Our Public Health Infrastructure Is Losing a Fight With Capitalism

COVID-19 teaches us why Medicare for All should be the floor of our demands, not the ceiling. As an epidemiologist argues, we need to radically rebuild our entire public health infrastructure.

People wait to be tested outside of the Brooklyn Hospital Center where testing for the coronavirus has started on March 19, 2020 in New York City. Spencer Platt / Getty

Medicare for All would not have saved us from this disaster, but it would’ve softened the blow. The global public health crisis ushered in by the COVID-19 pandemic reminds us that single payer is a vital necessity but not a magical solution to our health care problems.

COVID-19 has revealed the long-standing fragmentation of our public health infrastructure. It has also confirmed how much of it, beyond direct clinical care, is controlled by the private sector (no coincidence Trump had corporate executives at the helm of this week’s Coronavirus Task Force press conference). Calls to reform and rebuild our public health infrastructure and liberate it from the shackles of capitalism need to be as resounding now as calls for Medicare for All.

As opposed to clinical care which centers treatment in the singular clinician-patient interaction, public health focuses on prevention and tracking of disease and provision of care in a broader sense. We should seize that difference. In the throes of this pandemic, usual protocols of care can become quickly obsolete, and this uncertainty opens up the opportunity to reexamine the undergirding (data, hospitals, health care providers, safety nets, housing) that make population health possible and in many cases, impossible.

When Biden cynically invoked Italy’s predicament (having lost three thousand lives, “despite” single payer), he was asking voters to pause on a health care revolution because now was the time to deal with “the crisis,” not worry about structures he claims take longer to reform. Never mind that Italy spends $8,000 USD less per capita on health than the United States yet outranks it in life expectancy and almost every measure of health care quality, affordability, and equity, Biden’s remarks ignore what the current crisis reveals: systems and structures either do not exist or are in crisis and can’t simply be resurrected or mobilized at a moment’s notice.

Our public health system is uncoordinated, if not chaotic. Disease surveillance is disjointed at every level of government: local, city, state, and federal.

Take our data architecture. Why, in the age of “big data,” do we not have access to data unified across private and public payers, readily enabling epidemiologists the opportunity to study emergent patterns of infectious and chronic disease and identify risk factors disaggregated by important parameters like age, race, sex, employment, and geographic location? Aside from publicly available data from the Centers for Disease Control and Prevention (CDC) and other government agencies and data from the Centers for Medicare and Medicaid Services (CMS) — Medicare and Medicaid claims data are also costly for researchers — the vast majority of our health care claims data are now owned by private corporations.

It’s a multibillion-dollar industry that trades in our sickness and health. This data needs to be nationalized and protected. We need it, across the board, to forecast, understand, and mitigate the adverse effects of a public health crisis.

But this is a pandemic. What must be done now? COVID-19 has been a masterclass in emergency unpreparedness revealing little cross-training or capacity-building at hospitals, now holding on to their last masks, with ventilator scarcity and ICU bed rationing. Emergency room physicians, nurses, and technicians are frontline providers and there simply isn’t enough of them to safely manage this situation.

We’ve long known there was a shortage of ER and primary care physicians in this country, as medical school students (often burdened by medical debt) have been disincentivized into entering these comparatively lower-wage specialties. Advocacy movements like Beyond Flexner and the Campaign Against Racism have been at the forefront of demanding changes that address these political determinants that ultimately limit access to care for already at-risk communities. We need to support their efforts now.

Testing must be our first emergency demand. Public health prioritizes access and effective systems of delivery. If and when the COVID-19 test is approved by the Food and Drug Administration, there need to be guarantees to ensure tests will make it to those who need it most. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, is right: unlike South Korea, we do not have a cohesive structure in place to implement broad-based testing. As a first measure, we can start with a demand for these tests to be free at point of access, and readily available to all — not just for celebrities and the Brooklyn Nets.

Priorities must be for those most vulnerable, but at some point, given the unknown nature of this virus, we must get as close as possible to universal testing.

What is the primary impediment to such a call? Privatization. At his press conference on Monday, Trump announced that 1.4 million tests will be available by next week and 5 million within a month. Will Amazon or McKesson, the principal distributors of equipment and pharmaceutical supplies in the United States and owners of a vast network of distribution centers across the country, be called on to leverage their logistical infrastructure for the public good and help distribute these tests? Should and who and how will any coordinated crisis system enforce testing?

These are all questions that a public health system would already have answers to, and would be able to communicate to the public. Yet the United States does not only not have answers, there seems to be no attempt to develop nor implement them now. Instead, several months in, we are still stumbling through a piecemeal mitigation framework, bleeding time otherwise calling for a rapid response.

As every sector of our public health system flounders, nearly 29 percent of the 46 million community-dwelling older adults live alone, and those who live alone are more likely to be poor. Whole communities of older adults over the age of sixty-five years are now in isolation and, in addition to the immunocompromised, are most at risk for dying if infected with virus. Their lives matter just as much as everybody else.

Mutual aid groups have sprung up across the country to support them and others. These groups (or care collectives) including one among health care students and professionals in the city of Baltimore, cannot shoulder the deteriorating material and social conditions of older adults, increasingly impoverished and lonely. Citizens should not be compensating for what a publicly funded and prioritized public health system should do.

Public health policy should require us to build an infrastructure that mobilizes additional aid (medicines, food, care) in a time of emergency, quickly and safely, to anyone who needs it. Yet that mandate has never been front and center of our health priorities. Given the aging demographics of this country, and persistent inequities in provision of care, this is unconscionable.

COVID-19 has exposed another fissure in our health system, one of essential resources already stretched thin by drug shortages and disruptions in the pharmaceutical supply chain. Travel restrictions implemented globally will impact all types of commerce and trade logistics — whatever exceptions Trump’s travel ban makes for them. Unlike Land Rover auto parts, raw materials necessary for pharmaceutical production can’t be stuffed in check-in luggage and transported internationally.

There are already reports of pharmacies out-of-stock on analgesic medications such as acetaminophen. Patients and providers may also begin resorting to alternative therapies for off-label use to prevent or mitigate symptoms associated with COVID-19, including essential antiretrovirals like Kaletra, used to treat HIV. This will be done with very little research of any adverse side effects.

Billionaire businessman Elon Musk most recently tweeted a controversial study that chloroquine (used to prevent and treat malaria) can be used to treat COVID-19. These two interconnected phenomena — increased demand and decreased supply — will have a domino effect on an already fragile essential drug supply chain to disastrous long-term effect on the capacity to keep any other pathogen or virus at bay.

The CDC makes the case that only a third of our health is determined by the medical care we receive; the rest is determined predominantly by social and political forces, among them access to quality health care, racism, incarceration and immigration detention, employment (to which insurance is tied), ungenerous sick and family leave policies, neighborhood safety, early exposures to lead and other pollutants, education, housing, access to quality affordable food and public transportation. All of these factors are now colliding as “social distancing” and quarantine and institutional closures take hold.

517,000 McDonald’s workers and 347,000 Walmart workers, and over a million more, don’t have access to paid sick leave. Their exposure to the public and difficulties of work means that they too will disproportionately be impacted by COVID-19.

COVID-19 teaches us why Medicare for All should be the floor of our demands not the ceiling. To truly address this pandemic, and any other smaller and bigger crises that might follow, we need to create and deploy a public health infrastructure that listens to and is accountable to the people who have long been foreclosed from care.