the nursing shortageintersecting with this pandemic, amore substantial commitment to thenursing workforce, education, andtraining on virtual monitoring andtreatment will be needed to addressthe demands and innovations. Byproviding virtual care, nurses canbridge geographic barriers tobringing services to patientswherever they are located.

Untapped Capacity

Furthermore, the COVID-19 pandemichas illuminated the untappedcapacity from all levels of nursingroles sting change going forward.including clinical practice,leadership, health policy, advocacy,and research. Nurses have a uniqueperspective and capability totranslate and integrate evidencefrom these areas into practice. As thehealth professional shortage hasbeen exacerbated by the crisis, manystates have permitted full practiceauthority for advanced practicenurses – and these new licensurelaws may lead to long-lasting changegoing forward. This long fought forreform has the potential to expand

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access to high-quality, affordableprimary care, where the majority ofNPs (nurse practitioners) practice. Atthe same time, new roles forregistered nurses in primary care canstrengthen primary care’s delivery ofservices – and this may be especiallytrue, as burnt out hospital RNs maybe seeking positions in other settings after the acute pandemic. Bymaximizing the capacity of thecurrent primary care nursingworkforce, services such as carecoordination, referral to socialresources, and addressing socialdeterminants of health, may be moreavailable in primary care settings andlead to higher-value care.

Another opportunity for nursinggrowth in the aftermath of COVID-19is in hospital and health systemleadership. Health system decisionsinvolving PPE shortages, staffing, andhealth informatics require the inputof frontline individuals whounderstand deeply the impacts ofthose decisions. Nursingrepresentation on hospital andhealth system boards can provideinvaluable insight, particularly duringdisease outbreaks and otherpopulation health crises.

Conclusion

The COVID-19 pandemic has madeclear that our care delivery systemsare fractured and lack an effective,coordinated response to populationhealth crises. Effectively addressingthese gaps, both during theimmediate crisis and in the long-lasting aftermath, will require theclose engagement and leadership ofthe nursing community. Nurses have

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a unique perspective on andexpertise managing infectiousdisease outbreaks, mitigating healthinequities, addressing social driversof health, and designing innovative,patient-centered care deliverymodels. These capabilities are critical- now, more than ever – toreimagining a better health caresystem, one where equity andpopulation health are at the center.

RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY MER I L POTHEN

PANDEMIC RESPONSE

IS A DEFENSE GAME ,

THE U .S . I S PLAY ING

OFFENSE

Like many American kids in thesuburbs, I grew up playing soccer. As a defensive fullback, I stood guardand enviously watched my midfielderand forward teammates attemptdramatic plays and exciting shots onthe other end of the field. Playingdefense wasn’t flashy. But, when aswarm of players came barrelingtowards our goal, no amount ofoffensive panache could save us.What could mitigate a goal was mydefense teammates and I operatingin lockstep, diffusing the pressureand dampening the other team’smomentum.

While the COVID-19 pandemic isclearly higher stakes than mychildhood soccer games, the strategyis similar. When faced with a newand aggressive opponent, a strongdefense can hold off losses while anoffensive play is developed, tested,and deployed. Although vaccine andtreatment development areincredibly important in the fightagainst COVID-19, they are not aneffective first line response. As theU.S. approaches 2 million cases and112,000 deaths, we must addresswhere our health care system is

failing Americans during thispandemic to ensure we’re betterprepared for the next one. Pandemicresponse for a novel disease can bethought of as a layered filter, witheach layer “catching” cases to reducethe number of hospitalizations anddeaths. An effective pandemicresponse “filter” for the health caresystem consists of a well-fundedpublic health infrastructure, a robustprimary care system, and adiversified supply chain (Figure 1).

Strong Public Health Infrastructure

The nation’s public healthinfrastructure is an essential firstlayer of defense during a pandemic,providing surveillance, education,and contact tracing support. Despiteevidence showing a median 14:1return on investment for publichealth initiatives in high incomecountries, public health is chronicallyunderfunded at the federal, state,and local level. In 2018, only $286 ofthe more than $11,000 spent onhealth care per person that year wentto public health. The Centers forDisease Control’s (CDC) budget hasfallen by 10% over the past decade

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commit to sustained, strongerinvestment in our public healthsystem.

Robust Primary Care System

When health care providers begancanceling appointments andservices to prevent COVID-19transmission, elective proceduresand in-person visits dropped by 70-80%. This drastic drop in volumewas a serious hit to providerrevenues. Although hospitals havereceived advanced payments tosmooth revenue losses, there havebeen no specific disbursements forprimary care. When well-resourcedduring an outbreak, primary carecan triage and test, educate 

and the CDC’s funding to state andlocal governments for emergencypreparedness dropped 33% fromFY03-FY19. Cuts have contributed toover 55,000 eliminated positions atlocal health departments from 2007-2018.

Under-resourced public healthdepartments cannot build theinfrastructure needed to combathealth crises like COVID-19. As shownby emergency funding for Ebola,Zika, the opioid epidemic, and nowCOVID-19, systemically under-resourced public health systems donot have the structures in place tomost effectively use surge funding.Instead of a reactive and erraticapproach to funding, the U.S. must

Figure 1: The Pandemic Response Filter

The early months of the COVID-19 pandemic in the U.S. revealed gaps in our defenses,resulting in fewer prevented and mild cases and more hospitalizations and deaths.

The image on the right represents a stronger future state than our status quo, wheregaps in our public health, supply chain, and primary care defenses are filled and able

to “catch” more cases before they become severe and/or end in death.

patients and family members, andsupport epidemiological surveillanceefforts. Unfortunately, the Americanprimary care system’s potential ishindered by clinician burnout,workforce shortages, and lowinvestment (5% of total medicalspending). A reliable revenue streamthat disconnects payment fromvolume can ease shocks for primarycare providers during a crisis.Alternative payment models (APM),like Comprehensive Primary CarePlus and Primary Care First, payproviders PMPM (per member permonth) fees for every patient theyare responsible or, as long as specificoutcome and quality metrics are met.This arrangement providespredictable revenue, relievespressure for volume-based care, andgrants flexibility in care plans.

An APM for community healthcenters serving low-income andvulnerable populations would beparticularly effective in pandemicpreparedness. It is well-establishedthat COVID-19 disproportionatelyaffects communities of color. Thesecommunities have beensystematically disenfranchised andoften live in conditions that preventeffective distancing, are more likelyto be essential workers and haveinadequate sick leave, and moreoften uninsured with less access toquality health care (see Brown andXie, Holtzman, Nikpour, and Brown,and Durbha, Holtzman, and Matulareflections). Population-based andlump-sum payments to invest incommunity health workers,culturally-sensitive and relevanteducation, and non-medical needscan lessen the impact of a newinfectious disease on the community.

Diversified Supply Chain

A final early COVID-19 challenge wasshortages of essential personalprotective equipment (PPE), medicalequipment, testing supplies, andmedications. Although hospitals anduniversities are collaborating todistribute supplies and communitymembers are making masks andgowns, clinicians are still rationing andreusing single-use PPE. Nearly 600health care workers on the front linehave died from COVID-19 since thepandemic began. Shortages in COVID-19 testing supplies slowed down thecountry’s testing rate, riskingincreased community spread.Heightened demand for antibiotics,hydroxychloroquine, and othermedications left hospitals scramblingand those with chronic conditionsunable to fill needed prescriptions. Tokeep costs low, U.S. health care supplychains are lean and narrow. Specificcountries or regions are often the soleproducer of a certain health care good.Test swabs, for example, are mainlymade in Northern Italy. Face masks arelargely sourced from China, and mostactive ingredients for medicines areproduced in China and India.

Health care leaders must diversify thehealth care supply chain to preventfuture shortages during a crisis. Whilesingle-source supply chains providetempting low prices, bringing onadditional domestic and internationalsuppliers allows for a reliable supplyand an ability to scale up productionwhen needed. This reform should alsomove upstream, diversifying rawmaterial producers for supplies. Inaddition to increasing supply, thefederal government should play alarger role in coordinating 

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procurement and distribution ofsupplies during a crisis. Throughoutthis pandemic, states, hospitals, anduniversities have created informalnetworks to ship supplies to hard-hitregions. Federal support to formalizethis coordination will preventcompetition and better ensuredistribution based on need.

Looking Forward

The ongoing COVID-19 pandemic hastaught us that a rapid, defensiveresponse is the best tactic todecrease infections and deaths. To bebetter prepared for the nextoutbreak, the U.S. must makereforms now to develop a well-resourced public healthinfrastructure, robust primary care,and diversified supply chain. Likeplaying defense on the soccer team,this work often goes unheralded andseems banal in comparison tovaccine and treatment development.But, when a new opponent comeshurtling towards our family, friends,and communities, it will be the onlybarrier standing in the way. For ourfuture, let’s ensure that defense isstrong.

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RESPOND AND REFORM : REFLECT IONS ON COV ID - 1 9

BY JASMINE MASAND

WHAT DOES COV ID - 1 9

MEAN FOR CH I LD

WELFARE ?

Rates of reported child maltreatmenthave plummeted in recent weeks,and at first glance, falling rates ofchild maltreatment referrals mightseem hopeful. In Los Angeles,reported cases have dropped nearlyfifty percent, and child welfareworkers in Texas have observed a dipin child maltreatment tips thatbegan in early March. In health care,we often equate success in a givenarea to decreased rates of adverseevents, such as decreased rates ofhospital readmissions or lessunnecessary emergency departmentutilization. However, in our newseparated reality, decreasing rates ofsuspected child maltreatment couldsignal that more children are nowisolated without access to other adultand community supports.

Vulnerable children are now isolatedfrom the adults that often act as theeyes and ears of the child welfaresystem, and the drop in reportedchild maltreatment suggests that thechildren who are struggling in theirhome environment are more isolatedthan ever. In North Carolina, over halfof child welfare referrals warrant aninvestigation or assessment, and over90% of maltreatment cases involvethe child’s parents. Most child

welfare referrals come from teachers,health care providers, neighbors, andother adults who interact with a childand their family. With schoolcancelled for the rest of the year, andmany people avoiding doctor's officeand other routine activities, caringadults are unable to monitor themost vulnerable children in ourcommunities.

In addition to reporting challenges,experts worry about a potentialincrease in the incidence of childmaltreatment and child exposure tointimate partner violence withinhomes. As WUNC and the New YorkTimes recently reported, research hasshown that the COVID-19circumstances has increased stresslevels in working families, especiallywhen family members haveexperienced job loss. Although it’sdifficult to draw an exact linkbetween increased family stress andchild maltreatment, the anecdotalevidence is troubling. Hospitals inOrlando and Texas have reported asignificant increase in hospital visitsfor children with serious injuriesrelated to suspected abuse.

The combined effects of strain onworking families and isolation of

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children exposes the limitations of analready stressed child welfare system.North Carolina child welfareservices, including foster care, areadministered at the county level. Thisyear, I was part of a graduate studentteam researching best practices toimprove health care for fosterchildren in North Carolina. I learnedthat key service providers like socialworkers, teachers, doctors, caregiversin the foster care system, and evenlaw enforcement officers all havecritical insight into a child's well-being. In recent weeks, I have heardanecdotally how this network ofcaring adults has been weakened bythe pandemic.

My good friend who is an educationalpsychologist in training now worriesabout the children she used tocounsel on a weekly basis, sincemany parents cannot arrange remotecounseling sessions for their children.

Another peer who works as a socialworker has been overburdened withan ever-increasing number offamilies in need, and the availablesocial services and communityorganizations are backlogged withrequests for assistance.

The pandemic has increased financialstrain, food insecurity, and housinginsecurity in our communities, andthese social drivers of health must beaddressed at the community level tosupport the mental and physicalhealth of vulnerable children (see Xieet al and Brown and Xie reflections).These challenges, along withdomestic violence, are included inNorth Carolina's HealthyOpportunities initiative to addresssocial drivers of health as part of

health care in the state. As our healthand human services infrastructurebecomes less burdened by COVID-19,state leaders should considerinvesting in social insurance benefitsand community-based supports.Policymakers at the local, state, andfederal levels can consider thefollowing suggestions to assist at-riskyouth and families during thepandemic:

In the short term, state and localagencies can compile onlineresources for caregivers to helpfacilitate access to online educationplatforms and information abouttelemedicine coverage and any otherrelevant changes in Medicaidcovered services or protocols. Somestates, including Tennessee andKentucky, have highlighted resourcesfor telemedicine and online contentfor foster children on the main pagesof their health and human servicesagency webpages.

In addition, policymakers shouldcontinue promoting information-sharing and telemedicine platformsthat can support health careengagement across foster children,caregivers, and other key health andchild welfare stakeholders. Strict dataregulations are necessary to protectthe privacy of children in foster care,but they can also limit coordinationbetween child welfare and healthcare entities. Ongoing efforts toexpand the NCCARE360 humanservices referral network will help thestate meet child welfare-specificgoals by supporting familiesholistically. The platform could alsobe used to track community-basedservices more effectively for childrenin foster care. In addition, increased

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use of telemedicine platforms due tothe pandemic could create a lastingopportunity for greater coordinationbetween child welfare case workersand health care providers.

Broader social supports such asincreased food assistance benefitsand rent relief can provide whole-family support by decreasing stressin homes and increasing permanencyfor children who have interacted withthe child welfare system. Increasingaccess to and monetary value ofbenefits like SNAP, TANF, andunemployment could reduce familystress and improve mental health.Cash and food assistance programscan also contribute to children'sphysical health by ensuring adequatenutrition and enabling neededhealth-related spending.

Finally, child welfare agencies andhealth and human servicesadministrators can encourage theuse of Medicaid and CHIP coveragefor behavioral health services forchildren. Under Medicaid and CHIPlaws, family counseling services canbe covered for children with certainbehavioral health diagnoses.Policymakers should pushinformation about telemedicinecoverage for behavioral healthservices to increase access forfamilies that need extra support.

Children may be less susceptible tothe worst physical symptoms ofCOVID-19 illness, but the pandemiccritically endangers children who arealready at-risk due to theirhome environment. Policymakersmust recognize that investing inshort-term aid and social supports tofamilies under financial strain could

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protect the youngest and mostvulnerable in our communities.

ABOUT THE AUTHORS

LAUREN ARR INGTON , DNP ,

MSN , CNMLauren Arrington, DNP, MSN,CNM recently graduated fromthe Duke University School ofNursing in May 2020 and was aMargolis Scholar in Nursing.She is a nurse widwife at theUniversity of Maryland St.Joseph Medical Center.

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YUN BOYLSTON , MD , MBAYun Boylston, MD, MBA,recently graduated from theDuke University Fuqua Schoolof Business in May 2020 andwas a Margolis Scholar inBusiness. Dr. Boylston is theManaging Partner atBurlington Pediatrics/MebanePediatrics.

SCOTT BO ISVERT , JDScott Boisvert, JD, recentlygraduated from the DukeUniversity School of Law in May2020 and was a MargolisScholar in Law.

KELBY BROWNKelby Brown is an MDCandidate at the DukeUniversity School of Medicineand a Margolis Scholar inMedicine. 

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SRAVYA DURBHA , MBASravya Durbha, MBA, recentlygraduated from the Duke UniversityFuqua School of Business in May 2020and was a Margolis Scholar inBusiness. She will be moving toMinneapolis, Minnesota to join theOptum Leadership Experiencerotational program. She will beworking on initiatives to promotepopulation health, health careinnovation, and health systemtransformation.

GEOFF CR ISANT IGeoff Crisanti is an MBAstudent at the Duke UniversityFuqua School of Business and aMargolis Scholar in Business.

MICHELLE FRANKL IN , PHD ,

MSN , FNP -BC , PMHNP -BC , CNMMichelle Franklin, PhD, MSN,FNP-BC, PMHNP-BC, CNMrecently graduated from theDuke University School ofNursing in May 2020 and was aMargolis Scholar in Nursing.She is now a Margolispostdoctoral researchassociate.

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HANNAH MAL IANHannah completed her B.S. inNutrition and Exercise fromVirginia Tech in May of 2018.Hannah is currently a ResearchSpecialist and Coordinator for thePsychiatry Department at Dukeand serves as a recipe developerand research coordinator for RootCauses. In August, she will starther Master of Public Health inNutrition at UNC Gillings Schoolof Global Public Health.

RACHEL HOLTZMANRachel Holtzman is an MPP/JDCandidate at the DukeUniversity School of PublicPolicy and the University ofNorth Carolina Chapel HillSchool of Law and a MargolisScholar in Public Policy.

JASMINE MASANDJasmine Masand is an MPPCandidate at the DukeUniversity School of PublicPolicy and a Margolis Scholar inPublic Policy.

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CHUCK MATULA , JDChuck Matula, JD, recentlygraduated from the DukeUniversity School of Law in May2020 and was a MargolisScholar in Law.

ALLYSON MICHELS ,

MSN ,CNM ,WHNP -BC

Allyson Michels, MSN, CNM,WHNP-BC, is a DNP Candidateat the Duke University ofNursing and a Margolis Scholarin Nursing.

NATHAN IEL NEPTUNE Nathaniel Neptune is anMD/MBA Candidate at theDuke University School ofMedicine and Fuqua School ofBusiness and is a MargolisScholar in Business.

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ELA INE NGUYENElaine Nguyen is a JDCandidate at the DukeUniversity School of Law and isa Margolis Scholar in Law.

JACQUEL INE NIKPOURJacqueline Nikpour is a PhDstudent at the Duke UniversitySchool of Nursing and aMargolis Scholar in Nursing.

MER I L POTHEN , MPPMeril Pothen, MPP, recentlygraduated from the DukeUniversity School of Public Policyin May 2020 and was a MargolisScholar in Public Policy. She willjoin Blue Cross Blue Shield ofNorth Carolina as a SeniorStrategic Advisor later thissummer. There, she willspecialize in developingalternative payment models andclinical pathways for specialtycare.

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NATAL IE WICKENHE ISSERNatalie Wickenheisser is an MDCandidate at the DukeUniversity School of Medicine.She serves as the co-researchcoordinator for Root Causes.

THA IN S IMONThain Simon is a JD Candidateat the Duke University Schoolof Law and a Margolis Scholarin Law.

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JUL IEN X IE Julian Xie is an MD/MPPstudent at the Duke UniversitySchool of Medicine and SanfordSchool of Public Policy and aMargolis Scholar in PublicPolicy.

M . BENNETT WRIGHT , JDM. Bennett Wright, JD, recentlygraduated from the DukeUniversity School of Law in May2020 and was a MargolisScholar in Law.

ABOUT THE MARGOL IS

SCHOLARS IN HEALTH POL ICY

AND MANAGEMENT PROGRAM

The Margolis Scholars program is a prestigious program for DukeUniversity students that demonstrate strong interest in andcommitment to a career in health policy and management, as well asleadership potential to improve health policy. Named in honor ofRobert Margolis, M.D., the founder of Duke-Margolis and a pioneer ofinnovative integrated care delivery models, the Margolis Scholarsprogram provides promising students with the necessary knowledge,skills, and abilities to be the next generation of health care leaders.Margolis Scholars is a competitive program open to students atundergraduate and graduate levels. Selected Scholars are engagedin the program for 1 to 2 years, depending on their program of study.

The Margolis Scholars program has four key components: knowledgebuilding, skills enhancement and training, professional development,and community building and networking. Activities offered across thefour components include, but are not limited to:

Knowledge Building: participate in health policy coursework, attendbi-weekly Margolis Seminars, and engage in a multi-day intensivehealth policy workshop.

Skills Enhancement & Training: participate in research, simulationand skills labs, and teaching assistantships, as well as plan policyevents and participate in peer mentorship programming.

Professional Development: receive 1:1 academic and professionaladvising/mentorship, attend professional conferences, receiveinternship/fellowship guidance and placement, and plan communityservice projects.

Community Building & Networking: receive monthly policynewsletters, plan annual events, attend Margolis Retreat and othersocial/alumni events, and participate in unique opportunities to meetexperts in the field.

For further information on the Margolis Scholars program, please visithttps://healthpolicy.duke.edu/margolis-scholars.

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