By Daniel Aaron
The U.S. government has ratified a record-breaking $2 trillion stimulus package just as it has soared past 100,000 coronavirus cases and 1,500 deaths (as of March 27). The U.S. now has the most cases of any country—this despite undercounting due to continuing problems in testing Americans on account of various scientific and policy failures.
Coronavirus has scared Americans. Public health officials and physicians are urging people to stay at home because this disease kills. Many have invoked the language of war, implying a temporary battle against a foreign foe. This framing, though it may galvanize quick support, disregards our own systematic policy failures to prevent, test, and trace coronavirus, and the more general need to solve important policy problems.
Coronavirus is an acute problem at the individual level, but nationally it represents a chronic concern. No doubt, developing innovative ways to increase the number of ventilators, recruit health care workers, and improve hospital capacity will save lives in the short-term — despite mixed messages from the federal government. But a long-term perspective is needed to address the serious problems underlying our country’s systemic failures across public health.
We are treating coronavirus like an acute disease
Scholars are discussing how to distribute scarce health care resources ethically when need is high and rationing is inevitable. Many Americans are angry that health care workers do not have enough protective masks and gloves, ventilators, or hospital beds. People agree that there is a coronavirus crisis. On the other hand, some officials have said they would jettison public health measures in favor of economic growth. For example, President Trump, worried about stock prices, wanted the U.S. “opened up and just raring to go by Easter.” (He has since extended social distancing guidelines through the end of April.)
These battles largely take place on the acute side of public health. One the one hand, health care workers are occupied with rising patient loads. They may be consumed in advocating for patients’ acute needs, in ensuring they have the supplies for safe medical practice. And acute measures are needed to flatten the U.S. curve. But these arguments are self-undermining: The more the curve is flattened, the more coronavirus becomes a chronic problem. This conundrum highlights the need of finding new ways of talking about coronavirus other than an acute “war,” lest a perception take hold that once the “war” is over, we can move on.
Some journalists and scholars have written on coronavirus as a long-term public health problem, but these stories have been far from the focus of COVID-19 media coverage. Beth Cameron wrote a perspective piece in the Washington Post entitled “I ran the White House pandemic office. Trump closed it.” The article covers the 2018 closure of a White House office tasked with preventing a future outbreak. Similarly, a 2019 federal simulation called the “Crimson Contagion” revealed a list of “high-level, cross-cutting issues” within the ability of the federal government to respond to a pandemic, including problems with funding, organization, and communication. And although health care is essential to treating and managing coronavirus, 45% of U.S. adults are inadequately insured. We were systematically unprepared from a public health standpoint.
A “chronic” approach to coronavirus is possible
Arguably the best response to the pandemic was in South Korea. The country began developing a test early, in mid-January, before the acute harms began. Then, public health authorities aggressively tested people with mild or no symptoms who were suspected of being infected. Tens of thousands of people were quarantined. And it worked. Although South Korea appears to be one of the countries with the most cases, its data may be the most accurate, and its curve has been flattened. No doubt, this is because South Korea began its response months ago and consistently took swift action on behalf of public health. South Korea also has had universal health coverage since 1989. As former FDA Commissioner Scott Gottlieb tweeted, “South Korea is showing #COVID19 can be beat with smart, aggressive public health.” This systemic approach might have obviated some acute need in the U.S. for ventilators and personal protective equipment (PPE).
We are obsessed with acute problems
In America, we tend to address acute problems and ignore the chronic. This bias came to the fore in August 2019, when the U.S. had a vaping epidemic in which thousands were hospitalized and sixty-eight people died. The disease was named EVALI—e-cigarette, or vaping, product use-associated lung injury. The illnesses were largely found to be related to the additive vitamin E acetate. Soon, cases tapered off, and much of the attention to vaping and e-cigarettes quickly faded. However, there continues to be a mounting epidemic of e-cigarette use among youth, which started as early as 2011, and now 27.5% of high-school students use e-cigarettes. Our failure to pay attention to this problem for eight years, and our fleeting concern during a period of 2019, highlights that we, as a country, have failed to take concern with the chronic problem of youth nicotine addiction.
Similar patterns can be seen in other public health issues. We underinvest in sound, evidence-based nutrition policies. We spend $19 per person annually on public health, compared with nearly $11,000 per person on health care. About 20% of Americans postpone preventive care due to cost, and this figure is three-times higher for people below 200% of the federal poverty line than for those above. We discourage people from seeing the doctor by charging them deductibles and copays, which are harder to pay for poor people. Money allocated to public health by the Affordable Care Act has been siphoned away to other causes. The remaining funds may be lost in a legal case that threatens to invalidate the Affordable Care Act.
Why are other public health disasters, like the opioid epidemic, not a “war?” Why is there no war against climate change?
Chronic, complex issues do not command enough attention in the United States. Acute, discrete concerns take precedence.
There are marvelous people working on chronic disease and long-term public health issues. They should be commended. But our focus on the acute is a systemic problem. We have yet to disentangle the social, governmental, and corporate regulatory structure that creates and perpetuates public health crises.
The battles to obtain more ventilators and PPE are worth having. However, we also need a response to the chronic “disease” underlying the coronavirus.