Still Fighting the Wrong Wars

What do the coronavirus and Navy ships have in common?  For that matter, what do our military spending and our healthcare spending have in common?  More than you might think, and it boils down to this: we spend too much for too little, in large part because we tend to always be fighting the wrong wars.

Workers trying to sterilize coronavirus.  Photo by STR/AFP via Getty Images

I started thinking about this a couple weeks ago due to a WSJ article about the U.S. Navy's "aging and fragmented technology."  An internal Navy strategy memo warned that the Navy is "under cyber siege" by foreign adversaries, leaking information "like a sieve."  It grimly pointed out:

Our adversaries gain an advantage in cyberspace through guerrilla tactics within our defensive perimeters.  Once inside, malign actors steal, destroy and/or modify critical data and information. 

This is the Navy, after all, that proudly tried to modernize by installing touch screen technology on some of its ships, only to have the disaster that hit the USS McClain.  Its vaunted Integrated Bridge and Navigation System was, ProPublica found, "was a welter of buttons, gauges and software that, poorly understood and not surprisingly misused, helped guide 10 sailors to their deaths."  And that wasn't the only technology-enabled naval disaster in recent years.

But don't just blame the Navy.  We've got a next-generation stealth fighter which, after over $400b of development, is still having major problems.  Elon Musk, who always seem to be living in the future, bluntly said: "The fighter jet era has passed.  Drone warfare is where the future will be."

We spend more on defense than the next seven largest militaries combined, spending trillions on advanced aircraft carriers, stealth fighter planes, and fancy personnel transports, and our adversaries are investing in cyber warfare, drones, IEDs, and other low cost, modern tech options.

We also fight with traditional tools like financial sanctions, which similarly are proving ineffective.  A new report concluded: "Our sanctions system needs a radical update."

It is no wonder that a recent report from the National Counterintelligence and Security Center warned:

The ever-changing technology landscape is likely to accelerate these trends, threatening the security and economic well-being of the American people and eroding the United States’ economic, military, and technological advantage around the globe.

We may be fighting the wrong wars, but at least we win the spending prize.  Just like in healthcare.

The coronavirus outbreak helps illustrate our misguided focus.  Yes, when we identify someone is critically ill with it, we've got the doctors, hospitals, and technology to help deal with it.  But that leaves a lot to be desired.  As Matthew Herper wrote in Stat News, "It is an invisible threat, and it is making vivid the shortcomings of our health care systems."

He noted:

We tend to overreact to problems that are facing us right now but underreact to long-term threats that build slowly...We panic, but we don’t prepare.

 Our public health system is fragmented, underfunded, and only appreciated in times of crisis like this.  We lack a solid tracking system to identify and swiftly respond to outbreaks.  We can't even seem to manage producing the diagnostic tests to help identify this outbreak.

Credit: CDC

Dr. Michael Mina, a Howard epidemiologist, told The New York Times: "The incompetence has really exceeded what anyone would expect with the C.D.C.," causing The Times to wonder: "Why weren’t more Americans tested sooner? How many may be carrying the virus now?"
Our system is creaky even -- or especially -- when someone is diagnosed with the virus.  We urge people who are or even may be sick to stay home, but, as Christopher Ingram pointed out in The Washington Post, 

The United States is one of the few wealthy democracies in the world that does not mandate paid sick leave. As a result, roughly 25 percent of American workers have none, leaving many with little choice but to go to work while ill, transmitting infections to co-workers, customers and anyone they might meet on the street or in a crowded subway car.

Mr. Ingram cites research on the effect of mandatory paid sick leave on flu rates, which found that they caused a major decrease.  In other words, he says, "at the population level, cities with paid sick leave policies are considerably healthier than those without them."  

Public health pays off.  

New York is trying to require health insurers to waive any cost-sharing for testing for the coronavirus, but, even if the requirement proves to be legal, it would only cover a small portion of associated costs, and would not apply to ERISA plans that are exempt from state regulation.

And, of course, for those unfortunate enough to be hospitalized or even just quarantined due to the virus, they're likely to be stuck with big bills, even if they have insurance.  One health law professor told Sarah Kliff of The New York Times:

The most important rule of public health is to gain the cooperation of the population.  There are legal, moral and public health reasons not to charge the patients.

But, of course, that is not the healthcare system we have. 

A couple of years ago I asserted that our biggest health problems are public health problems, which are ill-served by our current medical care system.  I concluded then:

We need to stop viewing public health as a boring, not glamorous, small part of our healthcare system, but, rather, as the bedrock of it, and of our health.

Mr. Herper urged that "outbreak should be a wake-up call...about infectious threats that we face together and that exploit vulnerabilities associated with income inequality, health disparities, and our slowness to recognize threats."  I agree with that, but do not think it goes far enough.

We need to stop fighting the wrong wars in healthcare.  We're arguing about universal coverage, surprise bills, transparency of pricing, the high price of prescription drugs, and, now, the coronavirus.  Each is a real problem, but none is the right war.

The real war facing us is a public health war.  Whether it is this or the next pandemic, or whether it is obesity or gun violence, the biggest threats come at the public health level.  We're spending plenty of money on healthcare, but we're not spending nearly enough on these wars.

If the coronavirus outbreak teaches us anything, let it be that we'd better be investing much more heavily in public health, as broadly defined as we can make it.