Trump’s incompetent handling of the covid-19 outbreak has set off a spate of criticism of him in the American press and on social media. But placing sole blame on Trump for the projected rise in American mortality disguises an ugly reality: no American president would be able to stem the flow of deaths, because America lacks a real healthcare system. A change in president would not magically fix that, unless our nation fundamentally reform our healthcare sector, which now puts profit before public.
A couple weeks ago, the American media ran story after story about Trump’s inability to ensure Americans were tested for covid-19. But at the same time, in other countries such as Spain, doctors were warning citizens to stop coming to hospitals for a test, as they were potentially exposing themselves to the virus, and distracting doctors from treating the sick. “Testing is not treatment,” says Joshua Sharfstein, the former Deputy FDA Commissioner, who is now Vice Dean for Public Health Practice and Community Engagement at Johns Hopkins University. “It’s one piece of the puzzle that is the response. It makes sense in a number of situations, but in others it can provide a false sense of security.”
In a JAMA Viewpoint published in early March, Sharfstein and colleagues detailed how bureaucratic snafus and bad luck led to a lack of tests in the States. They also noted that testing does not substitute for other steps to control the spread of the virus, such as handwashing, isolation, and social distancing. In the Guardian, Robert Reich, the former US secretary of labor wrote that America’s dirty little secret is that “there is no real public health system in the United States.” More than 30 million Americans have no health insurance and lack a system to pay and administer the test, and likely have no paid sick leave so that they can stay home.
In a later op-ed in USA Today, Sharfstein expanded on this, writing that America’s health insurance system is not designed to fund testing, treatment and recovery services. It was only on 18 March that the US Congress passed the Families First Coronavirus Response Act which required public and private insurers to provide free testing for the SARS-CoV-2 infection—but this still does not cover treatment.
Even if a test was available, every state is using its own algorithm and protocol for who should be tested, when, and how. Because of this, an American journalism outlet sent public records requests to all 50 states to gather and understand these protocols.
And if someone tests positive, the US does not have clear policies telling them what to do next.
Andrew Noymer, a population health scientist at the University of California Irvine, says that he has advised family members who have no symptoms to stay at home, and avoid being exposed to the virus while going for a test. In an email, he explains that scholars have written about isolating and avoiding people with disease since the Old Testament. Quarantining originates from the fourteenth-century plague pandemic, the Black Death. The word comes from Italian, for forty days, the length of time ships had to stay at anchor before coming ashore in Venice to verify they were clean.
But six hundred years after the Middle Ages, America’s healthcare system lacks a coherent system, and does not have a policy for ensuring people stick to quarantine. Earlier this month, ProPublica reported that, after exposure to coronavirus, Americans were given quarantine information that was faulty or that conflicted with the policy of the Centers for Disease Control and Prevention. Exposed reporters were told they could still go outside by one state health agency while maintaining social distancing; a different state agency advised isolating in a room at home, and no contact even with family.
Even when federal or state agencies have a clear written policy on quarantine, ProPublica found that they fail to carry out these policies, and can give conflicting advice. Because agencies are giving Americans mixed messages, ProPublica is collecting and fact-checking the instructions Americans get from state and local health departments.
In another example, it seems obvious that America should have had a firm and widely disseminated policy on face masks, long ago. There has been much debate and misinformation shared about the effectiveness of wearing masks. Much of this was discussed in a New York Times op-ed which explained how advising against masks made health officials seem untrustworthy. Masks are not perfect, but in recent days the CDC sent memos to the Department of Health and Human Services and the White House coronavirus task force to revise policy, advising that people wear masks to slow the spread of the pandemic.
Catching Donald Trump in another lie or tweeting another story about something dumb he said at a press conference will not eradicate the real plague endemic to the United States— the complete lack of a coherent healthcare system. Having a public healthcare system is more important during a pandemic than any particular leader—brilliant or incompetent. Americans can soothe themselves by complaining about Trump, or start coming to grips with this reality, and begin an honest discussion about our country’s fundamental problems.
Paul D Thacker is a freelance journalist. Twitter: @thackerpd
Competing interests: I have read and understood BMJ policy on declaration of interests and note that I am paid to write for various media outlets, consult part time for a nonprofit research institute that studies brain disorders, and have had universities provide expenses for talks on corruption in science and medicine.