First of all, many more Americans will die of heart attacks than will ever die of Ebola. This is not like smallpox, whose spread can only be controlled with great difficulty. The nature of the disease is that, because it can only pass from person to person through direct contact with bodily fluids, it is self-limiting. It is chiefly a disease of caregivers for that very reason. In that regard, we must give the doctors and nurses on the front lines credit for being willing to take significant risks to help and treat others afflicted with this horrific disease. There are heroes in the military, and we’re seeing some real heroes in our public health system, too.
Once we get beyond the individual heroics, however, we should be quite concerned about breakdowns of protocol in the nation’s hospitals. Ironically, part of the problem may be the unintended consequence of scientific advancement in the United States. In the absence of having to be on alert for treating infectious diseases, American hospitals have let their guard down and their skills lapse. Partisan politics has exacerbated the problem by leaving the nation in the lurch without a surgeon general. Normally that’s the person responsible for managing major public health issues, the leader with the skills to coordinate responses and put the public at ease. Absent that, the President has tapped Ron Klain, a Washington insider known for his ability to manage crises, to be his “implementation expert.” We desperately need someone like that because, while the Center for Disease Control has fantastic scientists, management has never been their main skill set.
"Ebola may serve as a badly needed wake-up call about something the public health and biosecurity community has been banging the drum about for years: the U.S. has massively underinvested in public health."
Our ability to safeguard against infectious disease is also stymied by the fact that public health in the U.S. is largely relegated to the states, which vary in their commitment and capacity, and none of which have the resources of the federal government. Ebola may serve as a badly needed wake-up call about something the public health and biosecurity community has been banging the drum about for years: the U.S. has massively underinvested in public health. As in so many other areas of the nation’s infrastructure, the elements of our healthcare system have eroded, and we need to shore them up before the inevitable next virulent disease threat materializes.
For example, hospitals are the first line of defense in an outbreak. Yet the number of patients that our hospitals can manage with extreme cases is extraordinarily low. We have only four bio containment units in the nation specifically equipped to handle a disease such as Ebola. Furthermore, in the interest of efficiency, we’ve decreased the number of beds available for extreme cases, leaving ourselves unable to admit patients in the face of an epidemic. There’s a constant trade-off between efficiency and slack capacity that seems unimportant until you are suddenly in desperate need of that slack.
With public health, however, efficiency should not be the chief goal. Rather, the goal should be to optimize to mitigate catastrophes while managing routine concerns without interruption. That way, when resources are required, they are available. We learned a parallel lesson in the wake of the 2008 financial crisis. The risk-management tools and safety margins needed to manage normal disruptions in the market were completely inadequate to handle a major catastrophe. We got rid of the buffers against crisis in the name of efficiency, but we would have been much better off keeping them around and paying for them so that we had them to protect us.
More broadly, people don’t appreciate how valuable a lot of the government’s services are until they need them. Public health is the quintessential example. If you’re doing it right, no one notices. As Benjamin Franklin said, “Experience keeps a dear school, but fools will learn in no other.” With Ebola, we’re learning the hard way about the decline of the public health infrastructure in the United States. The time has come to take action before something even worse comes along.
Harvard Business School assistant professor Gautam Mukunda (@gmukunda) is an expert in political science, leadership, and international relations, and the author of “Indispensable: When Leaders Really Matter.” He draws from that background and his former roles as National Science Foundation Synthetic Biology ERC Postdoctoral Fellow at MIT and IGCC Biosecurity Fellow at the University of California San Diego to discuss how the Ebola virus should serve as a catalyst for change in the U.S. healthcare system.