by Tina Liang, MPH, MBA and Matt Holman, MPH, MBA
Amid a national dialog on systemic racism and police use of force and the continuing need to manage COVID-19 through efforts that include contact tracing, the creation of public health case management forces could be a compelling and cost- effective way to address both challenges.
COVID-19, Black Lives Matter, and Defund the Police. In recent weeks, a confluence of crises has led to a national conversation on racial equity after COVID-focused news cycles that had previously dominated our collective mind share for most of 2020. Making progress on systemic racism requires new policies and practices, no doubt, but in the near-term it also requires a more immediate and direct response to offset and mitigate systemic failures that will take years to solve. Case management provides a great model to begin this work, and the current need for COVID-19 contact tracing provides a unique launching point. Add to this the current dialog on police funding, which provides potential municipal discretionary funding sources to expand and elevate the contact tracer’s role, and these ingredients could come together to transform US social services and even healthcare delivery in a powerful and lasting way.
At the heart of the outcry to “Defund the Police” is the very real need to re-evaluate the role and responsibilities of police officers, including tactics and use of force. While defund the police is currently polarizing, in time, it is likely there will be consensus that the role of policing in the US has evolved to include many responsibilities that officers are simply not well trained or suited to address. Are they best suited to intervene on calls about homeless loitering? Mental health checks? Substance use? The list goes on – if we take a detailed look at the case load of police officers we quickly realize a lot of what they do, day to day, can and should be done by qualified case workers, public health workers, or social workers, who understand the issues better and are more likely to show up with relevant community context, specialized training and expertise, resources and solutions.
Now consider our ongoing battle with COVID-19, which requires investment in an estimated 100,000 temporary public health contact investigators at an estimated cost of $3.6B in the US[i][ii]. While, significant, this investment barely exceeds what the NYPD spends annually on pensions and bolsters a public health workforce in the US that has declined by 50,000 workers since 2008[iii][iv]. In many ways, the temporary role of COVID-19 contact tracers aligns well with the responsibilities currently placed on police officers that many cities are re-evaluating. Contact tracers are trained to go door to door in our communities, document cases, talk to individuals about their needs and living conditions, provide information, and identify necessary behavior changes or clinical needs. This new workforce is temporary, but it has the potential to serve a broader and more permanent need.
Imagine if we expanded upon this investment in contact tracers to make their role permanent as a new ”public health force“ of case managers trained in basic medical/clinical knowledge as well as mediation, conflict resolution, and de-escalation. These workers would be tasked with documenting issues, providing resources, solving problems with empathy and making connections to specialists or other social services in the community. Police officers would still need to play a role in security in some instances for this work, but likely a supporting role and only when needed. This is not an entirely new idea. Camden, NJ disbanded its police department in 2012 and replaced it with a force expected to show up to calls “more like the Peace Corps than the Special Forces”. Eugene, OR and San Francisco are also in the process of re-imagining ways to supplement their police forces with officers trained in public health and social services skillsets. In 2019 the Oregon program called CAHOOTS responded to 20% of 911 calls by sending out a medic and crisis worker team to respond to behavioral health incidents; of the 24,000 calls received only 150 times were the policed called for backup. The program costs $2.1M annually, compared to the budgets of the Eugene-Springfield Police Departments $90M. On average, from 2014-2017 the program has saved the community $8.5M annually, by picking up calls otherwise would have required law enforcement, EMS response, or ER visits[v]. Around the world, countries including Sweden, Scotland, Switzerland, and Finland have all established social and public health workforces to replace and augment traditional policing responsibilities[vi]. Meanwhile, robust COVID-19 contact tracing programs and teams have been highly effective in managing and containing spread in S. Korea, Germany, Taiwan and Australia[vii].
Contact tracers-turned-community case workers could be a big part of identifying and addressing both infectious disease as well as current social inequities in the US while identifying opportunities to create sound policies and practices to drive longer-term systemic change. A shift this dramatic would not come without a cost. Expanding the remit and scope of contact tracers beyond COVID-19 would likely require redirecting discretionary funds away from police departments and possibly other state and municipal services, but reflects a rebalancing of focus versus “de-funding”. Creating such a workforce would require case workers to develop a basic understanding on a wide variety of health and social issues in the specific communities they serve – everything from food insecurity, homelessness, substance use, domestic disputes, petty crimes, cultural and race considerations and more. These case workers need to know what issues they are likely encountering during the house call and how to offer an immediate solution or resources. It also requires training to know when to use their direct line to police back-up for security, or an ambulance to help save a life, or some extra muscle from the fire department. If done well, they could become a critical fourth leg of our first responders – a public health force of case workers that connect the dots and navigate citizen needs for a wide range of social services in appropriate measures where today we have in many cases become out of balance in our incident responses. This will require case worker “detectives” who live in the communities they serve, who understand the people and local nuances, and who know how to start solving the problem.
We are currently in a “once in a lifetime” crisis that is forcing our country to rethink everything from policy and business to politics and values. We are also in some ways fortunate to be stuck in a “new normal” purgatory for 1-2+ years as we await COVID-19 vaccines, which requires prolonged behavior modifications and investments that would be unheard of during normal times. This is the time for local and state government leaders to seize the moment and take bold actions in addressing racial inequities and our broken social safety net. Investments in innovative public health case management models can address two needs at once and are a great place to start.
[i] “”A National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the US”, Johns Hopkins University, April 2020, https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2020/200410-national-plan-to-contact-tracing.pdf
[ii] “A National, Tiered Approach to Scaling up Contact Tracing”, Association of State and Territorial Health Officials, April 2020, https://www.astho.org/COVID-19/A-National-Approach-for-Contact-Tracing/
[iii] Citizens Budget Commission, https://cbcny.org/research/seven-facts-about-nypd-budget
[iv] ”A National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the US”, Johns Hopkins University, April 2020, https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2020/200410-national-plan-to-contact-tracing.pdf
[v] “’CAHOOTS’: How Social Workers and Police Share Responsibilities in Eugene, Oregon”, NPR, June 10, 2020