A Health System Primed to Fail

When the anthrax scarce began a few weeks ago, the U.S. public health system was as ill-prepared for bioterror as our armed forces were for war when the Japanese struck Pearl Harbor. Within weeks of the attacks on the World Trade Center and the Pentagon, our airmen and Special Forces delivered a blow to the leadership of Osama bin Laden’s terror network and Taliban supporters. But here at home, the faltering responses and conflicting messages of health authorities have fanned fears and may cost lives.

Why? With hindsight, it’s easy to spot mistakes. Why, for example, did health officials not realize that powder as fine as chalk dust might leak from an envelope? Why were postal workers not tested and treated as quickly as congressional staffers? Why were statements about the size and hazards of the spores so inconsistent and confusing?

These criticisms, though, obscure the larger story--of institutions programmed to fail. For at least a half century, our national commitment to an effective public health system has been on the wane. In differing but parallel ways, political liberals and conservatives have become skeptical, even hostile, toward government’s role in the health sphere.

Liberals have come to see personal choice as paramount in medical matters--and government constraints on individuals’ health-related behavior as intrusive. In the 1960s and 1970s, activists and scholars targeted doctors’ paternalism toward patients and remade the law of health-care provision to protect patient autonomy. Public tracking of community-wide disease troubled civil libertarians, who feared invasions of personal privacy and stigmatization of disadvantaged groups.

Conservatives, meanwhile, have opposed most public financing and provision of medical services. They have cast health care as a matter of consumer choice and pushed public policy toward deference to the medical marketplace. Conservatives have taken a similar view of disease prevention, treating it as a personal matter, not a public responsibility.

The unsurprising result has been an absence of political support for strong public health programs and institutions. Instead, we have the public health system we’ve “wanted”--ill-funded, fragmented, highly respectful of personal choice and unprepared for a nationally coordinated response to crisis.

It wasn’t always this way. Public-health authorities in the 18th, 19th and early-20th centuries acted decisively, on a grand scale, against population-wide health threats, including frightening epidemics. Before the Civil War, health officers helped to plan towns and cities with an eye toward controlling infectious disease by securing clean water and food. Public-health authorities drained swamps to contain mosquito-borne illnesses, and they organized the safe disposal of animal and human waste.

Americans saw these activities as vital to their security, no less so than military force or police and fire protection. Taxpayers supported the needed spending. Lawmakers empowered local health authorities to move robustly when contagion threatened. Destruction of buildings, killing of infected animals and even restraints on the movement of infected people were provided for by law and widely accepted by citizens.

Because the hazards of contagion crossed class and racial lines, public health measures that aided the worst-off won support from the well-off. Mosquito-infested swamps, sick farm animals and airborne infections threatened everyone, though the poor often lived in areas at highest risk.

The Industrial Revolution of the late-19th and early-20th centuries brought new health dangers, from the building of factories in densely populated areas and the crowding of poor people into slums. Filth and squalor spread disease, and government responded. Physicians and sanitary engineers made regulatory decisions concerning location of factories, control of poisonous substances and other city planning matters. In proportion to other public expenditures, public health budgets were much larger than they are today.

The U.S. commitment to public health--and its regulatory powers--as vital to the pursuit of the common good persisted through two world wars. Campaigning for the presidency in 1932, Gov. Franklin D. Roosevelt reaffirmed this commitment, proclaiming, “Nothing can be more important to a state than its public health; the state’s paramount concern should be the health of its people.”

But after World War II, American public health fell victim to its own success. Thanks to city-planning and sanitation campaigns of the early-20th century and the antibiotic revolution of the 1940s, fear of infectious disease waned. The conquest of polio through vaccination in the 1950s delivered the coupe de grace for public health’s middle-class constituency.

Although sexually transmitted diseases, tuberculosis and other infectious illnesses by no means disappeared and continued to disproportionately afflict the nation’s poor, many in the middle and upper classes believed mankind’s age-old struggle against contagion had ended in triumph. In 1969, the U.S. surgeon general told Congress as much, concluding that the nation could “close the books on infectious diseases.”

No longer frightened by contagion, middle-class Americans increasingly saw health as a private matter, looking to high-tech medicine for the next great advances. Federal spending on medical research surged as state and local public-health spending ebbed.

As the perceived need for robust public-health measures diminished, concern about violation of personal autonomy in the health sphere soared. Revelations of Nazi medical atrocities and reports that American clinical researchers exposed unknowing people to radiation and other life-endangering hazards inspired a large shift in medical ethics, toward patient autonomy as the central principle. The civil rights revolution of the 1960s and 1970s quickened this transformation.

Then came the AIDS epidemic in the 1980s and 1990s. AIDS activists battled successfully for public-policy responses that intruded minimally on personal autonomy and privacy. The AIDS paradigm for coping with a public health crisis treated government as more of a threat than a solution. This civil-libertarian response to AIDS was of a piece with the individualism and the cult of the entrepreneur that have flourished in American culture for the past 20 years.

So, what remains in the public health sphere is a profoundly flawed system, chronically starved of funds, without political support and founded on antiquated laws. These laws actually thwart decisive public-health action. They prohibit data-sharing between public health, law enforcement and emergency management agencies; and they do not provide adequate powers for controlling property and persons in the event of bioterrorism.

In an era of intercontinental travel, the U.S. is vulnerable to epidemics of potentially massive proportion. Think about the resurgence of multidrug-resistant tuberculosis, AIDS and the West Nile Virus. Or think about the prospect of natural or intentional spread of smallpox or Ebola, both highly contagious and untreatable. These naturally occurring and terrorist-created threats could produce mass civilian casualties, straining the public health system far beyond the current anthrax threat.

There is an urgent need for new federal and state laws to mobilize the needed resources and to permit, indeed require, information-sharing and other cooperation among public health, law enforcement and emergency-management agencies. Our medical technology--powerful antibiotics, vaccines and the science base necessary to develop myriad new biological security measures--is sufficient to cope with the threats we face. The challenge ahead is a matter of organization and resources--and willingness to see the virtues of personal autonomy against the larger backdrop of the common good.