Community “PPE” (Public Health, Primary Care, and Health Equity)
As with many health issues in the United States, public health, primary care, and health equity have emerged as crucial components of the COVID-19 pandemic response and recovery. The national scale and universal impact of COVID-19 requires a robust collaboration between public health agencies, healthcare organizations, businesses, and social services. Current COVID-19 recovery and many of the most crucial health issues facing the nation will require a focus on the disparate impact on vulnerable communities. A strong local public health infrastructure is needed to monitor local infection rates and population health trends and implement contact tracing and other efforts to reduce transmission. Primary care is critical for implementing testing and medical care, and for addressing the long-term needs of post-infection illness. Primary care is uniquely poised to provide for ongoing health needs and additional secondary surges in poor physical and mental health resulting from the economic disruption and difficulty in accessing regular healthcare during the surge or lockdown. The strategy for an optimal pandemic response and recovery requires a concerted and coordinated multisector effort, informed by a health equity lens, integrated into policies, practice and evidence.
The COVID-19 pandemic has introduced many of us to a new vocabulary: coronavirus, herd immunity, surge capacity, contact tracing, and personal protective equipment, to name a few. Personal protective equipment (PPE) includes all the equipment we wear to minimize exposure to and spread of this novel coronavirus, SARS CoV-2. PPE includes disposable gloves, N-95 masks, face shields, gowns, and cloth masks. PPE is an essential component of COVID-19 response.
Public health, primary care, and health equity each have unique and synergistic impact on a community’s response to and recovery from the COVID-19 pandemic. Primary care has focused on the individual and family, public health at the population level and on the community. However, there is growing appreciation for the need for primary care and public health to collaborate if we hope to improve the health of our nation. Wellness and illness are more than just the etiologic characteristics of an infection, injury, or pathology. Wellness and illness always exist in the context of the patient’s environment, social factors, and community. This need for aligning the work of primary care and public health goes beyond COVID-19. Many health conditions may be best addressed through the combined efforts of primary care and public health. And addressing health equity through mitigating the negative impacts of the social determinants of health is essential.
The Robert Graham Center has created a new “PPE” that will provide communities with the knowledge, assets, tools, and plans to respond to and recover from the pandemic and a host of other community health conditions (diabetes, tobacco use, heart disease, etc.) The combined efforts of Public Health, Primary Care, and Health Equity (aptly, “PPE”) may provide a path towards pandemic recovery and to address the myriad other health issues facing our communities. Providing a path to link public health and primary care while addressing the social determinants of health will set the stage for a new health care system that builds local communities of solution.
The Community PPE Index will be a robust estimate of a local community’s capacity to respond to and recover from the impacts of this pandemic. These are not the only factors that impact the health of a community, research has found that each element of the Index has a large impact on the health of the community. The relative impact of each of these factors may vary for a given community. The index aims to standardize this impact across local county jurisdictions for ease of interpretation, individual decision making, and policy efforts. Each component has equal weight in the overall index so that it is clear to the consumer and policy maker that each component plays a significant role in the health of the community. Primary care capacity and access have been shown to have a positive impact on overall health outcomes. Starfield described the impact of an expanded primary care workforce on a host of health outcomes and costs. The primary care goal is one primary care provider per 1,500 population. Public health has a robust literature on the improved health outcomes of individual programs as well as investment in the general public health infrastructure. The National Health Security Preparedness Index (NHSPI), was created to guide public health resources to improve the opportunity to respond to widespread disaster, national security issues, and pandemics. Comprised of over 50 components of public health resource capacity, the index creates a 10-point scale that provides easy interpretation of a local county health department capacity for emergency response and recovery. The Social Determinants of Health (SDOH) are known to have a profound impact on health outcomes, engaging the broader community in multisector approaches to addressing health equity and quality of life. The Social Deprivation Index (SDI) is a county measure of social determinants of health that predicts health outcomes better than poverty alone.
The Community PPE Index is more than a county ranking system. It provides a comparison of each county to an aspirational goal. Each component, public health, primary care, and health equity is based on a 10-point scale with 10 being the highest possible score, for a total score from 3-30. The public health goal is a score of 10 on the NHSP Index. The primary care goal of 10 represents 1 primary care provider per 1500 population. For health equity, a score of 10 on the social deprivation index is the goal. Combined, the Community PPE Index will provide consumers and policy makers with information about local risks, health inequities, and potential clinical, public health, and policy levers to improve community health and address health disparities.
The Community PPE Index (Community Health Index) will provide the evidence necessary to inform local, state, and federal policy making decisions related to program implementation, resource allocation, and long-term investments in the health of local communities, counties and states. For a county with a poor primary care index component, policies related to recruitment and retention of primary care clinicians may be important. For counties with a low public health index component investment in public health infrastructure will be crucial. For counties with disintegrated social determinants of health, long-term multidimensional solutions may be sought to improve employment, address poverty, food insecurity, housing and transportation. The COVID-19 pandemic has laid bare the inadequacies of our primary care workforce, insufficient funding for public health, and the profound impact that health inequalities and the social determinants of health have on the our communities facing this pandemic. Currently, the index could be called the COVID-19 Response and Recovery Index. While the name “Community PPE” conjures masks and gowns, we believe it also reminds us that the local community can be part of the solution; that COVID-19 response and recovery requires more than gowned intensive care staff and ventilators. Call it the Community PPE Index or call it the Community Health Index. The name is not important. The index will provide an easily accessible, reliable, and reproducible guide to COVID-19 response and recovery. It may also provide a long-term tool to help build and sustain healthier communities.
A portion of this content was originally included on a Health Affairs blog: "A New 'PPE' For A Thriving Community: Public Health, Primary Care, Health Equity."