“WE HAVE MET THE ENEMY AND HE IS US”
This quote from the 1970 Walt Kelly cartoon, Pogo, celebrating the first annual observance of Earth Day, couldn’t be more fitting for describing America’s response to COVID19. Pogo’s friend Porkypine was complaining about the difficulty of walking over trash and filth left behind in the Forest Primeval.
COVID19 was an act of nature, and no individual is responsible for it. But, its effects, including the number of lives it has claimed in the U.S., were not a given.
The testing, contact tracing, and isolation that are currently the primary focus of discussion right now is essential and is critical for attacking the epidemic itself. However, in the end, we will still be at higher risk because of differences in the health of our population, access to care, and the structure of our healthcare system.
America’s Outsized Failure
The U.S. is 4.25% of the world’s population, while, as of the date of this post, we account for almost 27% of confirmed pandemic deaths globally.
No doubt results for the U.S. are skewed by the slowness of our response, the dismantling of crucial surveillance and monitoring programs, and failed actions in many areas. We will debate those issues for years to come and they must be addressed.
I know many of us may want to point our finger at Trump and his administration, charging them, and them alone, with the mind-boggling tragedy unfolding around us. But, as loathsome as some behavior might have been to many people, we are collectively responsible for what has occurred.
And, focusing only on politics or mismanagement of the response creates the risk that we overlook some more significant issues. It also risks that we miss more valuable lessons about the overall state of American health, and our healthcare system that are essential factors influencing the size and scope of the tragedy we’ve experienced.
Why are U.S. COVID19 deaths almost 500% greater than our share of the population in the world?
Beyond bureaucratic and political bungling, the bigger reality is that multiple factors have contributed to America serving as extraordinarily fertile ground to be the global epicenter for COVID19 mortality.
The Reality of Life for America’s Working Class and Poor
As with Hurricane Katrina, policymakers failed to appreciate the reality of life for many of those who make up the working class and poor in our country. These are people who couldn’t stay home. Low wage and hourly workers are more likely to be among the more than 30% of U.S. workers don’t have paid sick leave, forcing them to go to work even if they may be ill.
And for those who were fortunate enough not to have to go to work, telling them to shelter in place made them easy targets for infection. Limited resources and crowded living conditions experienced by many of these individuals allowed the disease to spread like wildfire. These facts are no mystery for those of us who work with safety net programs. But, it is still shocking that so few decision-makers seem to understand what life is like for many Americans, and it speaks to the growing disparities in our society.
And, whether you think this is a problem for you or not, the reality is that the sheer numbers of people falling into this category magnify the risk for all Americans. They are more likely to be essential workers, food processing, and nursing home employees. And, their numbers are large. After a sharp decline in poverty rates in the U.S. with the start of Johnson’s War on Poverty, numbers have stubbornly stabilized at a level of 11% to 15% of Americans. At any point in time, there are roughly another 5% of the population living near poverty.
In New York City, the center of the COVID19 epidemic, poverty rates are even higher, at an average of 19%, and with some areas experiencing rates of more than 30%. 43.1% of New Yorkers live near poverty. Think of that, in a city of 8.4 million people, approximately 3.6 million may very well not be in a position to follow social distancing and similar guidelines. It’s too early in this pandemic to have solid information on the income distribution of those infected and dying from COVID19. Still, an early investigation by the New York Times uncovered a clear pattern that shows the poorer boroughs of the city are suffering much higher rates of disease and death.
Many of those southern states now opening up their economies have similarly high poverty rates.
Being Elderly and Alone
Surprisingly, many also ignored the fact that one in three American’s experience chronic loneliness and social isolation, and that 28% of the elderly – a population highly vulnerable to COVID19 – lives alone. These numbers are even higher in urban settings. This isolation means telling them to stay home, to take care of themselves until they were too sick to do so, was equivalent to issuing a death sentence. It ignored the reality that for many people, there is no one to check in on them or to bring them food or medicine while they struggle with their illness. The result, record numbers of people dying at home.
The elderly and frail living in nursing homes are even more exposed – in part because workers in many of these facilities are exactly the near-poor talked about above. According to the Paraprofessional Healthcare Institute, the median pay in the industry is only $19,000 annually. And, the CDC’s analysis of the high rates of COVID19 nursing home deaths, identified the fact that most staff work in multiple facilities for the rapid spread of the disease. This pattern of multiple jobs is a common practice precisely because they cannot come close to making a living by only working at just one job.
Hubris About the American Healthcare System
American hubris and the belief that we were somehow protected from the virus by our “superior” medical technology allowed us to be oblivious to the underlying population-wide risks we faced. And the systematic and long-term dismantling of our public health infrastructure in pursuit of those “superior” technological solutions, left us flying blind without the tools needed for early detection and rapid intervention even where we could have done so. Thankfully, that superior technology probably saved some individuals who might have died elsewhere. But, at what cost to millions of others?
Healthcare Affordability
We’ve also ignored the fact that for many Americans, accessing the healthcare system is a dicey gamble, with fees they can’t afford to pay. Though the rate of uninsured is lower than it was before the ACA, according to the Kaiser Family Foundation, one-third of Americans find it very difficult to afford the deductibles for the insurance they have.
So, not surprisingly, many Americans avoid using the health system for fear of expenses they won’t be able to absorb. This reluctance to access care shows up in our health outcomes. The U.S. has the 7th highest rate of deaths from preventable causes, and 11th highest rate of deaths from treatable causes, among OECD (Organization for Economic Cooperation and Development) nations, falling behind countries like Columbia, Chile, and Slovenia.
Those data are typically indicators of a lack of timely access to care. So, showing total ignorance of that reality, many Americans have been told to stay home until their COVID19 symptoms were severe. This suggestion increases the likelihood their illness would become acute, that they had an undiagnosed or untreated underlying condition that would increase their risks, or that they would simply die without ever receiving care.
Those Who Do Not Understand History are Doomed to Repeat It
And, as usual, we have failed to pay any heed to our history. American cities, and New York in particular, with its unique character as a gateway to our country, has been the site of epidemics for centuries. This has included smallpox, typhus, typhoid, yellow fever, tuberculosis, and AIDS. As Laurie Garrett points out in her wonderful book, Betrayal of Trust: The Collapse of Global Public Health, “the 1743 yellow fever epidemic…claimed an estimated 5% of New York City’s population” At that time, the city also experienced extraordinarily high rates of smallpox, typhus, and typhoid. Though it’s been a while, epidemics in the region are not new.
And, predictably NYC, and other urban areas, have served as THE hotspots for COVID19. U.S. cases are heavily concentrated in a select number of more densely populated, diverse urban communities, with 24% of all U.S. deaths just in New York City, and an additional 6% clustered in Detroit, Chicago, and Los Angeles. If you add in smaller cities, you start getting very close to 40% of all deaths nationwide that have occurred in urban areas. To some extent, this is predictable, regardless of underlying demographics. The challenges of controlling such an easily transmitted disease are much greater due to sheer population density. Commuting and travel patterns increase infection risk, and that’s what the data show. The New York, New Jersey, and Connecticut corridor accounts for almost 50% of all deaths in the nation.
But, there is an even more significant underlying factor here than the tactical errors discussed above. A great big elephant is sitting in the middle of our living rooms.
America is An Unhealthy Country
Let’s be bluntly honest. Americans are profoundly unhealthy, particularly when compared to other wealthy nations. And this unhealthy state has had tragic, and undesired consequences for the American people, particularly when it comes to the COVID19 pandemic.
Three months into this outbreak, we still don’t have comprehensive data about who is most at risk of death from SARS-CoV-2. It is inexplicably killing some young people and individuals without diagnosed underlying conditions, with many dying from blood clots, strokes, and heart attacks. However, we do know the elderly are more at risk (75% of hospitalized are over 50). And, we have enough data from the U.S. and other countries to know that it is more likely to kill individuals with certain underlying conditions. Initial data from the CDC (Centers for Disease Control and Prevention) showed that 89% had one or more chronic diseases. And, the most common chronic diseases were hypertension/high blood pressure (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes (28.3%), cardiovascular disease (27.8%). Data from New York state, several other hot spots, and other countries follow this pattern.
Why Does This Matter?
It is the higher risk associated with these underlying conditions that put Americans at greater risk, because of our overall higher burden of these and other chronic health conditions. Americans don’t consistently have the highest rates in the world for each of these chronic conditions. But, we consistently rank in the top three for ALL of these conditions, when compared to other developed countries.
Approximately 45% of Americans are living with at least one chronic disease, with that rate of illness being roughly double that of the OECD average.
And, almost across the board, Americans have extraordinarily high rates of the chronic “lifestyle” illnesses posing the most significant risks with COVID19. As an example, America is the most obese developed country in the world, with 42.4% of American adults who are obese, and a whopping 9.2% designated as seriously obese.
The U.S. has the third-highest age-adjusted rate of diabetes for adults among the OECD nations, at 10.8%, placing us just ahead of Mexico and Turkey.
And, hidden in the U.S. National Center for Health Statistics Health E-Stats, January 2020 summary of Changes in Life Expectancy at Birth, 2010 – 2018, was this nugget. One of the significant negative factors affecting life expectancy for women between 2017 and 2018 was nutritional deficiencies. Let that sink in. This deficiency is an outcome that is almost unheard of in a developed country.
Many would like to attribute these results to our ethnic diversity. And, indeed, we have some genuine issues with health disparities that do contribute to these poor outcomes. But, when you look behind the data, we find that regardless of ethnicity or economic status, Americans still live more years being unhealthy, and they die at a younger age.
As pointed out in “U.S. Health in International Perspective: Shorter Lives, Poorer Health,” written by The National Academies of Science, Engineering and Medicine, the gap between U.S. life expectancy and the world’s wealthy developed countries continues to grow. The startling outcomes contributing to these results when compared against this group include:
Highest infant mortality rates
Highest rates of injury and homicide
Highest rates of teen pregnancy and sexually transmitted disease
Second highest rates of HIV and AIDS
Highest rates of drug-related deaths
Second highest rates of ischemic heart disease
These results also apply to mental health. Suicide rates in the U.S., even before the pandemic, were already 14/100,000 overall and a whopping 22.4/100,000 for men. This rate was a 31% increase just between 2001 and 2017. By comparison, the highest rate seen in the Great Depression was 17.4/100,000, which up until that time, were the highest numbers ever recorded.
When combined with our tragically fumbled COVID19 response, this disturbing picture of American health has rendered the U.S. particularly vulnerable to the ravages of any disease, but especially this illness.
People of Color Are Even More Unhealthy and More at Risk
Data from both the CDC (Centers for Disease Control and Prevention) and the New York State Department of Health (NYDoH) have already revealed a striking pattern of disparities by race and by gender when it comes to COVID19. Men and individuals who are black or Hispanic are over-represented among non-elderly hospitalizations and fatalities.
That’s where the overall burden of disease that is evident across all U.S. populations places minority populations at even higher risk. 28.5% of individuals in OECD countries suffer from hypertension versus 29% overall in the U.S. That rate jumps to a whopping 39.9% among American black women and 40.6% among black men. We see similar results for obesity, with both blacks and Hispanics having higher obesity rates at 49.6% and 44.8%, respectively. Rates are even higher for women in both groups. And, blacks have substantially higher asthma rates, at 10.6% versus 7.6% for white Americans and 6.4% for Hispanics. Black men also have the highest smoking rates at 20.9%. Each of these put Americans of color at much higher risk if infected by COVID19.
When you consider that Americans of color also have uninsured rates at multiples of that of white Americans, it is not surprising that these populations are bearing disproportionate costs due to this tragedy.
The COVID19 epidemic has laid bare the reality of the issues we face when it comes to the health of Americans, with the poor, people of color, and the elderly bearing a disproportionate cost for our failures.
These Issues Point to the Lack of Clear Priorities Focused on Health
We must ask ourselves what this says about the health of Americans, our healthcare system, and the inequities experienced by so many.
Remember, these failures are despite the massive investments in healthcare that we make as a society. We spend more per capita on healthcare than any other country at approximately twice the average paid by other OECD countries.
And, health programs for poor and vulnerable populations are so significant that they threaten to bankrupt states, with Medicaid expenditures averaging 28.7% of state spending from all sources for the 2016 state fiscal year. These expenditures don’t count an equivalent amount paid by the federal government. And remember, this was before the mass unemployment caused by the COVID19 pandemic.
Remember the adage: “the definition of insanity is doing the same thing over and over and expecting a different outcome.”
These Outcomes Should Cause Us to Rethink Our Health Strategies, Policies and Priorities
The results of the COVID19 pandemic should be a clarion call. We’ve continued to throw more and more money at the healthcare industry, all while watching America’s performance on almost all measures of health outcomes fall further and further behind that of other countries. Simultaneously, Americans on both the right and left, and many in the healthcare industry itself, have looked the other way. In some instances, we’ve cheered on massive investments in new insurance programs, bigger and more stately hospitals, and health systems, and more expensive and sophisticated medical and information technology. Much of that investment has just added to the costs of care.
During this same period, there has been the systematic destruction of our public health programs and public health safety net starting as early as the Nixon administration. Those efforts gained full speed at the beginning of the Reagan administration. And in short order, the effects became clear as progress toward improved health, including American life expectancy, had stalled out.
Very quickly, after taking office, Reagan eliminated or implemented massive budget reductions for public health programs. These changes included shutting down the Public Health Services Hospitals and the Public Health Services Corps (which incidentally policy leaders are now clamoring to recreate). Massive cuts occurred in the Indian Health Service (another demographic group severely affected by COVID19), the Office of Refugee Health, and federally subsidized care for civilian seamen. Many public health programs that had previously been led by the federal government transferred to the states through block grants. This transfer ignored the fact that many of those states were ill-equipped to support those activities. Many lacked any capabilities at all. This pattern continued under the first Bush administration.
Still, as Laurie Garrett demonstrates in her book, Betrayal of Trust, (iBook page 548), she points out that neither political party is exempt from this peril. When discussing the reforms proposed as part of the Clinton healthcare reform program, several leaders in public health asked, “ ‘Why has the debate about health care reform neglected public health?’, asked public health leaders Phyllis Freeman and Anthony Robbins. ‘Health insurance is a necessity for every American. It buys medical services and avoids personal financial disaster. The ultimate purpose of health care reform, as currently debated in the United States, is to pay for insurance against the costs of illness. This narrow focus on sickness insurance misses opportunities to improve health, yet it is perfectly tuned to the concern of the public.’ ”
And sadly, more recent reform efforts, including the ACA, have just contributed to this phenomenon. (More about this later in several future posts.)
We’ve consistently failed to focus on building a balanced, comprehensive and well-designed system for safeguarding the health of Americans. Instead, we have focused almost exclusively on expansion of our system for financing treatment of American sickness. This approach has largely ignored the other elements required to keep a society healthy and improve that health over time. Sadly, our abysmal performance with COVID19 was the inevitable result.
In my next posts, I’ll explore the weaknesses of the strategies we’ve pursued. I’ll discuss why health insurers and healthcare systems, although essential, are ill-suited for the responsibility of managing the health of Americans. And, I will talk about what is missing in our overall approach.
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