As the coronavirus outbreak swept across the country, President Trump for months promised high-tech solutions on the horizon: thousands of new fans, miracle drugs and vaccines developed at “warp speed”.
He showed decidedly less enthusiasm for simpler measures, such as wearing masks and social detachment. This frustrated public health officials, who are now asking Americans to make some small changes in their behavior to help control the growing pandemic.
But if the president’s disdain for masks can be extreme, his desire to seek the latest and greatest medical intervention reflects a strong tradition in the American health care field that has long valued new drugs, larger medical systems and more technology, often at the expense of public health initiatives that other nations have shown to be more effective at a lower cost.
“We are much more willing to spend money on treating something than preventing it,” said Dr. Richard Besser, former acting director of the US Centers for Disease Control and Prevention, which now runs the Robert Wood Johnson Foundation.
It is a mindset that helps explain the annual medical assistance of more than $ 3.6 trillion in the country, by far the highest in the world.
It is also responsible for some of the American struggles with the current pandemic, which is exploding across the country, threatening to claim tens of thousands of additional lives, even if it disappears in Europe and other wealthy nations.
Likewise, the longstanding American resistance to public health hinders efforts to contain diabetes, heart disease and other chronic diseases that are generating hundreds of billions of dollars in medical spending.
“Public health is a public action par excellence,” said Dr. David Blumenthal, president of the New York Commonwealth Fund, which studies healthcare systems in the US and abroad. “This must be done by people who work together on behalf of themselves and others. In a fiercely independent culture, this is very difficult to undertake. “
The United States spends more than $ 237 billion a year on health care for people with diabetes, for example, most of them to control a disease that can be prevented or managed with simple interventions, such as eating healthier foods.
Only the guide to prescription drugs to control the disease reached $ 85 billion in 2017, according to research by American Diabetes Assn.
On the other hand, the efforts of public health lawyers, nutrition experts, pediatricians and others to strengthen dietary standards or create more incentives for healthy eating have run up against persistent barriers, preventing these initiatives for decades.
“This double standard has been around for a long time when it comes to public health,” said John Auerbach, president of the nonprofit organization Trust for America’s Health. “If there is a new drug, there is only an assumption that it will be paid, regardless of the cost. But every public health policy requires a cost-benefit analysis that shows that it not only improves health, but saves money. “
Even the structure of the American healthcare system tends to favor high-cost interventions, such as surgery and treatment by specialists such as endocrinologists, orthopedists and cardiologists, rather than primary care physicians who traditionally helped patients maintain their health and prevent disease.
At the national level, the US devotes, on average, only 5% to 7% of total health care spending to primary care, although there is growing evidence that places with stronger primary care systems have healthier populations and lower overall health costs.
Other wealthy nations invest up to twice as much in primary care services and have substantially lower overall health expenditures.
The U.S. spent more than $ 10,000 per person on health care in 2018, more than double what large European countries, such as France, Britain and the Netherlands spend, according to data compiled by the Organization for Economic Cooperation and Development.
The roots of these imbalances are deep in American health care, which goes back to doctors’ efforts in the early 20th century to maintain control of medical care against a growing public health movement championed by government reformers.
As healthcare in America became big business, the creation of what the New England Journal of Medicine editor in 1980 called the “medical industrial complex”, drug makers, medical systems, dialysis companies and other addicts. high medical spending expanded its influence.
And while medical spending in the U.S. has skyrocketed, government caution has helped to control any parallel expansion of public health.
“Americans have been much more comfortable with allowing money to flow into the private sector, rather than the public sector,” said Blumenthal of the Commonwealth Fund.
Since the 2008-09 recession, the Trust for Public Health of America has estimated that nearly 60,000 state and local public health jobs were lost when public health investment declined.
Meanwhile, even small efforts to address public health challenges, such as removing soft drinks and junk food from school vending machines, have proven to be monumental tasks that require years of advocacy.
Auerbach, who was Boston’s health commissioner before taking over at Trust for America’s Health, called the effort to limit smoking in restaurants in the 1990s as “one of the most difficult struggles I’ve been involved in for 30 years in public health” . Today, smoking cessation is one of the great public health success stories in the United States.
Even victories have sometimes been short-lived.
Although the Obama administration in 2012 issued rules setting standards for less salt and more whole grains in school meals, the Trump administration has been working since 2017 to reverse the rules under pressure from the food industry.
“It’s just ridiculous,” said Colin Schwarz, deputy director of federal affairs for the nonprofit Center for Science in the public interest, who has spent years pushing for food standards. “The evidence is clear that strong patterns reduce obesity and prepare children to improve health in the long term, but they are obviously not looking in the long term.”
Currently, there is a growing consensus among experts and health leaders that combating chronic diseases like diabetes and heart disease – and controlling costs – will require even more robust public health interventions.
This includes new efforts to tackle the underlying causes of poor health, such as poverty, inadequate housing and education and poor child care, areas in which the United States has also invested little over the years.
“We need to move forward,” said George Halvorson, a former chief executive of Kaiser Permanente, who currently chairs First 5 California, an ambitious state effort to improve early childhood education and development.
Besser, the former interim director of the CDC, warned that the country’s failure to address these issues and build an adequate safety net is now also complicating efforts to control the coronavirus.
“We don’t have the social contract we need,” he noted. “It is much more difficult to succeed in America, because we do not believe that everyone deserves things like health insurance, jobs that pay a living wage and sick leave. These things are not available to tens of millions of people in America. … and therefore it is more difficult for people to do the right thing. “