Written by Erin Lee, Designed by Farhaanah Mohideen

The Deeper Implications of Public Health on our Lives

By Erin Lee

Designed by Farhaanah Mohideen

The concept of public health has become increasingly more that - public. It’s difficult to remember a time where no one would bat an eye if someone coughed or sneezed on the train, or in a classroom. Fast forwarding to today, that one-second cough can generate a wave of assumptions, skepticism, and even fear in others. The entire world knows far too well how COVID has affected our everyday lives, and how it has affected our health system. But another drastic effect has been the popularization of public health, and how it has been integrated in our day-to-day actions, conversations, and thoughts. With such visible cues of public health compliance, like masking and social distancing policies, it has become common practice to assume we know other’s beliefs regarding the severity of the pandemic. Subtle signs like a mask hanging below the nose, or no mask at all can decide our first impressions of someone before they even speak.1 Because of public health measures - some of our privacy has been lost, namely due to health reporting, tracking, and limits on our physical movement due to social distancing and quarantine protocols.2 But access to the lives of others have been gained; we have become increasingly aware of the activities of others in their personal life and how those activities have affected us. Personal beliefs and health decisions that wouldn’t normally be shared with anyone but close friends and family have now been brought to light, such as feelings towards vaccines and relationships with doctors and medicine in general. Our health is now so closely woven with our social relationships, and our actions more visible to others. This increasing awareness and transparency between us has both benefits and ill effects as we navigate this new space of public health in the years to come. The contrast between the somewhat “private” health of the past and the much more public health we experience now presents an interesting conflict with American ideals. As a whole, Americans value independence, privacy, and individual freedom to make our own choices. These are the very principles that our nation was founded upon. The pandemic, to some, has infringed on these values, with countless mandates and restrictions that have called for total compliance and uniformity in an effort to stop the spread of the virus. With political and economic systems that are often rooted in individualism and privatization, the use and enforcement of public health mandates served as a culture shock for many.3 Amidst a deeply polarized political landscape, the pandemic completely severed America’s biggest political parties, creating arguably the largest division yet, further exacerbated by polarization in media coverage.4 Public health became a political weapon, with logic being thrown to the side and some using non-compliance as a way to channel their feelings towards changes in political power, and express their frustration with their freedoms being taken away. In particular, in the summer of 2020 when lockdown mandates were in full effect, many grouped together in protest of mask and lockdown protocols. Some refused to acknowledge the evidence proving the benefits of wearing masks, while others went as far to claim that COVID is just a conspiracy theory or a hoax.5 While there is too much scientific evidence to disprove the false statements or bewildering excuses that anti-maskers/vaxxers may use, there is no argument that the polarization of our country due to differing views on COVID has held us back from collectively moving forward to continue fighting against the virus, and progressing in other social and political issues. The new found transparency in our social relationships has also caused polarization in our personal relationships. Social situations and gatherings became

an incredibly tricky space to navigate, as otherwise close friends and family members may have come to hold different beliefs on what was acceptable to them in each phase of this changing pandemic. In a sense, we’ve lost the privacy to compartmentalize different parts of our life and the people we spend time with. We have to be transparent about where and with whom we spend our time to be responsible about meeting up with others without potentially exposing them. This isn’t to say that we shouldn’t have to be transparent - in fact, we should all be cognisant of the situations we are putting ourselves and others in, as well as the boundaries that each individual is comfortable with. This is the only way we can limit the spread and the loss of life due to this virus, and any other that we may encounter in the future.

While not everyone exactly adopted these practices, the people who adhered to COVID guidelines and continue to be aware of the risks, as the virus still exists, have experienced the subtle but impactful shift in the way that public health is integrated into our lives. Although we have suffered many losses because of the pandemic - having a greater awareness of public health can help us moving forward. With all of the information available to us about the virus, many people have become better at doing their own research and finding out what is or isn’t factual. Additionally, we have become more educated and engaged in our own health. We have experienced ourselves how our own decision-making affects the health of others. We have been able to expose the health disparities that exist and what needs must be met in the healthcare system, particularly in terms of social determinants of health for minority and low-income communities.6 We have become greater health advocates for ourselves, for our loved ones, and for those that are at higher risk. Yes, we should look forward to the day where the virus is completely eradicated, and masks no longer need to be worn. However, we should not try to bury the pandemic deep in our memory and forget all the lessons we learned with it. We should ask ourselves - how can we continue to be aware of our actions and the implications they have on others? How can we take advantage of this new dynamic between health and social spaces to protect others? At the end of the day, we are all humans with our own lives and loved ones that we care deeply for. Positioning our mindset to be more public health oriented may be a change, but by now, we are experts on change. Our empathy for others should triumph over the minor discomfort of having to be more transparent about our lifestyle. We must learn to protect each other, because above all else, empathy is what we must hold on to - with or without a pandemic.

Covid-19 and Transparency in Healthcare:

Learning from the Theranos Trial

The past two years have been cataclysmic for the healthcare industry, as a global pandemic has disrupted major market dynamics, exacerbated inequities, and overwhelmed infrastructure, workforces, and supply chains. The AHA estimates that recent financial challenges include an average of $50.7 billion per month, including drug shortage costs, wage and labor costs, capital costs, and equipment costs.2 A significant percentage of hospitals in the United States reported negative margins of operation, which tend to significantly impact those who are at a socioeconomic disadvantage as these losses, caused mainly by supply costs, overwhelmed by Covid-19 patients, lack of resources, and cancelled procedures, continue to pile on.5 Among the many pre-existing issues that existed in the American healthcare system that were exacerbated by the onset of the pandemic, one of them is a major lack of transparency between healthcare behemoths and its internal and external stakeholders, as well as its customers and patients.

Written by Saraswati Sridhar Designed by Farhaanah Mohideen

Healthcare markets in the United States have struggled with transparency on a variety of issues for a significant amount of time. For example, the pricing of certain services involves a complex maze of stakeholders, third-parties, and contractors. This results in an extremely complicated scenario, where it is difficult to guarantee efficiency and transparency for all parties, including price transparency for users.4 This issue, as of recently, translated to a lack of transparency in the sales of vaccines during interactions between governments and major pharmaceutical companies to mitigate the pandemic. These dynamics are highly beneficial to specific executive stakeholders, “...Official price rates as it provides a competi- are often negotiated behind tive advantage by making highly vital information inaccessible from the genclosed doors, and the vast majority of price variability eral public, and instead is shielded from patients...” choosing to partake in elaborate rebate schemes and co-pay accumulator programs that usually work against customers and patients. Official price rates are often negotiated behind closed doors, and the vast majority of price variability is shielded from patients.1 One consequence of this lack of transparency is that stakeholders benefiting from this arrangement is an augmentation in out-of-pocket costs, which in turn, leads to poorer patient compliance and worse outcomes, further increasing major health disparities. The issue of transparency in healthcare costs has become even more important after the advent of a global pandemic. A major risk to the response to the pandemic on a global scale is an extension of the previously described lack of data transparency to government deals. This issue was demonstrated when 41-45% of entities conducting clinical trials for a wide variety of vaccines and therapeutics being tested disclosed only their top results and only 12% of clinical trial results were made publicly available, while only 7% of contracts and deals involved in vaccine distribution were made publicly available.2 Government agencies, like the FDA, play a role in this phenomenon, because while they choose to explain key decisions and authorizations to the public, they often fail to provide comprehensive access to the concrete data and trends they used to make these decisions. This results in major hindrances in our ability to monitor the true safety and efficacy of the Covid-19 vaccines, as well as safeguard against political corruption and manipulation and fraud. One prominent example of a major shortcoming in vaccine transparency can be illustrated by a serious allegation of potential corruption in a deal between the Brazilian government and an Indian biotechnology giant known as Bharat Biotech for their Covexin vaccine8; these deals subjected the Brazilian government to investigation of possible fraud and financial and contractual irregularities. Moreover, major vulnerable stakeholders were also privy to a lack of transparency in the distribution of federal relief funds and pandemic aid. Congress distributed more than $100 billion worth in aid as part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, but major concerns were raised by the American Hospital Association (AHA) about the manner in which these funds were distributed: for example, only 44% of federal funds were truly made available to hospitals and health systems during the pandemic.3 The frenzy and desperation for quick solutions in the realms of COVID-19 management and treatment also causes widespread vulnerability to powerful agents acting in bad faith and participating in extremely unethical activities such as price-gouging and fraud, similar to the case in Brazil mentioned above. A prominent case of widespread scamming and fraud surfacing throughout the pandemic is that of Elizabeth Holmes’s Theranos, a well-known biotechnology startup aiming to devise technology that could employ tiny amounts of blood to detect a wide variety of illnesses using portable, inexpensive, and accessible machines. Although the crimes this company has been charged with are unrelated to the pandemic, the transparency problems that led to Holmes’s racket are very similar to those experienced by many stakeholders throughout the pandemic. Activity referred to collectively as “stealth research” routinely employed by a variety of up-and-coming medical breakthrough and biotechnology startups, characterized by a broad lack of peer-reviewed evidence.9 As a result, the valuation of these companies are often significantly 25

disconnected from concrete and externally-sourced data. As seen with this particular case, a lack of transparency about a company’s prog-

ress and numerically quantified technological outcomes among the internal stakeholders and investors in the company led to fraudulent behavior and serious legal consequences. Unfortunately, such major issues presented in the Theranos dealings are not unique solely to larger healthcare markets; studies have shown that more than half of all biotechnology startups are worth more than $1 billion and 40% of companies in the general context. Overvaluation of certain companies can lead to unrealistically high expectations from both stakeholders and consumers that contribute to a wider-scale hindrance of important predictions and action regarding outbreak response, management, and treatment. It also contributes to reduced trust in large pharmaceutical agencies and governments as well as the promulgation of conspiracy theories and misinformation.6 During the pandemic, there was an uptake in a wide variety of new startup companies dedicated to the development of novel vaccines and therapeutics, so the issue of data transparency, especially with regard to clinical trials, is highly prescient and applicable. A lack of transparency in healthcare dealings contributed to an exacerbation of healthcare inequities that have a disproportionate impact on the most vulnerable members of our populace including low-income families and communities of color. Factors that aggravate inequity include loss of health insurance, lack of price transparency, and the spread of misinformation and distrust. Often, the vulnerability of these populations places them at higher risk for being exploited by the many faults in our healthcare system. There are many possible solutions to the meagre healthcare transparency at the industrial and governmental levels. For example, large companies and startups should be required to participate in scientific peer-review of their data beyond a clandestine circle of investors and executives, in order to produce a greater level of accuracy in predictions of disease management and company valuation. At the level of hospitals and medical care, legislation was introduced during 2019 and 2020 by the Trump administration to audit hospitals for compliance with existing transparency requirements, and requiring all hospitals to present services in a comprehensive and user-friendly shoppable format. During a historic price transparency initiative during this time period, most private healthcare plans were required to disclose price and cost-sharing information to the public. This information is presented to the public in the form of an online, personalized tool containing information about all of a patient’s out-of-pocket costs, negotiated rates between providers and third parties, and historical information on all charges and prices.7 Similar laws (both pre-existing and new laws) could be implemented to make all dealings between governments and companies completely accessible to the public. Another step towards increased healthcare transparency could also involve eliminating large quantities of red tape, third-party dynamics and sometimes the parties themselves, as well as exploitative rebate and copay-accumulation schemes. In conjunction, these solutions employed in a concerted and compre-

hensive manner, can be instrumental to reducing costs and improving outcomes and healthcare security both nationally and globally.

“A lack of transparency in healthcare dealings contributed to an exacerbation of healthcare inequities that have a disproportionate impact on the most vulnerable members of our populace including low-income families and communities of color.” “...laws could be implemented to make all dealings between governments and companies completely accessible to the public.”