A year into a pandemic that is far from over, we have reached a grim milestone: More than 550,000 Americans have died, a staggering toll that has been gruesomely unequal. We all know that the elderly are far more likely to die of COVID-19, but if we control for age, we see patterns of inequity that are produced by society and policy choices, not biology. Black Americans, Latinxs, and Native Americans, for example, all have more than twice the risk of dying of COVID-19 than white Americans. Those living in poverty are also at significantly more risk. Working people, especially those on the precipice of poverty, have been caught in particularly dire situations, many either losing their jobs due to COVID-19 or continuing to work under treacherous conditions.
Vaccination programs are having a real impact, but here too protection is unequal. Across the U.S., we see a consistent pattern of Black and Latinx people receiving vaccinations at rates lower than their shares of cases and deaths. This is an example of what health equity scholars have long known: New interventions to control disease, even ones as remarkably effective as the new COVID-19 vaccines, do not necessarily advance health equity—in fact, they sometimes worsen it. The result is not just terrible for vulnerable communities, but for all of us. Broad vaccination, for example, is essential to herd immunity, and to protecting us all from new COVID-19 variants. This is a replay of what we saw at the pandemic’s start: Social distancing never really crushed the curve in the U.S., in part because so many had to continue to work in person—from nursing homes and meatpacking plants to grocery stores—without adequate protection, and because so many remained locked and vulnerable in our jails and prisons. Not surprisingly, then, the death rate per capita in the U.S. has been among the highest in the world.
COVID-19 is like iron filings on a magnet—it shows the underlying structures that make our society vulnerable. COVID-19 has been so deadly, and so unequally devastating, because we lack an infrastructure of care in the U.S. Workers are denied basic protections on the job. Our public health infrastructure has been devastated by years of austerity. And structural racism has left us with a legacy of unequal health outcomes that did not start with COVID-19, and that will be with us for many years more unless we take dramatic steps now.
How can we strengthen the power of working people, and in particular the women and communities of color who have borne the brunt of COVID-19 and of crises before? How can we address health inequity, simultaneously building a public health infrastructure that can better protect us all from calamities like COVID-19? The answer, we argue, is a new, 1.6 million-strong, permanent Public Health Job Corps. Federally funded and locally implemented, and scaled up over several years, it would allow the U.S. to not only take on the drivers of health inequity around the country, from cities to rural communities, but also to build power among workers. It would also act as a test-run for the bigger jobs programs that many believe are central to the long-term sustainability of not only our economy, but our democracy. To bring an end to the devastation of COVID-19, and to build a better future, we need an immediate, and long-term, investment in rebuilding our public and community health infrastructure—a critical component of our infrastructure of care.
Austerity in Public Health
COVID-19 has laid bare the profound weakness of our public health infrastructure, and in particular the public health workforce at the state and local levels. The U.S. once had a public health sector that was well-resourced and had capacity to address crises. Those days are long gone. We would need to more than triple the existing public health workforce to reach the ratio of public health workers to population that we had in 1980, for example. Public health workers are overworked, underpaid, and like many state and local employees, saw particularly steep cuts after the 2008 financial crisis. The local public health workforce, for example, has shed nearly a quarter of its jobs since 2008.
State and local health department employees are among the most essential workers in a pandemic, particularly because the U.S. devolves most control over public health to the state and local level. They are critical to the COVID-19 response—they track and surveil infections and illnesses, assist in infection control, help set state COVID-19 policy, conduct public education campaigns, and manage contact tracing and vaccine rollout. In ordinary times, they also help ensure safe drinking water, prevent food-borne illness, protect environmental health, address addiction, and remedy health disparities. They are epidemiologists, environmental health workers, nurses, behavioral health staff, community health workers, and lab workers, among many others.
Why these massive cuts in recent years, when our health needs—and the need for strong, coordinated public health policy—have only grown? After all, populations are aging, the planet is warming, opioid addiction has become a national crisis, and we know new pandemics will continue to recur. Austerity politics is the answer, and it has shown its deadly short-sightedness with COVID-19.
When COVID-19 hit, scaling up testing and contract tracing required not just tests and contact tracers, but people to procure tests and hire contact workers, set up testing sites, connect residents being asked to quarantine to resources allowing them to do so, and coordinate efforts across localities and states. Vaccinating the American public is a still more massive effort—one that involves not only managing websites and overseeing mass vaccination centers, but that also must include vaccine outreach, to reach populations who have poor connection to care, do not speak English, or who have been burdened by a legacy of racist healthcare and research programs, like the infamous Tuskegee experiments. But we do not have the person-power in state and local health departments to properly run these programs. States, in fact, are being forced to turn away from contact tracing efforts to focus on vaccination, because they do not have the staff and resources to manage both. No wonder we’ve seen so many reports of local public health leaders resigning or retiring over the course of this pandemic.
We cannot turn the tide on COVID-19 without a massive surge in our public health workforce. We also need to make these jobs good jobs again, and set this newly replenished workforce free to work on the health crises that predated COVID-19, and will persist beyond it: The high rates of asthma driven by poor housing and pollution; the overdose deaths that have killed tens of thousands of Americans each year and surged during the COVID-19 pandemic; the crisis in rural healthcare and health disparities around the U.S.; the health effects of climate change; and the new pandemics that experts tell us are certain to arise in years to come.
Structural Racism and the Fundamental Causes of Disease
COVID-19 did not affect everyone equally, both because low income-workers and people of color were more likely to be exposed to COVID-19, and because they were more likely to become seriously ill and die—the result of the health inequities and unequal access to care that preceded the pandemic. The cause of these deaths, in a very real sense, is not COVID-19 but the underlying structures of racism and vulnerability that put people at unequal risk.
Health inequity is deeply entrenched in the U.S., and is visible in government statistics going back to the founding of our country. The problem is not just inequitable access to healthcare or structural racism in medicine. Disease and ill health are shaped by social structures and power. There is robust literature in public health about what scholars call the “fundamental social causes” of disease. Though we tend to attribute sickness to the most proximate biological cause—a virus or a cancer, for example—this literature shows that if we look across time and space, we can see that even when one disease is cured, others emerge in their wake. And vulnerable groups, over and over, tend to bear the brunt, even if the nature of those groups and the diseases that affect them changes somewhat over time. History doesn’t repeat itself, in other words, but it rhymes.
Patterns of who dies not only of COVID-19, but also HIV, cancer, and heart disease are just the bodily expression of how our society prioritizes different lives, and so what kinds of ways of working and living we allow for different social groups. As researchers have explained, structural racism, for example, shapes “housing, education, employment, earnings, benefits, credit, media, healthcare, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources.” All of this influences health, and the results are devastating.
Immigration status is another important influence on health. Immigrants, who are overrepresented both in fields of essential work and in many industries hardest hit by the pandemic, continue to face a disproportionate risk of COVID-19 and of pandemic-related financial hardship. The story of immigrant workers during the pandemic demonstrates the deeply ingrained inequities which determine who is thrust to the frontline, who is cast aside, and ultimately, whose health is expendable in our society.
Though we don’t yet know the full toll of COVID-19, many vulnerable groups experience a level of excess risk in ordinary times that privileged groups are now experiencing in the pandemic. Models suggest, for example, that the enormous wave of death that COVID-19 caused for white Americans may not exceed the heightened risk of excess death that a Black person in America experiences every year. And this too is not new. A Black person living in the U.S. in the early 19th century experienced a death rate each year comparable to that of whites in 1918, when a flu pandemic killed as many as 50 to 100 million people around the world.
COVID-19 and Worker Power
We’ve known many of the ways to mitigate the spread of COVID-19 since the earliest days of the pandemic: Physical distancing, handwashing, and proper ventilation are key, and the protective role of masks became clear as soon as we knew that the disease could readily be transmitted by asymptomatic carriers. American workers were extraordinarily vulnerable nonetheless.
This is a product of a host of policy choices, all of which reflect the waning power of labor in our politics. We lack comprehensive sick leave, and regulatory agencies like the Occupational Safety and Health Administration, or OSHA, are weak. Unemployment insurance can be denied to those who leave their jobs because they fear a deadly disease. The decline in union membership has made it easier for management to impose unfair conditions on workers, conditions that can be deadly in a pandemic. Many workers in nursing homes, for example, are only given part-time positions and are pressured to care for more residents than they can safely serve, making the control of infectious disease extraordinarily difficult. As of March 2021, according to official figures (which may be an underestimate) 1,625 nursing home staff have died of COVID-19 and more than 550,000 have contracted the disease. But there is evidence that unions helped protect those workers who had them, resulting in better access to personal protective equipment and other benefits like hazard pay. Unionized nursing homes also have had significantly lower COVID-19 mortality rates.
New evidence suggests that most labor markets are highly concentrated, with broad implications for minimum wage laws, worker protections, and antitrust law, among other policies. Declining worker power has also been linked to wage stagnation and the declining share of income captured by labor—trends that also have implications for the sustainability of our democracy. There is good evidence that labor unions raise wages and improve working conditions, and also help increase workers’ political power, and so are critical to reversing growing inequality and deepening our democracy.
Public Health Jobs Now
Learning the lessons of COVID-19 means looking beyond the horizon of this terrible pandemic to ask how we can use the focus and political will that exists now to make structural change. We need a deep investment in a new politics of care—one that does more than give lip service to essential workers, and that recognizes and reverses the deep way that our society has marginalized care, whether in the home or in the workplace, and whether given by parents, teachers, or home care workers. This agenda must be sweeping, and rooted in a rebuilding of the power of ordinary working people over the conditions of their work and lives.
We need healthcare for all, as well as a new home care benefit that will both expand care for people who need it, and ensure better wages and conditions for the people—mostly Black, Latina, and Asian and Pacific Islander women—who provide it. A key part of reconstructing a politics of care, though, is fixing our disastrously underfunded public health system, and building a new workforce to address health inequity—a cadre of public and community health workers that helps us also redefine public health from a technical field to one focused on health equity and the social determinants of disease.
The good news is that the historic American Rescue Plan (ARP) that was signed into law on March 11 helps lay the groundwork for this. The federal plan is the result of the strong advocacy from community groups, labor organizations, and campaigns like Public Health Jobs Now (which our organizations, SEIU and the Yale Global Health Justice Partnership, have supported).
The ARP includes $7.66 billion specifically for the hiring of public and community health workers to combat COVID-19. Funds for building this workforce can also be drawn from tens of billions of dollars that the ARP provides for COVID-19 vaccination programs, contact tracing, and community health centers. The ARP is intentionally flexible, and enables states, localities, and community-based organizations to hire a wide variety of workers. They might be epidemiologists or public employees who can help run the local health department, or they might be community health workers and vaccine ambassadors, or they could be paralegals, legal aid attorneys, or resource navigators who might prevent evictions and help people get access to benefits and insurance. There are also funds to finally ensure that schools can reopen safely, including by hiring school nurses, custodial staff, and food service workers.
States and localities are now in the position to do something that they have needed to do since the pandemic began: rapidly hire hundreds of thousands workers to help bring the COVID-19 crisis to an end, and to redress the health disparities that long predated COVID-19. But states and localities, and the Department of Health and Human Services (which oversees these funds), will need to focus on three key elements if the ARP is to succeed against COVID-19, and provide a foundation for the new public and community workforce that we need.
First, while some COVID-19 roles will be short-term, we need most of these workers to stick around. States and localities should aim to create jobs that last for a minimum of two years, hire for broad skill sets, and redeploy people into new roles as needs change. This will give us the benefits of workers’ learned experience, and also time to appropriate longer-term funds to sustain these jobs. President Biden’s own vision was that the ARP fund 100,000 new public and community health jobs that will “transition into community health roles to build our long-term public health capacity.” This is the right model. The funding is there, including for jobs that pay well and last several years, but only if HHS draws upon all of the relevant sections of the ARP and develops a concerted workforce strategy.
Second, these need to be good jobs. HHS and the states should mandate a living wage, good benefits, and that workers have the choice to join a union. This workforce must also include strong representation from the communities most hit by COVID-19. This will bring these communities some relief, and is also the only way to succeed against the disease and the inequities that made us so vulnerable to the pandemic. Consider what is truly needed to get vaccines to the communities of color and essential workers who are not yet receiving their fair share, for example. This will require tens of thousands of vaccine ambassadors, substantially drawn from and overseen by community groups that already have deep networks and trust. Particularly in communities that have little access to primary care, where English is not a first language, and where immigration status or the long history of racist public health interventions still loom large, this workforce is critical.
Finally, ARP envisions a role for community-based organizations, but we need deliberate efforts to ensure that the most effective, smallest community-based organizations are not left out. They have essential expertise and trust, and will be among the most effective at hiring from, and building care infrastructure in, our communities. However, these organizations often lack the infrastructure to promote themselves and navigate complex application processes. We should be deliberately trying to reach them, by creating opportunities at the state and local level for community groups and unions to influence how the funding will be spent, and to receive funds themselves.
Building a Permanent Public and Community Health Job Corps
The ARP is only a down-payment. Within the next year, we must ensure not only that these workers have long-term positions, but that we add to this workforce to dig out of both COVID-19 and the ill-health that has burdened our communities—immigrant, rural, communities of color, and working-class people—for so long.
Many of these workers will have important skills that we need in order to address the other health crises around us. We need to rebuild the county and state health departments that can help us plan for the disruptions of new pandemics, climate change, and address opioid addiction. We also need to begin to build a healthcare system that integrates public and community health, and that does not conceive of health as something just produced by pills or doctors. Along with healthcare reform that moves us toward universal coverage and Medicare for All, we need a surge of community health workers—people who share life experience with those they are serving, and who improve health for others by advocating for them, providing social support and connection to services, and providing education and coaching. There is now strong evidence that these workers increase access to healthcare, reduce hospitalization, and improve the health outcomes of people with chronic diseases like diabetes and asthma.
The Biden Administration has committed to adding 150,000 permanent new Community Health Workers through Medicaid and COVID-19 funding, but we will need even more than that to address health inequities and build our capacity for community care. In our work with the Public Health Jobs campaign, we estimate that over the next two to three years, we need to turn the surge in COVID-19 jobs into a new, permanent public and community health workforce that is 1.6 million people strong.
We need 540,000 permanent new community health workers, to meet the needs of vulnerable communities around the country. We also need 250,000 state and local public health agency workers just to get even half the way to the capacity we had in the 1980. We should add 600,000 school-based workers over the long term, to ensure that all of our children have permanent access to school nurses and mental health counseling, and to ensure adequate nutrition and sanitation staffing in schools. Finally, we also need 100,000 new social workers, attorneys, and paralegals to provide the legal and structural support that people need, and absorb the referrals from Community Health Workers that enable them to provide effective care. All of these can be federally funded and locally managed, overseen by local entities shaped by inputs from communities and workers, and organized to meet local priorities.
If we structure these jobs so that they enable worker voice and hiring from vulnerable communities, we will also build long-term power for workers and the women and people of color who disproportionately make up the low-wage workforce, and who also carry so much of the burdens of care in the U.S.. These workers, who will be the backbone of our nation’s well-being, deserve more than mere survival. They must be paid living wages, plus benefits; have the right to organize and a pathway to joining a union; the right to a safe workplace, with training, pathways for advancement; and access to wraparound support services.
These jobs will pay for themselves in savings. (One recent randomized controlled trial showed that Community Health Workers save Medicaid budgets almost $2.50 for every dollar invested.) But more importantly, they will accomplish three other things that our democracy needs to thrive. They will help us tackle the health inequities that have plagued this country since its inception. They will build power, so that we have an organized constituency who can fight for public and community health—and also for good wages, anti-racism, and democracy over the long term. And they provide a model that can help us test out how we might implement still more ambitious jobs programs in the future. In an age of wage stagnation, precarious work, and the decline of the middle class, it is clear that we will need new strategies to support flourishing and employment, and a job guarantee is clearly something we should be considering. Beginning to build experience and infrastructure for such programs will teach us a lot about their viability and benefits, and help lay the tracks on which future jobs programs might run.