American medicine and public health fail their Ebola stress-tests.
A reader asked me why I was not writing about Ebola. I considered doing so, but I have no special expertise in the disease itself. I had concluded that there are enough experts– self-professed or otherwise– churning the waters. I could have used the opportunity to reinforce my feelings about how badly information about medicine or other science is communicated to the public by some sensationalistic commercial news industries. I was embarrassed at how some public health officials violated one of the first laws of medicine taught to medical students– “never say never or always.” Much credibility was lost when it was inappropriately claimed that “it can never spread here,” as the number of Ebola contacts that needed to be followed rose to triple digits, the number of cases acquired in America went from one to two, and as those with incubating disease or risky exposures walked, flew, or sailed among us. American medicine is infrequently humble and Americans don’t like to be told what to do.
It was troubling to watch public and political figures who knew less than I pontificate and pander to advance their own agendas. I was sympathetic but not surprised that my fellow citizens are so easily manipulated or frightened about the wrong things. Influenza and tuberculosis kill millions of us worldwide and are much more infectious than the current strain of Ebola.(One case of tuberculosis on an airplane can infect a number of other people.) Thus is proved another law of medicine: “the devil we know is not as scary as the devil we do not.” I worked in hospitals in the 1970s when a Lassa fever victim came to New York City, and in Philadelphia when Legionnaire’s disease was identified. I can personally attest to the truth of this latter aphorism!
What might I offer?
On reflection, the impact of Ebola virus in America confirms my belief that the American healthcare bubble is bursting– albeit in carefully documented slow-motion and in response to a piling-on of other factors. Some comment is in order. One dictionary’s definition of a “bubble” is a “good or fortunate situation that is isolated from reality or unlikely to last.” I believe this describes healthcare in the United States today. The irrational exuberance that fueled the real-estate crisis of 2008 and the tech-bubble earlier in that decade is compounded in healthcare by an unjustified optimism in how much American medicine has to offer, or how much profit can be extracted without killing the goose. Will half of us be paying to take care of the other half? The most recent indicator I could find was that in 2011, 18% of our gross national product was going to pay for healthcare. In 1994 it was 13.6% and in 1950 is was 4.4%. Surely– and especially as my baby-boomer generation enters its dotage– this is not sustainable!
Following the real-estate bubble that plunged the United States and the world into recession, virtual “stress-tests” were applied to banks to judge their financial health. Some were quite sick. Few were completely well. I put to you that the Ebola virus is only the most recent stress-test telling us that our non-system of health care is in its sickbed if not in need of the last rites.
Me or Us?
The term “population medicine” is now widely used to acknowledge the universally recognized fact that non-medical and social determinants of health are even more important for both individual and population health than the biomedical factors on which our current “non-system” of medical care is based. Of course, this is the core principal in public health science. The importance of providing clean water was a sentinel implementation of modern public health. It wasn’t penicillin that made rheumatic fever go away, but changing the conditions in which our children lived.
And yet, we have allowed our public health system to dwindle, starving it of the resources of money, manpower, and respect. We politicize public health to the extent that even today, the U.S. Senate is unable or unwilling to appoint a permanent Surgeon General to administer a national public health system. An impressive and competent, but “Acting” Surgeon General is serving us at this time of unexpected but not unpredictable need! This is what happens when politicians treat our healthcare like poker chips.
Health departments are often considered just another part of the healthcare safety-net, as though the more fortunate of us have little need of their services. I assert that the health of our community as a whole is necessary for the well-being of every individual in it. Ebola reminds us that our society is only as healthy as its sickest individual. Ebola will not be our last challenge. We were not even doing a very good job of handling the drug resistant pathogens that currently plague our hospitals and communities– a failure that was bright-lighted when Ebola showed how big the cracks are.
Are we going in the wrong direction on purpose?
What is the private healthcare market offering in support of population health? We place the bulk of our investment resources in “personalized medicine” because that is where the money is. (Note in contrast that Salk didn’t patent his polio vaccine.) We have increasingly fragmented systems of independent actors. Even the Affordable Care Act creates isolated silos of individual Accountable Care Organizations caring for highly selected populations. These and competing hospital and insurance programs slice and dice us into ever-narrower provider networks competing with each other instead of cooperating. Even worse, our society has developed an institutional tolerance to having large swaths of our neighbors living without access to even the sometimes minimal healthcare most of us enjoy through our employers or government programs like Medicare. Even the public health systems we do have are administered in inconsistent ways by states and local communities. A sheriff in Texas seems to have more influence on what happens than experts from the Centers for Disease Control! I suggest that to talk about national public health policy or national population health improvement is to use oxymorons. I believe that our current system of healthcare is actually an impediment to, if not incompatible with the public/population health that we must have. I do not know if a nationally coordinated single-payer system is the only way to give us what we need, but I am confident that what we have now is collapsing– even bursting under its own ponderous wasteful unsustainable burdens.
There is lots that needs to be discussed.
Enough for now. I generated additional thoughts while preparing the comments above, including my reaction to leafing through pages of infectious disease death records while researching my family history. How is it that we tolerate a reemergence of the lethal childhood diseases that plagued our parents’ or grandparents’ generations? Why do we make it so easy to avoid the immunizations that prevented innumerable childhood funerals? How much sense does it make to exclude non-citizens from access to health care in America? Tuberculosis, HIV, syphilis, hepatitis, influenza, or Ebola cannot read a passport. Designating “Ebola hospitals” is not going to keep people with fever from going to the nearest facility when they are sick nor obviate the need of all hospitals to provide safe medical care to the rich and poor alike! Ebola is not the first disease to come out of the old world to plague the new– there will be others. Irrational fear will amplify any harm but preparation can only help. That means changing the way we do our medical business. Finally, but most difficult of all, we need to come to a societal consensus how to balance things like individual rights against the rights of the community as a whole. Government is not all bad and it is certainly not our enemy. Government is us! The constitution was written to preserve the heath and safety of our citizens. Why, as I write this, does the military have to be called in to organize our medical care? That’s our job.
Game not over.
As I push the button to publish this, a new case of Ebola was diagnosed in New York City– a physician who cared for patients in Africa. He made it through airport screening just fine. We already know that healthcare workers in America are similarly at risk. We will respond, but the truth is that we won’t know what will happen, or what is possible or impossible until it is all over. Dealing with risk is dyed into the fabric of the health professions, into the public health system, indeed into the circumstance of being alive. To speak honestly and in acknowledgement of that risk is to be respectful of the public. Not to acknowledge or to minimize the medical risks we face every day is to be dishonest, or at the very least to provide less than fully informed consent to our patients. To inflame non-constructive fear in the interest of ratings or other secondary gain is even worse.
Peter Hasselbacher, MD
Emeritus Professor of Medicine, UofL
October 24, 2014