Pandemics and Public Health and the Tragedy of the Commons

Αssociated press

(AP Photo/Petros Karadjias)

“Nobody wakes up in the morning and says, ‘thank God I don’t have smallpox.’ Or, ‘Thank God my water is potable.” This quote from Dr. Alfred Sommer, former dean of the Johns Hopkins Bloomberg School of Public Health summarizes the problem with Public Health preparedness in the United States. We spend billions on treating illnesses but pennies on preventing them. Americans have a ‘can-do’ spirit but only when the can-do reacts to an immediate threat. Otherwise, can-do means making quarterly profits. Hopefully, this mindset will itself succumb to the COVID19 virus before the next viral mutation makes its appearance at our gates.

All of us who went to grade school should remember Benjamin Franklin’s axiom, “an ounce of prevention is worth a pound of cure.” Unfortunately, modern finance prefers “just in time supply chains” that maximize profits. “Just-in-time” works wonderfully when each factor works in synchronicity with the next factor. When someone tosses a monkey wrench into the works, it doesn’t. 

To complicate the discussion, America, more than any other developed country, buys into the ideology that only the private sector does things efficiently. We define ‘efficiency’ as financial rather than saving lives. 

Public Health is a common good that the private sector will not and cannot finance. We delude ourselves if we expect the private sector to develop defenses against future pandemics. Future pandemics will come faster and faster. Microbes may mutate at near lightning speed but need human interaction to spread. An early pandemic, the Justinian Plague, devastated the Eastern Roman Empire about 541 AD. Biological archaeologists discovered it began in Mongolia about 180 AD. It took about 250 years to arrive in Constantinople. This year, Italians scientists report that COVID19 arrived in Italy before the Chinese even knew they had it. 

Only South Korea and Singapore appear to have invested in public health services prepared for a pandemic. Everyone else focused on financial efficiency, just-in-time supply chains and minimal staffing to keep costs down. No one else had masks, ventilators, hazmat suits, or even toilet paper stockpiled in quantities anywhere near sufficient. The United States is singularly behind the eight-ball in preparation for a pandemic. Even had President Trump not muddied the waters by his self-congratulatory blame-every-one-else public obfuscations, we still would have been in trouble.

But, even now we whine, “who will pay for the stockpiling and preparations? Oh My God, we can’t afford it! This is a thousand-year event!” Really? And can we afford a trillion-dollar offline expenditure that might, just might, prevent us from falling into a Depression like 1929?

We seem to regard the coronavirus pandemic as a thousand-year event for which no preparation seems possible. Let’s look at the facts since 1900. Spanish Flu killed 40-50 million in 1918-20. Asian Flu killed 1.1 million in 1957-58 and Hong Kong Flu killed the same number ten years later. HIV-AID has claimed 25-35 million lives since 1981 and still rampages. SARS and the Swine Flu each took a few hundred thousand lives between 2002 and 2010 respectively. MERS, and EBOLA, both particularly lethal viruses, have killed ”only” 12,000 souls from 2012 but still claim new victims. And now, COVID19 has brought the entire globe to a standstill. The timelines should terrify you.

We do not seem to mind spending eye-watering sums to maintain Armed Forces preparing for wars far less likely than pandemics. Since the end of World War II, the annual U.S. defense budget has exceeded $500 billion (in today’s dollars), excluding the two trillion or so in the off-budget costs of our many small wars. This year the defense budget may pass $700 billion. Since the 1960’s we have maintained and sustained armed forces designed to fight simultaneously with two “peer competitors” (DoD budget-speak for countries that can put up a real fight). We have not fought a war with a “peer competitor” since 1945. In other words, we have spent upwards of 4% of our annual Gross National Product (GDP) preparing for an event that has not happened in 75 years! 

By comparison we spend more on healthcare as a percentage of our GDP (18%) than any other nation in the world but almost all of that is spent on providing health care to the already sick; a minute amount is spent on public health services designed to prevent sickness. According to the National Institutes of Health, expenditures on preventive public health care have rarely exceeded 3% of total health expenditures. Let’s turn percentages into dollars. In 2019 we spent about $655 billion on defense of which $69 billion covered our small wars. The rest went to maintaining and sustaining the Armed Forces. By comparison, in 2017 America spent $3.5 trillion on total health care. Of that amount, the Federal Government spent $1.5 trillion of which only $45 billion went to public health preventive activity, i.e., we spent just over half of one percent of GDP on public health prevention! The Public Health Service Commissioned Corps (PHSCC), the uniformed branch of public health, has 6,000 members; the armed forces total active duty strength is 1,430,000. 

The pandemics will keep coming. We cannot stuff the globalized world genie back into the lamp. Rather, we need to make preventive public health an integral part of national security budgeting, rather than an underfunded orphan. We are much more likely to suffer a pandemic than fight a major war with China; the budgets should reflect those trade-offs. Perhaps the time has come to reinstitute the draft. The men and women called to colors would not only go to the Armed Forces but to the PHSCC. They could also help preserve both public health and the rule of law by going into ICE, CBP, the Coast Guard, and the Park Police, as well. The Armed Forces maintain 600,000 trained reservist and warehouse trillions in equipment for wars we hope never come. We should do the same preparing for pandemics we know WILL come. 

We have prepared for wars that will probably never happen with China and Russia. We are at war with disease. We need to reorganize ourselves to address that reality.