COVID-19: Huge shortfall in public health investment ...

Source: Steven Battle

The mission of public health is to recommend policies and utilize procedures to ensure the health of a population and keep leaders from getting fired — or voted out of office.  Ensuring a thriving economy and environment free of violence is the responsibility of civilian government authorities.  This clearly implies that public health recommendations and policies are inherently political, and we are living with the repercussions of this reality now more than ever.  As a physician who has completed residency training and board certification in both emergency medicine and preventive medicine/public health, and been practicing for over 20 years in military and civilian organizations, what follows is my high-altitude take on our current COVID-19 crisis.

The severity of public health counter-measures overwhelmingly reflects a political calculation.  Public health authorities and civilian government leaders weigh multiple factors beyond the epidemiology or health care policy implications of interventions.  All too frequently, when making decisions on interventions to improve the health of a population, the medical discipline of preventive medicine/public health takes a back seat to non–health care considerations.

A review of notable U.S. public health initiatives of the past 100 years reveals different policy strategies depending on political forces — for example, the federal government responses to the West Africa Ebola epidemic and the HIV pandemic.

West Africa 2013–2016 was the site of the most widespread outbreak of the Ebola virus in history.  There were over 11,000 deaths and more than 17,000 survivors, many of whom reported post-recovery symptoms termed “post-Ebola syndrome.”  U.S. and international aid flooded into the region.  There was no halt of travel into the U.S. from any of the six African countries involved.  Travel restrictions for such dramatic circumstances intuitively and scientifically were warranted.  However, due to concerns of the economic impact of such a measures, these completely appropriate interventions were eschewed.  Unnecessary and inefficient measures of screening and contact tracing placed an enormous strain on federal and state public health authorities.  The U.S. and the rest of the world were fortunate to escape the West African Ebola virus epidemic with very few (but not zero) cases imported into Western nations.  The impact to individual liberties of U.S. government interventions regarding Ebola were negligible.

Now consider the case of the government’s response to the HIV pandemic.  Worldwide, as of 2016, approximately 36.7 million people worldwide have HIV.  As of 2018, about 700,000 people have died of HIV/AIDS in the U.S. since the beginning of the HIV epidemic, and nearly 13,000 people with AIDS in the United States die each year.  What have been the major public health interventions against this scourge?  There has been a decades-long public awareness effort.  Pharmaceutical innovations and better prophylaxis against opportunistic infections have resulted in a dramatic improvement in fatality rates.  However, there is a significant disease burden and massive expenditures on HIV/AIDS treatments.  Lifetime cost to treat one person with HIV is over $500,000.  There was never any government mandates or controls placed on individuals to reduce transmission of this terrible disease.  There were no widespread closures of bath houses or massage parlors catering to homosexuals.  There was no increased enforcement of prostitution laws.  There has been minimal impact on civil liberties of the response to the HIV/AIDS pandemic.

There are examples of our government severely infringing on people’s rights and property in efforts to improve population health and well-being.  A hundred years ago, Prohibition was intended to decrease alcohol-related problems such as alcoholismfamily violence, and saloon-based political corruption.  There was a moral component to the effort, but in retrospect, it was clearly a radical public health effort.  The effect on individuals and business, and entire industries, was massive.  However, the ban on the production, importation, transportation, and sale of alcoholic beverages was ratified by 36 of 48 states, and Congress passed enabling legislation.  It is not widely recognized, but Prohibition was, in fact, an enormous public health success.  Regardless, during the Depression, Prohibition was repealed — however, this was again achieved through thoroughly democratic means.

Consider the contrast of these efforts to our current COVID-19 response.  Massive disruptions in individual and societal norms and liberties have been implemented by government authorities of all levels.  Why have the political/public health calculations of infringing on freedom changed so dramatically?  The institutions that protect constitutional freedoms are severely damaged.  This is vastly different from the constitutional Prohibition/Repeal efforts.

Tightly knit, well financed political groups or communities who have powerful political allies can usually successfully impact political decisions and thus public health policies.  Unfortunately, these are not the circumstances we find with COVID-19.  Draconian infringements on individual liberties have successfully been implemented precisely because they impact all of us as individuals.  Politically, the individual is far more vulnerable than any group.  Responses to COVID-19 should be based on encouraging individuals to behave responsibly, not oppressing use through clumsy, poorly effective, ham-handed government mandates and laws. 

The fix to the contamination of public health by politics is to embrace non-governmental solutions.  The private sector has the efficiencies, expertise and incentives to lead us back to a vibrant, open, free society.  It will be the private sector developing the best medical interventions for COVID-19.  Developing best practices and utilizing the best or new medical interventions and vaccines will be accomplished by health care professionals and organizations and vaccine and pharmaceutical companies. 

Of note, the private sector is already developing assessment and intervention products that will help ensure the safest possible environments for people to interact socially, conduct business and otherwise perform all the activities of daily living that we had grown accustom to prior to this pandemic.  On multiple fronts, private-sector innovators are developing and implementing the most advanced techniques available to keep employers, employees, customers, and students and teachers as safe as possible.  By utilizing expertise in public health and industrial hygiene, and rigorous, standardized procedures for surveillance, reporting, environmental monitoring, and behavioral interventions, some businesses are finding a way to protect themselves and their customers effectively.  One innovative method is assessment, training, validation, and certification of business by external experts.  At this very moment, these exciting interventions are being rolled out in many parts of our countries across various industries such as manufacturing, gaming, education, restaurants, and entertainment.

A strong focus on private-sector innovations and asking for similar public health strategies that have been used for decades to be applies is reasonable and moral.  Recommitting our government to prioritize securing our liberties and entrusting private-sector experts to develop solutions will reawaken our society and restore our health, safety, security, freedom, and success.