Why community trust and engagement must be cornerstones of pandemic response

Harvard Medical School

This article is part of Harvard Medical School’s continuing coverage of medicine, biomedical research, medical education, and policy related to the SARS-CoV-2 pandemic and the disease COVID-19.


When the 2019 Global Health Security Index was released in January 2020, the United States was named the best-prepared nation in the world to deal with a health emergency like an outbreak of epidemic disease. Fast forward to March 2021, and the United States had claimed the top spot on a very different rank list-, as the country with the most COVID-19 cases and the most COVID-19 deaths in the world.

More than a year into the pandemic, the U.S. has tallied more than 540,000 deaths and more than 30 million confirmed cases, according to the latest count from the World Health Organization.

“When we think about how to balance control of an epidemic over chaos, we have to double down on care and concern for the people and communities who are hardest hit,” said Joia Mukherjee, associate professor of global health and social medicine in the Blavatnik Institute at Harvard Medical School and chief medical officer at Partners In Health, an organization focused on strengthening community-based health care delivery. “In the U.S., we have the building blocks of a health system, but without trust and leadership and engagement and care, we don’t really have a system.”

The problem with the index was that it underestimated the importance of several elements that are necessary for real health security, Mukherjee said, including a coherent, integrated system that can help people meet their needs for clinical care while providing clear messaging and social support to make preventive public health efforts effective and sustainable.

Mukherjee is part of a cadre of HMS community members who have taken a leadership role in building a more comprehensive response to the outbreak in Massachusetts and around the U.S. They are drawing on their combined decades of experience building integrated health systems, researching the results, and training generations of global health care workers to fight outbreaks and endemic disease around the world in the fight against the coronavirus.

To contain an infectious disease epidemic, Mukherjee says the following elements are crucial: Making sure that the people who need testing can get tested, that those who need to be isolated have the resources they need to do so, and that those who need treatment have access to clinical care. More broadly, widespread community consensus on the best way to stop the spread of the disease must be ensured.

These aren’t just idealistic goals. They’re pragmatic, essential elements of a functioning health care system during an outbreak, Mukherjee said.

“If you don’t provide community engagement and material support, you can’t really have a pandemic response that’s successful,” Mukherjee said.

Community-level strategies and old-school public health approaches can’t be replaced with technological advances like smart phone apps or biomedical breakthroughs like the new vaccines. Continued vigilance, including personal contact and human interaction with those who are infected or at risk remain critical.

Even as more and more Americans receive vaccines, public health experts emphasize that controlling the pandemic by limiting infections will remain vital for the foreseeable future. Indeed, slowing the spread of the disease will be crucial for preventing the natural evolution of more dangerous variants that could potentially evade both immune defenses developed from natural infection and limit the effectiveness of immune protection from the current generation of vaccines.

Making crucial connections

During disease outbreaks in low-resource settings, the consensus has often been that treatment is too complicated or too expensive, said Paul Farmer, the Kolokotrones University Professor of Global Health and Social Medicine at Harvard and chair of the HMS Department of Global Health and Social Medicine.

The phenomenon, Farmer said, is called treatment nihilism. In these cases, most of the energy and resources available for health care are devoted to prevention and public health efforts. A mirror image of the same conflict has played out here in the U.S., he said. The country has resources dedicated to increasing hospital capacity and is developing therapeutics and vaccines, but many experts have said prevention and containment are impossible-a form of containment nihilism.

All of these-prevention and infection containment, hospital-based care, therapies, vaccines-are by themselves clearly necessary elements for a pandemic response to a disease like COVID-19, Farmer said, but they cannot work in isolation. The best approach is to integrate prevention, clinical care, and social supports in a single, comprehensive plan.

Farmer is one of the founders of Partners In Health, and over the years, he and his colleagues from HMS and PIH have fought epidemics of HIV, Ebola, cholera, tuberculosis, and a host of other infectious and noninfectious diseases, repeatedly seeing the importance of integrated care and community trust in achieving results that skeptics doubted were possible.

Since last April, PIH has used its international experience to help build a more integrated response to COVID-19 in the U.S. in the hopes of building the foundations for a long-term shift toward a more care-centered, community-based health care system.

The process began with the launch of the Massachusetts Community Tracing Collaborative (CTC), a statewide contact tracing initiative made possible through a partnership among several state bodies, local boards of health, and PIH. The CTC was launched in April 2020 by Governor Charlie Baker, with leadership from HMS faculty.

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