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2020-03-21

Infectious Pandemics Are Our Achilles Heel

Infectious diseases claim most of our attention. Whether it is the Black Death, the 1918 Influenza Pandemic, or the more recent outbreaks of SARS and Ebola, they scare us--as they should. The reason we generally do not contain them is partly a lack of scientific knowledge, but actually more about the public health system.

Liberia Emergency Operations Center
More people die from infectious disease when public health systems are weak and fragmented. Ebola ravaged West Africa because the public health systems there were quickly overwhelmed when frontline health workers were unable to receive direction from experts. Ebola in Liberia persisted because the public were not reliably informed about contagion and continued normal interactions, accelerating the spread of the virus. Health workers did not have personal protection equipment and a large proportion died in a country that had far too few to begin with. 

I saw that myself when I made my first trip there in 2015. Even then, the outbreak had passed its peak, but it had ravaged the country and decimated the healthcare system. In a society that treasured physical touch, not just of the living but with funeral rites that included touching the dead, their society had been radically changed. (Even a dead Ebola victim is still highly contagious.) People did not give hugs or shake hands. Every building open to the public required people to wash their hands in a bleach solution before entering. Here's a picture I took in front of the Emergency Operations Center where you can see one man washing his hands. On the far left is a guard who made sure everyone did so. 

Lest we think that it cannot happen here, we should know that funding for personnel in public health from the federal to the state to the local level has decayed over the past generation. Moreover, our system of public health is fragmented across thousands of agencies. Thousands, you say? Yes, every county and major city has its own public health department. So does every state. And at the federal level responsibility for public health is split across Health and Human Services, Homeland Security, Defense, CDC, the US Public Health Service, the Indian Health Service (that's on the reservations), Medicare, Medicaid, the VA, etc. Some may argue with including healthcare services, but they are the front lines in immunizations as well as reporting infectious disease cases. If we tried to design a more confusing network of agencies and workers, we would not do worse that what we have. 

Now we have our own major crisis. It is exposing the inherent weaknesses in our system of protecting the health of the public. But that could be addressed by strong, consistent leadership from the top. Too bad. We don't have it. We have confusion and partisan bickering. 

We get conflicting signals from the bully pulpit of the White House. Health workers lack appropriate personal protection equipment. As of this week, the president has refrained from using available powers to mandate the production of that equipment. Turning to immunization, we have no coordination in the development, much less the hoped for manufacturing of a vaccine. 

Perhaps most alarming, a strong majority of Republicans think that the danger of COVID-19 is exaggerated—twice the proportion of Democrats. Main Street Republicans give Trump stellar poll numbers that they approve his handling of the crisis, as high as 87% in polls conducted this month.

Let's hope that the federal government succeeds in bandaging this public health wound but remember, the underlying health of our fragmented, underfunded, and overwhelmed public health system remains in dire straits. It's a victim of longstanding neglect and now partisan division.

2020-02-22

How We Got Trump, Part N-1

There have been a few essays recently that the age of bipartisan in American politics is dead. Some even suggesting that it was a political aberration. For those unsure of when that age began, it seemed to emerge after World War II in the 1950s and persisted into the late 1990s where the Clinton impeachment marked the period at the end of that sentence. While many have sought to explain its demise, often with fretful thoughts about the future of the Republic, few talk about the reasons for its rise. 

American victory in 1945 was supposed to usher in an American Century where our values, practices, and economic institutions would dominate the world. Hubris was hyperventilating periodically over the next few decades, but with the other industrial powers literally smoking ruins, we did have the run of the place. 

Did we overreach? Sure. We toppled the elected government in Iran and installed the Shah who set about turning the country into an ugly dictatorship--secret police, torture, and all the usual practices that feature in spy novels. We had harnessed the atom for war and continued to build bombs and delivery systems that piled up the megatonnage to planet-incinerating levels. We declared that we had achieved "consensus" in our society and politics--you could see it if you tuned into entertainment available on the new TV sets inhabiting our living rooms. Everyone depicted on TV was reasonably comfortable economically with that poverty and unionism of the 1930s gone from popular culture. Father knew best long before the Bradys were a bunch. The most disturbing entertainment was in the Twilight Zone, "a place that exists at any moment of time, of space or of mind" but not when you looked out your front window. No demons on Main Street. 

Did we achieve justice? Not if you read The Letter from Birmingham Jail and saw "that there are two types of laws: just and unjust." Not if you probed more deeply into The Feminine Mystique to learn about "the problem that has no name." Not if you sought out The Other America, an exploration into the quarter of the nation that lived in poverty in the midst of the greatest wealth in human history. While these pricked at our consciences, the great train of presumed prosperity and consensus rolled on. Politics was usually as bland as Wonder Bread. 

While post-war society had some pressures that would explode later, one question we should ask is did World War II give us wisdom? Perhaps not enough, but still a lot. The horrors of the war and the reasons it happened haunted those leaders who had made victory possible. They diverged into two paths: One of reaction in the Soviet Union to achieve the totalitarian state explained by Hannah Arendt. Another of revolution in China where the Communists took control of the government and eventually achieved their own version of totalitarianism in the Cultural Revolution. On the other hand, western nations--particularly the US--sought to correct the issues that had prompted the conflagration. Their response was in building multi-national, and even global, institutions. 

[Let us pause for a brief word from institutions: "You hear a lot of grousing about institutional this and institutional that. You hear complaints that it's neither white nor black but an unsatisfactory shade of gray. Well, we embrace gray because it is neither simple or complete. We love the complexity and don't get the respect that institutions should have for their abilities to navigate confounding morality and practice. Institutions offer guidance, granted gray and dim, during turbulent times. Ignoring them or, worse, overthrowing them is never understood fully. Civilization--that way of many, many people living in relative harmony--is based on institutions. Have one, today!"]

Boy, did we build them. The United Nations, the World Bank, the World Health Organization and other formal organizations. We also reached fundamental agreements for world trade and financial operations. The world settled on the US dollar as the currency of reference. (It's not called "almighty" for nothing.) We convened tribunals to convict and punish those who committed crimes against humanity. 

Domestically, we built out political parties as the methods to determine what we thought government should do, and not do. Government became ordinary and gray--generally non-threatening despite its ownership of the means of societal annihilation. And it worked. The man in the gray flannel suit was in charge (okay that's not really what the story was about). Taxes were high on people who made high incomes with the marginal tax rate edging close to 90%. The distance in pay between the line employees and the CEO was about 20 times (it's above 270 times now). Essentially, things were average or close to it. 

So, what the hell happened? Well, it's complex, but your patience is probably wearing thin. Look at it this way: That "consensus" wasn't, and began to crumble in the Civil Rights Movement when "uppity" people began to call for equality in rights. Soon after, our Cold War got hot in Vietnam when young men were subject to the draft. Seeing that they had no influence on the federal government, they started demonstrating on college campuses. Meanwhile, pressures of a displaced population--mostly formerly southern blacks--where their rising expectations from civil rights laws collided with realities in northern cities. They saw economic promises unfulfilled and northern discrimination as more insidious than its southern brother prompting an explosion of riotous violence in Los Angeles. The metaphorical (and literal) fire spread, consuming the dry, socially unjust tinder in every major northern city. At the same time, the college students, energized by draft resistance, expanded into the "New Left", an ad hoc movement that criticized everyone--conservatives for being atavists, liberals for being weak, and the old left for being a tool for the Soviet Union (and for just being old). 

Yet all these activists were really a small, albeit vocal and sometimes violent, minority. What about the rest of the people? With all the noise coming from urban areas and college campuses, many white, middle-aged, middle-income, middle-America people felt silenced. Not that they really were, but they felt that way. Granted, many did not understand civil rights because they lived far from the inner cities that were burning. They could see the injustice of southern blacks marching peacefully and savaged by police dogs, but not urban, northern blacks who looted corner liquor stores. They thought that the college kids were just ungrateful louts led astray by evil Commies and pointy-headed professors. They were concerned about rights and wars, but still were wrestling in the gray coat of consensus. They had seen the progress since the Depression, so why didn't everyone? 

[Enter from stage right.] Then came Richard Nixon. A man who felt wronged by Eisenhower (his one-time boss,) cheated out of victory by the dazzling Kennedys, and nursing his grudges afterwards for years. He founded the politics of resentment based on the "silent majority", the aforementioned middle-everything group who could not understand the country in turmoil. Aided by Roger Ailes, a man who would resurface later, Nixon harnessed the fears of northern white people into an Electoral College win in 1968. Not satisfied with gaining only the presidency, he sought to guarantee his re-election in 1972 by attacking democracy itself. 

[To be continued]