America’s Preexisting Conditions

How Donald Trump, a broken health care system, and disinformation made COVID-19 worse in America

America’s Preexisting Conditions
Vitals of America’s politics/Getty Images

For some, a bout of COVID-19 can mean going from walking and talking to requiring life support to breathe in a matter of days. For others, it may mean some annoying sniffles — or no symptoms at all. While it is impossible to predict any individual’s course, there are clear patterns. Older people and those with preexisting chronic conditions like diabetes, asthma, or hypertension suffer shockingly high rates of mortality. Indeed, 40% of those who have died of COVID-19 in the United States have been residents of long-term care facilities.

The same is true for societies. For some, like New Zealand, it has meant instituting a round of preventive measures to fully contain transmission with intermittent lockdowns when outbreaks are observed. For others, like the United States, it has meant hundreds of thousands of deaths and economic instability on a scale that has not been seen since the Great Recession. Again, there is a pattern: Societies with the worst preexisting conditions have suffered the most.

Few have suffered worse than the United States. We account for over 400,000 of the world’s two million deaths — one in five deaths globally, despite being only 4% of the world’s population. That means that Americans have been 20 times more likely to die of COVID-19 than the global average.

There are two societal preexisting conditions that have been particularly devastating. First, we suffer a profound social insecurity that has threatened American lives and livelihoods well before most of us had ever heard of the word “coronavirus.” The second is that Big Tech has corrupted our social discourse, leaving it to be instrumentalized by a political demagogue to destroy public trust in our institutions. Alone, each of these chronic preexisting conditions has been slowly sickening our country. But together, in the context of this pandemic, they have put the United States on life support.

Consider first the systematic, crippling insecurity that too many Americans suffer for lack of basic resources. The pandemic has accentuated this insecurity. Two in five Americans do not have $400 in their bank account to cover emergency expenses. Fourteen million Americans are facing eviction, collectively holding upwards of $25 billion in back debt on their rentals. By September of last year, one in five student loan borrowers was in default.

But nothing is more emblematic of American insecurity than America’s health care system. Top-heavy and corporatized, our health care system seemed destined to buckle under the pressure of a pandemic, leaving millions of Americans without health care access while frontline health care workers struggled for even the most basic personal protective equipment.

Americans spend 18% of every dollar that moves through the economy in gross domestic product on health care — nearly double what other high-income countries spend. Yet we have the unique circumstance of being the only country in the world where one in 10 of our residents is uninsured. Far more yet are underinsured — meaning they have insurance but still face considerable out-of-pocket costs should they fall ill. The average insured family’s deductible — the paywall that stands in the way of accessing the insurance dollars one has already paid in premiums if one should get sick — is over $3,500. This is part of the reason why medical debts account for nearly two-thirds of personal bankruptcies in America. And as the pandemic led to massive job losses in April, an additional 5.4 million Americans lost their insurance, too.

Beyond health insurance, the for-profit health care delivery system relies on lucrative elective procedures to stay afloat. That profit model has already led to a hollowing out of health care centers that do not have a high enough density of privately insured patients demanding care, such as rural or poor, urban communities. But even those that were hanging on by a thread were nearly knocked out by the pandemic. To make room for COVID-19 patients, health care centers were forced to cancel elective procedures. The move was a boon for health insurance companies that got to keep the reimbursements they would have paid to hospitals — but hospitals were left without that lucre, battling both COVID-19 and bankruptcy at the same time.

And nationwide, hospitals were unable to provide their staff with the personal protective equipment needed to face this pandemic head on. Why? In an industry constantly aiming to increase profit margins, hospitals routinely hold a limited supply of personal protective equipment — assuming that an emergency supply chain will bail them out instead. Perhaps this strategy is fine for one hospital, but not for the entire health care system.

Our national public health infrastructure — previously ranked as the best in the world according to the Global Health Security Index — had been slowly decaying over decades of disinvestment. Funding for public health emergency preparedness is down over the last decade. And state and local health departments saw their budgets drop by 45% over the past 15 years — a result of the austerity policies of the Great Recession. Even the National Security Council’s pandemic preparedness unit, designed to take on such a threat should it arise, was disbanded, and the pandemic playbook containing the wisdom gained from the H1N1 pandemic and Ebola epidemic was disregarded.

Then there were the economic consequences of the pandemic and the lockdowns needed to combat it. Millions lost their livelihoods. Yet more were forced to choose between their livelihoods and the public health advice meant to protect their lives. These people who drive our buses, cook our food, stock our groceries, and clean our childrens’ schools have recently been the subject of a public debate about whether they should earn at least $15 an hour for their work. To excuse their newfound risks, we deemed them “essential,” though without meaningful relief that allowed them to stay home and continue to feed their families, we might as well have called them “expendable.”

Unemployment spiked, but curiously, so did the stock market. Without anywhere else to go, capital found its way into the coffers of the richest corporations — netting the richest billionaires in America billions more. Indeed, billions of dollars in Paycheck Protection Program loans, intended to bail out small businesses and protect their workers, found their way to major corporations instead. The “K-shaped” recovery destroyed thousands of small businesses, consolidating the market power of the largest corporations, while millions were forced into poverty. And yet, COVID-19 relief packages stalled for months — with the most recent package halving direct cash payments as Republicans held out for liability protections for corporations whose employees might have become sick.

As millions lost their income, they worried about paying rent, buying groceries, or even affording water. They had to worry about paying for college for their star young student, or going “underwater” on that mortgage they struggled to afford.

Just as a lingering chronic lung illness can tip what would have been a mild infection into a near-death experience, preexisting societal conditions became a national catastrophe as COVID-19 made landfall. Circumstances such as lost health insurance, failing hospitals, lost jobs, corporate consolidation eliminating small businesses, foreclosure, and eviction were all chronic features of the American landscape well before COVID-19. Every day, Americans lost their lives or livelihoods because of them. The rest held on as best they could. The uninsured scraped by, rationing medicine or avoiding needed doctor’s visits. People found more gigs to make up for lost jobs or stagnating income. But as COVID-19 decimated the American economy and filled its hospitals, holding on became that much harder.

Persistent insecurity has had another consequence: fraying public trust. That’s the second major preexisting condition. And because public health is about collective action — the will of people to do their part for a common good — it requires a level of trust in public institutions. You have to trust that the folks making public proclamations about how to prevent the disease are acting on the best available science; you have to trust that public officials are acting in your best interest, not for some pecuniary or political gain; you have to trust that others in the community are going to take actions to prevent the spread of the virus as you choose to do the same. Without that trust, without that collective action, the work of prevention breaks down.

Like health care, the collapse in public trust has been accelerated by another set of major corporations exploiting Americans for their profits: Big Tech. We often think of ourselves as the consumers of various tech platforms and the services they offer. We are not. We are the product. The customers are the ad sponsors who monetize our eyeballs to spend ever more time on those platforms. One of the hallmarks of addiction is tolerance. The more you see, the more you need to see to get the same effect.

So to keep us there, they have devised algorithms to offer us ever more enticing content. It is even called a feed. Rather than challenge us with information that might force us to reconsider our worldview or force us to consider the reasonable arguments on the other side, the algorithms drive engagement with more and more extreme content. One study out of Brazil analyzed 72 million comments on 330,925 videos on 349 channels on YouTube and found that users who engaged with middle-ground, right-wing content would often end up engaging with the most extreme, far-right content by way of video suggestions. Meanwhile, more and more time on tech platforms means less and less time in real-world social engagements that bring people together.

Nobody has exploited this polarization machine like the twice-impeached former president, Donald Trump. His Twitter presidency weaponized the fear and insecurity of poor white people by blaming the failure of corporate capitalism on immigrants and urban Black communities — “American carnage.” Meanwhile, his administration moved to consolidate corporate power through tax cuts and deregulation. He called the media “enemies of the people” and told his supporters: “I alone can fix it.” Instead, he made it worse. But his disinformation, particularly about the outcome of the 2020 election, culminated in an insurrectionist mob storming the U.S. Capitol on Jan. 6.

As the pandemic emerged, Trump did not simply downplay the virus and distract from the public health response. He marginalized the voices of experts in his administration, muzzling Dr. Anthony Fauci, the leading infectious diseases official, and hijacking the likeness of the Centers for Disease Control and Prevention to support his administration’s political narrative about the pandemic. Worse, recognizing that his supporters were chafing under the weight of lockdowns and public mask-wearing directives, he echoed and amplified their anger — feeding raw meat to his base in an election year. In fact, one Cornell University study found that Trump was the biggest source of COVID-19 misinformation.

All of this eroded public trust and cast doubt on anything his administration touched — even if it was largely the work of independent scientists and researchers, such as the effort to produce a safe and effective vaccine. In fact, a September Kaiser Family Foundation poll found that the majority of Americans believed that the Trump administration would apply political pressure to rush a vaccine. And public support for taking a coronavirus vaccine dropped throughout the election season.

As mis- and disinformation flooded their platforms, social media corporations were slow to respond. Their profit model requires them to occupy more and more of our ocular real estate to advertise to us — and disinformation is clickbait. Indeed, peddling division through political ads and right-wing echo chambers is part of the business model. And stopping medical disinformation, well, that just does not seem worth the effort. The nonprofit organization Avaaz found that by August 2020, medical misinformation was viewed an estimated 3.8 billion times on Facebook across five countries. Worse, only 16% of the misinformation they found had a warning label — meaning their lax fact-checking missed the vast majority of misinformation, and the rest was allowed to stay up anyway.

As challenging as the last 10 months have been, the worst may yet be in front of us. Cases have consistently climbed over the past several months, driven by indoor migration that comes with the fall and winter. The holidays increased hospitalizations beyond capacity in many communities, and the death count is over 4,000 per day nationwide.

At the same time, however, the end is in sight. Though they have been slow to be deployed, there are now two safe and effective vaccines that are already hitting shelves nationwide. More could yet be on the way. As doctors, nurses, and public officials who have been the first to take the vaccine share their benign experiences with it, public support for the vaccines is on the upswing, though vaccine hesitancy remains a constant threat to achieving the level of vaccine distribution we need to achieve herd immunity.

But immunizing individuals is not enough. We must immunize our society, as well.

Healing is not just about ending the spread of this virus. It also has to be about making the spread of the next one less likely. That will require us to address the systematic insecurity that left us so vulnerable. It must mean rethinking our health care system so that it protects our health, rather than maximizing the bottom line of ever-larger corporations. It has to mean addressing the economic vulnerability that pitched so many Americans into poverty while growing the billions of those who already had them. And it has to mean addressing the forces of climate change that are accelerating the probability of the next virus. Stopping the next pandemic also requires us to inoculate our public discourse. That means regulating Big Tech. Public health depends on public trust, and our public trust depends on freeing ourselves of the yoke of a system of public discourse intended more to monetize eyeballs than to achieve a reason-oriented and truth-dedicated public debate.

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