Improvements in United States Public Health Leadership

Although vaccination for the coronavirus has not yet begun in Colombia, and is barely starting in Ecuador and Panama, the new Administration in the United States is tacking in a remarkably better direction on vaccination and on public health. President Biden will increase the number of vaccine doses available by 200 million by this summer.

German Lopez wrote an article for Vox that emphasized the vaccination campaign in the context of the long-term underfunding of public health agencies across the various states. This underfunding is well-documented and long-standing. Until now, no one has really done anything about underfunding in public health, despite the slow slippage of United States life expectancy that became an avalanche of COVID cases during 2020. The current system where public health responsibilities are mostly devolved to the 50 states lacks the necessary coordination for effective leadership to occur.

It was not always this way in the United States. During the 1950s and 1960s, major advances and expansions in public health occurred, even in “backwaters” like Mississippi. Not only was smallpox eradicated from the United States, but polio vaccination occurred that led to its eventual eradication from the US. All the while, county clinics were built and staff were hired rather than being laid off.

Is this the beginning of a renaissance in US public health after a long “dark ages” that lasted from around 1980 through the end of 2020? I hope so.

In other brief notes, the Colombian Minister of Defense Carlos Holmes Trujillo died of COVID at age 69 on 26 January 2021. The land borders of Colombia are still closed owing to the pandemic and I anticipate that the border with Ecuador will remain closed until vaccination campaigns are well underway in Colombia and in Ecuador. Venezuela anticipates using the Russian vaccine Sputnik V.

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How Public Health Was Gutted in the United States

Dado a que este es un blog sobre salud publica en América Latina, voy a compartir un enlace en español para quie mis amigos pueden leer sobre la realidad choque sobre la caida de sistemas de salud públic en los Estados Unidos. Han sido muchos cortes de servicios y de empleos en salud pública desde 2008. ¿Está listo los Estados Unidos para vacunar una población de 330 millones? Se presentan ejemplos en Florida sobre la caida de salud pública y como los trabajadores han sido silenciado. Incluso programas de vigilancia y control de zancudos han sido cortadas.

Given that this is a blog about public health in Latin America, and I have written about the decline in public health under the Maduro regime in Venezuela, I had expected to write more about that. However, rather than the once-wealthiest country in Latin America, I need to focus on the “wealthiest country in the world,” the United States.

Kaiser Health News is presenting a series on the decline of public health departments in the United States both before and during the COVID-19 crisis. This series was reported using extensive funding and employment data from the Census Bureau and professional associations.

An analysis by Anna Maria Barry-Jester, Hannah Recht, Michelle R. Smith, the Associated Press, and Lauren Weber indicates that at least 181 public health officials across the United States have resigned, retired, or been fired since April 1 of 2020. Some have been receiving hate mail and feel that there are other safer and possibly more remunerative places to work, despite the fact that they usually have specialized training in public health or epidemiology or mosquito control.

This has occurred at a time when interest groups such as anti-vaxxers and anti-maskers have been launching vitriol against state and local public health officials. These groups are mostly right-wing. (Caveat: Robert F. Kennedy, Jr., prominent anti-vaxxer is registered as a Democrat, but he has recently spoken in front of right-wing groups both in the US and in Germany).

Burnout, job pressure from the pandemic, political pressure (even death threats), and normal retirements have been factors in the departures of public health officials. The departures have been all over the country, but with more numerous foci in Colorado, Kansas, Iowa, Wisconsin, Kentucky, North Dakota, Maryland, Washington, and California. They represent a brain drain that will take years and millions of dollars to repair.

This is occurring at a time when both the Federal and some state governments are neither cooperative with nor supportive of public health. The 24 state governments are considering proposals to limit the emergency powers of public health agencies. This is linked to pressure from the right-wing special interest group ALEC. .

Recently, the Shawnee County, Kansas Board of Commissioners loosened pandemic-related restrictions. This occasioned the departure of health officer Gianfranco Pezzino. He resigned from the Shawnee County, Kansas public health department with a letter that stated, “

  1. You disregard data and best practices that have been proven to be effective all around the world in favor of your own narrative, anecdotal evidence, and opinions not based on facts.
  2. You do not value the opinion not only of your health officer, but also the most qualified health and public health professionals in our community.
  3. You value the pressure from people with special economic interests more than science and good public health practice.

…Therefore, I am resigning my position as Shawnee County Health Officer effective immediately.

What are the “pre-existing conditions” to this sudden rash of resignations and retirements of public health officials across counties and states? Lauren Weber, Laura Ungar, Michelle R. Smith, Hannah Recht, and Anna Maria Barry-Jester wrote a damning article for the Associated Press. in which they said,

“Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHN and Associated Press analysis of government spending on public health. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world’s top public health systems.”

Professor Lawrence Gostin of Georgetown University was quoted as saying,

“What we’ve taken for granted for 100 years in public health is now very much in doubt,

Robert Redfield, the CDC Director told the AP that his “biggest regret” was “that our nation failed over decades to effectively invest in public health.”

Take these three quotes and they can be condensed into the conclusion that the United States is losing or has lost the pre-eminent position it once held in worldwide public health. Although incoming President Joe Biden will likely reverse Donald Trump’s decision to withdraw the United States from the World Health Organization, some of the damage has already been done. The worst of that damage is probably the loss of the United States’ position as a leader in global public health. Other countries, including those in the developed world, will see the United States as being highly unreliable because whether it supports public health is dependent on who is in power, and what ideology is in power.

In the case of the United States, it is overwhelmingly right-wing ideology that is antagonistic to public health. Whether that ideology is manifested by budget cuts at the local public health department or by people refusing to wear masks in public and refusing to distance, it is enormously damaging to the health of people in the United States. Budget cuts since 2010 have hurt Minnesota and other states’ coronavirus response.

All this sounds really familiar to me, because it resembles what happened to public health in Venezuela since 2014 that led up to the enormous malaria resurgence. In Venezuela, corruption and kickbacks from illegal mining are the commercial interest that led to the decline in malaria surveillance and reporting. Health officials faced reprisals when they diagnosed cases of malaria in clinics. There was a rise in infant mortality and suppression of the publication of the Boletín Epidemiológico.

In Venezuela, it has been corruption under the Left-Wing regime that has damaged public health. In the United States, the combined effects of Right-Wing ideology are the culprits:

The United States has many excellent schools of Public Health and related fields, such as Entomology. Thousands of people have graduated from those schools and bring strong skill sets to a field that is desperately needed.

Talent is being wasted. Shameful.

Culture, Public Health, and the COVID Pandemic

Readings have been recently showing up that link the performance of countries against the COVID pandemic to their scores on the Hofstede index of individualism or collectivism.

One of the best of these readings is a preprint by Bo Bian, Jingjing Li, Ting Xu, and Natasha Z. Foutz. The authors used Big Data techniques to track individualism in the United States and plot it against COVID incidence data. They used the amount of time a location spent as a frontier zone as a proxy for individualism because time spent on the frontier has been linked to high levels of individualism in the culture. The authors also made use of Hofstede cultural scores of individualism/collectivism to compare countries and then analyze their response to COVID. In some charts on pages 47 and 48 of the preprint, Bian, Li, Xu and Foutz plotted various countries’ Hofstede scores versus the rate of growth in COVID and related factors such as how much people stayed home versus going to workplaces, parks, retail stores, etc. In the charts, the US is at the top right of the charts, being the world’s most individualistic country and having its rampant COVID pandemic.

Vietnam is at the bottom left of the charts because it is collective-minded and also successfully controlled COVID. Most countries in Asia are collective-minded with high social cohesion, whether they have a history of communism like Vietnam and China or whether they have always had a capitalist economy like Singapore.

China is the archetype of a collectivist society. China has an ancient culture based on Confucianism. Confucianism is based on social relationships and family structure including reverence for elders.

The results in the preprint by Bian, Li, Xu and Foutz regarding the Andean countries were highly interesting. Colombia (13), Ecuador (8), and Venezuela (12) have very strong Hofstede scores indicating collectivism in the society. This has a lot to do with tight-knit family relations, extended families, and the role of Catholicism in the countries. Each of these countries were able to somewhat, but not completely control COVID. We just don’t have anti-maskers here in Colombia. Venezuela in particular has done much better with COVID than the 2014-2018 malaria epidemic seemed to predict.

The United States score of 91 on is at the opposite pole on the Hofstede individualism score and is Earth’s most individualist country.

The United States’ response to the COVID pandemic has been disastrous and marked by a recent fusion of the anti-vaxxer movement with the political Right wing. The anti-vaxxer crowd is no longer congruent with “crunchy granola” types who are usually on the Left. Rather, anti-vaxxers are often the same people who hold to conspiracy theories falsely believed by the Right and “Don’t Tread On Me” extreme individualism. There have recently been a number of incidents where anti-vaxxers hang banners from highway overpasses, distracting traffic and posing a safety hazard. The rise of irrational thought in the US is disturbing to anyone with a scientific background, even if that person is a logically-thinking libertarian who is highly individualistic.

From reading these articles, it can be seem that the anti-vaxxer movement is a consequence of extreme individualism in the United States. If someone in China, for example, tried to propagandize as an anti-vaxxer, his family and neighbors would probably reject him as a “tall poppy” who doesn’t accept Chinese cultural norms.

Sama Kubba, writing in the Harvard Political Review, says:

If a culture of collectivism encourages a faster and more effective COVID-19 response, as research and empirical evidence have shown it does, then the governments of individualist countries have a duty to follow in Canada and Germany’s footsteps and encourage a cultural shift in that direction.

 

New WHO Guidelines on Physical Activity

The World Health Organization has released new guidelines on how much physical activity people need to do:

  • Children and Adolescents need to engage in an average of 60 minutes per day of moderate to vigorous activities. That could include riding a bicycle, playing futból (soccer), playing basketball, playing tag, running track, riding a horse, walking or running the dog, and the like. The activity should happen at least 3 times per week. Weight training and things like pushups and other bodyweight exercises are appropriate for adolescents to strengthen muscle and bone.
  • Adults from 18-64 years of age should participate in 150 to 300 minutes per week of moderate activity and/or 75 to 150 minutes of vigorous exercise. Activities could be walking the dog, riding a bicycle, doing farm chores, cleaning house, dancing, yoga, playing a sport, working in a warehouse pulling orders, or the like. Adults should do something to strengthen muscles and bones at least twice a week. That could be bodyweight exercises, work with resistance bands, balancing on a balance dome, working out on the machines, or weight training with free weights. The recommendations include people with disabilities and chronic conditions. In general, no medical consultation is needed to begin an exercise program, although those with disabilities or chronic conditions might want to seek recommendations.
  • Adults over age 65 should do the same things as other adults but should do strength and balance training three times a week.

By the way, I support these guidelines.

Can the World Trust the United States on Public Health?

Anyone who follows public health issues in Venezuela probably knows that publication of the Boletines Epidemiológicos has been subject to serious delays or suppression since 2014 under the administration of Nicolás Maduro. The Boletines for 2014, 2015 and 2016 are finally available after significant delays. By the way, the Boletín Epidemiológico in Venezuela is analogous to the Mortality and Morbidity Weekly Report (MMWR) in the United States.

I have known about the issues with Venezuelan health reporting for several years, and have associated the suppression of epidemiological information with the political motives of the Chavistas.

A year or two ago, I was optimistic that maybe US and European and other Latin American public health experts would be able to help Venezuela deal with its significant public health problems, that include infant mortality, malaria, measles, and diphtheria.

That was before COVID-19…

Regarding COVID, Venezuela has fared quite a bit better than the United States, which has the worst situation in the world, followed by India and Brazil. Although Nicolás Maduro has been terrible regarding malaria, at least he has been seen wearing a mask against COVID.

What’s more, there is an emerging scandal over attempts at suppression of epidemiological information in the United States. This time, the political motives are those of conservative Republicans, rather than Chavistas.

Articles in Scientific American and in POLITICO detail the actions of HHS assistant secretary for public affairs Michael Caputo and his underling Paul Alexander in attempting to alter or suppress COVID reporting in the MMWR. Alexander no longer works at the agency, and Caputo has taken a leave of absence.

The articles detail how these politically-motivated actions undermine trust of North Americans toward their own public health infrastructure.

Not only that, but these attempts to suppress epidemiological data and information also undermine the trust of people in other countries regarding the once-excellent public health system in the United States. They undermine the future ability of the United States to help other countries with public health issues. The withdrawal of the United States from WHO only serves to further undermine the US’s reputation in public health. Even if another Administration takes over in January and rejoins WHO, as Biden has promised to do, the trust factor is slow to be repaired.