Public health, pandemic response, and the 2020 US election

From a health perspective, the upcoming US election could be the most consequential in our lifetimes. Before the COVID-19 pandemic, the USA already had a modest standing across many global health measures: among 11 industrialised nations, the USA ranked last in life expectancy and highest in suicide rates, had among the highest number of hospitalisations for preventable causes, and had the highest rate of avoidable death.¹ Moreover, the USA has the highest numbers of uninsured people in the developed world: one in four individuals report foregoing care because of out-of-pocket costs, even if they are insured, and one in four do not take needed drugs because of prescription costs.² Fatal opioid overdoses nearly doubled between 2010 and 2018, from 38 000 to 67 000 deaths.³ Existing health disparities include a life expectancy for Black Americans 3·5 years lower than for white Americans; for Native Americans, life expectancy is 5·5 years lower.⁴ People from ethnic minority populations receive worse care than do white Americans for chronic non-communicable diseases such as kidney disease⁵ and cardiovascular disease,⁶ and inequalities in treatment are seen for those who are pregnant and for children.⁷ Furthermore, the USA has underinvested in public health initiatives such as local, county, and state public health assistance, global and emerging infectious disease programmes, and the Strategic National Stockpile.⁸ The budget for the US Centers for Disease Control and Prevention (CDC) has fallen by 10% over the past decade,⁹ adjusting for inflation, and the budget for the Health Services and Research Administration is US$10·7 billion,¹⁰ which is a tiny amount compared with the $3·6 trillion spent on health-care expenditures nationally.

With the arrival of the COVID-19 pandemic, the already dire situation with respect to health outcomes and inequities will worsen without urgent course correction. Since January, 2020, the US Government has fumbled on testing, contact tracing, social distancing, face masks, and hospital supply; it has failed to lean on scientific leaders to manage the crisis; and it has not provided consistent, coordinated evidence-based messaging for the public. This response would have been terrible under any circumstance, but combined with complacent co-existence with an increasingly penetrable public health and health-care system, the USA has entered a perfect storm, the threat from which has universal reach.

The COVID-19 pandemic has shined an unflattering light on every flaw in the US health-care system: disparate social determinants, chronic disease burden, and limited health-care access; a fragile safety net; astronomical costs of care; and system complexity, misaligned incentives, and disjointed communication. Further, the pandemic has shown how problems outside the traditional health-care system intersect with our health: too many Americans cannot afford rent; too many children go hungry and are falling behind at school (to the extent school is even happening); and workforce segregation and a childcare crisis have left too many people without options for staying solvent and staying safe from COVID-19.

The USA has underperformed globally in its pandemic response but still has unparalleled resources and potential. It is not too late to mitigate the effect of the current crisis. Any plan needs to invest massively in testing, contact tracing, and support for Americans if further shelter-in-place orders are needed. Such a plan needs to be rooted in science, present a capable and coordinated government response, and show a fundamental understanding: what happens to our most vulnerable, marginalised communities dictates the success of the whole country.

The next US administration and Congress not only need to solve this current crisis but also put in place safeguards to prevent it from happening again. In the short term, thoughtful detailed proposals are needed to describe how we might enhance the Affordable Care Act to shore up health-care coverage, bolster the Prevention and Public Health Fund, and address key weaknesses of the US health-care system, including the absence of cost transparency and the staggering expense of pharmaceutical drugs. Health equity considerations need to be embedded in all public policies; priorities need to be set; and presidential and congressional candidates should be honest and realistic about what can be achieved and by when, and what the tradeoffs might be—in a headcount of American lives—for each decision.

There are, roughly, two choices for the 2020 candidates. Either they can deny the effect of the COVID-19 pandemic, and both the immediate failures and structural forces that let it play out so disastrously in the USA, or they can accept that we need change and articulate a real plan for it. The USA can achieve global health excellence, but leadership is needed to guide the country away from counterproductive assumptions of US exceptionalism, recognising with humility where we fall short and where we have much to learn from countries that fare better in health outcomes, both before and in COVID times. We need to start rebuilding with a solid framework, one capable of sheltering every American individual's health and one that will stand strong through the next global health crisis.