The daily Covid updates from the Barnstable County Health and Environment Dept. epidemiologist Vaira Harik continue to trend very favorably, with a few exceptions, and give us a genuine basis for cautious optimism about the coming summer season. Quite possibly, by this time a year from now, with all willing Cape Codders fully vaccinated — and likely, by then, booster shots, as well — we will be able to let down the cloak of contagion fear that has enveloped us for the past year.
Part of the credit for our generally better-than-state-average Covid statistics here must go to the collaborative efforts of the county in establishing links with Cape Cod Healthcare, the four community health centers, and town boards of health, and our legislative delegation.
This collaboration organized testing sites and contact tracing early on to slow transmission, and made preparations for the potentially overwhelming surge of hospital cases that, fortunately, we avoided. Currently, the drive to reach all willing residents (and maybe persuade some of the skeptics) has involved close ongoing coordination of vaccination clinics and dose-sharing when there is an excess.
There are powerful lessons to be learned from the past year, perhaps none more significant than the role of public health in modern society.
Generally, when we think of health care systems, we picture hospitals, clinics, and the doctor’s office. This is the network of services that keep us healthy and work to heal us when we are sick or broken.
In contrast, the public health system, which long antedates modern health care, cares for us at the population or community level, primarily through efforts to prevent disease and its contagion and to ensure that every person has a standard of living adequate for maintaining health.
Of the three decades or so of life expectancy that we in the U.S. gained in the 20th century, only about five years can be attributed to personal medical care. Eighty percent of the gain — or 25 more years of life — are the result of improvements in our living standards, especially sanitation and drinking water, air quality, and control of infectious outbreaks. This is the domain of public health work.
In recent decades, as health care became more profit-driven, public health budgets declined. Public health spending was estimated to account for only about 1.5 percent of the U.S. budget in the late 20th century, and the last two decades saw more cuts, especially at the federal level.
The Barnstable County Assembly will likely approve an 8.6-percent increase in health and environment spending for the next fiscal year, in response to the demands of Covid control. That will represent 9.4 percent of the total county budget.
There have been tough lessons in the last year as well.
We have learned, painfully, that access to urgent medical care matters when illness strikes. We have learned that social and economic status matter greatly to disease outcomes. We have learned that people without access to care are not only at risk themselves but also put at risk everyone with whom they come in contact.
One key piece of our national public policy response reflects the understanding that all are potentially vulnerable: the determination to have no financial barriers in the way of vaccination. Insurance is billed when available, but no one is supposed to be denied the vaccine for not being able to pay, nor for citizenship status. This has theoretically made vaccine available to all who are willing to receive it.
The 1948 United Nations Declaration of Human Rights prominently includes access to health care. Here on Cape Cod in 2006, a ballot initiative declaring “health care is a human right” was overwhelming approved by voters.
What has taken place here, driven by the urgency of need, has been the emergence of a prototype for an integrated and comprehensive health system, bringing in public health, hospitals, clinics, medical offices, and outreach workers. Those who fell ill have been skillfully cared for by our acute health system, and much of the greater community has been tested, educated, and vaccinated by our public health service.
At the same time, outreach efforts to the most vulnerable residents of the Outer Cape, especially the homebound elderly and immigrant populations, have been shockingly inadequate. We must do better.
This experience can and should preview a more functionally integrated health system, one which would certainly deliver health care more effectively and at lower overall cost than our traditional silos of autonomous health units. When we are able catch our collective breath and reflect on pandemic response successes and failures, this union of our traditional health care and our public health system clearly belongs on the agenda.
Brian O’Malley, M.D. is Provincetown’s elected delegate to the Barnstable County Assembly. Write him at [email protected].