CHW affiliate Heather Howard, lecturer for the Princeton School of Public and International Affairs (SPIA) and director of the State Health and Value Strategies program, has taught the undergraduate SPIA Policy Task Force on “Health Care for Vulnerable Populations in the U.S.” since 2018. The course, which fulfills a SPIA requirement, empowers juniors to explore inequities within our health care system and propose policy solutions for the State of New Jersey. Last fall, as the nation confronted an escalating pandemic and the effects of structural racism, Howard recognized a unique opportunity to modify the class and study the unprecedented confluence of events in real time.
“We had two pandemics converging: COVID-19 and the reckoning with racial injustice,” stated Howard. “Students were hungry to bring these issues into the classroom. I thought it would be a shame not to seize the moment.” Thanks to a grant from Princeton’s 250th Anniversary Fund for Innovation in Undergraduate Education, she was able to do just that.
Equalizer or Magnifier?
The funding allowed Howard to redesign the course curriculum to examine the intertwining dynamics of COVID-19 and systemic racism, shifting the focus from state health policy generally to policy addressing health disparities exacerbated by the pandemic. In fact, she kicked off the class by posing the following question: Is COVID-19 an equalizer or magnifier? In other words, does the pandemic affect everyone in the same way, or does it expose and amplify inequities?
As a central theme of the course, students investigated how the pandemic has disproportionately affected communities of color. They studied how states have responded to COVID-19 – from expanded access to testing and health insurance to supporting struggling “safety net” providers – along with the role of federalism, or federal-state relations. Furthermore, the class probed and developed potential state responses for advancing health equity.
The evolving nature of the pandemic required Howard to restructure the Task Force with innovative, virtual strategies for exploring current events. Each week, students tackled a specific topic through robust discussion, debate, and exercises. For example, they took a shot at balancing the California budget to further their understanding of fiscal constraints facing states and analyzed COVID-19 data to uncover racial and ethnic disparities in disease outcomes.
The cornerstone of the course was independent research on a policy issue related to COVID-19 or health equity in the State of New Jersey, culminating in group recommendations presented to state officials. “I am so proud of the work they did,” noted Howard. “Each topic was compelling, and I was impressed by their ability to dive deep and grapple with the challenges and tradeoffs in implementing health policy.”
Researching the Issues
The students’ research reflected three central themes, giving rise to their presentation named “REACT New Jersey,” or Resilient Policies to Empower Communities And Create Trust. They worked collectively to present findings within these broad categories, investigating how we can learn from the pandemic to strengthen our health care system.
Within the realm of resilient policy, students addressed the impact of COVID-19 on the state’s opioid crisis and federally qualified health centers. They also developed empowering recommendations to expand home and community-based services as well as policies to protect those in congregate living settings, such as long-term care, prisons, and migrant housing.
Emma Davis ’22, a SPIA concentrator pursuing a certificate in Gender and Sexuality Studies, delved into the problems affecting nursing homes and other long-term care facilities, from staff shortages to care requiring close contact and lack of personal protective equipment. “The lacking federal response wasn’t bad at its root because states could shape policies according to their populations and resources, but it led to avoidable mistakes. There is clear evidence, for example, that if these facilities were warned earlier about the threat of COVID-19, actions could have been taken sooner to prevent spread.” Davis studied qualitative and quantitative data, pored through newspaper articles, and conducted interviews to identify core issues and offer policy solutions. Her recommendations included targeted testing and isolation of sick patients to curb transmission, higher wages to bolster staffing, and a prioritized vaccine protocol for staff and patients.
Task Force member Jacob Barber ’22, a SPIA concentrator pursuing certificates in Global Health Policy and Statistics & Machine Learning, researched congregate living from a different angle. “My family is quite involved with the food movement, so I focused my project on how the pandemic has affected agriculture, food insecurity, and migrant labor in New Jersey.” Barber’s research revealed the amplified effects of structural inequities, such as poor, cramped living quarters and restricted access to health care for migrant farm workers. “It was really interesting to see how the state treated different populations. For example, New Jersey mandated COVID-19 testing in long-term facilities, for both staff and residents, but farms could opt out of testing their workers,” he stated. Accordingly, his policy recommendations included a compulsory COVID-19 testing program for New Jersey farms, educational materials (related to the pandemic) that account for language and literacy barriers, and enforceable safety measures and quarantine procedures.
Turquoise Brewington ’22, a SPIA concentrator pursuing certificates in Spanish and African American Studies, explored a third pillar of research: the challenge of building public trust for contact tracing, vaccination, and health care for vulnerable populations. Brewington chose to focus on birth equity. “Black women in New Jersey are seven times more likely to die in childbirth than white women,” she pointed out. “And the pandemic has only worsened this crisis.” Interviews with midwives, physicians, and other health care practitioners illuminated the harmful effects of COVID-19 protocols that isolated women during hospital deliveries, limited options for childbirth locations, and provided outdated information on C-section rates and midwifery metrics. Her proposals sought to improve outcomes for Black mothers by expanding Medicaid coverage for home births and midwives (to make them more affordable and accessible), while promoting better data collection and a collaborative approach to prenatal care and delivery.
The Task Force presented its research findings and policy proposals via Zoom to more than a dozen officials at the New Jersey Department of Health, who eagerly engaged with the students and welcomed their recommendations, Howard noted.
Lemons to Lemonade
By all accounts, the redesigned Task Force was a tremendous success. Feedback from students was overwhelmingly positive, with many valuing the opportunity to examine an evolving public health crisis. The course enlightened their views on responses at the federal and state levels, the disproportionate effect of COVID-19 on vulnerable populations, and the nuanced connections between structural racism and health inequities. The experience also influenced their perspective on public health policy and, in some cases, their upcoming pursuits.
“I thought that policy was closely related to politics, but this class helped me realize that they can be two separate entities,” said Davis. “Also, I really enjoyed researching a topic that was constantly changing and so relevant to our lives. This was my favorite class at Princeton so far.” Looking ahead, Davis has lined up a summer internship at the State Department and is considering a career in policy to help the nation’s vulnerable populations.
“I plan to expand upon my Task Force research for my senior thesis,” asserted Brewington. “The course definitely clarified my interest in combatting health disparities, particularly within the area of maternal health. I’m still undecided about the direction of my career, whether I’d like to do something on the policy side or practice law, but I’m sure it will be health-focused.”
Barber, who was recently accepted into the CHW Health Scholars Program, also ended the semester with a renewed interest in health care. “Professor Howard was great, bringing her expertise as a former Commissioner of Health and Senior Services for New Jersey,” he noted. “I’m hoping to continue my research on COVID-19 with a more technical senior thesis.” Barber plans to study how demographic heterogeneities in vaccine hesitancy impact virus spread, and how vaccine distribution policy should address these differences.
“It was a tumultuous semester, but we made the best of it,” remarked Howard. “At times it was like drinking from a fire hose, but I’m glad that I changed the course and provided an intense seminar experience – something I couldn’t have done without the University grant.”
“It was exciting to see the students care so much about the issues and produce such outstanding work,” she added. “Rather than missing an opportunity, we made lemonade from lemons.”