In the 1980s many of us witnessed the near lack of concern and urgency in the AIDs epidemic because it was initially perceived that it affected only a small minority group whom many disliked and who were easy to discriminate against. The affluent and government officials view themselves as unaffected and often did not wish to commit the needed resources to reverse the epidemic.
The same was true in the 1925 outbreak of the bubonic plague. At that time the plague was 90% fatal and emerged in a Los Angeles, Mexican community, a disparate population with meager resources and social status. From the start the outbreak was framed as a Hispanic problem with the names of the afflicted published in the newspaper. A quarantine of five Mexican urban districts was enacted. However, only two had verified cases. Although arguably effective, such mass quarantines would not be tolerated today. Similar to the AIDs epidemic, this infection control policy was blatantly discriminatory.
Recently, the devastation from the plague epidemic in Los Angeles was again retold in the devastation in Haiti. The book, “The Deadly River,” describes the killing of almost 9,000 defenseless souls by a largely treatable and preventable disease, cholera. The epidemic targeted the poor. Despite being caused by the U.N. relief workers, the interests of wealthy nations took precedence over the defenseless by not promptly implementing preventive strategies such as vaccinations, environmental cleaning and proper sewage disposal.
Most recently, an editorial in the New York Times reassured readers regarding the United States’ epidemic of deadly antibiotic resistant-bacteria. It was asserted that readers “almost certainly don’t need to worry about any of this.” And reassurances were given by describing practices in the best hospitals. Setting aside the validity of the premise which can be questioned, the statement appears to ignore the socioeconomically disadvantaged, many of whom may not have access to the described high-quality care.
Those responsible for the epidemic and impacted financially will often deny responsibility and lobby government leaders to let them continue business as usual, often citing contradictory poorly performed research. However, when epidemics affect the affluent and elected officials, action rapidly takes place. This happened in the United States parrot fever epidemic of 1930.
Epidemiologists had all but proven that California parrot farms were acting as the reservoir and were the source of the disease. California enacted a ban on sales which had a profound financial impact on parrot farmers who lobbied the governor for relief. They falsely argued that if a parrot was not sick by age 4 months, it could be safely sold. Dollars blinded clear policy decisions and the embargo was lifted. A year later, the wife of Utah Senator William Borah contracted parrot fever, barely escaping death. Senator Borah persuaded President Hoover to reinstate the embargo, and the epidemic was finally brought under control.
These are just micro-examples of the inequities in healthcare and in our society as a whole, but unfortunately for those of privilege, resistant bacteria do not discriminate and the creation of reservoirs in the socioeconomically disadvantaged will eventually wreak havoc on all of society, including those who view pandemics as someone else’s problem.
One wonders if the devastation of the bubonic plagues and cholera epidemics would have occurred in predominantly affluent and white communities. Such communities are viewed as having better sanitation and are not plagued by rat infestations. But in reality, Haiti’s cholera epidemic has been attributed to U.N. relief workers and the common ground squirrel can transmit bubonic plague. No one is truly safe.
Obviously, mankind has a long history of ignoring and not investing resources in disadvantaged “disparate” populations. But what needs to be done? Should we risk-adjust these reports and mathematically lower the devastation of these epidemics as reported to the public and recorded in history?
Unfortunately, that is a major initiative that the United States government has directed toward the National Quality Forum, the non-profit organization under contract for recommending standardized quality measurements which are used by government agencies. An initiative which will “correct” or mathematically adjust the reported poorer outcomes seen in socioeconomic disadvantaged disparate populations, under the guise of “promoting equal treatment of all patients who enter the healthcare system”.
Frontline facilities do not wish to be penalized for poorer outcomes, when these outcomes are associated with a disparate population. However, this association may be due to quality problems caused by reduced healthcare access and the underfunding of Medicaid and frontline facilities, and not a direct characteristic of the population. The end result may cause the reported quality of care to look better than it actually is. And the data which supports the desperate need for a change in our healthcare system, becomes less alarming or not alarming at all.
In the United States, a foundation of our society is that all “men (and women) are created equal”. Healthcare is a right and high-quality healthcare needs to be available to all, not just a select few. This is an imperative which we must uphold and not shrug off our responsibility by mathematically hiding our society’s moral and medical lapses.
Kevin Kavanagh is a retired physician from Somerset Ky, Board Chairman Health Watch USA and Associate Editor of the Journal of Patient Safety.