The two biggest American tragedies of the 21st century have elicited two very different responses.
Twenty years ago, a terrorist attack took 2,996 lives and is still regarded as a symbol of our nation’s resolve to defend democracy and fight terror—wherever it lives and whatever the cost. The second tragedy is currently in progress and has taken more than 700,000 lives. Though its history hasn’t yet been written, I predict that once this dark and deadly period has passed, Americans will be quick to forget it.
At the center of this strange imbalance—between our nation’s responses to 9/11 and COVID-19—are three basic truths about the American mindset. These truths explain how we asses risk and process fear, and why we often make illogical choices in times of crisis. More important, these truths help us understand why millions of Americans have died needlessly over the past two decades.
Truth 1: Single-day events mean more to us than lingering tragedies
Americans dutifully remember and annually honor great battles and tragedies, provided the event took place on a specific day. Even wars that last for years are taught and remembered in terms of their turning points (think: Pearl Harbor, D-Day and Hiroshima). The terror attacks on 9/11 fit this paradigm. The date and its horrific events remain etched into our consciousness with the help of an estimated 700 permanent memorials across the country. Some of them are beautiful, multimillion-dollar projects meant to ensure that we as a nation “never forget.”
By contrast, you’ll find precious few COVID-19 memorials or exhibits—and no permanent national memorial as of yet. Of course, had 700,000 Americans perished on a single day, we would mark and mourn the date forever. Instead, Americans continue to die each day by the thousands, month after month—each month passing without a “milestone” moment. As such, few can remember when the first American died from the virus. Or the date of the 100,000th death. Or the 500,000th. Or 700,000th.
And because the coronavirus pandemic is a lingering tragedy, our nation has grown numb to the pain. Its importance will likely be lost to history, along with all the valuable lessons it should have taught us.
What this truth means for our health: Not all deaths or threats against life are seen as equal in the United States. If they were equal, the current pandemic, which has killed more than 700,000 Americans, would be roughly 233 times more terrifying and saddening and angering than the terrorist attack that took 3,000 lives on the morning of September 11, 2001.
But knowing why the American mind perceives COVID-19 and 9/11 differently can help us understand our nation’s equally illogical views on healthcare.
You’ve no doubt heard the expression “serious as a heart attack.” In the United States, acute and unexpected medical events—be they heart attacks or a strokes—get all the attention and stoke the most fear. As a result, Americans view the cardiologists and surgeons who perform life-saving interventions as medicine’s greatest heroes.
But consider this: An estimated 80% of cardiovascular events, including heart attack and stroke, are preventable. So, shouldn’t we be focusing a major portion of our medical resources on stopping these terrifying events from happening in the first place? And shouldn’t we recognize and heroize the primary care physicians who save lives through preventive medical care?
We should, but we don’t. Today, only 2.9% of our nation’s $4 trillion in annual healthcare expenditures go toward programs that preempt illnesses. Prevention is such an afterthought that people with chronic conditions receive only 56% of recommended preventive healthcare services. To add insult to injury, the physicians best equipped to get ahead of deadly diseases (internal- and family-medicine doctors) sit at the bottom of the healthcare hierarchy and near the bottom of the wage scale.
Until these flawed priorities change—until we fear and address chronic illnesses the way we do single-day medical crises—Americans will continue to suffer hundreds of thousands of premature and preventable deaths each year.
Truth 2: Human threats scare us much more than biological ones
Think for a moment about the fears and threats that titillate Americans. As of this article’s publication, 6 of the top 10 podcasts on Apple were true-crime stories involving people doing terrible things to other people. As Americans, we are drawn in by the darker side of humanity and all its evil intents. We can’t help but be rivetted by terrorist attacks, ghastly murders, bloody battles and countless other manifestations of human cruelty.
Conversely, biological threats are like background actors. Even the occasional movie about a viral pandemic tends to focus the camera and conflict on people (not on the virus itself). And, true to Hollywood, these depictions play to the extremes of human behavior. In Contagion, for example, people didn’t hem and haw for months over whether to take a highly effective and safe vaccine. That wouldn’t make for good cinema. Instead, people panic, they riot, they act recklessly and selfishly. How others react in times of fictionalized crisis explains, in part, why Americans horded toilet paper and guns during a real pandemic.
Ultimately, we’re far more preoccupied with each other than we are biological diseases. If you doubt it, ask yourself how many days you spent in school learning about past epidemics and pandemics compared to the number of days you spent learning about 20th-century American battles. Unless you are an epidemiologist, the former is undoubtedly less than the latter. But in terms of which proved deadlier, consider the facts: U.S. wars of the 1900s (WWI, WWII, Korea, Vietnam and Gulf) killed a combined 615,000 Americans whereas the 1918 “Spanish” Flu Pandemic killed an estimated 675,000 Americans. The HIV/AIDS Epidemic killed approximately 700,000.
What this truth means for our health: Elected officials know which policies get constituents to the polls and prompt donors to write big checks. They know that every time people board a plane or walk into a train station, they do so with an undercurrent of fear. Americans can easily envision explosions masterminded by evil humans. Thus, laws that fund “the war on terror” and keep the bad guys at bay help voters feel safe and secure. By contrast, the idea that a random mutation in a virus could inflict massive harm upon us seems far less imminent, despite what scientists say.
This explains why the United States has spent an estimated $3 trillion to $6.4 trillion on counterterrorism since 2001 and why, each year, more than half of all discretionary spending from the U.S. government goes to the military. Make no mistake, these dollars are well spent because they’ve helped us avoid another attack like 9/11. But that’s not a justification for how little we spend on preventing new biological outbreaks.
The White House and Congress are currently embroiled in a fight over a paltry $15 billion allocation toward future pandemic prevention as part of the $3.5 trillion reconciliation package. Despite the modest amount, this sum would constitute a decent upgrade in anti-pandemic funding. Since 2003, federal grants for the CDC’s Public Health Emergency Preparedness program sank from $939 million to $675 million last year.
Given the relative threat to human life, why is there such a massive difference in spending between counterterrorism and countering the next pandemic? Objectively, the allocations should be at least equal.
Truth 3: Americans do a poor job of calculating risk and opportunity
In the United States, your chances of being murdered in a terrorist attack are about 1 in 30 million. Your chances of dying from COVID-19 are 1 in 500. That’s a massive differential in actual danger, but stats and ratios are not how our minds compare relative risks.
Dating back to 1970, there have been fewer than 4,000 deaths from terrorist activities on U.S. soil. And while any incident of terrorism is tragic and shouldn’t be diminished, the threat should be placed in context. For sake of comparison, the H1N1 virus—that scarcely remembered flu pandemic that hit the United States in 2009—killed more than 12,000 people, three times as many as all terrorist attacks in this country over the past 50 years.
Despite these statistics, Americans worry far more about a repeat of 9/11 than they do about the next viral pandemic. We overestimate the probability of dying from the things that scare us most (namely, other people) and we underestimate the threats we can’t see, envision or understand. The same sort of mental distortion is true of U.S. healthcare, as well.
What this truth means for our health: As Americans, we think of hospitals, clinics and physician offices as the best places to be when we’re sick and want to get better. As a corollary, we assume that doctors and healthcare facilities have the greatest impact on our overall health. So, as the thinking goes, if we want to increase the odds of becoming a healthier nation, we ought to look for answers and make investments inside the traditional walls of medicine.
In reality, the quality of your local hospital or your choice of doctor accounts for only 10% to 20% of your overall health outcomes and life expectancy. Once again, our poor assessment of risk leads to misinformed actions and faulty solutions. The truth is that the conditions of our daily lives influence our health to a far greater degree than traditional medicine ever could.
For example, studies show the zip code in which you were born is a factor that can lengthen or shorten your life by up to seven years. Your race or family income account for at least 20 percent of your health status. Health institutes like the Centers for Disease Control (CDC) and the World Health Organization (WHO) have done extensive research to quantify the impact these “social determinants of health” have on our well-being.
When communities lack balanced food options, safe places to play and programs that encourage healthy behaviors, the health of people in those communities will suffer. High crime rates, unemployment, polluted air and contaminated drinking water also have an outsized influence on life expectancy. In fact, based on analysis of nearly 50 studies, it has been determined that social dynamics account for at least one-third of all American deaths in a given year.
Overall, social settings are two times more likely to determine our risk of premature death than the places we go for medical care.
Despite this information, Americans spend twice as much on direct medical care as people in other developed nations. More importantly, other high-income nations spend a far greater percentage of their dollars on “non-traditional” healthcare programs—for the elderly, infants and the poor—each aimed at addressing the social determinants of health.
As a result of our nation’s inability to properly assess health risks, we’ve designed a “sick care” system that’s ill equipped to improve public health.
According to the latest Commonwealth Fund report from August 2021, the United States ranks dead last in health outcomes among 11 of the world’s wealthiest nations. It is the seventh time in seven consecutive reports since 2004 that our nation has come in last place. These tragic and unnecessary outcomes will continue until the United States makes the investments needed to address non-medical factors that lead to poorer health.
To this end, Congress is considering legislation to decrease the cost of medications and use the added savings to address various social determinants of health. From a statistical perspective, Americans would live longer and healthier lives if we based this decision on the data, not on our wildest fears or assumptions.