When governments are not enough

We were talking the other day about the public health needs of Baltimore City in particular and the world in general. If you look at what is going on with regards to the health of the world, there is a lot to be done. Sure, we’ve already done a lot when it comes to public health. Smallpox has been eradicated. Infectious diseases are no longer the leading causes of death in most parts of the world. Lots of people are getting the necessary vaccinations to live beyond childhood.

But there are other things already here and on the horizon that are going to test our ability to look after the people’s health. A very recent and very clear example is the Ebola crisis in Western Africa. Because we failed to recognize and react to it in time, a handful of cases left there and traveled here… And now we’re all freaking out about it. It was the same way with HIV/AIDS back in the 60s and 70s. (Though, in defense of public health practitioners back then, technology was not as advanced as it is today to detect aberrations and go check them out.) And who can forget what happened with SARS?

Beyond infectious diseases, we have an epidemic of obesity and the chronic diseases that come with it, like diabetes and heart disease. Because of the overuse of painkillers, the United States is seeing an epidemic of opioid abuse. There are also twice as many suicides as there are homicides in this country. And don’t even get me started on people who use pseudoscience to sell you snake oil. They’re a public health problem that is special in its own way.

So the question is: Can the government deal with all this?

The clear answer is, of course, that it cannot. Unfortunately, it is the government that is empowered with the authority to do something about public health problems. After all, we form governments to look after the general welfare of all of us within a geo-political area. You can’t contract out public health… Or can you?

In the United States, and the rest of the world, there are plenty of public health professionals graduating from colleges and universities and getting to work on public health problems. Many of them work with government agencies to that end. Others work with companies hired by governments to do the job. When it comes to their paychecks, however, they all get paid from the pool of money collected from taxes and fees by the government. In austere times, it is not enough, so they leave that work and go work on something else that pays better. I can’t blame them for that, really.

A man’s gotta eat.

But what if we started looking at public health just a little bit differently, a little bit like a business. After all, plenty of healthcare providers do their work as businesses, charging people for curing them. Yes, there are a lot of wrinkles to fix in that system, and it even opens itself up to be abused or be abusive, but what if?

What if we went to a neighborhood and told the families in that neighborhood that we will help them be the healthiest they can and be available to them to consult on their public health needs and we charged a fair price? Can you imagine? We’d tell neighborhoods in the South to drain all the standing water on their properties to minimize the risk from mosquito-borne infections. We’d tell them to build a park or set aside an area for walking 20 minutes a day every day or for the kids to get in an hour of play a day. It would be public health at a very focused level and for a minimal fee.

Believe me when I tell you that I have already anticipated most if not all of the objections to this. “Are neighborhoods who cannot pay for this service not entitled to know about disease prevention?” Or, “Do affluent neighborhoods get public health experts who graduated from top-notch institutions while poor neighborhoods get the JV team of epidemiologists?” And so on and so forth.

Hey, it’s just an idea. It’s something that we are going to have to think about as governments de-fund public health more and more, and people are left to figure out things on their own. Remember when the government shut down? Remember how web sites from CDC and NIH had that big disclaimer that they were not being updated because everyone was home? Imagine that lasting more than it did if our elected representatives in the government don’t get their act together. If there is no CDC, who will take it upon themselves to study “that which comes upon the people”? And how much will they charge?

cdc_closed

I’m just saying.

  1. I do find it fascinating that the far right pushes both libertarian views and anarchist views, yet said group desired to govern.
    They, quite literally, undermine that which they seek to obtain.
    Case in point; the blathering that the CDC is incompetent when dealing with Ebola, factual history being irrelevant (such as zero CDC workers involved in the epidemics since 1976 becoming infected).
    To be honest, I’m actually worried. They’ve pushed the hot buttons that set off the less than mentally stable long enough that “militias” actually committed treason and went unpunished (rancher defying paying the grazing fees he owes by law and armed militia threatened US government agents with lethal force).
    Indeed, political speech today, for the far right, is nothing other than the felony of sedition. Seditious speech is *not* protected free speech, the case law on that goes back as long as our nation has existed under our Constitution.
    If Dorit is reading, I do invite her thoughts on the matter.
    I will say that the civilian populace has it easy. For the military, sedition, treason, espionage and mutiny are all crimes punishable by death by lethal injection. For civilians, it’s only a significant stay in a federal prison.

    To put it in infectious disease terms, it’s like developing an engineered strain of Ebola that is airborne and as infectious as norovirus (a mere eight viral particles results in an infection), then trying to control it.
    Or more humorously (as that notion is beyond horrific to consider), trying to herd gnats.

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  2. It would be much harder to act against seditious speech today. Our jurisprudence, which you are right, historically allowed it, has changed dramatically. It’s much harder to act against any speech on matters of public concern, with some limits (see Snyder v. Phelps). You’d have to prove a high level of risk from the speech.

    To the issue of the post, I want to highlight that there are multiple ways to deal with it. Offering paid services for some things is certainly an option, and I see no reason not to at least discuss it. So is a move, at least on the local level, to participatory budgeting, as for example in Porto Allegro, also tried in Eugene, Oregon. So is non-profit provision, though that runs into fundraising challenges.

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