PERSPECTIVE

published: 26 October 2020

doi: 10.3389/fsoc.2020.579991

Covid-19 Requires a Social Medicine

Response
Lucas Jacob Trout* and Arthur Kleinman
Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, United States

Covid-19 is an inherently social disease, with exposure, illness, care, and outcomes
stratified along familiar social, economic, and racial lines. However, interventions from
public health and clinical medicine have focused primarily on the scale-up of technical
and biomedical solutions that fail to address the social contexts driving its distribution
and burden. Fused with a moment of reckoning with racial injustice and economic
inequality in the U.S. and across the world, these disparities charge policy leaders to
develop, study, and share a response grounded in social medicine. As a yardstick for
formulating, evaluating, and implementing health policy and care delivery, social medicine
recommends at least three things: integrating health, social, and economic responses;
bringing care to the points of greatest need; and focusing on broad equity-driven reforms
in the pandemic’s wake. With these tools, Covid-19 presents us with an opportunity to
address the inequities that the disease highlights, exploits, and may otherwise entrench.
Keywords: social medicine, COVID-19, health equity, health disparities, global health

Edited by:
Sangeeta Chattoo,
University of York, United Kingdom INTRODUCTION
Reviewed by:
Karl Michael Atkin,
The informal charter of social medicine is generally taken to be a quote from physician-
University of York, United Kingdom anthropologist Rudolf Virchow: “Medicine is a social science, and politics is nothing more than
Dharmi Kapadia, medicine on a large scale” (Ashton, 2006). There have been few moments in recent history
The University of Manchester, when Virchow’s words feel more instinctively relevant, or when we find them more clearly
United Kingdom operationalized in acts of care from health workers, neighbors, and communities caring for those
*Correspondence: affected by Covid-19. From massive racial justice protests responding to the continued murder and
Lucas J. Trout oppression of Black Americans, to the tandem implementation of health and social interventions
[email protected] for the pandemic globally, we find broad resonance for the idea that health and social life are
inherently connected—and that health care and social care work best delivered arm in arm (Baker
Specialty section: et al., 2020; Cherry, 2020; Hardy and Logan, 2020).
This article was submitted to
Still, a far broader, more integrated, and institutionalized response will be required to redress the
Medical Sociology,
waves of suffering that have already arrived—and the many more still to come. Covid-19 charges
a section of the journal
Frontiers in Sociology communities and their health leaders to develop, study, and share a response grounded in social
medicine: a rejoinder to this crisis that centers the experience and expertise of patients, families,
Received: 03 July 2020
health workers, and scientists engaging with the social realities of pandemic disease, and which
Accepted: 14 September 2020
Published: 26 October 2020 cares for its medical, social, and economic dimensions at once.
Social medicine means understanding health and delivering care around an understanding of
Citation:
Trout LJ and Kleinman A (2020)
our deep sociality (Trout et al., 2018). It is a recognition that the lion’s share of health determinants
Covid-19 Requires a Social Medicine are social in nature, and that the highest-yield interventions are often social—in their design,
Response. Front. Sociol. 5:579991. implementation, targets, and outcomes—as well (Kasper et al., 2016). In this way, social medicine
doi: 10.3389/fsoc.2020.579991 represents the practical application of a long scientific tradition that casts health and social

Frontiers in Sociology | www.frontiersin.org 1 October 2020 | Volume 5 | Article 579991

Trout and Kleinman Covid-19 Requires Social Medicine

inequities as twin phenomena, and which drives action to address efforts to de-socialize its meaning, causes, and care, for instance
each as contingent upon the other (Trout and Wexler, 2020). by falling back on tired stories of genetic predisposition, moral
Grounding our local, national, and global pandemic responses in fault, and individual agency (Jones, 2009). By the same logic,
this framework will be one of the central challenges of our time. we will likely find ourselves prone to overestimating the real-
world efficacy of technological solutions such as vaccines and
therapeutics, absent tandem efforts toward social care (Jones,
COVID-19 IS A SOCIAL DISEASE 2020). Bearing witness to the differential impact of Covid-19
across populations, we can bank on conversations that center
The initial framing of Covid-19—by journalists, celebrities, and “risk factors” as a proxy for racial and class disparities, without
even a few public health experts—invoked the notion of an adequate attention to the systems that structure, stratify, and
“equal opportunity killer” (Blow, 2020). The dismantling of sustain such risk (Farmer et al., 2006). Finally, we can expect
this narrative couldn’t have come any sooner. It is clear that fierce battles over the allocation of resources deemed too few
this disease, like nearly any other, seeks out and exploits the to alleviate the physical, economic, and social suffering caused
weak threads of our social fabric, stratifying exposure, illness, by the pandemic—and which, in both government and industry,
care, and outcomes along familiar social, economic, and racial the wealthy and white overwhelmingly control (Roberts and
lines (Van Dorn et al., 2020). Already well-documented are the Mayo, 2019; Chayes, 2020; Congressional Research Service, 2020;
staggering racial disparities in Covid-19 mortality in America, United States Senate, 2020).
with emerging focus on the manner in which racism is driven into But Covid-19 is also a unique and historic event, striking just
Black, Brown, and Indigenous bodies; similarly, across the world as the pervasive social, economic, and racial inequalities that
we have begun to map links between the severity of outbreaks and define American life come clearest into view (Kendi, 2020). This
social and economic inequality (Blundell et al., 2020; Hardy and pandemic represents a crisis of such exigence that we may be
Logan, 2020; Kendi, 2020). As Americans, we find in our county willing, as a nation and world, to entertain ideas about what
not only an abdication of global leadership in providing care and a robust response might look like—and who is responsible for
aid, but also a mirror up to the lives we’ve collectively made: We delivering the goods. Social medicine offers meaningful guidance
find that it is the poor and marginalized who are at greatest risk of in answering these questions.
contracting Covid-19; it is the already-ill who weather the worst
version of the disease; it is the uninsured who suffer at home for
lack of access to care; and it is disproportionately the victims of COVID-19 REQUIRES A SOCIAL MEDICINE
these collective forms of structural violence who die (Chen et al., RESPONSE
2020; Williams and Cooper, 2020).
Covid-19 is a social disease. In the most straightforward Social diseases require social remedies. As a yardstick for
sense, of course, infections move through social networks: that formulating, evaluating, and implementing health policy and
is, within families, through communities, and across networks care delivery, social medicine recommends at least three things:
of global commerce (Farmer et al., 2004). But the sociality of integrating health, social, and economic responses; bringing care
the disease runs deeper. The ability to social distance is socially- to the points of greatest need; and focusing on broad equity-
mediated, for example, by one’s economic position, housing driven reforms in the pandemic’s wake.
arrangement, employment, criminal record, and immigration
status—all of which track race (meaning, racism) in America Integrating Health, Social, and Economic
(Douglas et al., 2020). Public health recommendations assume Policy Responses
access to rights and resources conferred only to some—for Social medicine holds at its core a concept of health that unites
instance, running water, a utility still denied a full third of Navajo the social, economic, and biological. Just as health is always a
Nation homes (Krol, 2020). Information about the disease— product of the confluence of these forces, care must be delivered
true or false—moves through social and political networks, through an understanding of their basic unity. This is not a
shaping a world of differential access to scientific knowledge novel perspective; the World Health Organization signified the
and differential compliance with public health recommendations relationship between these drivers of health—and the state’s
(Simonov et al., 2020). Finally, the allocation of scarce resources responsibility for their collective care—in its constitution more
reflects the calculus of various social systems, from how families than 70 years ago (World Health Organization, 2020). The
prioritize their needs to how protective equipment, diagnostics, challenge, as always, is operationalization.
therapeutics, and (someday) vaccines are distributed across In the context of the Covid-19 pandemic, this means that
localities, states, and nations (Emanuel et al., 2020; Van Bavel we need to be clear-eyed about the purview of care required
et al., 2020). to address its health, social, and economic impacts. While the
From a social medicine perspective, we already know—or development of effective antivirals and vaccines is more than
can surmise—a great deal about Covid-19. Looking to historical essential, other high-yield Covid-19 treatments will involve rapid,
analogs, we can anticipate many of the same reactions, from targeted, and sustained shifts in housing policy, unemployment
discrimination and blame to the reassessment of national and and health insurance, jobs programs, sick leave, and monetary
global priorities, as past plagues (Mann, 2020). We can expect and fiscal policy. Such policies preferentially serve those at

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Trout and Kleinman Covid-19 Requires Social Medicine

greatest risk for the worst outcomes from the disease itself, for health workers, and re-centering the moral dimensions
and from its economic and social fallout—but ultimately every of caregiving (and the moral lives of caregivers) who are
person, family, and community stands to benefit greatly when the dedicating—and in some cases sacrificing—their lives in acts
pandemic’s spread and impact are lessened. of care.
This is a time for investment in communities as a health
intervention. Moreover, the best delivery platforms for these Focusing on Equity in the Pandemic’s
“social medicines” will almost certainly involve a level of
Wake
horizontal integration rarely found in health care, government,
Pandemics inevitably remake societies. How precisely Covid-
education, and social institutions. Among other things, this
19 restructures American life is a question still very much
means addressing the social determinants of health in clinical
unresolved—and the stakes could hardly be higher. Covid-19
settings, as well as addressing the social arrangements governing
presents us with an opportunity to correct the very inequities that
the distribution of these health determinants on the policy level.
the disease itself highlights, exploits, and may otherwise entrench.
It means bringing testing and care to accessible community
This is a pivotal moment in the American project: a chance to
settings, providing financial and logistical support to family
form that more perfect union, and to lay a new foundation where
caregivers, and facilitating the effective transfer of information
race, class, and social circumstance no longer define who lives,
across health and social sectors. Nations with the infrastructure
who suffers, and who dies.
and political will to implement and sustain such an integrated
Covid-19 hands us a veritable check-list of social problems
response provide us with early signals that wedding social care
to be solved. Immediately, the pandemic requires governments
and health care is key to emerging from this pandemic not only
to ensure food on the table, roofs over heads, and quality,
healthier, but more economically and socially sound (Gentilini
affordable health care for all. In the mid-term, it provides
et al., 2020; Kolbert, 2020). The alternative—the economic
communities and their health leaders with opportunities to
decimation of the already-marginal, and consolidation of power
map and rank the social arrangements, laid especially bare
among the protected and rich—is a path to greater health
by the pandemic, that both produce and are propagated
inequities, and greater social unrest, than America has yet seen
by poor health. In the long-term, it presents us with the
(Davis, 2020).
opportunity to reimagine these arrangements and to remake
society in ways that center the just and humane treatment
Bringing Care to the Points of Greatest of all citizens, eradicate health disparities shaped by racism
and class, and benefit the vast majority of Americans. Such
Need reforms will undoubtedly make the next pandemic that much
Social medicine means delivering care according to need, which,
easier to weather: While Covid-19 is not an equal opportunity
in the American situation, suggests a corrective and preferential
killer, there are very few winners when the global economy
option for the poor, marginalized, and those without ready
freezes, when political systems fracture, and when hundreds of
access to care. A central challenge of the coming months and
thousands die. This is a moment to recognize that the health
years will be to distribute public health, medical, social, and
of one is tied to the health of all, and to take bold action to
economic resources to the individuals, families, and communities
shape a more equitable future for our communities, nations,
in greatest need—with academic medicine, NGOs, and most of all
and world.
governments playing essential roles. The historic and present-day
underlayment of racism, economic and political exclusion, and
other forms of structural violence against marginal groups in the CONCLUSIONS
U.S. suggests that this will, at best, be an uphill battle. But given
the nature of infectious disease—where a single uncared-for case Covid-19 is a social disease: a mass event of social suffering
risks the health of all—this is a battle with our collective moral, that requires an integrated, caring, and equity-focused response.
economic, and physical lives at stake. Social medicine brings with it a set of tools for responding
In the context of scarcity, the pandemic requires that to the waves of suffering that have already arrived—in the
we take stock of our collective resources and put them form of disease and its attendant social fractures and economic
to use for the greatest possible good. This means the wreckage—as well as others still to come. It provides a lexicon
distribution of personal protective equipment (PPE) and for the myriad ways that health tracks social and economic
deployment of clinicians to high-risk and highly-impacted life, and a set of tools to undo these connections in favor of
communities. If and when a vaccine is proven safe and a fairer and more just society. It shapes the intellectual and
effective, the same principle should guide its distribution. moral scaffolding upon which our caregiving rests. Most of
It means appropriating funds for social programs that all, social medicine serves as a call to do something, now:
preferentially serve the poor, and for health programs to bring social care to our response, to care for those in
that preferentially serve the already-sick. Finally, it means greatest need, and to make equity central to our recovery. As
reimagining the act—and actors—of care itself: that is, health workers, policymakers, and citizens, this is our charge
providing training and financial support for family and if we are to honor the trust of our communities in leading
community caregivers, reevaluating how we as a society care this response.

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Trout and Kleinman Covid-19 Requires Social Medicine

DATA AVAILABILITY STATEMENT AUTHOR CONTRIBUTIONS

The original contributions presented in the LT drafted the original manuscript in collaboration with AK,
study are included in the article/supplementary who contributed sections on racial disparities and theoretical
material, further inquiries can be directed to the discussions of social medicine. All authors contributed to the
corresponding author/s. article and approved the submitted version.

REFERENCES social sciences into the preclinical curriculum. Acad. Med. 91, 628–632.
doi: 10.1097/ACM.0000000000001054
Ashton, J. R. (2006). Virchow misquoted, part-quoted, and the real McCoy. J. Kendi, I. X. (2020, April 14). Stop blaming Black people for dying of the
Epidemiol. Public Health 60:671. coronavirus. The Atlantic Available online at: https://www.theatlantic.com/
Baker, M., Wilson, N., and Anglemyer, A. (2020). Successful elimination ideas/archive/2020/04/race-and-blame/609946/ (accessed August 25, 2020).
of Covid-19 transmission in New Zealand. N. Eng. J. Med. 383:e56. Kolbert, E. (2020, June 1). How Iceland beat the coronavirus. The
doi: 10.1056/NEJMc2025203 New Yorker. Available online at: https://www.newyorker.com/
Blow, C. M. (2020, April 5). Social distancing is a privilege: the idea that this virus magazine/2020/06/08/how-iceland-beat-the-coronavirus (accessed
is an equal-opportunity killer must itself be killed. New York Times. Available August 25, 2020).
online at: https://www.nytimes.com/2020/04/05/opinion/coronavirus-social- Krol, D. U. (2020, April 18). Navajo Nation’s water shortage may be supporting
distancing.html (accessed May 30, 2020). COVID-19 spread. Arizona Republic. Available online at: https://www.
Blundell, R., Costa Dias, M., Joyce, R., and Xu, X. (2020). COVID-19 and azcentral.com/story/news/local/arizona-health/2020/04/18/navajo-nation-
inequalities. Fiscal Stud. 41, 291–319. doi: 10.1111/1475-5890.12232 water-shortage-contributing-covid-19-spread/2992288001/ (accessed Agusut
Chayes, S. (2020, April 17). Look out, corruption ahead. The Atlantic. Available 25, 2020).
online at: https://www.theatlantic.com/ideas/archive/2020/04/course-relief- Mann, C. C. (2020, May 10). Pandemics leave us forever altered: what history can
money-will-be-ill-spent/610126/ (accessed September 4, 2020). tell us about the long-term effects of the coronavirus. The Atlantic. Available
Chen, J. T., Waterman, P. D., and Krieger, N. (2020). “COVID-19 and the online at: https://www.theatlantic.com/magazine/archive/2020/06/pandemics-
unequal surge in mortality rates in Massachusetts, by city/town and ZIP plagues-history/610558/ (accessed May 31, 2020).
code measures of poverty, household crowding, race/ethnicity, and racialized Roberts, L. M., and Mayo, A. J. (2019, November 20). Toward a racially just
economic segregation,” Harvard Center for Population and Development Studies workplace. Harvard Business Review. Available online at: https://hbr.org/
Working Paper Series, 19. Available online at: https://cdn1.sph.harvard.edu/ cover-story/2019/11/toward-a-racially-just-workplace (accessed September
wp-content/uploads/sites/1266/2020/05/20_jtc_pdw_nk_COVID19_MA- 10, 2020).
excess-mortality_text_tables_figures_final_0509_with-cover-1.pdf (accessed Simonov, A., Sacher, S. K., Dubé J. P., and Biswas, S. (2020). The Persuasive
September 8, 2020). Effect of Fox News: Non-compliance With Social Distancing During the Covid-19
Cherry, M. (2020). Anger can build a better world. The Atlantic. Available online Pandemic. Cambridge, MA: National Bureau of Economic Research. Available
at: https://www.theatlantic.com/ideas/archive/2020/08/how-anger-can-build- online at: https://www.nber.org/papers/w27237
better-world/615625/ (accessed August 25, 2020). Trout, L. J., Kramer, C., and Fischer, L. (2018). Social medicine in practice: realizing
Congressional Research Service (2020). Membership of the 116th Congress: A the American Indian and Alaska native right to health. Health Hum Rights J.
Profile. Available online at: https://fas.org/sgp/crs/misc/R45583.pdf (accessed 20, 19–30.
September 10, 2020). Trout, L. J., and Wexler, L. W. (2020). Arctic suicide, social medicine,
Davis, W. (2020, August 6). The unraveling of America. Rolling Stone. Available and the purview of care in global mental health. Health Hum Rights J.
online at: https://www.rollingstone.com/politics/political-commentary/covid- 22, 1–11.
19-end-of-american-era-wade-davis-1038206/ (accessed August 25, 2020). United States Senate (2020). Ethnic Diversity in the Senate. Available online
Douglas, M., Katikireddi, S. V., Taulbut, M., McKee, M., and McCartney, G. at: https://www.senate.gov/senators/EthnicDiversityintheSenate.htm (accessed
(2020). Mitigating the wider health effects of Covid-19 pandemic response. September 10, 2020).
BMH 369:1557. doi: 10.1136/bmj.m1557 Van Bavel, J. J., Baicker, K., Boggio, P. S., Capraro, V., Cichocka, A.,
Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., et al. Cikara, M., et al. (2020). Using social and behavioural science to
(2020). Fair allocation of scarce medical resources in the time of Covid-19. N. support COVID-19 pandemic response. Nat. Hum. Behav. 4, 460–471.
Engl. J. Med. 382, 2049–2055. doi: 10.1056/NEJMsb2005114 doi: 10.1038/s41562-020-0884-z
Farmer, P., Bourgois, P., Fassin, D., Green, L., Heggenhougen, H. K., Kirmayer, Van Dorn, A., Cooney, R. E., and Sabin, M. L. (2020). COVID-
L., et al. (2004). An anthropology of structural violence. Curr. Anthropol. 45, 19 exacerbating inequalities in the US. Lancet 395, 1243–1244.
305–325. doi: 10.1086/382250 doi: 10.1016/S0140-6736(20)30893-X
Farmer, P. E., Nizeye, B., Stulac, S., and Keshavjee, S. (2006). Structural violence Williams, D. R., and Cooper, L. A. (2020). COVID-19 and health equity—a
and clinical medicine. PLoS Med. 3:e449. doi: 10.1371/journal.pmed.0030449 new kind of “herd immunity”. JAMA 323, 2478–2480. doi: 10.1001/jama.
Gentilini, U., Almenfi, M., Orton, I., and Dale, P. (2020). Social Protection and Jobs 2020.8051
Responses to COVID-19: A Real-Time Review of Country Measures. Washington, World Health Organization (2020). Basic Documents: Forty-Ninth Edition
DC:World Bank. Available online at: http://documents.worldbank.org/ (Including Amendments Adopted up to 31 May 2019). Geneva: World Health
curated/en/377151587420790624/pdf/Social-Protection-and-Jobs-Responses- Organization. Available online at: https://apps.who.int/gb/bd/pdf_files/BD_
to-COVID-19-A-Real-Time-Review-of-Country-Measures-April-3-2020. 49th-en.pdf#page=7
pdf
Hardy, B., and Logan, T. (2020). Racial Economic Inequality Amid the Conflict of Interest: The authors declare that the research was conducted in the
COVID-19 Crisis. Washington, DC: Brookings Institution Essay 2020- absence of any commercial or financial relationships that could be construed as a
17. Available online at: https://www.brookings.edu/research/racial-economic- potential conflict of interest.
inequality-amid-the-covid-19-crisis/
Jones, D. S. (2009). Rationalizing Epidemics: Meanings and Uses of American Indian Copyright © 2020 Trout and Kleinman. This is an open-access article distributed
Mortality Since 1600. Cambridge, MA: Harvard University Press. under the terms of the Creative Commons Attribution License (CC BY). The use,
Jones, D. S. (2020). History in a crisis—lessons for Covid-19. N. Engl. J. Med. 382, distribution or reproduction in other forums is permitted, provided the original
1681–1683. doi: 10.1056/NEJMp2004361 author(s) and the copyright owner(s) are credited and that the original publication
Kasper, J., Greene, J. A., Farmer, P. E., and Jones, D. S. (2016). All in this journal is cited, in accordance with accepted academic practice. No use,
health is global health, all medicine is social medicine: integrating the distribution or reproduction is permitted which does not comply with these terms.

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