Monday, October 20, 2014

The Irish Widow and the Liberian Fiancé:
Ebola, CEO Disease, and the Public Good


The Ebola crisis highlights the absurdity of pretending that a private, for-profit health system can do what a real public healthcare system must.

Remember the deadly-Ebola-like-virus movie where Dustin Hoffman and Renee Russo and Morgan Freeman and a whole state-of-the-art medical team, along with a small army (There’s always an army!) swoops in to quarantine the sick, catch the monkey, whip up a vaccine, and save the country?

Keep dreaming. That’s a fantasy. In reality, there is no public healthcare system. There is no serious publicly-funded and publicly-managed infrastructure, institution, or set of resources devoted to healthcare as a public good.

As the Washington Post said: “The hospital that treated Ebola victim Thomas Eric Duncan had to learn on the fly how to control the deadly virus.” The CDC? It runs a web site and holds press conferences. The medical professionals are all in private hospitals, now mostly folded into large private healthcare conglomerates, that do whatever the MBAs who manage them dictate—which is what the MBAs who manage the private for-profit health insurance companies are willing to pay for. As Rob Urie points out: “Missing from this ‘process’ that now finds Mr. Duncan dead, two nurses who attended him with Ebola themselves, the American health care system revealed as wholly unprepared to deal with what at present seems a moderately communicable disease, is any notion of a public interest.”

Here’s Juan González, talking to Karen Higgins, to co-president of National Nurses United:
The executive director of your union, RoseAnn DeMoro …, specifically raised the fact the CDC has no control over these individual hospitals, that in the privatized hospital system that we operate in here in the United States, the CDC can only offer guidelines, and it’s up to individual hospitals whether they’re going to enforce those guidelines, practice those guidelines. And, in fact, the CDC said yesterday…that they have no plans to investigate what happened at Texas Health Presbyterian, that that’s the responsibility of the local Department of Health in Texas. 
Karen Higgins: I think, you know—unfortunately, I think she’s right, as far as what powers the CDC has. … And what happens is then CDC makes recommendations, guidelines, and then it falls apart, because what you do with it as an individual hospital, because every hospital is pretty much individual, is where it starts to fall apart.
When we look at what happened to “index patient” Thomas Eric Duncan at Texas Health Presbyterian Hospital Dallas hospital (known as “Presby”), we see concretely how the interest of the patient and the public starts to fall apart.  National Nurses United union co-president, Deborah Burger recounts what happened:
When Mr. Thomas Eric Duncan first came into the hospital, he arrived with a temperature that was tested with an elevated temperature but was sent home. On his return visit to the hospital, he was brought in by ambulance under suspicion from amongst his family he had Ebola. Mr. Duncan was left for several hours, not in isolation, in an area where other patients were present. Subsequently, a nurse supervisor arrived and demanded that he be moved to an isolation unit, yet faced resistance from other hospital authorities. Lab specimens from Mr. Duncan were sent through the hospital tube system without being specifically sealed and hand-delivered. The result is that the entire tube system, which all the lab specimens are sent, was potentially contaminated.
There was no advance preparedness on what to do with the patient. There was no protocol. There was no system. The nurses were asked to call the infectious disease department. The infectious disease department did not have clear policies to provide either. Initial nurses who interacted with Mr. Duncan wore generic gowns, used in contact-droplet isolation, front and back, three pairs of gloves with no taping around the wrists, surgical masks with the option of an N95 and face shields. Some supervisors said that even the N95 masks were not necessary. 
In defiance of the hospital management’s threat to fire anyone who spoke to the press, Briana Aguirre, a nurse at Presby, told reporters about the “extreme chaos” in the treatment of Thomas Eric Duncan:
“The nurses were throwing their hands up and saying this is unbelievable,” she said of the isolation ward. 
Aguirre also said the protocols from the U.S. Centers for Disease Control and Prevention were confusing and not clear. When Aguirre was given personal protective equipment that left her neck exposed, she was horrified. 
“We were told, ‘You take our guidelines and you do with it what you will,’” said Aguirre of CDC guidelines.
Aguirre also said that “suspected Ebola patients were wheeled around the hospital without protection and that doctors were told it was acceptable to move between rooms without disinfecting.” She also confirmed Deborah Burger’s observation that: “Our infectious disease department was contacted to ask 'What is our protocol?’ And their answer was, 'We don’t know’. There were no special precautions, no special gear. We did not know what to do with his lab specimens.”

The CEO Disease

Be aware that this hospital—part of the Texas Health Resources (THR) conglomerate, which describes itself as “one of the largest faith-based, nonprofit health care delivery systems in the United States, and includes 17 hospitals”—is not a rinky-dink operation. In fact, as one patient said to the New York Times, it has “always been considered the Neiman Marcus of hospitals, because a lot of wealthy people came here” (adding: “Now we wonder if it’s going to become the J. C. Penney.”). Its Margot Perot maternity wing is named for the wife of billionaire and former presidential candidate Ross Perot, and the board of its parent company, Texas Health Resources, is chaired by Anne T. Bass, the wife of the another billionaire, Robert M. Bass.

On the other hand, Presby’s emergency department is strictly J. C. Penney, rated below state and national averages.  In 2013, when Dwain Williams showed up in the emergency room coughing up blood, the doctors sent him home with antibiotics. Two weeks later, in Los Angeles, after having exposed his family, a few dozen airplane passengers, and who knows how many others, Dwain got diagnosed correctly, with tuberculosis. Sound familiar?

Upstairs, Downstairs, healthcare edition. At “faith-based” Presby, as with medical care throughout the USA, Margot gets her personal shopper at Neiman’s, while Dwain and Eric get the checkout line at Penney’s.

It’s also important to understand that, though the hospital (along with its parent THR conglomerate) is “non-profit,” that does not mean it can’t make or be run to make a profit. In fact, it is thoroughly imbued with a capitalist business ethic and management strategy, as its board of billionaires might suggest, and as is typical of the increasingly concentrated and corporatized healthcare “industry.” 

In a post at Naked Capitalism, Roy Poses, MD, Professor of Medicine at Brown University, talks about the “huge problems with concentration and abuse of power,” including “leadership of health care organizations that is ill-informed, incompetent, unsympathetic or hostile to health care professionals’ values, self-interested, conflicted, dishonest, or even corrupt[,] and governance that fails to foster transparency, accountability, ethics and honesty.” He lambasts “hospital CEOs and other top executives making millions of dollars a year based on their supposed ‘brilliance,’ or ‘visionary’ capacity, at least according to the board members … and the public relations people they hired....[even though] Most such ostensibly ‘brilliant’ hospital executives had no direct experience in clinical care, public health, or biomedical science.” He explicitly includes Doug Hawthorne who just retired as CEO of Texas Health Resources in September, 2014, after being inducted into the Texas Business Hall of Fame as a “healthcare visionary”—even though he has “no direct patient care experience, public health experience, or biomedical or clinical science experience.”

Hawthorne “was among the most highly compensated not-for-profit CEOs in the region,” with a 2012 base salary of about $1 million, and another $1.1 million bonus. He’s now taken a position on the board of the LHP Hospital Group Inc, a definitely for-profit “privately held company established to provide essential hospital capital and expertise to not-for-profit hospitals and hospital systems, with which it forms joint ventures.” Glimpsed here is the way American healthcare has become a complex web of symbiotic non-profit/for-profit relationships, overseen by “disconnected, unaccountable, self-interested,” careerist MBA managers who, suffering from what Dr. Poses calls this the “CEO Disease,” “feel entitled to make more and more money regardless of their or their institutions’ performance,… [and] may be particularly willing to countenance suppression of any facts or ideas that might raise doubts about their brilliance.” 

They know that, whatever any particular “non-profit” hospital they are working in is supposed to be doing, their job is to make sure it obeys logic of private capital, and feeds the very profitable pharmaceutical, insurance, medical equipment, and “essential hospital capital” industries in which it is enmeshed.  As the man said, Missing from this ‘process’ is any notion of a public interest.

So when we hear that, faced with a potential Ebola infection, a man with high fever and stomach pains, who said he had recently been in Liberia, was released with some antibiotics and Tylenol, should not we demand to know exactly why he was released. And when we hear that, on this patient’s second visit, with his family specifically warning about Ebola, a nurse supervisor “face[d] resistance from other hospital authorities” when s/he wanted to move the patient to an isolation unit—when we hear all this, should not every voice be raised, with urgency and anger, to ask: Which “hospital authorities”?! What kind of resistance?!

Why is every US media outlet not hounding every executive (including MDs with executive responsibility) of Texas Presbyterian and Texas Health Resources (Has any media outlet even identified the latter parent entity?) for the answer to those questions? How can I watch hours of news coverage, including PBS, and not detect any urgency about getting those questions answered, and remarkable complacency about the fact that every answer the hospital administrators have given has turned out to be misleading at best, or an outright lie at worst?

Again, we have a media spectrum running from rabidly right-wing coverage that irresponsibly stokes fear-mongering for the benefit of Republicans, to moderately right-wing coverage that treats dangerous, literally deadly failings of a healthcare system, and the real imminent danger of Ebola, with a great big yawn, so as not to overly discomfit the Democratic administration.

What’s In Your Wallet?

The reason we don’t hear the questions is because everybody knows the answers, and nobody (in the media) wants to call attention to them. Thomas Eric Duncan’s nephew, Iraq War veteran Josephus Weeks, knows why his uncle was released with a Tylenol: because “he was a man of color with no health insurance and no means to pay for treatment.” Counterpunch writer Rob Urie knows why “hospital authorities” resisted putting Duncan in isolation: because he “risked hospital bills in the tens of thousands of dollars that he reportedly didn’t have. The hospital ‘risked’ providing expensive treatment to a man who likely couldn’t have paid for it.”

Is there a sentient adult in the United States who does not know these answers?

The problem is: What are we going to do about them?

Everybody knows the first question at the hospital is “What health insurance do you have?”—i.e., Who is going to pay your bill?  What we do know from watching the news, and seeing hospital bills, is that the cost of treating just three patients so far has to be over a million bucks. Of course, that’s in American medical billing funny-money, but, hey, that’s the game, isn’t it? In our best-in-the-world capitalist healthcare system, someone has to pay those inflated bills, or write them off. If the current few become thousands or tens of thousands of domestically-infected Americans, what are we going to do—that is, who is going to pay for them? 

And it goes beyond the hospital. The friend in whose apartment Thomas Eric Dyson was staying was trying for days to figure out on her own what to do with the sheets and towels he had been using. It was not until the television audience heard her talking about this with Anderson Cooper that “officials” were publicly embarrassed into taking responsibility for getting the apartment—potentially deadly for the five people living in it, and the whole community—cleaned up in some kind of medically professional manner. As USA Today reports, the state-of-the-art protocol followed was for these “officials”—From where? The hospital? The CDC? The city of Dallas? Who exactly is responsible here?—to call around and beg local cleaning companies to take the unprecedented and dangerous job. As might be expected, “One after another, the companies declined,” until The Cleaning Guys, a Fort Worth company, stepped up.

This is a job that took “15 workers in hazmat suits stripped the northeast Dallas apartment, ... tearing up carpets, mattresses, furniture, ‘everything not bolted down,’” triple-bagging everything and “cramming” it into 140 55-gallon drums, getting permits “specifically for Ebola transport,” and driving the drums 400 miles to an incinerator.

And let’s not forget the people who were living in the apartment--Duncan's fiancée, Louise Troh, her 13-year-old son, and her two nephews in their 20s. For their mandatory quarantine, Dallas Mayor Mike Rawlings and County Judge Clay Jenkins had to arrange for a friend, or friend of a friend, to give Louise and family a decent place to live for the duration of the quarantine.

Just out of quarantine, Louise has lost the deposit she had put on a new apartment before the drama began, and is now, for lack of money and other reasons, having a hard time finding new, permanent housing with her “Ebola family.” As her pastor says: “There is a lot of concern and fear out there in the rental property community.”

Hospital care, on the fly. Cleanup, on the fly. Housing, on the fly. It’s nice that a local cleaning company, and the mayor’s friend with a spare house, pitched in. The USA Today article previously cited is entitled: “Ebola fight takes a community-wide response,” and it lauds such gestures. But depending on the kindness of strangers to prevent the outbreak of one of the world’s nastiest communicable diseases is not—is the opposite of—a public health system.

A public health system would be funded, provisioned, trained, and ready to mobilize and intervene instantly and comprehensively, without having to call on The Cleaning Guys. An effective “community response” requires permanent institutions backed not only by sufficient funds and skills, but, most importantly, by a deeply-entrenched social ethic that understands and embraces things like the public good and the common welfare. Unfortunately, our political and media culture is dominated by a “Laissez-faire and such like,” enrich yourself, CEO-diseased ideology that worships private wealth and denigrates public interest, and precludes us having a real public health system. We’re left to hope that The Cleaning Guys answer the phone, because Dustin Hoffman isn’t coming.

All of the resources and activity mentioned above had to be mobilized for one patient.  How’s it going to work if we end up with thousands of tens of thousands? Are all the private health conglomerates that now run most of the hospitals in the US, and all the private, for-profit health insurance companies that pay all of the bills, going to forgo their profit-seeking until everybody who might have Ebola is thoroughly taken care of? Is the dreaded “government” going to pay those bills? Or will we just throw the Ebola-infected moochers out on the street? Why should those sick people get a free ride, when everybody else, even children with horrible diseases, have to pony up?

Why, indeed? Why, in the world’s wealthiest country, should anyone who is seriously ill be denied medical care because s/he doesn’t have enough money? 

Nobody’s talking about this because the media don’t want to go there. People might notice that the worst infection in American hospitals isn’t Ebola; it’s CEO disease. They might notice that the only way we can deal with a real epidemic danger like this is to effectively suspend the private for-profit healthcare system, and rig up an ersatz public healthcare system on the fly. With the hope that no one will ask: “If that’s what we need, why don’t we just have it?” Let’s talk about everything else.

Who’s WHO

This is not just an American problem, either. Tariq Ali remarks, in his interview with Allyson Pollock, professor of public health policy at Queen Mary University of London:
[T]he entire world capitalist system as it functions is basically not in favour of public health services, they are in favour of privatised solutions, privatised facilities which means that in most countries increasingly you have a two or three tier system; you have very good quality hospitals for the rich and people who can afford them, you have a second tier for more middle class people who also have to pay but not so much and their facilities aren’t so good and then you have public hospitals, not just in Africa but in countries like India and Pakistan and Sri Lanka, which are a total complete disgrace and nothing is done about it on a global level at all because this is not a priority.
Allyson Pollock remarks how even formerly Social Democratic Europe is infected by CEO Disease:
European health care investors need to find new markets and they are busy attempting to penetrate and open up the health care systems of Europe.  And of course the biggest trophy for them is the United Kingdom NHS because it was for a long time the most socialised of all the health care systems.. …[T]he NHS has now been reduced to a logo and what the government is now doing is accelerating a break up of what remains of the national health service under public ownerships, so closing hospitals, closing services and privatising or contracting out. …
The government in England …wants to reduce the level of services that are available publically, create a climate of discontent with the NHS, forcing people who are in the middle classes, that’s like you and me Ali, to go privately and pay either out of pocket or with our healthcare insurance, so that we desert, we exit what is left but at the same time the government is reducing all our entitlements because there is no longer a duty to provide universal healthcare. 
Margaret Kimberely, in a must-read article at Black Agenda Report, reveals who has WHO—the whole wide World Health Organization—in his hands:
The largest contributor to the WHO budget is not a government. It is the Bill and Melinda Gates Foundation which provides more funding than either the United States or the United Kingdom. WHO actions and priorities are no longer the result of the consensus of the world’s people but top down decision making from wealthy philanthropists.... 
Privatization of public resources is a worldwide scourge. Education, pensions, water, and transportation are being taken out of the hands of the public and given to rich people and corporations. The Ebola crisis is symptomatic of so many others which go unaddressed or improperly addressed because no one wants to bite the hands that do the feeding....
The WHO and its inability to coordinate the fight against Ebola tells us that public health is just that, public. If the CDC response to Ebola in the United States fails it may be because it falls prey to the false siren song of giving private interests control of the people’s resources and responsibilities.
Professor Pollock elaborates on this point:
[W]hen Western governments and the US come in, they tie [aid] to conditionalities, which is usually around the Bill & Melinda Gates priorities and not around the essential public health priories and the WHO has its hands tied. …[W]e are talking about democratic deficits that are happening when large global funds like the Gates Fund or the Buffett Fund can actually determine what the world priorities are and so distort what the priorities should be for public health because it is tied to the economics, they need to industrialise, they need to medicalise and they need to pharmaceuticalise. …. [O]ne of the big problems is that because of this huge amount of money that the Bill & Melinda Gates Fund have, is that the technicians, like myself, the public health tribes, have been captured because of their success in predicated upon getting jobs, or research, tied to the interests of the Global Fund. 
As Pollock emphasizes, ensuring public health “doesn’t need magic potions or millions of dollars spent on genetics and the laboratories, it needs very, very basic things, but they are essential because they are what the public health infrastructures are built on.” It needs, she reminds us, “re-building public health infrastructure and that includes putting in community primary health care, community health systems, infection control units at community level, putting in hospitals and training nurses and doctors.” These kinds of basic services are what ensure the health of a population, and stop an infectious disease from getting out of control. Yet they are precisely what capital-oriented NGOs, the vectors of CEO Disease, undermine:
[B]ecause a few doctors and nurses are there, they want to leave …, or they want to work in the private sector or they want to work for these NGOs because the money is much better and so the whole public health system is completely hollowed out.  And this is a real problem because the Gates Foundation, Bill & Melinda Gates, do not believe in the public sector, they do not believe in a democratic, publically owned, publically accountable [healthcare system]. 
Remember the deadly-Ebola-like-virus movie where Marion Cotillard, playing a WHO scientist, teams up with Laurence Fishburne of the CDC to quarantine the sick, defeat the Chinese extortionists and the evil conspiracy blogger, whip up a vaccine, and save the world? Fuggetaboudit. Marion’s not coming either. But Bill Gates has some gadgets to sell.


In a previous post on Obamacare, I evoked the conservative 19th-century essayist, Thomas Carlyle, who trenchantly criticized the insurgent capitalist ethic of “Supply-and-demand, Laissez-faire and such like,” insisting that “Cash payment is not the sole nexus of man with man.”  I present it again, because it’s spot on here, his example of an incident that perfectly illustrated for him, and should for us, the utter folly, certainly when it comes to health and disease, of putting private profit over public interest:
A poor Irish Widow, her husband having died in one of the Lanes of Edinburgh, went forth with her three children, bare of all resource, to solicit help from the Charitable Establishments of that City…referred from one to the other, helped by none; "You are no sister of ours; what shadow of proof is there? Here are our parchments, our padlocks, proving indisputably our money-safes to be ours, and you to have no business with them. Depart! It is impossible!"
—till she had exhausted them all; till her strength and heart failed her: she sank down in typhus-fever; died, and infected her Lane with fever, so that 'seventeen other persons' died of fever there in consequence. The humane Physician asks thereupon, as with a heart too full for speaking, Would it not have been economy to help this poor Widow? She took typhus-fever, and killed seventeen of you … she proves her sisterhood; her typhus-fever kills them: they actually were her brothers, though denying it!  Had human creature ever to go lower for a proof?  [Slightly rearranged. Carlyle’s emphasis.] 
Yesterday’s Irish Widow is today’s Liberian Fiancé. The resemblance is uncanny. Rob Urie puts it in a discourse that might resonate even with those susceptible to CEO Disease: From typhus to Ebola, from 19th-century Edinburgh to third-world Monrovia to red-state Dallas, it remains the case that, regarding “stopping the spread of communicable diseases in the public interest, the profit ‘motive’ that in theory supports capitalist efficiency is the antithesis of social efficiency in the public realm.”

How much lower do we have to go for proof?

See related post: Ripley Was Right: Ebola, Science, and the Precautionary Principle


Contagion (2011) - IMDb

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