Swine flu and the case for a single-payer healthcare system in the United States
By Billy Wharton
June 3, 2009 -- On April 13, 2009, 39-year-old Adela María Gutiérrez Cruz became the first victim of a new virus that would become known as the swine flu (H1N1). By the time Cruz arrived at a local hospital on April 9, she had already entered acute respiratory distress due to an “atypical pneumonia”. Further investigations led to a town outside of a factory farm, run by a subsidiary of the US meat conglomerate Smithfield Foods, in the neighbouring state of Vera Cruz. Causalities began to mount. Yet, nearly two weeks after the first deaths, none of the families of the dead had received anti-viral medications.(1) Mexican health officials claimed to not have the resources to visit the families.
The swine flu grew from a local event to a global pandemic. Strategies of isolation and containment proved futile as human carriers circulated through all corners of the globe. Grounded airlines in Japan, a travel ban in Cuba and masked pedestrians on the streets of New York City did little to stem the tide of this potent disease. Early medical intervention proved important, as those infected who had immediate access to anti-viral medications, such as Tamiflu, tended to fare better. The flu was shorter and the possibility of complications thereby reduced. Some European governments used their public health systems to quickly distribute such medications. However, the response in Mexico and the US was different. There, decades of lack of medical access and limited capacity left populations vulnerable to being infected rapidly. An ominous question began to be raised: Was healthcare in the Americas capable of responding to the swine flu?
Mexico's healthcare system `overrun and underfunded'
Since 1983, Mexican officials have followed the World Bank blueprint for healthcare reform. This plan decentralised control of public facilities from the federal government to impoverished state governments. The result is a tripartite system as exclusionary as it is underfunded. Only 1% or 2% of Mexicans, the country’s elite, receive medical care in well-funded private hospitals. About 50% of the population, those with either state or formal sector employment, rely on a system of public hospitals. This leaves half the society, those employed in the vast informal sector of the economy, to a network of uncoordinated and severely underfunded municipal or state-run hospitals. Though doctors move seamlessly inside this system, taking shifts in all three parts, the quality of care is often determined by the level of funding. One commentator described municipal/state facilities as “overrun and underfunded”, with wait times for care from “hours to days”.(2) This, despite the fact that access to care is a stated right in the Mexican constitution.
People have attempted to adapt to the structural limitations of this separate and unequal system by fostering a culture of self-diagnosis and self-medication. Pharmacies in Mexico work fast and loose, providing nearly any medication, on demand, to those able to tender hard currency. However, for one-third of those self-medicating home remedies substitute for expensive trips to the pharmacy.(3) Easy access to medication, the precarious position of employment in the informal sector and an inaccessible health system, has rendered most Mexicans defenceless in the face of a virus that demands early intervention.
Specific complaints about the slow response of the federal government have also emerged. John Ackerman, a professor at the Universidad Nacional Autónoma de México, claims that at least one month of cases went unnoticed because of a lack of systemic coordination. Only the first death on April 13 elicited a response from the right-wing government of Felipe Calderon.(4) Even then, the lack of medical technology resulted in a three-day delay in identifying the swine flu as samples needed to be mailed to a lab in Winnipeg, Canada for analysis.
The Calderon government has also been reluctant to reveal the names of the swine flu victims. Ackerman, as well as other opponents of the president, suspect that most of the deaths are of poorer Mexicans who fall into the lowest rung of the system. “Poverty and inequity”, he argued, “really explain who dies in this crisis”. 25 years on, the neoliberal healthcare schemes of the World Bank bear an important responsibility for facilitating the rapid spread of the swine flu in Mexico and throughout the globe. Separate and unequal access to care left millions of people vulnerable to a virus for which they had no natural immunity.
Exclusion in the land of plenty
Most Americans would shudder to think that the healthcare system in US features some of the same inequities as that of Mexico. However, the United States' privately controlled system now excludes 48 million people (16% of the population), under-insures another 20 million and leads to the death of more than 20,000 people a year from treatable illnesses. Even those who are insured have faced a 117% increase in the costs of healthcare since 1999 as employers shift rising costs onto their workers.(5) Private control has also translated into long wait times for care. In Boston, for instance, it is easier to schedule an appointment for cosmetic surgery than for a skin cancer treatment, the average wait time of which is 73 days.(6) Despite utilising the highest levels of medical technology in the world, healthcare in the US is often inaccessible, costly and features long wait times for necessary procedures.
Americans, just as their Mexican counterparts, have adapted to this unjust system by avoiding care. A recent study conducted by the Kaiser Family Foundation reported that 6 in 10 of those polled had delayed or skipped medical treatment in the last year.(7) In this environment of avoidance, chronic conditions can quickly be converted into hazardous public health crises. Diabetes, hypertension and HIV/AIDS infection all continue to spread at alarming rates within the borders of the US.(8) Yet, access to care continues to be dependent on a person’s ability to pay. An airborne virus, such as the swine flu, becomes all the more efficient while filtering through a healthcare system directed by profiteering health insurance companies such as Oxford, CIGNA and Aetna. Both Americans and Mexicans have been left exposed by inefficient health systems.
Private corporations over public interest
Working Americans and Mexicans are not the only ones who have adapted to their countries exclusionary healthcare systems. With 85% of “critical infrastructure resources” in private hands, including much of the healthcare system, even US Department of Homeland Security officials avoid discussions regarding roadblocks in accessing care in their “preparedness strategy”.(9) Its December 2006 report, “Pandemic Influenza: Preparedness, Response and Recovery”, focuses almost exclusively on isolating and containing any outbreak of influenza. “Radically increased demand”, they argue, “will overwhelm local public health systems that currently have insufficient surge resources”.(10) One study estimates that a significant episode of influenza would create demand for 10 million hospital beds, yet there are only 1 million, two-thirds of which are currently occupied.(11) Instead of seeking necessary healthcare, employers are directed to send workers home.
The fault lines in the relationship with private industry can be clearly seen in the increasingly fierce debate over a potential H1N1 vaccine. The “seed stock” needed to create a vaccine is currently being produced by the taxpayer-funded Centers for Disease Control and Prevention (CDC). Once produced however, the stock is turned over to private pharmaceutical companies, such as GlaxoSmithKline and Sanofi-Aventis, which then concoct a vaccine for the commercial marketplace.
The problem with this arrangement is two-fold. First, drug companies limit their production capacity to levels that will be profitable in a “normal” business environment. Thus, much like the lack of hospitals, they cannot make a sufficient amount of the vaccine to meet demand for both H1N1 vaccination and the regular flu vaccine.(12) The same problem holds true for limited supplies of Tamiflu, which is produced primarily by the Swiss drug maker Roche.(13)
The resulting vaccine shortage has spurred intense competition between nations to purchase supplies for their citizens. After a round of arm-twisting by the World Health Organisation (WHO) and the United Nations, Roche agreed to allow drug makers in China, India and South Africa to create generic versions of Tamiflu.(14) No such compromise has been reached regarding the potential vaccine. First World countries, such as the US, France and Britain, have already secured deals for delivery of the first batch of vaccine while nations in the Global South remain on the outside of this emerging market. Sangeeta Shashikant of the Third World Network used clear terms to describe the precarious relationship, "There needs to be a better system in place so that WHO does not have to rely on the goodwill and charity of drug makers to get medicines for poor countries."(15) Viruses, of course, have little concern for levels of development or drug maker’s desire to conquer market share. H1N1 can easily spread into the Third World claiming millions of victims, mutate and return to stalk First World prey, setting off new “pandemic alerts” and creating more customers for the next set of privatised anti-virals.
Healthcare for the Americas
A virus that knows no borders or human immunity demands a fundamental re-thinking of what constitutes disaster preparedness. Open access to healthcare resources for all people in a society is a key for human survival. As the buzz around Washington now revolves around “healthcare reform”, single-payer healthcare, the proposal that most clearly addresses the weaknesses exposed by the swine flue panic, has been yanked off the table. Activists who demanded consideration of single-payer during recent US Senate finance hearings were silenced by arrest. In single-payer’s place is US President Barack Obama’s plan, which offers a public and private mix and seems to have gained the support of his benefactors in the private health insurance industry.
A single-payer healthcare system, as embodied in House Resolution 676 (HR 676), would eliminate private health insurance companies, thereby providing universal access to care regardless of the ability to pay. This would go far toward challenging the culture of avoidance, which has been a feature of an inequitable health system and facilitates the transmission of airborne infections such H1N1.
A single-payer healthcare system would do more than make healthcare universally accessible. Removing private interests from health insurance would also clear the ground for the development of a unified system of record keeping. Under our current privatised system, companies such as Google, Texas Instruments and Microsoft market incompatible records systems to an uncoordinated network of hospitals and practitioners. “A unified computerised database”, wrote single-payer advocate Dr Mary O’Brien prior to the appearance of H1N1, “would permit early detection of epidemics like a severe flu season and allow prompt immunisation to better control it”.(16) Only a single-payer system administered nationally could allow for such a development.
Winning a single-payer system in the US would only be a first-step toward a rational healthcare system. As demonstrated above, the role of private drug makers place severe limits on the general ability to respond to outbreaks and reinforces divisions between rich and Third World nations. This puts millions of people at risk. Adding private drug makers to a program of publicly administered universal healthcare would greatly enhance the health prospects for all Americans, while providing a platform to build a global response capacity.
Finally, this most recent flu panic should serve to challenge the imaginations of all single-payer system advocates. Perhaps, in fact, we have been thinking too small. What may really be needed is a universal healthcare plan for the Americas ambitious enough to encompass a wide geographic area and sensitive enough to provide local controls over some operations. There is certainly a wealth of knowledge draw on in the region. From Canada, there are many lessons about maintaining universal access. Brazilian drug makers have pioneered the production of low-cost generics. Cuba is a forerunner in the education of doctors and the dispensing of primary care. From the US, there is another type of lesson. That private companies should have no role in the dispensing of healthcare or production of pharmaceuticals. Such things should be located in the realm of human rights.
1. Niko Price, “Mexico Faces Criticism Over Swine Flu Response”, Associated Press, April 27, 2009.
2. Interview with John Ackerman, Chicago Public Radio, http://www.wbez.org/content.aspx?audioID=33869
3. Leyva-Flores R, Kageyama ML, Erviti-Erice J., ``How people respond to illness in Mexico: self-care or medical care?'', Health Policy 2001;57:15–26.
4. Interview with John Ackerman, Chicago Public Radio.
5. “Employer Health Benefits 2008 Annual Survey”, Kaiser Family Foundation, September 24, 2008, http://ehbs.kff.org/
6. Joanne Landy and Oliver Fein, “It’s What Most Americans Want – and We Can Make it Happen”, in 10 Excellent Reasons for National Healthcare, Mary E. O’Brien and Martha Livingston, ed., New York: The New Press, 2008, 112.
7. Kaiser Health Tracking Poll, April 23, 2009, Kaiser Family Foundation, http://www.kff.org/kaiserpolls/posr042309pkg.cfm
8. For instance, at least 3% of residents in Washington, DC, have HIV/AIDS well above the 1% mark for a “severe and generalised epidemic”. Jose Antonio Vargas and Darryl Fears, “HIV/AIDS Rate in D.C. Hits 3%”, Washington Post, March 15, 2009.
9. “Pandemic Influenza: Preparedness, Response and Recovery: Guide for Critical Infrastructure and Key Resources”, Dept. of Homeland Security, September 19, 2006, 24.
10. “Pandemic Influenza: Preparedness, Response and Recovery: Guide for Critical Infrastructure and Key Resources”, Dept. of Homeland Security, September 19, 2006, 28.
11. Nicholas D. Kristof, “A Nation of Typhoid Mary’s”, New York Times, May 2, 2009.
12. Maria Cheng and Frank Jordans, “WHO Meets on Production of Swine Flu Vaccine”, Washington Post, May 14, 2009.
13. Maria Cheng, “Critics: WHO Slow on Generics for Swine Flu”, Washington Post, May 11,2009.
14. E. Eduardo Castillo, “As Swine Flu Spreads, Who Should Get Tamiflu?”, Washington Post, May 12, 2009.
15. Maria Cheng, “Critics: WHO Slow on Generics for Swine Flu”, Washington Post, May 11, 2009.
16. Mary E. O’Brien, “It Will Assure High-quality healthcare for all Americans, Rich or Poor”, in 10 Excellent Reasons for National Healthcare, Mary E. O’Brien and Martha Livingston, ed., New York: The New Press, 2008, 32-3.