Should Politics and the Marketplace Trump Public Health?

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    The current Ebola crisis raises profound questions about whether the public health system of the U.S. and our political institutions are equipped to cope with contagious diseases and related, potential health emergencies. The answers to these questions are likely to become more pressing in the wake of global climate change and the significant ecological changes and population shifts that are likely to occur as a result, along with the migration of new and dangerous pathogens. The existing evidence is not reassuring.

    First of all, our public health system is hopelessly fragmented. Because the federal system of the U.S. is based upon vertical and horizontal distributions of power, the responsibility  for public health in the United States, under the Tenth Amendment to the U.S. Constitution, has been delegated to state and local government, many of which have inefficient and inadequately trained personnel who are ill-equipped to deal with pandemics and other medical emergencies that are not local in origin but that require a coordinated national or international response.

     Larry Copeland, reporting for USA Today ("U.S. lacks a single standard for Ebola esponse," October 13, 2014) asked the question "Who is in charge of the response to Ebola?" Copeland was reminded by Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, that "One of the things we have to understand is the federal, state and local public health relationships. Public health is inherently a state issue. The state really is in charge of public health at the state and local level. It's a constitutional issue. The CDC can't just walk in on these cases. They have to be invited in."

    Copeland noted that the Emergency Operations Center which was set up to address the Ebola outbreak at Texas Health Presbyterian Hospital was comprised of officials from Dallas County, the city of Dallas, the Center for Disease Control, as well as county and state health departments and the Dallas County Sheriff's Department and that "This was the team that made decisions on matters such as isolating people who had been in direct contact with Duncan, including his fiancĂ©e, Louise Troh, her teenage son and two other male relatives."

     Robert Murphy, director of the Center for Global Health at Northwestern University's Feinberg School of Medicine, expressed his opinion to Copeland, "In Texas, they really were slow to the plate. Texas is going to be the example of what not to do. The question is, who's in charge?" Murphy stated. "The states can follow all the guidelines and take the advice, which they usually do, but they don't have to. It's not a legal requirement. So there really is no one entity that's controlling things."

     Secondly, the public health system in the U.S. is severely underfunded. In large part, this is because of austerity measures insisted upon by the GOP's Congressional caucus and their ideological antipathy to government in general. Joan McCarter expressed an opinion in the Daily Kos ("Republican budget cutting nearly halved CDC's emergency preparedness since 2006", October 16, 2014)  that "The Republican fetish with starving government has helped land West Africa in an Ebola crisis. The director of the National Institutes of Health made that clear when he told Huffington Post that steep budget cuts by Congress has set back the institute's work on both prevention and treatment for the disease and that if it hadn't been for a decade's worth of cuts, "we probably would have had a vaccine in time for this that would've gone through clinical trials and would have been ready."

    McCarter reported that the emergency preparedness budget of the Center for Disease Control had been cut almost in half during the past seven years. The CDC's discretionary funding was reduced by $585 million during the 2010-2104 fiscal years, and  the annual funding for the CDC's public health preparedness and response efforts were $1 billion lower in 2013 fiscal year than in fiscal year 2002. As a result of these ill-considered measures, the funding decreases resulted in the loss of more than 45,700 job in state and local health departments during the past six years.

    Third, partisan politics has exacerbated the response to Ebola. Intense opposition from the National Rifle Association caused GOP Senators and "pro-gun" Democratic Senators to put an indefinite hold on a vote to approve the appointment of Dr. Vivek Murthy as President Obama's nominee for surgeon general. For that reason, the United States lacks a  recognized medical spokesman with the gravitas necessary to assuage public concerns and to provide accurate and unbiased medical information.

    GOP politicians and professional right-wing fear mongers  - who thrive in the current environment of scientific illiteracy and denial  - have also enthusiastically stoked the flames of public hysteria. Rebecca Kaplan of CBS News (October 15, 2014 ) reported that New Hampshire Senate candidate Scott Brown became the most recent Republican to claim that a "porous" southern border could cause to Ebola-stricken immigrants or terrorists to spread the disease from Mexico into the United States. Not to be outdone, Texas Congressman Louie Gohmert, a certifiable lunatic, lambasted President Barack Obama for dispatching troops to Africa to fight an Ebola outbreak, and he prophesied that they would bring the disease back to infect American citizens.

     Further, as public anxiety has risen, a number of  GOP legislators willingly sacrificed ideological consistency for political expediency. House Speaker John Boehner issued a statement that called for "a temporary ban on travel to the United States from countries afflicted with the virus is something that the president should absolutely consider."

    Meredith Shiner, writing in Yahoo News ("GOP senators who opposed Obama 'czars' now want one for Ebola" October 15, 2014), observed the irony that "Republican Senator Jerry Moran of Kansas was one of the first lawmakers to call on the Obama administration to appoint a czar to help coordinate the U.S. response to the Ebola crisis in Africa, along with a cluster of cases at home. The problem? Almost five years earlier to the day, Moran introduced legislation urging Obama to cease the practice of appointing czars. Moran, who was then a congressman running for the U.S. Senate, also sponsored a bill that would prohibit the federal government from using taxpayer money to pay the salaries of such unconfirmed administration officials -- which would have effectively ended the practice of appointing them."

    Fourth, there is ample evidence that this country's reliance upon a largely private hospital system and private medical insurance, driven as they are by cost-considerations and bottom-line accounting concerns, are not conducive to best medical practices. The Associated Press reported on October 15, 2014 that Thomas E. Duncan, the Liberian Ebola patient, was not placed in isolation after his second visit to the emergency room at Texas Health Presbyterian Hospital, but was allowed to remain in an open area of a Dallas emergency room for hours, while the nurses who treated treating him for days were not  provided with proper protective gear and faced constantly changing protocols, according to a statement released by the country's largest U.S. nurses' union.

     Deborah Burger of National Nurses United said that she had received complaints that nurses at the hospital who said they were forced to use medical tape to secure openings over their flimsy garments, and they and were concerned because their necks and heads were exposed as they cared for a patient with explosive diarrhea and projectile vomiting. The nurses also alleged that other patients who may have been exposed to Duncan were kept in isolation only for a day before being moved to areas where there were other patients; that the nurses treating Duncan simultaneously cared for other patients in the hospital; that, other than one optional seminar for staff, there was no preparation for Ebola at the hospital; and that, in the face of constantly shifting guidelines, nurses were allowed to follow whichever ones they chose. Ms. Burger concluded, "There was no advance preparedness on what to do with the patient, there was no protocol, there was no system."

    Other news reports stated that, when a nurse supervisor insisted that Duncan be removed to a isolation unit, a hospital administrator challenged her decision.

    One suspects that a subsequent post-mortem will show that, despite the hospital's tax-exempt status and its putative obligation as a charity to give back to the community, Duncan was refused admission the first time that he reported to the hospital because he did not have health insurance, and that the reluctance of the hospital to place Duncan in an isolation unit and to assign specialty nurses to him was also driven by cost considerations.

    The Word Bank reports that, as of 2012, the United States spent 17.9% of its GDP on a health care system that still excludes millions of Americans because of the premiums assessed by profit-driven insurance companies.  These uninsured Americans are among the most vulnerable in the event of an epidemic because they lack access to primary care physicians and preventive medical treatment, and they are the least likely to receive immediate treatment for contagious diseases.

     By contrast, the French medical system - which is viewed as the best in the world - consumes only 11.7 % of that country's GDP. Canada - which has a single-payer system - spent 10.9% of its GDP on health care in 2012, while the U.K. and Spain - both of which have socialized, single-provider systems - devoted 9.4% and 9.6% respectively of their GAPS to provide free and accessible health care for all of their citizens.

    Further anecdotal evidence that suggests that high costs do not guarantee good outcomes is provided by Kevin Sack of the New York Times ("Downfall for Hospital Where Ebola Spread," Oct. 15, 2014). He reports that the most recent 2012 tax filings for Texas Health Presbyterian Hospital revealed that the hospital received $613 million in revenue and had $1.1 billion in net assets. Further, the president of the hospital at the time was paid $1.1 million.

    In his important book, What Money Can't Buy, Harvard Government Professor Michael Sandel warns that the values of the market place are continuing to encroach upon and are displacing all other values and measures of worth in our society. If everything and everyone is for sale to highest bidder, and money is the sole arbiter, justice, decency, compassion, empathy and what we owe to one another as fellow human beings become casualties of the marketplace.  

      Lastly, our culture apotheosizes individualism, as David Brooks grudgingly notes in the New York Times ("The Quality of Fear," October 21, 2014). That pervasive worldview  - which provides the ideological rationale for our federal system of limited, largely unaccountable and increasingly gridlocked political institutions as well as for market capitalism  - increases social isolation and fuels suspicions of government, of science and in our capacity to cooperate to address common concerns.

    Erich Fromm observed in Escape From Freedom that, "Once the primary bonds which gave security to the individual are severed, once the individual faces the world outside of himself as a completely separate entity, two courses are open to him since he has to overcome the unbearable stage of powerlessness and aloneness. By one course he can progress to 'positive freedom;' he can relate himself spontaneously to the world in love and work...he can thus become one again with man, nature and himself, without giving up the independence and integrity of his individual self. The other course is to fall back, to give up his freedom, to try to overcome his aloneness by trying to eliminate the gap which has arisen between his individual self and the world."

    Sadly, it appears that far too many Americans today are increasingly willing to surrender their true autonomy and sense of confidence to irrational fears, and to permit non-elected, private, and, more often than not, profit-driven entities to make decisions on their behalf to our collective detriment.

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