{"id":3518,"date":"2014-10-23T23:42:41","date_gmt":"2014-10-24T03:42:41","guid":{"rendered":"http:\/\/www.khpi.org\/blog\/?p=3518"},"modified":"2014-12-07T16:57:18","modified_gmt":"2014-12-07T21:57:18","slug":"ebola-in-america-exposes-weaknesses-of-healthcare-system","status":"publish","type":"post","link":"http:\/\/www.khpi.org\/blog\/ebola-in-america-exposes-weaknesses-of-healthcare-system\/","title":{"rendered":"Ebola in America Exposes Weaknesses Of Healthcare System."},"content":{"rendered":"

American medicine and public health fail their Ebola stress-tests.<\/h1>\n

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\u2013 self-professed or otherwise\u2013 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\u00a0sensationalistic commercial news industries. I was embarrassed at how some public health officials violated one of the first laws of medicine taught\u00a0to medical students\u2013 \u201cnever say never or always.\u201d Much credibility was lost when it was inappropriately claimed that \u201cit can never spread here,\u201d 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\u2019t like to be told what to do.<\/p>\n

It was troubling to watch public and political figures who knew less than\u00a0I 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.) \u00a0 Thus is proved another law of medicine: \u201cthe devil we know is not as scary as the devil we do not.\u201d I worked in hospitals in the 1970s when a Lassa fever victim came to New York City, and in Philadelphia when Legionnaire\u2019s disease was identified. I\u00a0can personally attest to the truth of this latter aphorism!<\/p>\n

What might I offer?<\/strong>
\nOn reflection, the impact of Ebola virus in America confirms my belief that the American healthcare bubble is bursting\u2013 albeit in carefully documented slow-motion and in response to a piling-on of other factors. Some comment is in order. One dictionary\u2019s definition of a \u201cbubble\u201d is a \u201cgood or fortunate situation that is isolated from reality or unlikely to last.\u201d 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. \u00a0Will half of us be paying\u00a0to take care of the other half? \u00a0The most recent\u00a0indicator\u00a0I could find was that in 2011, 18% of our\u00a0gross national product was going to pay for healthcare. \u00a0In 1994 it was 13.6% and in 1950 is was 4.4%. \u00a0Surely\u2013 and especially as my baby-boomer generation enters its dotage\u2013 this is not sustainable!<\/p>\n

Following the real-estate bubble that plunged the United States and the world into recession, virtual \u201cstress-tests\u201d 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\u00a0us that our non-system of health care is in its sickbed if not in need of the last rites.<\/p>\n

Me or Us?<\/strong>
\nThe term \u201cpopulation medicine\u201d 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 \u201cnon-system\u201d of medical care is based. Of course, this is the\u00a0core principal in public health science. The importance of providing clean water was a sentinel implementation of modern public health. It wasn\u2019t penicillin that made rheumatic fever go away, but changing the conditions in which our children lived.<\/p>\n

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 \u201cActing\u201d Surgeon General is serving us at this time\u00a0of unexpected but not unpredictable need! This is what happens when politicians treat our healthcare like poker chips.<\/p>\n

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<\/a> that the health of our community as a whole<\/span> 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\u00a0last challenge. We were not even doing a very good job of handling the drug resistant pathogens that currently plague our hospitals and communities\u2013 a failure that was bright-lighted when Ebola showed how big the cracks are.<\/p>\n

Are we going in the wrong direction on purpose?<\/strong>
\nWhat is the private healthcare market offering in support of population health? We place the bulk of our investment resources in \u201cpersonalized medicine\u201d because that is where the money is. (Note in contrast that Salk didn\u2019t 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\u00a0us into ever-narrower provider networks competing with each other instead of cooperating. Even worse, our\u00a0society 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! \u00a0I suggest that to talk about national public health policy or national population health improvement is to use oxymorons. I believe\u00a0that 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\u2013 even bursting under its own ponderous wasteful unsustainable burdens.<\/p>\n

There is lots that needs to be discussed.<\/strong>
\nEnough for now. I generated additional thoughts while preparing\u00a0the comments above, including\u00a0my reaction\u00a0to\u00a0leafing through pages of infectious disease death records\u00a0while researching my family history. How is it that we tolerate a reemergence of the lethal childhood diseases that plagued our parents\u2019 or grandparents\u2019 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? \u00a0Tuberculosis, HIV, syphilis, hepatitis, influenza, or Ebola cannot read a passport. Designating \u201cEbola hospitals\u201d is not going to keep people with fever from going to the nearest facility\u00a0when they are sick nor obviate the need of all hospitals to provide\u00a0safe\u00a0medical care to the rich and poor alike! Ebola is not the first disease to come out of the old world to plague the new\u2013 there will be others. Irrational fear will amplify\u00a0any harm\u00a0but 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\u00a0things 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\u00a0is 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\u2019s our job.<\/p>\n

Game not over.<\/strong>
\nAs I push the button to publish this, a new case of Ebola was diagnosed in New York City\u2013 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. \u00a0Dealing 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\u00a0less than fully informed consent to our patients. To inflame non-constructive fear in the interest of ratings or other secondary gain is even worse.<\/p>\n

Peter Hasselbacher, MD
\nPresident, KHPI
\nEmeritus Professor of Medicine, UofL
\nOctober 24, 2014<\/p>\n

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