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How American Health Was Broken Before COVID-19

Building something better starts with knowing what was broken.

by Nason Maani and Sandro Galea

In recent weeks, there has been an increasing conversation, including in prominent medical journals, about the failure of current U.S. political leadership during the COVID-19 pandemic, the preventable deaths it has caused, and that it is time for a change. These contributions reflect the fact that, as Virchow famously said, “Politics is nothing else but medicine on a large scale.”

Building on the challenges posed by this failure for the COVID-19 moment, we suggest that a fuller assessment of the role of leadership must also include an honest and unflinching assessment of longstanding shortcomings in our country’s health, which also contributed enormously to the challenges of the moment, and in which we all have a hand.

Before the pandemic, U.S life expectancy was lagging behind peer countries, and, uniquely, was declining. It suffered from double the chronic disease burden of the OECD average. It lacked universal health coverage. While some have wondered how the US fared so poorly considering its vaunted biomedical industry, world-leading hospitals, and history of medical innovations, the overall population health of the U.S before COVID-19 was far from the envy of its peers. Why?

The U.S. indeed led the world in medical innovation and investment, but these overwhelmingly benefited a small subsection of society. As an example, a recent study examining cardiovascular trends found that improvements in the outcomes of heart disease have been almost exclusively within the top 20% of earners in the US, as opposed to the bottom 80%. These disparities were possible in part because those in the richest 20% were not affected by the poorer outcomes in the bottom 80%. In a pandemic, different rules apply. The health of others affects ours, and vice-versa. But the foundational pathology existed long before the pandemic.

Why did we fail on the simple solutions that could have kept the pandemic in check? It is true that rules on social distancing were not appropriately set, communicated, or maintained. It is also true, however, that the U.S., in spite of its enviable expertise in health policy, lacks the basic workplace protections, access to sick leave, and healthcare that many other countries regard as essential. Inequality, exacerbated by COVID-19, but long a source of our poor health outcomes, hampers simple responses.

Social distancing demands a greater sacrifice, when only one in three Americans could work remotely pre-pandemic, a number that falls to less than 1 in 10 for the bottom quintile of earners. It is harder to maintain, when nearly 40% of Americans could not afford an unexpected $400 expense before the pandemic. It is understandable that over 10 million undocumented migrants might fear any form of testing or contact tracing, or fear seeking unemployment benefit, due to our hostile immigration policies. It is hard to ask over 2 million prison inmates, the largest per capita prison population in the world, to avoid infection spreading in overcrowded conditions.

As the U.S. passes the grim milestone of 200,000 COVID-19 deaths without pause, it seems important not to lose sight of what it is that made us so vulnerable. These factors are equally relevant as the failure of leadership, and it is imperative that we highlight and underline them, if we wish them to be addressed by future leadership. We suggest that all of us in medicine have too long accepted a status quo that made us vulnerable to the pandemic, and it is on us to demand that political leaders move us beyond the unacceptable present state of poor health in the country.

In the year 2000, long before most of our current political leaders emerged, approximately 245,000 deaths in the U.S. were attributable to low education, 176,000 to racial segregation, 162,000 to a lack of social support, 133,000 to individual-level poverty, 119,000 to income inequality, and 39,000 to area-level poverty. In the year 2015, working-age African Americans had a 40% higher mortality rate compared to working-age white Americans. These deaths were also premature, preventable, and a consequence of inaction, a failure of our sense of collective responsibility.

In bearing witness to the urgency of this moment, it is right to point to the role of failed leadership in turning this crisis into a tragedy. We must also accept that the current tragedy was worsened by one long in the making, in which many Americans have needlessly suffered due to deep and entrenched structural inequities, etched sharply along socioeconomic and racial lines, that shaped our poor national health. We must therefore indeed hold leadership to account as we seek to overcome COVID, but also hold ourselves to account for long accepting cracks in our society that COVID has exploited and exposed.

Nason Maani, Ph.D., is a Harkness Fellow in Health Care Policy and Practice at the Boston University School of Public Health. Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His latest book is Pained: Uncomfortable conversations about the public’s health. Follow him on Twitter @sandrogalea

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