Is Health Public?

I've been laid up with H1N1 for over a week now, so perhaps that makes me particularly obsessed with health issues.  (I can't recommend the disease at all; my fever broke after 8 days and I still feel totally worn out.)  But reading an article in the Times - Lack of Sick Days May Worsen Flu Pandemic - reminds me of how our nation's conception of health puts us at risk of major health crises.  The sick leave issue is one good example.  We imagine sick leave as a benefit to individuals, one that must be earned through hard work.  This isn't an incoherent view.  Employers worry about malingering employees, recognize that many health absences are unrelated to broad public health concerns (e.g., a broken leg is not contagious),  and, in any case, have no particular interest in subsidizing the general protection of public health even in pandemics. 

But private employer needs can be in direct conflict with public health priorities.  The government (or to put it more crisply, the public at large) has a huge stake in incentivizing those with Swine Flu to stay home.  Not only that, it has a stake in using medical resources to treat serious cases - rather than taking up valuable physicial time for the purpose of issuing  excuse notes for employes in less serious cases.   For now, we resolve the conflict in favor of employer priorities.

Then there's the national health care debate.  What is the third rail of this discussion?  It's not the public option, of course: that debate is still robust.  Rather, there is no space for conversation about coverage of illegal immigrants.  (At least we're talking about coverage of legal immigrants.)  Again, this is because we see health care as a private entitlement that should flow only to the deserving.  But everyone in the public health community realizes that when diseases start to spread, there are no barriers based on immigration status. 

Like those who defend employer sick leave policies, opponents of complete health coverage aren't incoherent.  Perhaps they worry that immigrants will come to the U.S. for its generous health coverage or that these status-less immigrants will bulk up on "non-essential" medical services at taxpayer expense.  Maybe they think that medical care has little impact on public health and is mostly about individual life-style improvement.  Or perhaps they think that in moments of crisis, one-off interventions targeted at all residents will successfully stave off a pandemic.

What are the costs of viewing health as a private, individual matter?  At minimum, we expose ourselves to the risks of both widespread illness and the costs of addressing these pandemics.  More broadly, this conception perpetuates a fantasy of exceptionalism ("hard-working Americans can earn their way to good health and disease immunity.")    That  fantasy is great for political organizing - it wins elections, for sure, and probably makes us feel safe most of the time.  But if and when the ax falls - when a pandemic arrives that requires an international, communal response to a mortal enemy - it's not clear we'll have the political will, or the medical infrastructure,  to adequately respond. 

Or perhaps behind the scenes, there is a public health establishment that's ignoring our political conception of individualized health and preparing for a very different reality.  Here's hoping there are some out-of-touch elites preparing for the worst...

Comments

[Laura]

Feel better, Dan!