Before exploring the public health sector, it is essential to examine some long-term trends of US big business.
Over the last decades, the economic elites’ control over politics has become very strong. In 2010 the Supreme Court ruled that it was unconstitutional to prohibit that corporations and unions spend from their general treasuries to finance independent expenditures related to campaigns. This gave new birth to the PACs (political action committees) and Super PACs, which can raise funds from individuals, corporations, unions, and other groups without any legal limit on donation size. The economic elite has obtained what it wants in terms of tax cuts, enormous budgets for 'defense' (higher than the next seven countries combined), huge subsidies to international fossil fuels (6.5 percent of global GDP in 2017 from all countries) and limited oversight for the finance, pharmaceutical, and insurance industries.
Also, there has been an emphasis on short-term outlooks and results, typically a year or less, which has dominated finance and politics. This brief time orientation emphasizes the individual self, whereas the longer-term may focus on future generations. Forms of communication also have privileged shorter and shorter periods. This short-term bias has helped many leaders be indifferent to longer-term impacts such as those of the environment and climate. This outlook is seen, during the Coronavirus crisis, in the pressure by the elite to get everyone back to their prior work situation and orientation as soon as possible without consideration of the deeper, longer-term issues.
Many managers, particularly at the top, have become more indifferent to Middle America and narrower in their interests, mainly centered around personal wealth. It has become possible and acceptable to accumulate enormous personal wealth. As widely reported, three US billionaires own as much as the bottom half of Americans (Collins 2019). Individualism has always been strong in America, but the self (and self-image) has become all-important. Countless new products and services have been created to serve, improve, and promote the individual. However, increasingly it has made many leaders indifferent to those considered to be less successful and thus the less disserving. “Growth in income in recent decades has tilted to upper-income households. At the same time, the US middle class, which once comprised the clear majority of Americans, is shrinking. Thus, a greater share of the nation's aggregate income is now going to upper-income households, and the share going to middle- and lower-income households is falling. The share of American adults who live in middle-income households has decreased from 61% in 1971 to 51% in 2019. This downsizing has proceeded slowly but surely since 1971, with each decade after that typically ending with a smaller share of adults living in middle-income households than at the beginning of the decade” (Horowitz 2020). Many of the middle and lower-income families are engaged in multiple jobs to make ends meet. It is ironic that in this time of crisis, the most indispensable jobs of food suppliers, transportation workers, police, firefighters, and nurses are among the worst paid.
The question is: what has this meant for the public health sector, or more precisely, what kind of health system has the elite desired? The elite wants the most advanced medical care for themselves. It comes in the form of research centers and highly equipped specialized clinics and hospitals. Cost is not important because they can pay for it. When they get sick, they want the absolute best. And that is what they got.
What about the plebe? The results are immediately visible. Without going into detail, the US has a complicated public-private system with heavy involvement of the insurance and pharmaceutical companies. Services are centered around the hospital and private care, with little attention to prevention. The high levels of obesity and opiate use testify to this. The total US health system costs are twice the average of other rich OECC countries. In 2018, the US spent about $10,600 per person on healthcare — the highest healthcare costs per capita across the OECD, while the average for wealthy OECD countries, excluding the United States, was only $5,300 per person (OECD 2019). Middle and lower-class US citizens often cannot afford it; and frequently when one losses their job they may lose their health insurance.
With the US Coronavirus pandemic, in the hands of a very self-centered President, the country is presently accumulating nearly 80 thousand deaths. A nagging unanswered question is the impact of the delayed introduction of lockdown and search procedures. The US is certainly not among the best-managed countries: Korea admittedly a much smaller nation (one-seventh the size of US) with 248 deaths; Australia (population 25 million) with 93 deaths; and Japan (population 126 million) with a total of 466 deaths. In America, African Americans and Hispanics are being hit harder. A recent CDC report found that in patients hospitalized with lab-confirmed COVID-19 that 45% were white, compared to 55% of individuals in the surrounding community. Also, 33% of hospitalized patients were African Americans compared to 18% in the community. New York City identified death rates among African American persons (92.3 deaths per 100,000 population) and Hispanic/Latino persons (74.3) that were substantially higher than that of white (45.2) or Asian (34.5) persons (CDC 2020).
Let us consider the more specific issue of how to better organize the health services in the light of the Coronavirus and possible future pandemics. For this, the experience in Italy is illuminating.
Physicians from the town of Bergamo write: “Western health systems are built with the patient at the center, but an epidemic requires a change of perspective towards an approach that puts the community at the center.” “Solutions are needed for the entire population, not just for hospitals. Home care and mobile clinics avoid unnecessary travel and relieve pressure on hospitals. Early oxygen therapy, pulse oximeters, and adequate supplies can be provided at home to patients with mild symptoms or in convalescence. A capillary surveillance system must be created that guarantees adequate isolation of patients, also using telemedicine. This approach would limit hospitalization to a targeted group of seriously ill patients, thus reducing the contagion" (Misuraca 2020).
The differences between the health systems of the Veneto and Lombardy regions of Italy are noteworthy. Veneto has the decentralized territorial model with many small, local public units; whereas Lombardy is based on the privatized hospital model with fewer decentralized public facilities. As of May 3, the number of Coronavirus cases per 100,000 residents was 373 in Veneto and 771 in Lombardy (roughly double), and the number of deaths per 100,000 was 31 and 141, respectively, more than four times greater in Lombardy.
Putting the community at the center implies privileging the promotion of collective well-being in its environmental, economic, psychological, and social components. Promoting individual and collective psychological well-being is today a national emergency. After the crisis, many people suffer from emotional disturbances. For example, they faced family bereavements without being able to be close to the dying, without celebrating funerals.
Above all, there is an urgent need to give more space to prevention, mobilizing positive energies, and the widespread desire to contribute to the rebirth of a better America. Emphasis should be placed on health education and active citizenship projects, which promote relational skills, mutual respect, a sense of community, care for places, mutual help between neighbors, and intergenerational solidarity.
CDC, COVID-19 in Racial and Ethnic Minority Groups, April 2020.
Collins, C., et al. Billionaire Bonanza 2018, Forbes, October 30, 2019.
Horowitz, J.M., Most Americans Say There Is Too Much Economic Inequality in the US, but Fewer Than Half Call It a Top Priority, Pew Research, January 9, 2020.
Misuraca, L., I medici di Bergamo ai colleghi stranieri: Evitate gli errori fatti in Lombardia, Il Salvagente, 25 marzo 2020.
OECD, OECD Health Statistics 2019, November 15 2019.