Not to bury the lede, I think it can, but it will be a lot harder than the talking heads on television predict.
I have been
writing about health care dysfunction since 2003. Lots of US politicians would have us believe we have the best health care system in the world (e.g., House of Representatives Speaker John Boehner (R-Ohio),
here), Much of the commentary on Ebola also seems based on this "best health care system in the world" notion. For example, in
an interview today (5 October, 2014) on Meet the Press, Dan Pfieffer, "senior White House adviser," said
There is no country in the world better prepared than the United States to deal with this. We have the best public health infrastructure and the best doctors in the world.
However, at least the statistics say compared to other developed countries, US processes and outcomes are at best
mediocre using the best of some admittedly flawed metrics (look
here), yet our costs are much higher than those of comparable countries. Furthermore, on
Health Care Renewal we have been connecting the dots among severe problems with cost, quality and access on one hand, and huge problems with concentration and abuse of power, enabled by leadership of health care organizations that is
ill-informed, incompetent, unsympathetic or
hostile to health care professionals' values, self-interested,
conflicted, dishonest, or even
corrupt and governance that fails to foster transparency, accountability, ethics and honesty.
Thus there is reason to worry that it will be harder than many expect for the US to deal with Ebola. There is already some evidence that some of the sorts of problems we have been discussing for years made it harder for the US to cope with even the so far limited incursion of Ebola.
Financialization of Pharmaceutical and Biotechnology Companies
George W Merck famously
said,
We try never to forget that medicine is for the people. It is not for
the profits. The profits follow, and if we have remembered that, they
have never failed to appear. The better we have remembered it, the
larger they have been.
In the pharmaceutical industry, the era of George W Merck is over. The failure to have access to an effective Ebola virus vaccine exemplifies how things have changed.
If we were to have an effective Ebola virus vaccine, we could have likely used it to vaccinate health care workers and contacts of infected patients and likely thus halt the epidemic early.
A
story in Modern Healthcare
suggested that now many of the big experts on Ebola and public health
are concluding having a vaccine available would be very helpful,
As West Africa's Ebola outbreak continues to rage, some experts are coming to the conclusion
that it may take large amounts of vaccines and maybe even drugs — all
still experimental and in short supply — to bring the outbreak under
control.
Specifically,
'It is conceivable that this epidemic will not turn around even if we
pour resources into it. It may just keep going and going and it might
require a vaccine,' Dr. Anthony Fauci, director of the U.S. National
Institute for Allergy and Infectious Diseases, told The Canadian Press
in an interview.
The main reason we do not yet have such a vaccine does not appear to be scientific, but economic.
Here we posted discussion of arguments that pharmaceutical and biotechnology companies up to now have been uninterested in developing Ebola vaccines because they did not anticipate that such vaccines would produce a lot of revenue. About one month ago, the Independent ran yet
another story about an Ebola expert who believed this was the main reason for the lack of effective vaccine development up to now.
The scientist leading Britain's response to the Ebola pandemic has
launched a devastating attack on 'Big Pharma', accusing drugs giants
including GlaxoSmithKline (GSK), Sanofi, Merck and Pfizer of failing to
manufacture a vaccine, not because it was impossible, but because there
was 'no business case'.
West Africa's Ebola outbreak, which has now claimed well over 2,000
lives, could have been 'nipped in the bud', if a vaccine had been
developed and stockpiled sooner – a feat that would likely have been 'do-able', said Professor Adrian Hill of Oxford University.
The US health care system is now heavily commercialized. Health care
corporations, including pharmaceutical and biotechnology companies, are
often lead by
generic managers who subscribe to the business school dogma of the
"shareholder value theory," which seems to translate into putting
short-term revenues ahead of all other goals. Thus they have been
"financialized." At least in the pharmaceutical and biotechnology sector, such financialization appears to now be global.
It may now be too late to contain this particular Ebola virus epidemic using a vaccine. But unless we change how decisions are made about vaccine development, and end the dominance of financialization over drug and vaccine development, we may not be able to control the next deadly epidemic using vaccines either.
Generic Management Deluded by Business School Dogma
On 2 October, 2014, InformaticsMD
posted on Health Care Renewal his speculation that the Ebola patient now hospitalized in Dallas was not identified on his first emergency department visit to Texas Health Presbyterian hospital even though a nurse apparently found out he had recently traveled from Liberia because of problems with how the hospital's electronic health record (EHR) transmitted or displayed this information. This supposition was later apparently confirmed, but then the hospital system CEO retracted this explanation, leaving the reason he was sent home from the ED, thus risking infection of more contacts, unclear (see
this post).
I now speculate that the larger reason for the problems the hospital had and is having both handling this patient, and explaining how it handled the patient is hospital leadership by
generic managers who do not really understand the relevant health care issues.
Mr Barclay E Berden, the
CEO of Texas Health Resources, has had a long career in hospital management. However, his most advanced degree was "a master's degree in business
administration with a specialization in hospital administration from the
University of Chicago Graduate School of Business." His official biography suggests that he has no direct experience or training in medicine, health care, or biological sciences. Nonetheless, when he became CEO this year,
according to Modern HealthCare, the chairperson of the hospital system board thought he was fully qualified,
'He brings a well-rounded perspective and unique leadership strengths to
the CEO position,' board Chair Anne Bass said in a news release. 'At
the same time, he represents stability and continuity that will be
critical to advancing our strategy as we confront the challenges of a
rapidly changing healthcare environment.'
Nonetheless, the hospital systems seems to have had trouble confronting the challenges of the change in environment due to Ebola. Also, according to a
very recent story in the Dallas Morning News, there have been performance issues at Texas Health Resource hospitals, and specifically at Texas Health Presbyterian,
Texas Health Presbyterian Hospital — under fire for releasing a
Liberian man who later turned out to have the Ebola virus — has lagged
behind its peers on emergency room care and lost some federal funds the
past three years because it had high discharge rates of patients who
later had to return for treatment.
The hospital scored
significantly worse than the state and national averages in five of six
emergency care indicators, with emergency room wait times twice as long
as the averages, according to data from the U.S. Centers for Medicare
& Medicaid Services.
The hospital also was the most penalized
in Dallas under a three-year program designed to reduce the number of
patients readmitted for care, according to the data.
The delays in
patient treatment in the emergency room, in particular, raise important
questions about Presbyterian’s emergency care, said Dr. Ashish Jha, a
professor at Harvard University’s School of Public Health and a
practicing general internist.
In 1988, Alain Enthoven advocated in
Theory and Practice of Managed Competition in Health Care Finance,
a book published in the Netherlands, that to decrease health care costs
it would be necessary to break up the "physicians' guild" and replace
leadership by clinicians with leadership by managers (see 2006 post
here).
Thus from 1983 to 2000, the number of managers working in the US health
care system grew 726%, while the number of physicians grew 39%, so the
manager/physician ratio went from roughly one to six to one to one (see
2005 post
here). As we noted
here, the growth continued, so there are now 10 managers for every US physician.
We have frequently
discussed how generic managers in charge of health care organizations may follow business-school dogma at the expense of patients' and the public's health. In particular, they may also prioritize short-term revenue ahead of all other concerns, and hence may favor high-technology and procedural care, often performed electively, ahead of the the less glamorous and remunerative parts of health care, e.g., ED care of poor, uninsured, febrile patients.
Unfortunately, much of the country's efforts to ward off Ebola are likely to be lead by generic managers who may have little understanding of epidemiology, public health or virology, and little understanding of the state of health care at the sharp end. So unfortunately I expect continuing "glitches," or worse. Hopefully, the country, although not every single one of its inhabitants, will survive them. Then we need to seriously reflect on the wisdom of
handing control of health care over to generic managers, rather than health care professionals.
Commercialization of Health Care Leading to Neglect of Routine Acute Care and Public Health
Just as national politicians and government leaders have repeated the meme of the US health care system being "the best in the world," now that Ebola has come to Texas, state leaders have sung the same song. For example, an
editorial in the Baltimore Sun quoted the state health commissioner,
'This is not West Africa,' Texas health commissioner Dr. David Lakey
said Wednesday at a news conference designed to dispel Texans' (and
Americans') fear of an Ebola outbreak after a man there was diagnosed
with the disease. 'This is a very sophisticated city, a very
sophisticated hospital.'
The Texas Tribune ran
a story produced in cooperation with Kaiser Health saying,
At a Wednesday press conference to discuss the Ebola case, Gov. Rick Perry
said he was confident in the state’s preparedness. 'There are
few
places in the world better equipped to meet the challenge that is posed
in this case,' he said. 'We have the
health care professionals and the
institutions that are second to none.'
However, another
Dallas Morning News story recounted various problems in the public health response to the Dallas Ebola patient, including,
Delay in blood testing
After
Duncan was admitted to the hospital, health officials waited nearly two
days to test his blood for the Ebola virus. This may have delayed
containment of people who had contact with him.
Slow containment and cleanup
Health officials left some of Duncan’s close contacts in the apartment where soiled linens and towels that he had used remained.
Failure to avoid contact with emergency workers
Ambulance workers and sheriff’s deputies are among those being monitored.
So, there is reason to suspect that the public health system in Texas may not exactly be the best in the world. In fact, there seem to be systemic problems with public health in Texas that the Ebola scare is bringing to increased public notice. The Texas Tribune/ Kaiser story went on to explain that in Texas, a state in which distrust of central government is great, and confidence in the private sector is high, public health is both decentralized and often poorly funded,
'We don’t really have a unifying construct for public health in Texas
that’s comprehensive,' said Dr. Eduardo Sanchez, the former commissioner
of the Texas Department of State Health Services (DSHS) and current
chairman of the Texas Public Health Coalition. 'The system is not as
connected as it could be.'
Furthermore,
But public health experts argue that the state’s response
system is 'fragmented' and vulnerable to local budget cuts, which they
say could hamper crisis-response efforts in the case of diseases that
are more easily transmitted.
Texas’ local health departments, which provide services
like immunizations and disaster response planning, operate autonomously
and are funded primarily by local taxes but may be supplemented by state
and federal grants. Because local health departments are not held to a
single standard, their services and budgets vary tremendously around the
state.
A report
critical of the state’s public health system, prepared by the Sunset
Advisory Commission, found that 'the roles and responsibilities of DSHS
and local health departments remain undefined.' The Sunset Commission is
tasked with highlighting inefficiencies at state agencies and
recommending legislative action.
'A ‘local health department’ can be a few staff conducting
restaurant inspections and animal control duties, or a large agency
directing sophisticated disease surveillance, operating a public health
laboratory and providing direct services to citizens,' according to the
report.>
Some public health officials have criticized the state’s
model as disjointed. Many local health departments operate
independently; however, if local budget cuts to a public health
department force it to discontinue a health service, DSHS is often
required to step in and take responsibility for that service. The state
is then left to foot the bill.
'In the event of a public health emergency ... the
resources necessary to adequately respond to that are not all in the
control of the health department,' Sanchez said. 'You have to have the
money and the authority — whether it’s informal or formal — to actually
lead a response and take care of business.'
Local entities have slashed funding for health departments
in recent years, said Catherine Troisi, an epidemiologist at the
University of Texas School of Public Health in Houston. Thirty-six
percent of local health departments in Texas laid off staff as a result
of budget cuts between 2008 and 2013, according to the National
Association of County and City Health Officials.
'Public health is politics,' Troisi said.
In the US, we have pushed commercialization of health, health care and public health. Much of our health insurance is provided by for-profit corporations. Some of our hospitals and other organizations that provide direct patient care are for-profit. As we noted above, most of our health care organizations are now run in a "business-like" manner by managers trained in business, but not necessarily in health care or biological science. The thus revenue-focused health care system has emphasized procedures and high-technology, often at the expense of the basics. So it should not be s surprise that
Reuters just reported,
Nurses, the
frontline care providers in U.S. hospitals, say they are untrained and
unprepared to handle patients arriving in their hospital emergency
departments infected with Ebola.
Many
say they have gone to hospital managers, seeking training on how to
best care for patients and protect themselves and their families from
contracting the deadly disease, which has so far killed at least 3,338
people in the deadliest outbreak on record.
Furthermore, using as an example Medstar Washington Hospital Center, the largest hospital in Washington, DC,
Nurses argue that inadequate
preparation could increase the chances of spreading Ebola if hospital
staff fail to recognize a patient coming through their doors, or if
personnel are not informed about how to properly protect themselves.
At Medstar, the issue of Ebola training came up at the bargaining table during contract negotiations.
'A
lot of staff feel they aren't adequately trained,' said [Emergency Department nurse Micker] Samios, whose
job is to greet patients in the emergency department and do an initial
assessment of their condition.
So Young Pak, a spokeswoman for
the hospital, said it has been rolling out training since July 'in the
Emergency Department and elsewhere, and communicating regularly with
physicians, nurses and others throughout the hospital.'
Samios
said she and other members of the emergency department staff were
trained just last week on procedures to care for and recognize an Ebola
patient, but not everyone was present for the training, and none of the
other nursing or support staff were trained.
'When
an Ebola patient is admitted or goes to the intensive care unit, those
nurses, those tech service associates are not trained,' she said. 'The
X-ray tech who comes into the room to do the portable chest X-ray is not
trained. The transporter who pushes the stretcher is not trained.'
If an Ebola patient becomes sick while being transported, 'How do you clean the elevator?'
Nurses at hospitals across the country are asking similar questions.
A
survey by National Nurses United of some 400 nurses in more than 200
hospitals in 25 states found that more than half (60 percent) said their
hospital is not prepared to handle patients with Ebola, and more than
80 percent said their hospital has not communicated to them any policy
regarding potential admission of patients infected by Ebola.
Another 30 percent said their hospital has insufficient supplies of eye protection and fluid-resistant gowns.
So up to now, it appears that in the state of Texas, and across the country, the preparedness of public health systems and of front-line hospitals to deal with Ebola is unclear. This may be due to political cuts in funding of public agencies, a payment system that favors procedures and high-technology over basic care, and leadership by generic managers who prioritize making money short-term over less financially advantageous priorities like preparedness for epidemics.
Summary
Thus again there is reason to fear that our commercialized health care system run by generic managers, and our neglected public health system scorned because it is not "business-like" may not be fully up to the task of containing Ebola. Again, hopefully this too will pass, without too many casualties. However, one, maybe the only silver lining in the dark clouds of the Ebola crisis seem to be its capacity to challenge the pompous certainty by those invested in the status quo that we have the best health care system in the world.
The Ebola crisis should, again, lead to serious reflection on true health care reform, reform that would address concentration and abuse of power, reform that would enable leadership of health care by well-informed people who are devoted to patients' and the public's health, who are honest and ethical, who are willing to be held accountable, and would shrink the size and power of individual health care organizations to make them truly responsive to patients' health care needs and the public's health needs.
ADDENDUM (10 October, 2014) - This post was re-posted
on the Naked Capitalism blog, and
on OpEdNews.com
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