Focusing Upstream: Imagining Post-COVID Times

January 20, 2021

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

As the daily death toll for COVID-19 continues to climb across the United States, it may be difficult to consider post-pandemic times. Yet despite the messy vaccine rollout, it’s possible to at least imagine what a “new normal” could look like. If we are to honor those who died, or were very sick, or had their lives upended, or all the healthcare workers who continue to work under unbearable and unnecessarily horrendous conditions, we ought to at least think this through. As a start, the following are a few considerations:        

        1. Structural violence and healthcare

The term structural violence refers to our societal structures of inequality that perpetuate poverty and ill health. And as we consider this term, we recognize the need tofocus upstream—that is, rather than endlessly pulling drowning people from the water, we must look upstream to determine why they’re being pushed in in the first place.

The COVID-19 pandemic has thrown racial disparities into stark relief and focused our attention on the fact that racism is central to this outcome. Structural violence puts communities of color at higher risk for COVID-19 transmission, severe infection, and death due to myriads of social conditions, including overcrowded housing, employment that requires in-person responsibilities, toxic stress and allostatic load, lack of health insurance to cover basic needs, and the daily racism of the healthcare system that keeps many people of color away from care. These factors are due to pervasive and persistent racism in our society.

Medical and public health professionals are crucial to addressing this violence. Whether it’s fighting to expand healthcare in underserved communities, or joining alliances to address food insecurity, unstable employment, or housing evictions, now is the time for medical and public health voices to be heard.

        2. Racism and medicine

Generations of scholars dating back to the 19th century have tried to bury the concept of racial categories in medicine, but thislogic of difference keeps reappearing, particularly as medical school curricula continue perpetuating these logics. More recently, research has shown how racism pervades medical technology and algorithms, the so-called “race corrections” that build biological race into medical practice, propagating concepts of racial difference based on faulty evidence.

As we eventually navigate into post-pandemic times, medical and public health professionals must seek to become structurally, not merely culturally, competent in the kinds of care they provide.

        3. Trust and trustworthiness

Fear of the COVID-19 vaccine, and belief that it is some vast medical experiment perpetuated by biotech companies or rushed out too fast to meet a political agenda, is rampant. And notably, the historical use of the bodies of people of color for medical experimentation has made communities of color particularly concerned.

Despite this country’s history of surgically experimenting on slave women, lying and failing to provide care during the syphilis studies in Tuskegee and Guatemala, or the use of Henrietta Lacks’ cancer cells to manufacture the most important cell line in medicine, it’s unlikely that mistrust of the COVID vaccine within communities of color is primarily stemming from this historical perspective. Instead, this fear more likely stems from the personal experiences of people of color during routine healthcare visits, or the ways in which medical concerns in communities of color have often been ignored.

It is on all of us to examine our biases and also counter misinformation, while understanding that fears exist for lived reasons and not mere ignorance. To address the existence of these fears, we must engage with patients, providers, public health professionals, and community members, and we must actively engage in anti-racism efforts. We’re also called to seek a more diversified healthcare workforce, one that truly reflects the diversity of the US.

Many of us have talked about returning to “normal” post-COVID, yet “normal” is what got us here in the first place. Let’s not continue endlessly pulling drowning bodies from the water. We must focus upstream, and we must make that change now.

**Feature photo obtained with standard license on Shutterstock.


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Reverby 2020 photo

Susan M. Reverby, PhD, is the Marion Butler McLean Professor Emerita in the History of Ideas and Professor Emerita of Women’s and Gender Studies at Wellesley College in Massachusetts. As a historian of American healthcare, her major research has been on gender and race in medical and nursing history, the ethics of public health and research, and health activism. Dr. Reverby is the author most recently of Examining Tuskegee: The Infamous Syphilis Study and its Legacy (2009) and Co-Conspirator for Justice: The Revolutionary Life of Dr. Alan Berkman (2020).

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