The New Politics of Care
The right response to COVID-19 is to rebuild our economy from the ground up, putting people to work in a massive jobs program to secure the public health of all.
April 27, 2020
Apr 27, 2020
25 Min read time
The right response to COVID-19 is to rebuild our economy from the ground up, putting people to work in a massive jobs program to secure the public health of all.
For many of us, the last few weeks have marked a new phase of our corona-lives—a dark and lonely corridor that stretches before us, no end in sight. Earlier, we counted this crisis in days and weeks. Now we are coming to see that this virus will in all likelihood be with us for months and years. We can’t stand social distancing any longer, but we also can’t stop, because there is no infrastructure in place to safely allow us to go back to school and work.
A Community Health Corps is one place to start to build a new movement that heals us and our body politic, and that will allow us—all of us—to survive a pandemic, and then, to thrive.
Our federal leadership remains ruinous. President Trump, obsessed with ratings, still cannot seem to think beyond the twenty-four-hour news cycle. In the last week he first insisted he would reopen things in May, then abandoned the idea, perhaps having learned that he lacked the necessary power. He then cast around for others to blame, taking to Twitter to cheer on tiny and malevolent groups of protesters calling for a reopening the economy, damn the consequences. Tragically, in the wake of the president’s remarks, Governor Brian Kemp of Georgia announced he would let many businesses resume operations, though the state is flush with new cases, and there is no viable plan for containment going forward. Trump tried to walk back his remarks, saying he disagreed with Kemp, but the damage was done, and Georgia is proceeding full-steam ahead. The press to return to school and work will only intensify, for all of us—while Georgia, and other states that are making similar rumblings, have nothing to offer their citizens but decimation.
What other way forward is there, over these coming months? As in the early phase, leadership and vision is going to come from elsewhere. It’ll come from reality-based local leaders, perhaps from Congress, and from us. As the timescale of our response to COVID-19 shifts to months and years, it’s time to ask: The day after all this is over, what do we want the world we share to look like? What are we willing to fight for? And how do we connect a long-term vision of that world worth fighting for with the things we need to do to mitigate the damage now?
• • •
Any response to the moment has to address two, twinned crises: the threat of a virus run out of control, and the carnage being visited on working people and families by the measures we need to undertake to contain the virus. While COVID-19 cuts its deadly swath from coast to coast, the disease follows the same patterns of inequality we’ve always seen embedded in the U.S. landscape, where the death rate for predominantly African American counties is six-fold higher than in predominantly white counties across the country, and where this crisis is just heaped upon others, which have been plaguing these communities for generations.
Meanwhile, as millions of Americans stay at home in solidarity with their neighbors to protect them from infection, the economic contraction has come at great cost to families and individuals, dragging them to the brink in the most spectacular economic collapse since the 1930s. We are in the middle of a disaster scene today, aided and abetted by a political culture that has rushed to give corporations billions in bailouts but has largely hung ordinary people out to dry. Food pantries are running empty as farmers—themselves facing bankruptcy—plow their crops into the soil. Last week, the number of people who filed for unemployment benefits surged to more than twenty-six million. Poorer families and school districts don’t have the resources for online learning, meaning that we are leaving millions of kids behind. Rent strikes are popping up from coast to coast.
We must build for a better future, not just climb out of the rubble of this pandemic, brush ourselves off, and start up in the same place we found ourselves in January 2020.
With a disruption looming that may be as severe as the Great Depression, our ambition to confront it should be at the same scale. But our answer to these twin immediate crises must connect to a broader politics and vision that addresses the deep structural roots of the problems we face in America. We must build for a better future, not just climb out of the rubble of this pandemic, brush ourselves off, and start up in the same place we found ourselves in January 2020. In our earlier pieces in these pages, we’ve argued for a new politics of care, one organized around a commitment to universal provision for human needs; countervailing power for workers, people of color, and the vulnerable; and a rejection of carceral approaches to social problems. The question now is how to connect that vision to programmatic responses that address the needs of the moment and beyond. We need to aim at “non-reformist reforms”—reforms that embody a vision of the different world we want, and that work from a theory of power-building that recognizes that real change requires changing who has a say in our political process.
Here’s one such reform: a massive new jobs program. Call it the Community Health Corps. Funded federally and organized locally, it would put millions of Americans to work caring for one another, and with far more sweeping goals than just turning around the sky-rocketing unemployment figures we see today. It would serve our needs for a vast force that can track and trace the virus, but add to it workers who can support those in need, all while securing our health and building real solidarity among us. Such a program, operating all around the country, in rural and urban areas alike, could help us get through this pandemic and mitigate the cataclysmic employment dislocation of the coming months and years.
In truth, this is just a new form of an old idea—a Works Progress Administration (WPA) for an age of pandemics. But the aim is larger, to bring us through the crisis by calling into being government as we wish it to be—caring for us, bringing us together, while also enabling us to live our different lives. It would go beyond providing care to communities by stitching back together the personal connections among us torn asunder by our self-enforced isolation and by building power together, as workers and patients are tied to each other through the act of caregiving. It wouldn’t just create jobs to fill a hole during the crisis—it would develop skills and foster solidarity that will form the basis of the post-crisis economy, too.
What jobs are needed? Start with contact tracing. The need here is straightforward and urgent. We cannot shelter in place forever, but reopening without measures to track the virus and sequester those exposed runs the same risk of swamping the health care system—infections and deaths will just come roaring back. Beyond the medical tragedy, such an outcome would also make a mockery of the sacrifices that millions of Americans have made over the past few months. That’s why every serious plan for reopening requires a massive scale-up in testing and contact tracing. The better we are at catching cases, notifying contacts, and supporting people who are sick or sequestered, the better control we will have over the virus, and the more “normal” life can be for those unexposed.
Think of the people hired for contact tracing as virus detectives, who also have the under-appreciated skill of being able to talk to others with ease and empathy. They will engage people infected with SARS-CoV-2 (the virus that causes COVID19) in a process of recalling everyone they’ve seen and everywhere they’ve been for days, while recording all this information in detail. They will then reach out to these contacts, advise them on testing and quarantine, refer them for testing, and link them to necessary resources to help them through their quarantine, from start to finish. Despite all the talk about technological shortcuts, this old-fashioned shoe-leather epidemiology is going to be the mainstay of our next phase of attempts to control COVID-19. Contact tracing in its most basic form has been around since the smallpox outbreaks in Leicester in the United Kingdom in the 1870s. We know how to do it, and it can be scaled up locally.
Shoring up the foundations of U.S. health care by valuing care itself isn’t just the first step towards a more rapid, effective response to health threats in the future. It will also move us toward a new politics of care, that starts from the ground up.
Technology can help supplement these human tasks but cannot replace them. The idea that apps alone will solve the problem of contact tracing is the product of the technological “solutionism” that writers such as Evgeny Morozov have rightly argued is endemic to our culture today: the notion that no matter the problem, an app can efficiently solve it. Why won’t apps be a silver bullet? For one thing, they raise serious privacy issues, especially if they are not voluntary. There are technical issues too. It will be difficult for some technologies, like those that rely on GPS, to distinguish true contacts from false ones in crowded, dense urban environments. The myriad apps under development now have not been beta-tested, let alone rolled out in the midst of a pandemic at such a scale. It also isn’t clear that app developers have spent time talking to the potential end-users of their products, building their tools to meet the needs of, and benefit from the expertise and experience of, local health departments. Finally, technological solutions almost always leave out many of those who lack full participation rights in a digitally enabled society. For example, in the rush to move our financial transactions online and replace paper money with electronic payments with apps from banks and start-ups such as Venmo, we’ve left out many from low-income communities, particularly from communities of color. Apps can help make contact tracing more effective, but we need to act now, hiring people to do this work that no app can do.
Spend a moment imagining a day in the life of a contact tracer working in Queens or Sioux Falls and you quickly see why an app alone cannot address the rippling crises that SARS-CoV-2 unleashes in every family. You also see the insufficiency, even, of contact tracing alone. Imagine you reach out to your first contact, who has tested positive and been sent home because they do not require hospitalization. Someone who has just learned that they have been exposed will have a myriad of important questions and needs. A father may wonder how, if he cannot leave his room, he will get food to his kids who are home from school. A shift worker who is wrongly fired for being sick will need help accessing unemployment insurance and legal support. A daughter may need help finding someone to provide essential daily care for a mother with dementia. Someone living alone will need help to walk the dog. We will need another group of workers to help them navigate these kinds of problems, which will require a mix of social work, advocacy, and even perhaps basic legal skills or the ability to make referrals to those who have them real-time.
Those going out to trace contacts are going to find more than just SARS-CoV-2 in the places they visit. There will be some homes they call where no one has been exposed to the virus, but where families are struggling to make ends meet, having trouble with their landlords or their utility companies, or struggling with lost or unhelpful health insurance. Recent data has shown that during this pandemic domestic abuse has become “more frequent, more severe and more dangerous” and that mental health and substance issue on the rise. We can’t just walk away from these people, our neighbors in crisis. In the narrowest sense, ignoring these needs will make it harder for people to keep social distancing. In a broader sense, if we use our politics at a time of existential need to impose an unlivable life on our fellow citizens—if we fail those for whom staying at home might be more dangerous than the virus—we will tear away at the fabric of solidarity and trust that we need to maintain the shared project that is democracy.
Right now we’re leaving help with all of this largely to individuals, families, and voluntary support. Most of us know people who are cutting corners with social distancing because they just can’t meet their daily needs any other way. In the next phase of the pandemic, we will need a much more precise and effective system of sequestering people if we are to get and keep the virus under control. While the mutual aid networks springing up around the country can handle a few requests for support, as we scale-up testing, the need of these kinds of social services and economic aid will explode. This can’t be handled simply as a matter of volunteerism even if “conservatives dream of returning to a world where private charity fulfilled all public needs.”
• • •
What is the alternative to genuine, public support for those who must remain isolated? Doctors Jim Yong Kim and Harvey Fineberg made the case in the New York Times recently that the ill, and their exposed families, should all be moved to facilities where they could be isolated from each other and the wider community, but they didn’t provide much guidance on how to do this humanely. Nor did they grapple with what it might mean to propose this sort of measure in a country with our history of state violence, especially as visited on families of color, who are vastly overrepresented among the sick today. We need to protect families from their sick loved ones, but forcibly warehousing families or the mildly symptomatic is not the way. We need a politics of support and care, not separation and deprivation. It’s clear that following public health advice isn’t as easy as it sounds—and its costs do not fall evenly. So we need support people to undertake this act of solidarity.
We need a politics of support and care, not separation and deprivation.
Alongside the test-and-trace brigade, then, we need other brigades too. We need a cadre of social workers who can provide specific help to individuals infected and affected by COVID, to enable them to follow public health and medical advice. We need a vastly scaled up testing workforce. Some will be dressed up in personal protective equipment (PPE), working at drive-through testing sites, visiting apartment buildings and nursing homes, and stationed outside of grocery stores and other businesses that remained highly trafficked even in the midst of the pandemic.
Others will be working in labs or transporting samples, helping to process the millions of tests we will need each week, possibly each day. If evidence mounts that early intervention and close monitoring is essential to saving lives, we will also need a new brigade of health workers who can make virtual or home visits. We can additionally train local workers to help us gather evidence—for example mapping local health and services needs through surveys, building on successful models of community-based research, and working to better guide local programs. These programs will not only help us understand and respond to the spread of the virus but help us build better health programs when it recedes.
We also need to address the explosion of infections in the workplace. We’ve seen outbreaks, large and small in meat processing plants across the country, in Amazon warehouses and Walmarts, leading to walkouts and lawsuits. As more and more businesses re-open, employees and employers need help to keep themselves and their customers and clients safe. Areas for employees and customers must be re-configured to maximize social distancing, and new workplace protocols need to be developed. Employers should be held responsible for taking the steps needed to protect their workers and the public, and some of this will likely not come without a stronger role for labor—via labor-management commissions, for example. An infection control brigade could work in cooperation with employees and employers, advising them on best practices in infection control, and assuring that supplies of PPE, from masks to gloves to physical barriers like plexiglass shields for cashiers are available. They can also ensure that early signs of failures in infection control are discovered and addressed immediately.
We are already seeing small steps in this direction. In Massachusetts, Partners in Health (PiH), which has experience building community health workforces in places hit by disease and disaster around the globe, has been asked by the state to spearhead their new contact-tracing program. In a matter of weeks, they have hired and trained close to a thousand people for these important and complex jobs. Aware of the importance of the work and the demands of the job, PiH is paying them the same rate as U.S. Census takers, $27 an hour, providing them with health insurance and making an emphasis on hiring the unemployed and building a diverse workforce. About 17,000 people have applied for these jobs, showing that there is clearly a deep pool of people willing and able to do this work. That should come as no surprise, given the staggering loss of work in recent weeks and the inadequacy of the current government supports, and the outpouring of support we’ve seen in communities and mutual aid networks. People want to help. We just need to organize them.
The problem is, while these efforts are admirable, state-level programs are vastly underpowered and underfunded. Before the crisis public health departments employed fewer than 2,000 contact tracers in the country. The best estimate we have projects that we will need to hire as many as 300,000 of them to address this outbreak. We have cohorts to build on for caseworkers and legal support too. One such pool derives from so-called community health worker (CHW) programs, which have a long history both in the United States and around the world.
The United States is sicker now with COVID-19, but we’ve been sick for long while in many other ways.
Today, we have about 120,000 community health care workers in cities and towns around the country doing health education and prevention work, collecting data, making links between local residents and the services they need. They are most often from the communities they serve and which have been underserved historically by the patchwork of a health system we have in the United States. In the context of need for testing-tracing-isolating in the age of COVID-19, local CHWs will go a long way to establishing trust and comfort in these troubling times. Contact tracers too should be recruited from local communities. Having a neighbor show up at your door (or on your screen) asking about your health and your personal contacts is more likely to be successful than a phone vibrating in your pocket telling you that you make have come in contact with someone with COVID-19.
There are also models for the caseworker and legal support component in the medical-legal partnerships (MLPs) that have emerged all around the U.S. in recent years. Driven by the recognition that illness—and healthcare costs—are shaped by factors that doctors alone cannot control (like access to safe housing and benefits), hospitals and non-profits around the country have hired legal professionals to assist clinicians, social workers, and case managers address larger structural issues affecting patients’ health and well-being. As of early 2019 there were MLPs active in about 330 hospitals and health centers in 46 states with evidence that MLPs can improve patient health outcomes and well-being, improve mental health, remove barriers to health care for low-income families, increase access to stable housing and other social support.
The idea is to build on these successes, which operate in small and disjointed ways, by integrating them into a federally funded Works Progress Administration for the age of COVID-19 and its aftermath. It will require significant federal funding, especially as states are forced into austerity by plummeting tax revenues and balanced budget requirements. But the cost will be small compared to the recent $2 trillion stimulus. Reports show that we can scale up contact tracing for just a few billion dollars—a fraction of the bailout we’ve handed over to big businesses. Some in Congress have already seen the need, and a federal bill awaiting the president’s signature provides some funds that could go towards such jobs, along with the massive scale up in testing that we need—though not nearly enough. Even a vastly larger program, hiring five million Americans for the duration of the crisis, would still cost less than the corporate bailout. This is a deal, if we consider what it can do to help not only save lives but also help employ people and buffer us against economic depression.
We could also mold the program to help shore up the present and future of those who are at grave risk, but not of dying from COVID-19. Many young people today are facing down a terrifying future. With more than twenty-six million unemployed and more to come, who will hire someone just out of high school? How will students get that first job to pay off their college loans?
By whatever accident of grace, young people are least at risk of developing serious complications of COVID-19, making them an obvious priority for a jobs program. The staggering health disparities of the pandemic make another priority clear. We need care workers who are from, and trusted, in local communities, both to reach those most in need, and to help build resources and power in those same communities. We also should demand a program that can hire those who are hardest hit by this downturn, and who we’ve cast aside for too long.
This means not focusing only on workers who are already highly skilled (much less volunteers, who will always skew toward those who need not worry about their daily bread). Some of these new recruits will need significant training, but we should not think of that as a problem—these are the same jobs we will need after COVID-19, and we have chronic shortages of exactly those skills nursing care and home health care workers that we will need to address this pandemic. And many of these jobs will use skills that come far more quickly: contact tracers can be trained in days, as can those who they will deliver food, masks, and hand sanitizer to families.
We know from the work of those who study the impact of jobs guarantees—including programs that have been running for many years in other countries—that such programs can be scaled up quickly, and provide essential counter-cyclical stability, as well discipline the private labor market. Especially now, creating alternatives to exploitative jobs is urgent, the only right thing to do. Many “essential jobs”—in janitorial positions, as cashiers in grocery stores, delivery workers—look a lot like forced labor today. With few exceptions, if you quit, you aren’t eligible for unemployment, and other forms of support like those elusive $1200 checks are too small, and not available to many. A Community Health Corps could provide better jobs, driving up the pay of those workers that we call essential, but do not pay that way. If these Corps jobs stick around (folded in, perhaps, to a Medicare for All program), they can help not only address our needs for care, but also our needs for decent work—and our needs to benefit collectively from the talents of so many who are now relegated to the margins, locked up or tossed away. We can also build the Corps as a springboard for further training, where those who have served their country can be funneled into higher education, in a new GI Bill for the age of COVID-19.
Getting back to normal was never going to be a solace for many in our country. Business as usual is precisely what has made us all more vulnerable to disasters like the one we are currently experiencing.
The United States may have the most technologically advanced health care system in the world, but we’re leading the number of worldwide coronavirus cases because we’ve badly trailed other industrialized nations in health outcomes for years. Many of the hardest-hit communities in the COVID-19 pandemic have been reeling from long-term health crises, from the opioid epidemic and deaths of despair in Appalachia to the burden of maternal deaths and the ongoing HIV epidemic in the South, to an explosion of obesity across the country with its downstream effects: type 2 diabetes, hyperlipidemia, high blood pressure, cardiovascular disease, and cancer. The United States is sicker now with COVID-19, but we’ve been sick for long while in many other ways.
Beyond helping to manage the current crisis, then, a Community Health Corps would help to improve the health of people historically left out of the circle of care. For too long we’ve focused at the top, spending on expensive, technologically advanced specialty care, while neglecting primary and community care and underpaying caregivers themselves. Even in the midst of the pandemic, community health centers, which should be the core of our health approach, have teetered on financial ruin. Meanwhile, the domestic workers and home health aides who perform the essential act of care have been underpaid and left out of federal labor protections. Not to mention that much of the work of caring is still done at home, falling disproportionately on women and people of color.
Shoring up the foundations of U.S. health care by valuing care itself isn’t just the first step towards a more rapid, effective response to health threats in the future. It will also move us toward a new politics of care, that starts from the ground up, in the places, we live, work and socialize. A politics that builds power among the caregivers, as the act of caring becomes publicly recognized and compensated for the productive work it is. Done right—and without the racialized and gendered exclusions that characterized the WPA—these new jobs can be a source of power for those who have never been fully allowed a voice in our democracy.
• • •
To scale this up quickly, we will need to bring together organizations like Partners in Health, who are experienced at mobilizing in a community though largely in the global South, and who are trusted and effective in their work on health, with local organizations, working on civil, social and economic rights such as national groups like the Center for Popular Democracy and Community Change, and their diverse roster of local community organizations.
Will it be easy to get our creaking, divided democracy to funnel resources into these programs? Probably not. But COVID-19 is conspiring to show us, all at once and in a way that no one can ignore, how central care is to a healthy society.
Over the past four decades we’ve seen the erosion of government as a force for good in people’s lives, most often by design as conservatives have looked to shrink the state, weaken its effectiveness, and privatize its functions. Liberals have gone along and lost their faith in the kind of government that built their political base while helping millions in the modern era, starting with the New Deal, and the civil rights, social and economic programs that were the hallmark of the Great Society period in the 1960s. The U.S. state is so weak and untrusted right now that banks have had to take over as the vehicle for the provision of many of the billions just released under the emergency appropriations by Congress, as many Americans cursed the IRS because of delays in the small checks they were promised in COVID-19 relief.
A Community Health Corps could be part of the remedy—in terms of the direct services and employment it could offer millions of Americans, in the ways in which this effort could lift up the health and well-being of so many, and also in terms of renewing faith in the power of government to help. The Corps would also be a prophylaxis—a first line in the response to the next challenges we face, whether it’s a seasonal return of COVID-19 or another pandemic, or the monumental troubles that climate change will rain down on our communities.
It would also serve as a model, a test of one essential component of a Green New Deal: the creation of millions of good green jobs. Green jobs, after all, are not just in construction, and many directly benefit health. That is why the most compelling versions of such a proposal prioritize new care work jobs, as well as jobs restoring our trails and parks, and even making a place for the artists and writers whose work is some of the greatest legacy of the WPA. Some of these jobs might even be initiated as part of the Community Health Corps. With so little traffic on the roads, there is no better time to build bike lanes—and green housing too, if the safety of workers can be assured. Greening our cities and improving housing for low-income communities are an essential component of a healthier society, as well as a healthier planet. Climate change is the largest foreseeable threat to our health; we can start to address this looming crisis right now, as we combat this pandemic.
We need more than a jobs program at this moment of national crisis, to be sure. We also need more SARS-COV-2 tests, more basic income, and better data about the pandemic, to name just a few. But rising up from under the cruel weight of this pandemic, we should also aim for something lasting and better. Getting back to normal was never going to be a solace for many in our country. Business as usual is precisely what has made us all more vulnerable to disasters like the one we are currently experiencing.
Will it be easy to get our creaking, divided democracy to funnel resources into these programs? Probably not. But COVID-19 is conspiring to show us, all at once and in a way that no one can ignore, how central care—writ large, broadly conceived—is to a healthy society. Rudolf Virchow, the father of social medicine, once said: “Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician . . . must find the means for their actual solution.” A Community Health Corps is one actual solution, one place to start to build a new movement that heals us and our body politic, and that will allow us—all of us—to survive a pandemic, and then, to thrive.
Authors’ Note: The authors would like to thank Lisa Hansmann, a second-year student at Yale Law School, for her research and editorial assistance in the preparation of this piece.
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April 27, 2020
25 Min read time