If there’s one thing made abundantly clear as the pandemic rages on, it’s this: Technology alone can’t save us.
Acknowledging that limitation is important because for too long, too many of us have regarded scientific and technological advances in a vacuum. Mesmerized by buzzwords and hype, propelled along by the next iteration, as a society we have been lulled into thinking that technological creations, whatever they may be—artificial intelligence, telemedicine, point-of-care diagnostics—save the day. We are awed by Google Health’s initiatives to use AI to diagnose lung cancer or eye disease. We are dazzled by Elon Musk’s Neuralink implants promising to treat people with spinal cord injury. Such technologies represent bold feats and worthy goals, but what sometimes gets lost in our love affair with high-tech is that our greatest successes, when it comes to health, revolve around more mundane triumphs—access to preventative care, clean air and water, nutritious food, maternal and infant health. During this pandemic, we have been shown just how important such lower-tech basics are. How much effect can a cool new phone app tracing the whereabouts of the COVID-infected have, when testing is not in place to determine who’s got the virus in the first place?
“There’s a legacy of failure of technological interventions in global health,” says Emily Mendenhall, associate professor in the Science, Technology, and International Affairs at Georgetown University. “That’s the history of global health. Everyone thinks there’s this technological intervention that’s going to fix things. But until you fix your health system and get your politics in place, you can’t fight a pandemic … in a lot of ways, the most important response is behavioral and political.”
In short, the razzle-dazzle of technology cannot replace the hard-fought efficacy of something as unglamorous as a societal decision to support a robust public health infrastructure. “It’s saved the most lives by far, for the least amount of money,” Tom Frieden, a former director of the Centers for Disease Control (CDC), said in an article titled “Why We Are Losing the Battle Against COVID-19” that appeared in The New York Times Magazine in July. “But you’d never guess that based on how little we invest in it.”
There’s a disconnect between the bright and shiny promise of new technological toys and the darker reality of what we’re now living through, including a lack of political leadership, underfunded health programs and a tenuous patchwork of decentralized, often ineffectual health departments, ill-equipped to mount a coordinated response when it really matters. The United States has been hit harder than many other countries because in 2020, it exemplifies these real-world problems.
Technology can do miraculous things, and it has helped manage COVID-19 in many ways. It has allowed for remote work to keep many businesses humming along and telehealth doctor’s visits for those who wouldn’t or couldn’t risk an actual physical visit (see also “From Face-to-Face to FaceTime” in this issue of IEEE Pulse). Robots have been used to deliver medicines and goods in contaminated areas and help doctors treat patients. (One of them, the UVD robot, developed by a Danish consortium, won an award at the European Robotics Forum in Malaga in March 2020. It works with virus-killing ultraviolet light and functions autonomously in hospitals and other high-risk areas.) Ultimately, however, it doesn’t matter how brilliant the technology if more fundamental structures are broken. Jeffrey Levi, professor of Health Policy and Management at the Milken Institute School of Public Health at George Washington University, names four crucial ways in which the U.S. public health system has floundered. First, is leadership. “A public health system is only as good as the leadership from the top,” he says. “In the context of an emergency, and when you have the president of the United States and many governors actively arguing against the science, that diminishes the impact any public health official may have.”
In addition, says Levi, there is the now well-known debacle around faulty and limited testing, as well as antiquated approaches to data collection. He argues that local health departments have no systematic approach to mining data in electronic health records to provide a situational awareness of how the virus is spreading through a community. Because states don’t have their own capacity to collect data, they rely on data collected by the CDC. “ This makes no sense,” he says. “There’s been a huge investment in technology for the health care system. There has not been a parallel investment in building the data capacity of public health departments. And so that’s a core infrastructure issue.”
And of course, there is public health funding. Or rather, the lack thereof. A 2019 report of The Trust for America’s Health, a nonprofit, nonpartisan group advocating for public health, named chronic underfunding of public health as a “consistent obstacle” with just 2.5% of all health spending in the country going to public health in 2017. “Such underfunding flouts overwhelming evidence of the life-saving cost-effectiveness of programs that prevent diseases and injuries and prepare for disasters and health emergencies,” the report went on to say.
Although the United States spends more than any other country on health care, it gets worse results because it spends money in the wrong ways. We ask private industry to innovate (and private industry receives billions from venture capitalists), but have dispensed with bolstering the areas that might have given us more resilience in this time of crisis, including better funding of local health departments and more money spent on public health emergency preparedness and chronic disease prevention. Although programs tackling chronic disease such as diabetes, lung, and heart disease may not seem to intersect with a pandemic, they do. Those who are obese or who have chronic illnesses, are at a much higher risk of dying of COVID-19.
“We could have been far more resilient when this virus came around if we didn’t have the underlying sicknesses in this country,” says Shelley Hearne, professor of the practice at the Johns Hopkins Bloomburg School of Public Health.
Public health experts believe that we can improve our public health system, not only by funding it better, but by reorganizing it. They propose better coordination through centralization into regional health departments rather than county departments. “You need to make sure that good surveillance, good epidemiology, good preparedness, are in place all the time,” says Levi. “And the way the United States has tended to deal with this is, we have an emergency, we build up a quick response capacity that takes time, the emergency passes, we lose interest, we cut back on that funding.” Until, of course, the next emergency.
The Public Health Leadership Forum, of which Levi is a part, estimates it would cost around US$4.5 billion to bring every public health department across the country up to speed. Levi and his coauthors call for a Public Health Infrastructure Fund for state, local, territorial, and tribal health departments that would allow public health offices to conduct proper surveillance; expand laboratory capacity; initiate community partnerships; improve hazard preparedness; and fine-tune policy development, information technology, and communications; among other things. His research shows that it would take US$32 per person to support the kind of public health system we want—the kind that would protect everyone in the country. We currently spend about US$19 per person.
Germany is a good example of a country that has a public health infrastructure with many of these competencies in place. “What the federal government did, under a chancellor who is a scientist and believes in the science, is use the bully pulpit and the resources that they can provide to make sure that there is a consistent policy across all the states in Germany,” says Levi. “And we see a much different pandemic in Germany than we do in the United States.”
Among those differences, as The New York Times reported in August, were thousands of functioning test kits ready to use when it became apparent the virus was a problem. In Germany, testing was free, unlike in most of the United States. In short, we have plenty of examples of how things should work in a functioning public health sector.
“What needs to be done is not rocket science, but the basic infrastructure has not been put in there and maintained,” says Hearne. “You can’t do big data, big tech, if you don’t have anyone turning on the machines.”