Free-market ideology, not sound analysis, is why the 9/11 Commission’s report didn’t include recommendations needed to address the hazard of bio-terrorism, considered by many to be the greatest threat to the American homeland.
Preparing for a biological attack requires greater federal investment in a deteriorating public health infrastructure, a progressive goal that is anathema to many in corporate America and Washington. Our healthcare system demands profits first and foremost, and that profit imperative means adopting "efficiencies" and just-in-time corporate management techniques unsuited to dealing with sudden public health crises.
And a biological attack would be just that on a grand scale. When asked what kept him awake at night, University of Southern California terrorism expert Terrence O’Sullivan said it was our "overall vulnerability" to bioterror. "Airline security or chemical attack response equipment may save thousands from terrorism," he said, "but bioterrorism has the potential to kill millions, or to dramatically frighten and disrupt the nation even if few die."
Biological weapons are known as the "poor-man’s nukes" -- they can be made relatively cheaply using off-the-shelf technology. And while the current administration suggests there was no way to predict that terrorists would use airplanes in the attacks of 9/11, the threat of biological terror is well understood: we know from both experience and comprehensive government studies that we’re unprepared today for either a biological attack or a large-scale naturally occurring infectious outbreak.
The most striking illustration of our vulnerability comes from simulations of large-scale outbreaks. One of the most informative of these was a multi-agency "drill" in 2000 known as TOPOFF.
In TOPOFF, local, state and federal agencies simulated the release of Yersinia pestis -- the bacteria that causes the plague -- in Denver, Colorado.
On the very first day of the exercise hospital capacity became overtaxed and understaffing in crucial areas of the system became apparent. By the end of the second day (about 5 days after "exposure"), the study found "The number of bodies in hospital morgues is reported to have reached critical levels."
Low drug stocks, poor communication and overwhelmed caregivers were all factors in a rapid deterioration of Coloradoans’ care.
By the third day of the simulation the study’s authors noted that: "Medical care is ‘beginning to shut down’ in Denver." Soon after, officials conducting the exercise determined that the notional disease had spread outside of Colorado.
Some time into the first week of the outbreak, civil unrest broke out, as people reacted to travel and isolation restrictions. As the final report details: "Stores were closed. Food supplies ran out because no trucks were being let into the state. Rioting began to occur." When the exercise was terminated, between 950 and 2000 people were "dead", and the disease remained uncontrolled.
It’s a terrifying picture. And given that it’s just as likely to arise from natural sources as via our terrorist foes, many experts consider a major infectious disease outbreak a matter of "when,' not 'if."
Given the urgency of the threat, one would expect to see dramatic efforts to prepare for an attack. But, according to USC’s O’Sullivan, since 9/11: "there continues to be insufficient funding, and little coordination or integration of our response efforts nationally." He blames that, in part, on our fiscal crisis. "For every dollar spent on the federal level or channeled to the states for bioterrorism, many more are being cut from state, county and local... public health and emergency response budgets because of massive federal tax cuts and state deficits."
But the problem goes beyond the current budget climate to our very political culture. The ultimate defense against the biological threat is a good public health infrastructure, and in this our faith in the private sector leaves us behind the curve and continuing to lose ground.
There are two pillars of homeland defense in public health. The first is "surge capacity," which is simply having enough beds, doctors, nurses and supplies to accommodate a disaster. The other is disease surveillance -- the vitally important task of quickly determining a pattern of infection when scattered patients first start appearing in emergency rooms.
In developed countries whose political center of gravity is not as far to the right as our own, universal healthcare is the norm and this vitally important but unprofitable capacity usually exists.
But we’re a country of free-market fundamentalists -- we embrace what Laurie Garrett, in her excellent book on the topic, calls "anti-governmentalism." The result, according to Tara O’Toole, a biological warfare expert at John's Hopkins is that: "Recent financial pressures have resulted in cutbacks and efficiency measures that have effectively eliminated any 'surge' capacity. [Italics added]"
But what’s behind those financial pressures? In 2001, the United States spent 13.9% of its GDP on healthcare, the highest share among developed states and more than five percentage points higher than the OECD average of 8.4%. So we’re clearly spending enough money.
But just 44% of that cash goes into public health, far below the OECD average [PDF] of 72%. And for-profit, private health means an emphasis on less-costly outpatient care. So, while the OECD countries spend an average of 65 percent of their health dollars on inpatient care, the United States is at just 52 percent.
The result is a decline in excess capacity. During the twenty years between Ronald Reagan telling us that "government is the problem" and the 2000 election, the number of American hospital beds per capita fell 34 percent -- from 4.4 beds per 1,000 to 2.9 per 1,000. The OECD average is 4.0 per 1,000. The same can be said of doctors: the U.S. has slightly less than the OECD average per capita and the level has remained stable for the past two decades, while the rest of the OECD countries have increased their numbers of physicians.
The market also doesn’t do well providing crucially important disease surveillance. Adequate reporting is costly and managed care organizations have assured that reporting remains uncoordinated and voluntary. According to O’Sullivan, "until the government significantly subsidizes reporting... the best surveillance systems in the world will continue to rely in part on luck and alert physicians, which is far from optimal [when] hours and days could make all the difference between control and runaway spread."
Despite the urgency of the threat of bioterror, the steps the current administration has taken since 9/11 have been heavily influenced by the pharmaceutical and healthcare industries, and have focused largely on the production of new vaccines and treatments. And while that’s a welcome development, it’s also controversial -- many experts believe we are devoting our dwindling resources to the wrong priorities.
The failure of status-quo policy-makers to invest in and improve our overall capacity to respond to bio-terror gives progressives a perfect issue to re-frame the national debate about homeland defense. Conservatives tell us that we must tolerate limits on our civil liberties in the face of today’s terror threat. We can argue just as effectively that while limited government might sound fine in theory, this ideology has created a healthcare system that places us in grave jeopardy and is a threat to our national security.
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