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 fiancée, 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.