Strengthening the U.S. health care system

Image of globe on light, McGill University. Photo by Smallman

In our textbook, the health chapter begins by this comparison of nations: “Chile, Costa Rica, Cyprus, Guadalupe, Hong Kong, Israel, Macau, Malta, Martinique, Singapore, and the United Arab Emirates are a diverse set of nations and territories. Yet they all have one fact in common: their citizens live longer than those of the United States, as do the citizens of many developed countries (United Nations 2006). This truth is unexpected, given the wide gap between the wealth, power, and technology of these countries and that of the United States. But health inevitably becomes linked to broader issues of politics and policy.” This is certainly the case in the United States’ ability to respond to a pandemic.

What have some of the lessons of this pandemic been for the United States? Our health care system has a number of weaknesses during an epidemic:

  1. A health care system that invests heavily in technology, but less so in people, such as the public health professionals who do contact tracing.
  2. A lack of recent experience with pandemics, such as South Korea and Canada had with SARS and MERS.
  3. An inadequate stockpile of personal protective equipment. A failed effort to develop a stockpile of ventilators wasted over a decade, and left the United States undersupplied.
  4. A popular belief that epidemics are something that happens elsewhere, so that the first and best response is only to put in place border restrictions.
  5. A sense of hubris, so that outbreaks in China or South Korea are assumed to be something that could not happen here, because our hospitals -with their advanced technologies- would be able to manage the situation.
  6. A health care system in which peoples’ insurance is tied to their employment. This has meant that when people lose their employment during a pandemic, they also lose health care.
  7. Deep health inequalities, which mean that case fatality rates may vary widely depending upon class and geography.
  8. A lack of sick leave for U.S. workers, so that people feel compelled to come to work when they are sick, or to face an immediate financial crisis if they are forced to stay at home.
  9. A sense of hubris regarding the U.S. medical system, which led U.S. health authorities to reject a German developed test for COVID-19 that the World Health Organization (WHO) endorsed. Instead, the U.S. frittered away precious time developing its own test. When that did not work, the CDC and FDA wasted even more time resolving the situation.
  10. A CDC and FDA that had become too swamped by bureaucracy and hence struggled to adapt, despite having outstanding and dedicated people. The system’s senior leadership has ossified.
  11. A U.S. health care system that is too decentralized to respond to a national level emergency, although this decentralization also has some benefits when there are failures at the top.
  12. An over-reliance on overseas manufacturing for key health goods, for everything from masks to medications.
  13. A society that undervalues the very people who turn out to be particularly critical during a pandemic:  janitors, grocery store clerks, truck drivers, nurses, farmers, and others. As many people have said, it is only during a pandemic you learn whose job really counts. And there is not a good correlation between peoples’ pay and how important their job truly is. The same holds true for respect.
  14. A high rate of chronic diseases that leave people vulnerable to a disease such as COVID-19. The “diseases of development” such as diabetes, sleep apnea, high blood pressure and morbid obesity have led to higher case fatality rates. Most of these issues connect to the Standard American Diet (SAD) and the U.S. food system. No technology can replace a good diet.
  15. A chronic underfunding of public health. A good public health system is like a seat belt. You forget that it should be there until you really need it. And it seems kind of basic, but when the moment comes, there is nothing else that can replace it.
  16. Basic public health relies on people, and salaries are expensive. But not having an adequately funded public health system is what is truly expensive. Contact tracing, outreach, education, follow-up, monitoring, epidemiology, and health communication take time and people. Perhaps because they do not rely as much on technology they are also undervalued in the United States, which always likes to use technology to solve all problems. But there is no substitute for public health professionals.
  17. The basic systems that are always there in public health -nurses in schools, communication campaigns, testing systems, contract tracing- are the same systems that are needed in a pandemic. So having good public health in ordinary times gives you the tools and the people that are needed during extraordinary times.

What is painful for me is how much suffering could have easily been avoided with COVID-19. There is still much we do not know about the start of this epidemic. Still, if China had closed down the wild animal trade in the wet markets after the lesson of SARS in 2003, this likely would never have happened. Instead there were temporary restrictions that were quickly released after SARS seemingly disappeared. The people who dined on these animals, or used their body parts for medicine, tended to be wealthier and better connected than the average Chinese. And the government listened to them. Exactly why remains a mystery to me, and this failure needs to be studied. Regardless, most other Asian countries have ended these markets. So it is difficult to argue that it is in some way these markets are an ineffable, enduring and essential aspect of Chinese culture that cannot change. For the world’s sake, these markets must be shut down.

In the United States there were many errors, of which the cardinal one was the failure to create an adequate testing system. If this had been done, perhaps the United States would have detected the first local outbreaks, and been able to limit them as South Korea did. While some travel restrictions may be useful, they cannot be the sole tool. Viral transmission is not impacted by citizenship status.

I will say something that nobody wants to hear. In the midst of all this suffering, it’s also true that this could have been much worse. This could have been an airborne virus such as H5N1 avian influenza that adapted to humans, and would have had a fatality rate greatly higher than COVID-19. And it could have been a highly mutable virus for which no good vaccine could be created for decades, or perhaps ever with our current technologies. Someday that virus will come. And when it does we will need a public health system that is prepared for it. We will need a health care system in which insurance is not tied to employment. And we will need to better fund the undervalued people -from the janitors to the field epidemiologists- who will be key at that time, just as they are at this moment. We will also need to change our mindset, so that we have the hubris to think that our health care system will succeed while others have failed. And that epidemics such as COVID-19 cannot happen in the U.S. as they have in China or South Korea. Only when we learn  from other countries, and build on their experiences, will we prepare well. For this, we will need to change not only our systems but also our world view.

Shawn Smallman, 2020

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