Former Nashville Mayor Bill Purcell joined the Nashville Health Care Council and NashvilleHealth to discuss “Strategies for Future Preparedness: Examining the Impact of COVID-19 on Nashville,” a NashvilleHealth study that will help cities and the health care community make evidence-based and equity-informed decisions before, during, and after disasters. The report, prepared by Avalere Health, is the first comprehensive examination of a U.S. city’s response to COVID-19. Kristi Mitchell, report author, and Nashville COVID-19 Taskforce Chair Alex Jahangir joined Purcell. The article below incorporates important points from their discussion.
Mayor Bill Purcell was Nashville’s chief executive for eight years. Two of the city’s worst disasters, the downtown tornado of 1998 and 2010’s flooding, bookended his tenure, but as a long-time resident, Purcell witnessed many catastrophic events. He also has seen how disasters profoundly affect underserved populations and the health care community.
Writing history in real time will help government leaders, public health officials, businesses, and charitable organizations improve future preparedness — and will inform decision-making as the COVID-19 pandemic evolves. “It is when a city forgets, or refuses to understand, the lessons of its past that its future comes into doubt,” Purcell said.
Investigating How Nashville Responded to the COVID-19 Pandemic
By January 2022, Tennessee had the highest per capita COVID death rate in the nation. Nearly 1,500 Davidson County residents had died of COVID-19, but the impact was uneven. Nashville zip code 37219, where the median income is less than $27,000, had the county’s highest fatality rate (2.15 percent). There have been fewer than 10 COVID-related deaths in Nashville’s wealthiest zip code (37220), meanwhile.
The pandemic highlighted consistent underinvestment in emergency preparedness, the health care community, and vulnerable communities. “Strategies for Future Preparedness” offers actions cities can take to guide disaster response. The report is the result of more than eight months of research that included the review of more than 130 public documents and 32 interviews with city leaders. It was made possible through the support of several partners, including The Frist Foundation, United Way of Greater Nashville, and the Nashville Area Chamber of Commerce.
“Strategies for Future Preparedness” identified three areas that will help cities and the health care community make evidence-based and equity-informed decisions before, during, and after disasters: strong partnerships, strong data, and strong leadership.
Strong Community Partnerships Build Trust
Trust has played an enormous role in ensuring residents’ adherence to COVID-related health protocols. A study published in Psychological Medicine in March 2021 found trust in government was “significantly associated” with adoption of handwashing, social distancing, and quarantining guidelines. Government bodies perceived as well organized, fair, and committed to disseminating clear messages and knowledge had higher levels of trust, and that trust was “was significantly associated” with a lower rate of decline in health behaviors over time.
The American Psychological Association has advised that government officials and the health care community “develop culturally competent mechanisms and transparent practices to encourage participation among communities made vulnerable by COVID-19.” Nashville is a “community of relationships,” said city COVID-19 Taskforce Chair Alex Jahangir, and these partnerships have been a significant resource for pandemic response. Several of Nashville’s successful efforts were with the Nashville Convention and Visitors Corp, as well as, with the healthcare systems in Nashville including Meharry Medical College, Vanderbilt University Medical Center, HCA/ Tristar Health, Ascension St. Thomas and Nashville General Hospital. These partnerships gave city officials an effective vehicle for disseminating important messaging through trusted community leaders and allowed for mass testing and vaccination opportunities.
Public-private partnerships were particularly beneficial to the city’s efforts to get residents vaccinated. The Metro Public Health Department leveraged community partnerships to increase vaccine uptake, for example. Grassroots partnerships between community health centers and nonprofit organizations were particularly critical for conducting outreach to immigrant and refugee communities.
Key recommendations from “Strategies for Future Preparedness” include:
- Leaning on faith community leaders as key influencers and trusted representatives for information sharing and emergency response.
- Forming a business leadership advisory committee to educate local business leaders on establishing, maintaining, and regularly updating disaster protocols.
Strong Data Practices Improve Equity
“The enormous amount of data the pandemic has generated has given researchers and providers the opportunity to analyze trends, monitor patient populations, and begin to rectify longstanding issues” in the health care community wrote HealthITAnalytics’ Jessica Kent just six months into the pandemic. “Having the ability to anticipate future events is critical in the midst of a health care crisis.”
Nashville leaders used a data-driven approach to COVID-19 response and health equity. The United Way of Greater Nashville leveraged digital platforms to track funds being deployed to help families pay rent or buy groceries, for example. These tools allowed funders to visualize areas where resources were lagging and allocate dollars accordingly.
Mayor John Cooper thoroughly embraced a data-driven approach. This commitment kept Nashville ahead of regional trends in implementing time-sensitive public health measures to mitigate COVID spread. City leaders also prioritized transparency. Science is “seeking the truth,” Jahangir explained, and as data becomes more accurate and available, response efforts need to evolve. “As new information came out, we shared it,” Jahangir said.
Key recommendations from “Strategies for Future Preparedness” include:
- Creating easy-to-use and mobile-friendly online information portals and dashboards for residents, the health care community, and businesses.
- Developing improved and standardized data sharing between health care providers to coordinate care and track outcomes.
- Leveraging a Social Vulnerabilities Index to identify communities where populations are at the greatest risk for negative socioeconomic and health outcomes.
Strong Leadership Will Drive Investment
COVID-19 shined a light on infrastructure deficits, particularly in underserved communities. Public health investment has been declining for 30 years. It will take political will to address underinvestment — especially when officials are facing a dissatisfied public.
According to a May 2021 survey from Harvard’s T.H. Chan School of Public Health, the public’s positive rating of public health officials fell from 43 percent in 2009 to 34 percent in 2021. Less than half of Americans approved of the performance of the Food and Drug Administration (48 percent) and the National Institutes of Health (47 percent) during the pandemic.
Politicization of pandemic protocols has driven mistrust. Nashville leaders largely rejected the nationwide trend, however, and the ability to work across ideologies improved the city’s response. Effective city policies are especially important when conversations are politicized at the state and national level. There is “no one better attuned to the needs of the community” than the people living in it, “Strategies for Future Preparedness” author Kristi Mitchell said.
Strong leadership and a commitment to bipartisanship will be important to sustain current public support for infrastructure investment. The Harvard poll found 71 percent of adults favor substantially increasing federal spending on public health infrastructure. The bitter debate over the U.S.-House passed Build Back Better plan, which includes $7 billion for public health infrastructure, is evidence this issue can be politicized despite broad public support.
Leaders must continue to work across ideologies and think of infrastructure holistically. Key recommendations from “Strategies for Future Preparedness” include:
- Ensuring city health departments have consistent and trusted leadership that has community buy-in.
- Recruiting future leaders through citizen committees whose membership is reflective of the community’s different constituent groups.
A Model for All U.S. Cities for Health Equity and Disaster Preparedness
Nationally, Black, Indigenous, and People of Color (BIPOC) have been more than twice as likely to die of COVID-19 than Whites. Addressing these outcomes will be “a marathon,” report author Mitchell said.
“Strategies for Future Preparedness” can serve as a valuable resource to guide evidence-based decision-making and equity-informed actions for future disasters. While the report is a look at one locality, it offers lessons for all local, state, and federal public and private sector leaders. Armed with strong data, partnerships, and leadership, civic officials and health care community can make sound decisions, protect vulnerable communities, communicate effectively, and know when data warrants a course correction.