Why America’s Heath Care is Failing
The following article is must reading for every American.
Jeneen Interlandi is a staff writer for the magazine and a member of The Times’s editorial board. Her last article for the magazine was about the history of universal health care. Rahim Fortune is a fine art and documentary photographer from the Chickasaw Nation in Oklahoma. His work focuses on culture, geography and self-expression.
A version of this article appears in print on
July 19, 2020 The New York Times
, Page 30 of the Sunday Magazine with the headline: Why We’re Losing the Battle With Covid-19. Order Reprints | Toda
The country was on track to achieve the least successful coronavirus response in the developed world, with the most total cases, the highest death toll and the worst projections for late summer and early fall: tens of thousands more deaths by year’s end, according to the most trusted models. And that wasn’t even accounting for a possible “second wave.” Or for flu season or hurricane season, either of which would almost certainly worsen the current crisis….
In the past century, the largest gains in human health and life expectancy have come from public-health interventions, not medical ones. Clinical medicine — treating individual patients with medication and procedures — has registered enormous gains. Hepatitis C is now curable; so are many childhood cancers. Cutting-edge gene therapies are curing rare genetic disorders, and new technology is making surgeries of every kind safer. But even stacked against those triumphs, public health — the policies and programs that prevent entire communities from getting sick in the first place — is still the clear winner. “It’s saved the most lives by far, for the least amount of money,” Tom Frieden, a former director of the C.D.C., told me recently. “But you’d never guess that based on how little we invest in it.”…
In 1988, the Institute of Medicine, an independent nonprofit group, now known as the National Academy of Medicine, published a seminal critique of the nation’s public-health apparatus. The system, the authors wrote, was arbitrary, reactive and wildly uneven from one part of the country to another. Crises tended to be addressed, or not, based on political will, not scientific knowledge. Investment in public-health programs was thin in many places, and the capacity to gather and analyze essential data was poor. Leadership was also weak and unstable, with health departments increasingly staffed by political appointees instead of career civil servants….
The institute published a follow-up report 15 years later indicating that few of those problems had been solved. The public-health system was still neglected and subject to political whims; the work force was still insufficient and the infrastructure and technology still dangerously outdated. Around that time, Hearne created a nonprofit, Trust for America’s Health, and began ranking all 50 states based on how prepared each was for a global pandemic. She considered factors like how many epidemiologists the state health departments had, how robust their laboratories were and what their pandemic preparedness plans looked like. What she found worried her. Some states had no such plans, and many others had plans that had never been tested or even discussed with key stakeholders, like hospitals and fire departments. One state refused to disclose its plan at all, even to its hospitals. “They were like, ‘We have a plan, but it’s a state secret,’” Hearne told me recently. “And we were like, ‘How can it be a plan if nobody knows about it?’”…
Shop owners were not the only ones confused. When The Houston Chronicle reported that the Harris County fire marshal and the Houston Fire Department had issued very few citations, despite receiving more than 12,000 complaints between mid-March and late May, a public fight ensued over who was responsible for enforcing occupancy limits and other strictures to which shop owners were technically bound. …
In the mid-1800s, even as American cities grappled with repeated cholera outbreaks, some officials balked at the expense of sanitation departments and municipal water systems, preferring instead to blame the poor for choosing to live in filth. And during the flu pandemic of 1918, public-health edicts were often subsumed by politics. The mayor of Pittsburgh, for example, ended a ban on public gatherings, not because the city was out of danger but because he had an election coming up and his constituents wanted to celebrate the Armistice with a parade. The city went on to suffer a spike in flu cases, even as the virus waned elsewhere….
And in the 1940s, in an effort to determine whether penicillin could prevent sexually transmitted infections, the U.S. Public Health Service experimented on prisoners, prostitutes, soldiers and mental patients in Guatemala, infecting them with sexually transmitted diseases without informing them or seeking their consent….
The Texas Health and Safety Code gives the local public-health authorities power to act in times of crisis to protect the community. But in May, Abbott suspended those powers, so that leaders like Hidalgo and Shah could not issue any rules that were stricter than those he issued….
America was a paradox — a beacon of science embedded in a culture increasingly suspicious of scientists …
The coronavirus pandemic has laid bare gnawing questions at the core of America’s many divisions: Are we willing to trust science and scientists in a crisis? What, exactly, do we want from our government? And what are we willing to sacrifice for one another?
Health departments across the country have seen their budgets shrink by nearly 30 percent since 2008. As a result, they have had to cut 56,000 jobs (nearly 23 percent of the total public-health work force) and to make do without a roster of operational essentials, including modern laboratory equipment, modern computer systems and routine pandemic preparedness drills. …
People in Texas, Florida, California and New Jersey are bracing for a second wave of outbreaks in the fall, even as the first wave has yet to fully recede. The root of this catastrophe, doctors, scientists and health historians say, is our failure to fully incorporate public health into our understanding of what it means to be a functioning society. Until we do that, we will be unable to effectively respond to crises like this one — let alone prevent them….
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