Few U.S. journalists, politicians, or public health officials expressed any extraordinary concern when reports of a novel respiratory virus began to emerge out of China in late 2019 and early 2020. After all, the U.S. had just ranked number one among 195 countries in the 2019 Global Health Security Index — the first major comparative assessment of national capacity to prevent, detect, and respond to infectious disease outbreaks.
Experts believed the wealthiest large nation on earth to be well-prepared to weather whatever might come its way.
Now, nearly two years since the first documented cases of Covid-19 appeared in Wuhan, more than 700,000 U.S. residents have been killed by a pandemic during which U.S. public health management has been among the world’s worst. Despite American wealth, monopolization of the global vaccine supply, and unparalleled spending on medical care, SARS-CoV-2 has decimated U.S. communities — especially those of color and lower incomes. Repeated policy failures have paved the way for the virus to rapidly replicate, mutate, and fuel deadly outbreaks not just inside this country but worldwide.
Why has the wealthiest and most powerful nation in the world proven so ineffective at stopping Covid-19? Will the factors that have fueled our ongoing catastrophe continue to put the U.S. and our neighbors at risk for future public health meltdowns?
The dominant answers to such questions have revolved around the actions of individuals, including the incompetent administration of Donald Trump and now the missteps of Joe Biden and CDC Director Rochelle Walensky. But it is a dangerous delusion to imagine that responsibility ends with any single individual, administration, or political party rather than with long-standing systems and institutions — responsibility for which is owned by both Democrats and Republicans — that have rendered the U.S. distinctly vulnerable to health disasters.
From the perspective of the roughly 70,000 U.S. residents who die preventable deaths each year during “normal” times due to the inaccessibility of health care, the crisis from which we are suddenly all suffering clearly began long before Covid-19.
It is now increasingly acknowledged — even as policymakers refuse to act adequately on these truths — that the U.S. has been left vulnerable by decades of interwoven underinvestments in public health, health care, and broader welfare infrastructures. When 25% of U.S. adults do not have a primary care provider, millions of Americans know medicine primarily through emergency room visits and the fear of bankruptcy from a medical emergency rather than trust-building relationships with health care providers. As a consequence, not only are American health care institutions lacking in their capacity to provide adequate care to meet the needs of U.S. communities, but their deficiencies and revenue-oriented operating procedures also bear considerable responsibility for fostering the deep distrust in medicine and government that is now impeding vaccine uptake and mask use in many parts of the country.
To overcome this, we — as a nation, and especially those in the medical profession — must confront our collective complicity with the political-economic conditions that have given widespread distrust such power to harm.
An essential step in this direction involves broadening our understanding of the structural factors and biosocial reality — how biology is always inseparable from social and political forces — at play in U.S. public health and public trust. A study I conducted with colleague Daniel Chen, recently published in JAMA Network Open, underlines this reality by highlighting three types of institutions that bear massive consequences for public health: jails and prisons, schools, and nursing homes.
Our research takes advantage of the fact that the absence of a strong federal response to the pandemic has resulted in a wide variety of state- and county-level policies. That provided us with an opportunity for a natural experiment with which to evaluate the ramifications of various anticontagion policies. We used econometric methods routinely employed to measure the effect of policies on economic growth but instead of economic growth we measured the association between decarceration — releasing people from prisons, jails, or immigrant detention centers — and 10 major anticontagion policies with daily growth rates of Covid-19 cases.
Due to poor public health data systems in the U.S., the available data are neither ideal nor universal. Even so, our analysis represents 1,605 counties representing 72% of the total U.S. population and provides one of the most fine-grained large analyses of anticontagion policies to date. As the Delta variant now fuels increases in Covid-19 around the U.S. and the world, our findings contain key evidence for informing effective policymaking to protect the public.
Jails and prisons
First, our headline finding: Jails, prisons, as well as immigrant detention centers, operate as epidemiologic pumps that fuel sickness and death, not just inside these facilities but also well beyond them, ultimately harming everyone everywhere. As a result, mass incarceration undercuts national public health and safety. It is also fundamentally incompatible with global biosecurity and pandemic preparedness. Decarceration, our study shows, is among the most important interventions for protecting community-wide public health during the Covid-19 pandemic.
In the U.S., an unparalleled system of mass incarceration holds nearly 25% of the world’s incarcerated people while the country represents just 4% of the global population. This has major implications for everyone. Carceral facilities are not separate from the rest of our society; they are highly porous institutions in constant biosocial relation with surrounding communities.
Due to overcrowding, poor health care, and routinized neglect, infectious disease on the inside quickly multiplies and — given the rapid turnover of people held in jails and the daily commutes of over 400,000 jail and prison guards — inevitably spills over into surrounding communities. The pandemic has underlined a long-standing truth: Neglecting the welfare of incarcerated people boomerangs back as compounding harm that undermines public health for everyone.
In light of this fact, as a matter of both rational domestic policy and international responsibility, the U.S. must invest in a national decarceration program. This is essential in order to dismantle America’s ineffective punishment system that harms all of us by spreading disease, multiplying harm rather than repairing it, and damaging the social fabric of marginalized communities — all of which undercut rather than improve public safety.
To be effective, decarceration must consist of releasing approximately 1 million incarcerated people for whom there is no plausible public interest served by their continued incarceration. It must also include intensive reentry support following release — guaranteed health care, housing, basic income, job training, dignified work, and the like. In the U.S., there are as many people with criminal records as with college degrees, and most experience severe job, housing, and health care discrimination, especially in the period immediately following release.
After the damage that more than 40 years of mass incarceration has done to people’s life chances, and particularly to overpoliced communities of color, simply abandoning formerly incarcerated people to fend for themselves — and then blaming them for whatever ensues — is unethical and irrational from a policy stance. Providing focused support is both our collective obligation and also necessary to prevent high rates of recidivism caused by poverty, homelessness, lack of health care access, and acute psychic distress.
Our study’s most original finding and politically demanding conclusion pertains to the community-wide health benefits of decarceration, but this is not our only urgent result. As Covid-19 continues to surge, largely due to poor pandemic management by local, state, and federal authorities, our research also shows how U.S. schools and nursing homes — many of which have been chronically underfunded, creating unsafe conditions — have been focal points of pandemic amplification.
The data confirm what should already have been very clear, despite opportunistic contrarian takes by those without adequate expertise in public health, infectious disease epidemiology, education, or child development who have promulgated dangerous and unfounded controversy: Schools are major sites for the spread of coronavirus. Our results show that school closures are strongly associated with large reductions in Covid-19 cases in communities. But closures are also likely to impose harms on children and families that are yet to be fully appreciated.
There is no easy way to weigh the unknown harms of school closings against the harms to kids caused by losing parents and grandparents to sickness and death from preventable cases of Covid-19 — a reality tens of thousands of U.S. children faced over the last year. For example, a friend of mine who teaches kindergarten in a dispossessed Hispanic neighborhood in Chicago that has been especially hard hit by the pandemic has had five of 30 students in her classroom suffer a Covid-related death of a parent over the last year. Such unquantifiably damaging experiences for children are not evenly distributed across class and ethnoracial lines — a fact that is often reflected in the very different racial and class positions of those who express opposed opinions about school precautions.
Clearly, lawmakers and school administrators should do all they can to avoid situations in which school closures are necessary to protect families and communities. To this end, federal, state, and local governments ought to have spent the last year emergently investing in safe school infrastructure, including installation of high-quality HEPA ventilation systems, masking rules, regular rapid antigen testing systems, properly spaced classrooms to address rampant classroom overcrowding, more robust staffing, overhead germicidal UV lighting, and the like.
Indeed, governments should have been making investments in U.S. school safety and quality for decades rather than systematically underfunding public education, particularly in low-income communities and communities of color. Rather than urgently doing so during a pandemic that has exposed our long-standing failures, policymakers instead dallied for more than a year while hundreds of thousands of Americans have died, failing to take necessary action to improve school infrastructure before the beginning of the 2021-2022 school year. As a consequence, basic public health principles dictate that targeted school closures will continue to be important interventions for public safety in areas where coronavirus spread is uncontrolled and vaccination rates are low.
The final key finding of our study concerns nursing homes. The data suggest that these facilities have been the single biggest amplifier of Covid-19 spread in the U.S. This should come as little surprise, as it was already well-known that nearly 200,000 people have died from Covid-19 in nursing homes, which — like jails and prisons — feature constant biosocial interactions with surrounding communities. The scale of daily flow between these facilities and broader communities is considerable: more than 1.6 million Americans work in nursing homes caring for approximately 1.5 million residents.
The numbers make clear that nursing homes meant to provide solace and care have instead put millions of people in danger. But why has this been the case? Could it have been otherwise? What might the widespread neglect of people confined in nursing homes mean for the rest of us? These basic questions have too frequently gone unasked. Indeed, few Americans are even aware of the wide variety of institutions to which the term “nursing home” refers. These range from luxurious assisted living facilities for the rich to, more commonly, for-profit facilities characterized by systemic patient neglect and exploitation of precarious workers — places that my patients often tell me they would rather die than enter but to which I frequently have no choice but to send them when discharging them from the hospital.
The waves of nursing home deaths that have affected so many families during the pandemic should compel Americans to confront the way we routinely consign poor, disabled, and both young and old people to long-term residence in warehouses of social abandonment. Deaths from Covid-19 and its spread through long-term care facilities were not inevitable. Like so much of the suffering endured over the last 18 months, they have been the consequence of deliberate policy choices over years to provide only the bare minimum of public care infrastructures in the wealthiest large nation on earth that has more than enough resources to provide good-quality care and living conditions to all its residents.
The pandemic makes plain that, going forward, Americans must hold their policymakers accountable to build accessible public systems of high-quality residential care and expanded at-home care options with housing support. This is needed not only to protect the safety, dignity, and health of disabled and elderly people but also to protect national public health at large.
Build public health from the bottom up
It is a damning indictment of U.S. political priorities that a global emergency would be needed to force lawmakers and other officials to confront long-standing political failures to adequately invest in decarceration, public education, residential and at-home care infrastructure, and effective public safety systems. Addressing America’s exclusionary, revenue-driven health care system and its disinvested disease-surveillance and public health infrastructure is essential, but if anyone thinks that new investments focused strictly on medicine or biological science alone will be sufficient to improve U.S. pandemic preparedness and public health, they are dangerously mistaken. The pandemic has made painfully clear that public health and associated faith in government cannot be separated from investments in broader social institutions of care.
For far too long, U.S. policymakers have exhibited more interest in spending tax dollars on nationally self-destructive punishment systems than on supporting people living in vulnerable circumstances. As a result, the country has allowed unsafe spaces of neglect — from prisons and jails to nursing homes and decrepit schools in poor areas — to grow at the heart of our communities. Where we ought to have built spaces of care, we have instead built epidemic engines.
If we learn anything from the pandemic, let it be this: Genuine public health requires robust, well-funded public systems designed to meet the needs of the most excluded members of society and to protect them from exploitation, disposability, and disease. If we continue to de-prioritize the health and welfare of those who our systems of inequality have rendered most vulnerable, we will be inviting deepening disasters for everyone.
Eric Reinhart is an anthropologist of public health, a psychoanalyst, and a resident physician at Northwestern University. He is also lead health and justice systems researcher in the Data and Evidence for Justice Reform program at The World Bank.