Public Health
“The first wealth is health.” ~ American essayist Ralph Waldo Emerson
Health has been a public issue throughout human descent. We have always been gregarious, and so subject to contagious infections and other health consequences from sharing food and close quarters. The problem became more pronounced with the rise of settled communities and trade among them.
Religion embraced public health early on. The Old Testament contains many adjurations and prohibitions for clean living.
Primitive societies looked upon epidemics as divine wrath for wickedness. Attributing pestilence to natural causes gradually developed in 5th-century Greece, but intrusion of rationality did not staunch religious superstitions.
Throughout the world, ancient cities developed ways to remove waste and provide clean water. The Indus civilization is a fine example.
The most famous water supply system in antiquity is that of ancient Rome, with its multi-storied aqueducts. Rome’s first aqueduct was commissioned in 312 bce to alleviate a chronic water shortage.
Water management has always been the key to the well-being of communities. Ancient settlements not near a freshwater source dug wells and used cisterns to collect rainwater.
Aqueducts let communities import water from a distance, and so inhabit otherwise untenable places. The Minoan civilization on Crete and contemporaneous Mesopotamia had aqueduct systems in the 2nd millennium bce. Incorporating tunnels which ran several kilometers, the first sophisticated long-distance canal system was constructed by the Assyrian empire in the 9th century bce.
Inoculation was practiced in ancient China, India, and other places. Health officials knew that those who recovered from certain diseases, such as smallpox, developed lifelong immunity. Doctors inoculated those not stricken by exposing them to infected blood or dried wounds.
Another early public health measure was to segregate sick people from healthy ones. Many communities kept their lepers in separate colonies or cast them out.
The eras of the Middle Ages were delineated by plagues, beginning with one in 542, and ending with the Black Death in the mid-14th century (which was a series out plague outbreaks lasting decades). Epidemics from a variety of infectious agents were a periodic feature of medieval European life.
The term quarantine comes from the Latin quadraginta, meaning 40. In Venice during the 14th century, officials kept ships out of port for 40 days if they suspected infection among its passengers.
Epidemics were sometimes lessened, or prevented, before the cause of a disease was known. The association between malaria and swamps was established in ancient Greece by the 5th century bce, even as the reason for the association between the 2 remained obscure.
In 1854, English physician John Snow found that Londoners with cholera were getting their water from a public pump on Broad Street. Closing that pump down dropped the incidence of the disease.
Local governments during the late Middle Ages made efforts to improve sanitation, including the provision of potable water, garbage and sewage disposal, and food inspection.
Political leaders during the Renaissance recognized that the economic power of the state required a population in good health. Nonetheless, no national health policies emerged in Europe during that time, as the government lacked the knowledge and capability to carry out such initiatives. Public health problems continued to be handled on a local community basis, as they had in medieval times.
From 1750, Europe’s population grew rapidly, despite high infant mortality. Countries struggled to improve sanitation and public health.
In the late 19th century, France and Germany pointed the way. In France, the public health movement was invigorated by political and social reform. The French significantly contributed to the science of identifying, treating, and controlling the spread of communicable diseases.
After Germany unified in 1871, it began a central public health administration. Germany introduced the science of hygiene into the field of public health.
19th-century economic liberals fantastically prophesized that the increased production of goods would eventually end scarcity, poverty, and suffering. By the turn of the 20th century, with malnutrition, alcoholism, and diseases of all kinds rampant in the slums of England and America, it was clear that the state would have to step it to address public health problems.
There were a few international public health efforts in the early 20th century. Among them were the Pan American Sanitary Bureau, founded in 1902 to improve health conditions in the Americas. The Paris-based International Office of Public Health started in 1907 to rely information about epidemics, and to develop standards for sanitation, and quarantine regulations, for train and ship travel. These organizations were later absorbed into the World Health Organization, established in 1948 as a specialized agency of the United Nations.
Health care continues to be dominated by national regimes. Every country has a public health system that reflects its history, cultural values, economic development, and political ideology.
United Kingdom
England was first to industrialize, and its people suffered accordingly. The health and welfare of workers deteriorated during the 19th century, owing to lack of decent urban housing and unsanitary conditions. This provoked a movement toward sanitary reform that ended up establishing public health institutions.
The explosive growth of cities was at root of the health problem. London’s population doubled 1801–1841; Leeds nearly tripled. With such growth came a jump in death rates. In cities across England, death rates nearly doubled as industrialization took hold.
“Friendly societies” emerged in the early 19th century. These were private associations of people in the same livelihoods who pooled funds for insurance for its members, including health care.
Though ostensibly designed to provide health care to the indigent, the Poor Law of 1834 was based on the principle that getting public assistance would be so unpleasant as to put off all but the most desperate.
English Poor Laws were recurrent attempts to provide relief to the indigent dating back to 1536. The Poor Law system declined from the early 20th century with the introduction of welfare reforms and improved private mechanisms, such as friendly societies.
After much campaigning by the Health of Towns Association, and yet another severe outbreak of cholera in London, the British government passed the Public Health Act of 1848. It established a central health board which had little power and no money. Local boards continued to do what little they could to improve public health infrastructure.
The idea of a unified state medical service began with the Poor Law of 1909. The National Health Service (NHS) was established in 1948, with separate services for England, Wales, and Scotland. Fearing loss of income and institutional constraints, doctors were initially opposed.
Though private health continues as an add-on, NHS provides the majority of British health care. Most patients pay nothing for treatment, which hugely saves administrative costs. Some must nominally pay for prescriptions. NHS is financed through taxation.
In the 21st century, the ruling Conservative Party allowed Britain’s public health system to sorely deteriorate. Long well-regarded by the public, the NHS showed severe stress from lack of funding in the mid-2010s. A shortage of doctors and medical staff had those on the job near revolt for their punishing hours and pay. Services of all kinds were slow, including emergency care. 3.9 million patients were on waiting lists for operations in 2016, yet the government refused to provide the needed funding.
The UK has fewer beds per head compared to virtually all other EU nations, fewer doctors and nurses, reduced access to investigations such as MRI scans, and is spending less on medications. ~ English physician Chaand Nagpaul, head of the British Medical Association, in 2018
United States
From the first arrival of European immigrants on American soil, epidemics recurred with regularity. The colonies lacked doctors. The death toll of the Revolutionary War was exacerbated by lack of medical practitioners.
Well into the 19th century, recurrent epidemics of yellow fever, cholera, smallpox, typhoid, and typhus made improving urban health a matter of urgency.
The people are constantly liable to great epidemics; and to consumption, and other fatal diseases, which destroy so many of the human race in other parts of the world. Neither clergymen nor physicians live as long now as they did during the last century. ~ American historian Lemuel Shattuck in 1850
The 1850 Shattuck report chronicled the unsanitary living conditions and serious health problems plaguing Massachusetts; but the report spoke to the state of the entire country.
The smoke of furnaces, manufactories, and other establishments, is often a great nuisance, corrupts the air, and is deleterious to health.
Drugs and medicines have been adulterated. Food is adulterated in various ways: to make the substance more saleable, and to depreciate its quality. Drink is also very extensively adulterated. Drugs and medicines have been adulterated.
The effects of patent medicines and other nostrums advertised for sale is one of the greatest evils of the present day. An insatiable desire to make money, frequently without regard to the justice or morality of the means, on the part of the manufacturers and venders, are the prominent causes of this monstrous evil. ~ Lemuel Shattuck in 1850
Shattuck recommended a state health department and local health boards. The first such municipal health board started in New York City in 1866.
The American Public Health Association was founded in 1872. With major epidemics raging around the world, Congress passed a national quarantine law in 1878. Toward the end of the 19th century, states and cities set up laboratories to fight epidemics.
A national Public Health Service (PHS) was established in 1889. Its primary focus was combating epidemics around the country, with watchfulness for sick merchant sailors. The PHS later expanded its scope to include investigations of various diseases, sanitation, water quality, and sewage disposal.
In reorganizing executive government after World War 2, President Dwight Eisenhower created a national Department of Health, Education, and Welfare (HEW) in 1953. Education was split off into its own departmental bailiwick in 1979. HEW became the Department of Health and Human Services (HHS), with the Public Health Service as its spearhead. Agencies within HHS aim to protect public health, enhance private health care, regulate the safety of food and drugs, and conduct biomedical research.
Despite spending well over $1 trillion a year promoting public health, US governments (federal, state, local) only provide health care to veterans of the military.
Veteran Health Care
The Veterans Health Administration (VHA) is the country’s largest health care system, providing comprehensive services to enrolled US military veterans.
The first federal agency to provide veteran medical care was a home for naval veterans in Philadelphia, Pennsylvania, established in 1812. A few others followed in the 1850s.
The high number of Civil War wounded resulted in greater federal efforts to provide health care to veterans. By the late 1920s, homes were providing hospital-level care.
The VHA expanded greatly after the 2nd World War. In 1988, President Ronald Reagan elevated Veterans Affairs (VA) to a cabinet-level position. By then the VHA included hospitals and care centers across the country.
Widespread dissatisfaction among patients and high operative mortality into the 1980s led to an effort to improve administration and focus on improving care quality. But the VHA continued to be underfunded. This led to lengthening wait times for care: a situation that erupted into scandal in 2014, when the FBI opened a criminal investigation of the VHA for faking paperwork to make delays appear shorter.
Owing to a funding shortfall of $3 billion, improvement was hard to come by, as Congress continued to neglect its responsibility to the country’s military veterans.
Something has to give. We can’t leave this as the status quo. We are not meeting the needs of veterans. ~ VA deputy secretary Sloan Gibson in 2015
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For the general public, US medical care is a private, for-profit enterprise. As a result, Americans spend far more on health care by every measure than any other nation; an upward trend with no end in sight.
This gross expenditure does not translate into quality. Besides being the most expensive in the world, the American health care system is the worst among developed countries for access, efficiency, and equity. Nearly 100,000 patients die in US hospitals every year from preventable medical mistakes.
(Consuming $3.3 trillion dollars in 2016 (17.6% of GDP), American health care costs over 2.5 times the average of developed nations. At least 1/3rd of the provided care is unnecessary. American health care well illustrates the corruption of capitalism.)
(The health care sector of the US economy is pollution intensive: generating voluminous wastes and accounting for 9.8% of the country’s greenhouse gas emissions; more than the UK generates altogether. The environmental impact of US health care is significantly detrimental to Americans’ health, thereby generating repeat business – for profit indeed.)
The US spends enormous sums on health care, much of which has little or no effect. ~ Scottish American economist Angus Deaton
In all parts of the healthcare system, the providers of care see themselves as competing businesses struggling to survive in a hostile economic climate, and act accordingly. The predictable result is a fragmented, inefficient, and expensive system. ~ American internist Arnold Relman
American health care as a price-gouging exercise has not always been the case. The US was in the realm of other countries in per-capita health spending until about 1980. Then it diverged.
Other countries put limits on health care prices and spending. We didn’t. ~ American health economist Henry Aaron
Over 25 countries have a higher healthy life expectancy than Americans can look forward to, at less than half the cost in medical care.
The most efficient way to improve population health is to focus on those at the bottom. We don’t do as much for them as other countries. ~ American economist Sherry Glied
Underspending is on early childhood education – one of the key socioeconomic determinants of health – has long-term implications. ~ American health policy maven Gerard Anderson
The less well-off can hardly afford to go to a doctor, who makes out like a bandit with patients, and who typically acts magisterial, not befitting a service provider. Understandably, many Americans do not trust their medical service provider.
I felt like I was a hostage. I didn’t have any clue how much they were going to bill. I had no idea it would be so much. ~ Kim Little, on having a tiny white spot removed from the side of her cheek
Health Care Insurance
The US has big pharma vs. big insurance vs. big hospital networks, with the patient, employers, and the government paying the bills. ~ Canadian economist Janet Currie
While well-insured Americans face the hazards of over-diagnosis and over-treatment, the uninsured lacked access to the health care system.
A revision to federal Social Security, which is a welfare program for the aged, established Medicaid and Medicare in 1965.
Medicare is a national health insurance scheme for those 65 and older which covers about half of health care costs. Medicare is a federal program, not subject to state caprice like Medicaid.
Medicaid is a health insurance program for the poor. States determine eligibility. Their miserliness means many of the needy do not qualify. This has left a vast number of the poor without access to health care.
Even hospitals whose mission includes treating indigent patients are reluctant to make the process too easy or too public for fear of being magnets for the uninsured. ~ American surgeon Joel Weissman
With upwards of 20% of the population (63 million) uninsured, the Barack Obama administration pressed for health care reform in 2010. The resultant law was the Affordable Care Act (ACA), commonly called Obamacare.
(Guesstimates vary as to how many were uninsured prior to the ACA, ranging from 13.4% to 21% or more. 20% is typical.)
The aim of the ACA was to provide universal access to health care by foisting insurance on everyone. Those too poor to afford insurance were to be subsidized. Everyone else was taxed if they did not buy health insurance.
There is no worse tyranny than to force a man to pay for what he does not want merely because you think it would be good for him. ~ Robert Heinlein
The law was a sop to insurance companies, who had the political clout to block the bill if it had been unfavorable to them. Shortly after adoption, those who already had insurance before the ACA had their coverage changed and their rates go up.
In the first 2 years of administering Obamacare, those uninsured dropped to ~15%. 18 million people gained insurance coverage. Then adoption stalled.
So you’ve got this crazy system where all of a sudden 25 million more people have health care, and then the people who are out there busting it – sometimes 60 hours a week – wind up with their premiums doubled and their coverage cut in half. ~ Bill Clinton in 2016
Losing money on online shopping exchanges intended to facilitate buying health insurance, many insurers pulled out, and raised their rates by up to 65% for existing plans. Insurers hanging in offered pared-down, restrictive plans that made health care practically as unaffordable as it had been.
Obamacare’s insurance expansion is on the path to looking like other safety net programs, offering limited services to a predominantly low-income population. ~ American journalist Sarah Kliff in 2016
Obamacare improved health care access slightly for the poor while substantially raising insurance and health care costs to everyone else. The law did nothing about the cost or quality of health care provided. This failure was foreseen.
Americans seem content to let their compatriots suffer, become seriously ill and die. What they ignore in being devoid of compassion is the cost of such injustice.
Even under Obamacare, the poor did not receive the care they need in a timely manner, and so they tended to become seriously ill. These indigent exigent cases are then handled by emergency care and extended hospitalization.
We are going to pay these costs one way or another: either explicitly or implicitly. By failing to do so explicitly, the cost will be much higher in both economic and human terms. ~ American physician and politician John Kitzhaber
In 2017, Republicans, then in control of the federal government, tried but failed to repeal the ACA. Nonetheless, the Trump administration took a hatchet to it, balking on paying the promised subsidies to health insurance companies. The Republicans rescinded the tax penalty for not buying insurance, thereby eliminating the incentive for healthy people to pay outrageously for health insurance. These measures created uncertainties in insurers, thereby perpetuating further cost increases for obtaining health care in the US.
Obamacare is gone, just gone. ~ President Donald Trump in 2017, preening about Republicans destroying affordable health care for Americans
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Bioweapons
The disdain for public health by President Trump went beyond keeping health care out of reach for most Americans. The Trump administration sponsored bioweapons research: trying to develop pathogens capable of causing a pandemic. Such work is banned by a 1972 international treaty to which the United States is a signatory.
Research involving potential pandemic pathogens is essential to protecting global health and security. ~ US Department of Health and Human Services in 2017
Japan
Via compulsory insurance, Japan adopted universal health care in 1947. Though the system is nationwide, it is managed at the regional and local government levels.
Patients are free to select their physicians and are never denied care. The Japanese get good basic care, and never have to worry about huge medical bills. Surgery and treatment outcomes generally equal or surpass those in the US.
Patients pay 10–30% of the fee. The government picks up the rest. Fees are waived for the poor and homeless.
Japan has one of the lowest per-capita costs for health care in the industrialized world. The Japanese have the longest life expectancy, and one of the lowest infant mortality rates.
The government controls medical fees. This keeps costs low, which is not an altogether unalloyed good.
Emergency care is often poor. One reason for this is that there are too many small clinics and not enough hospitals. Doctors prefer this because they can work less and earn more.
Some doctors see as many as 150 patients a day. Patients can nearly always see a doctor within a day. Waiting for an hour or more for an appointment is common.
Because their salaries are low, doctors tend to overprescribe tests and drugs. Clinics commonly have their own pharmacies. Prescription pill popping by the Japanese is excessive.
Japan has too few doctors – 1/3rd less than the rich-world average – because of state quotas. The shortage is severe in rural areas, and in certain specialties.
Hospital stays are 4 times as long in Japan as in the US. Japanese hospitals do not prioritize patents, so there can be a crowding-out effect for emergency care or more patients.
Patients are treated too equally. Beds are occupied by less-urgent cases, and there are no penalties for those who over-use the system. ~ Japanese health care analyst Naohiro Yashiro
Hospital doctors are often overworked, and so lack the time to hone life-saving specialized skills. Japanese are much less likely to have a heart attack than Americans, but when they do, they are twice as likely to die.
Sweden
During the Middle Ages, health care in Sweden was financed via community coin chests: the forerunner of guilds, which later evolved into provident societies.
From the 9th into the 16th century, the church was the primary provisioner of health care in Sweden. By the 17th century, community-financed physicians were providing health care throughout the country.
The first hospital in Sweden was constructed in 1752: 7 centuries after England built its first hospital. Shortly thereafter, community-funded hospitals sprouted across the country.
Following established tradition, the Swedish health care system is part of a comprehensive social policy aimed at meeting the needs of its people. Health care is considered a basic human right. This is commensurate with the Nordic model: economic and social policies common to the Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden).
Health care provision in Sweden is capable and affordable. Urgency is prioritized and emergencies are treated immediately.
The state pays 97% of medical costs. Prescription drug fees for patients are capped at an affordable maximum.
Though Swedes do not look favorably upon for-profit enterprise for public education or health and social care, private medical service provides 30% of basic care and 20% of hospital care.
With caveats, Swedish health care is comparatively excellent. Sweden has managed to control costs in a way that remains undreamt of in the US.
Access and waiting times can be a problem. The Swedes have a tradition of steering patients away from their doctor unless they are really sick.
