1. Section Editor(s): Goldfield, Norbert I. MD
  2. Editor

Article Content

Public Health, Public Trust and American Fragility in a Pandemic Era: Its Impact on Ambulatory Professional Practice

We will continue to confront the implications of the COVID pandemic for years to come. In the meantime, The Journal of Ambulatory Care Management will publish contributions to our understanding of how to best reorganize our ambulatory response to this health care crisis. With pediatric vaccine access now approved by the Centers for Disease Control and Prevention and widely available, Dr Boogard and colleagues highlight issues of vaccine program implementation. Dr Fifolt et al examine how COVID has successfully forced many health professionals adjust how they manage their professionals. Quoting from their article: "Team-based, interprofessional nature of patient care was one of the primary reasons the clinics continued to function at a high level during the pandemic." Yet, these accomplishments are necessary but hardly sufficient if we are to finally address the fundamental "wound" (Selllers, 2022) that COVID has inflicted on the United States and the rest of the world. At the end of this FTE, I make a proposal that begins to address the need to not only rebuild our public health system but truly focus on population health.


The next 2 articles (Quigley and Elder) analyze different aspects of ambulatory care and underserved populations.


In 2022, we will highlight changes in ambulatory care practices both in the United States and overseas. We are interested in submissions on this topic. Impact of COVID is of interest but by no means required. The final 3 articles by Chaney, Razai, and Smithline together with their colleagues provide an outstanding to this series.


A State Level Proposal to Place Community Health Workers at the Center of a Revitalized Public Health System.


This proposal's central arguments for a state-wide public health initiative are as follows:


a. We will continue to face ongoing pandemics and endemics.


b. Effective public health is one ingredient in improved public trust in an increasingly "fragile" United States.


c. An effort to implement a national, federally directed public health response to the COVID pandemic is not politically feasible at the present time.


d. States have historically taken the lead on important national issues. We can implement a state-wide public health initiative in Massachusetts that builds on existing strengths.


e. A public health initiative needs to place community health workers (CHWs) at the center for at least low- and middle-income counties in the state.


f. This initiative can only function effectively in our fragmented health care system if bipartisan, senior state-wide elected political officials play an active leadership role.



A recent The New York Times article (Anthes, 2022) highlights the challenge the United States face in its COVID response:


"I'm confident in our ability to detect the variant," Dr Fauver said, "What I'm not confident in is our ability to do anything about it.... One thing that we've lacked continuously through the pandemic is a goal. We still don't have that. Certainly, we don't have that for Omicron" (Emily Gurley).


Fragility, a term used in the "peace through health" field, describes countries that are emerging from conflict. The United States, assessed in 2018 to be the country most able to deal with a disaster, has tragically performed the worst of any industrialized country. There are 2 components of this fragility: the political polarization around the COVID pandemic, and the dramatic disproportional impact of the pandemic on lower socioeconomic strata. These 2 factors continue and in fact have become exacerbated despite many American strengths.


Health care is a significant economic driver in the United States. A bipartisan group of senior elected officials needs to lead the pandemic response. Without this active leadership, economic interests will continue to struggle with each other, resulting in a lackluster or failed public health response. Grant-making and encouragement of localities are not sufficient.


What should the "goal" or model be? We need a state-wide public health system that elected officials lead in a bipartisan manner and places CHWs at the center of the wheel. Such a model provides ample opportunity for variation in implementation (Goldfield et al., 2020). Numerous CHW-led models exist.


The price of failure is severe. Without public trust, American fragility and resultant polarization in American society will not only continue but also worsen. This will only exacerbate the pandemic and our socioeconomic disparities. Our economic growth will be stymied. Without effective public health at the time of a pandemic, public trust cannot be reestablished.


-Norbert I. Goldfield, MD






Anthes E. (2022). Omicron is a dress rehearsal for the next pandemic. The New York Times. Retrieved January 3, 2022, from [Context Link]


Goldfield N. I., Crittenden R., Fox D., McDonough J., Nichols L., Lee Rosenthal E. (2020, July-September). COVID-19 crisis creates opportunities for community-centered population health: Community health workers at the center. The Journal of Ambulatory Care Management, 43(3), 184-190. doi:10.1097/JAC.0000000000000337 [Context Link]


Selllers F. S. (2022, January 1). Much has changed since the start of the pandemic. But the nation's public health system remains fractured. The Washington Post. Retrieved January 3, 2022, from[Context Link]