2022 was a rough year for America’s public health system.
It was plagued by public distrust, competed with raging misinformation, and dealt with institutional dysfunction, legal challenges, and financial insecurity. But amid the chaos, a handful of public health victories gave me hope.
In particular, these wins reinforced the importance of an undervalued and, usually, underfunded public health strategy: using grassroots, community-led campaigns to save lives and improve health.
These mostly local campaigns subdued an outbreak of a disease traveling fast through sexual networks, extended Covid-19 vaccines to those underserved by the status quo, and overcame stigma and provider shortages to soften the impacts of mental illness, substance use, and overdoses.
What they had in common: a “for us, by us” public health approach in which people working with community-led groups provided health outreach to members of their own, often marginalized, communities.
It’s worth championing these successes, especially as rampant dysfunction in US health care creates an increasingly large gulf between health haves and have-nots.
Mpox met swift action in the LBGTQ community
In May, rapidly accumulating cases of a little-known virus, mpox (formerly called monkeypox), started to raise alarm bells. While rarely fatal, the virus was spreading fast among people and in places that had previously never seen big, sustained outbreaks.
From the early days of the outbreak, the vast majority of cases were among gay men and their sexual networks, and the most effective responses to the outbreak came from within these communities.
In the US, government-led public health institutions were slow to communicate clearly about specific sexual risk, acquire adequate vaccine supply, and streamline treatment access. Meanwhile, gay men’s health organizations led immensely successful mpox education, vaccination, and prevention efforts.
Most of the community-based queer health organizations that partnered with health departments on vaccine rollouts were run by members of the LGBTQ community. Gay men and organizations they lead helmed effective advocacy and public education efforts that helped increase the US supply of the Jynneos mpox vaccine, streamline access to mpox treatment, and provide guidance to men on playing safe. Dating apps, bathhouse owners, and party promoters got on board.
And the mpox curve eventually flattened: As of December 14, only five cases daily, on average, were being reported from across the US, down from a high of 460 on August 1.
The mpox response has been far from perfect, and not all communities benefited equally from vaccination and treatment efforts: Although people of color accounted for 70 percent of cases, they received less than half of the share of vaccines. And thousands of mpox diagnoses in women and nonbinary people have likely been missed over the course of the outbreak. (The Centers for Disease Control and Prevention is funding the efforts of community-based organizations to overcome these disparities.)
Despite these problems, it’s worth acknowledging that without the swift action in the early days of the crisis by organizations rooted in the gay community, the shape of the mpox outbreak would likely look very different than it does.
Community-led Covid-19 vaccination campaigns reached underserved communities
Nearly three years into the Covid-19 pandemic, 31 percent of Americans still have not completed their primary vaccine series. Overrepresented in this group: communities of color. Here, community-led efforts have also moved the needle.
Early in the pandemic, Black Americans bore the highest burden of severe Covid-19 disease but also had the lowest rates of vaccine uptake. More recently, a massive wave of outreach led by Black medical professionals in coordination with community leaders — including faith leaders and respected local influencers — has yielded some important success stories.
In Philadelphia, the Black Doctors Covid-19 Consortium’s vaccination outreach helped narrow the immunization gap between the city’s Black and white residents from 18 to 7 percentage points. Testing and vaccinating Black Philadelphians was just the start for the organization: It recently opened a primary care clinic to provide a full suite of medical services to the community it has fought for since the outset of the pandemic.
The city of Clarkston, Georgia, achieved some of the highest vaccination rates in its region by employing vaccine outreach workers from refugee communities, which comprise 40 percent of the city’s population by some estimates. As of July, 70 percent of residents were fully vaccinated. That’s a substantially higher rate than in surrounding DeKalb County, where 62 percent of residents were fully vaccinated. Other community-led programs have contributed to improved vaccination rates among Marshallese, Vietnamese, and Hispanic communities elsewhere in the US.
Community-led public health works because it’s delivered by workers people trust
Community-based public health is not just for infectious diseases.
Other community-led programs aimed at curbing drug overdoses, reducing substance use in pregnancy, and improving mental health among farmers and Black men have recently been shown to work. For all of them, the secret sauce is a cadre of health workers that comes from the community they’re serving.
When community-led public health programs succeed, it’s often because they effectively deploy trusted messengers.
If you’re not a person who trusts experts or health providers, think about the person you most trust to give you health information. Now, imagine they had the support and tools to work full time as a health resource for you — for example, to answer questions about your health risks or to screen you for certain conditions. That’s powerful, right?
The approach recognizes that not everyone trusts the same people, so a scientist citing a bunch of studies won’t be equally convincing to all audiences. That’s especially important when trying to reach people in marginalized groups, who often have less trust in experts than in faith leaders, teachers, or other influential people in their communities. If you can’t be sure your trusted messenger endorses a vaccine, you’re way less likely to stand in line to get it.
Grassroots approaches created by and for people within marginalized groups — including peer support networks and community health worker programs — are often particularly effective at changing opinions and actions. But they’re less common in the US than in the rest of the world. If we pay closer attention to the equity gains these strategies can make, that could change.
There’s some good news on this front: More support for these programs is on the way.
This year, the Biden administration announced it would commit $226 million in pandemic funding toward developing community health worker programs that train people without medical backgrounds to provide health services to underserved members of their communities.
Nobody knows what new public health challenges the coming years will bring. But to have any hope of meeting them with effective and equitable responses, we should let communities lead.