12 February 2021   Leave a comment

The Lancet, one of the most respected public health journals in the world, has published a report entitled “Public policy and health in the Trump era”. It is a protected essay, but simple registration will give one access. It is a truly devastating report on how the Trump Administration mishandled the COVID pandemic. But the essay goes further and explains how the politics and economics of the US republic over the years contributed to the abject failure of Americans to deal with the disease. The opening of the essay is brutal:

“This report by the Lancet Commission on Public Policy and Health in the Trump Era assesses the repercussions of President Donald Trump’s health-related policies and examines the failures and social schisms that enabled his election. Trump exploited low and middle-income white people’s anger over their deteriorating life prospects to mobilise racial animus and xenophobia and enlist their support for policies that benefit high-income people and corporations and threaten health. His signature legislative achievement, a trillion-dollar tax cut for corporations and high-income individuals, opened a budget hole that he used to justify cutting food subsidies and health care. His appeals to racism, nativism, and religious bigotry have emboldened white nationalists and vigilantes, and encouraged police violence and, at the end of his term in office, insurrection. He chose judges for US courts who are dismissive of affirmative action and reproductive, labour, civil, and voting rights; ordered the mass detention of immigrants in hazardous conditions; and promulgated regulations that reduce access to abortion and contraception in the USA and globally. Although his effort to repeal the Affordable Care Act failed, he weakened its coverage and increased the number of uninsured people by 2·3 million, even before the mass dislocation of the COVID-19 pandemic, and has accelerated the privatisation of government health programmes. Trump’s hostility to environmental regulations has already worsened pollution—resulting in more than 22 000 extra deaths in 2019 alone—hastened global warming, and despoiled national monuments and lands sacred to Native people. Disdain for science and cuts to global health programmes and public health agencies have impeded the response to the COVID-19 pandemic, causing tens of thousands of unnecessary deaths, and imperil advances against HIV and other diseases. And Trump’s bellicose trade, defence, and foreign policies have led to economic disruption and threaten an upswing in armed conflict.

“Although Trump’s actions were singularly damaging, many of them represent an aggressive acceleration of neoliberal policies that date back 40 years. These policies reversed New Deal and civil rights-era advances in economic and racial equality. Subsequently, inequality widened, with many people in the USA being denied the benefits of economic growth. US life expectancy, which was similar to other high-income nations’ in 1980, trailed the G7 average by 3·4 years in 2018 (equivalent to 461 000 excess US deaths in that year alone). The so-called war on drugs initiated by President Richard Nixon widened racial inequities and led to the mass incarceration of Black, Latinx, and Indigenous people. Overdose deaths soared, spurred by drug firms’ profit-driven promotion of opioids and the spread of despair in long-afflicted communities of colour and among working-class white people. Market-oriented health policies shifted medical resources toward high-income people, burdened the middle class with unaffordable out-of-pocket costs and deployed public money to stimulate the corporate takeover of vital health resources.”

The point is clear: the US health system is far from the “best” in the world. Indeed, compared to other countries of comparable wealth, it is one of the worst health systems in the world. One can measure how bad it is by looking at the phenomenon of “excess deaths”–those deaths that could have been avoided with appropriate care and economic circumstances as shown by the graph below.

Excess deaths each year in the USA relative to other G7 countries average (1980–2018)

The article puts a fine point to the argument:

“The global COVID-19 pandemic has had a disproportionate effect on the USA, with more than 26 million diagnosed cases and over 450 000 deaths as of early February, 2021, about 40% of which could have been averted had the US death rate mirrored the weighted average of the other G7 nations.35Many of the cases and deaths were avoidable. Instead of galvanising the US populace to fight the pandemic, President Trump publicly dismissed its threat (despite privately acknowledging it),36 discouraged action as infection spread, and eschewed international cooperation. His refusal to develop a national strategy worsened shortages of personal protective equipment and diagnostic tests. President Trump politicised mask-wearing and school reopenings and convened indoor events attended by thousands, where masks were discouraged and physical distancing was impossible.

The COVID-19 pandemic is one of many US health failures. The fact that COVID-19 affects Black, Indigenous, and Latinx people disproportionately has reinforced long-standing health inequities driven by racially patterned disparities in housing,37 wealth, employment, and social and political rights.

Declining US longevity between 2014 and 2017, and the minimal uptick in longevity in 2018, attracted substantial media attention. However, a focus on these recent trends risks obscuring how far the USA lags behind other high-income nations (figure 1), and how long these cross-national gaps have been in the making. Life expectancy in the USA was average among high-income nations in 1980, by 1995, it was 2·2 years shorter than the average of other G7 countries, and by 2018, the gap had widened to 3·4 years.4

The extent of difference can also be quantified as the number of missing Americans—ie, the number of US residents who would still be alive if age-specific mortality rates in the USA had remained equal to the average of the other six G7 nations. By this measure, in 2018 alone, 461 000 Americans went missing, an annual figure that has been increasing since 1980 (figure 2appendix pp 2–3).38 Most of the US mortality excess is among people younger than 65 years. If US death rates were equivalent to those of other G7 nations, two of five deaths before age 65 years would have been averted. To put this number in context, the number of missing Americans each year is more than the total number of COVID-19 deaths in the USA in all of 2020.

The article also points out how the election of Donald Trump changed the health dynamics of the American people, as indicated by the graph below.

Trends in life expectancy in counties that voted predominantly for or against Donald Trump in the 2016 election

The article goes into great detail about the disparities in health outcomes among the various racial and ethnic groups in the US and the evidence is clear that white Americans enjoy highly biased access to healthcare relative to other groups.

Finally, the article makes it clear that the issue is not money. The US spends far more than other countries to receive an inferior level of health care.

Health-care spending in five wealthy nations (1970–2018)

The need for a far more informed debate over health care in the US is long overdue. Americans should be both ashamed and humiliated by how poorly the country ranks in the world. I have done little justice to how detailed this report is. I recommend highly that people read this article carefully and act upon its insights and conclusions.

Posted February 12, 2021 by vferraro1971 in World Politics

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