Should Public Health Be a National Security Issue?

After the Crimean War in the 1850s, Florence Nightingale did a massive statistical analysis of the deaths suffered by the British army in that conflict.

For every British soldier who died in combat, she found, seven died of preventable diseases. That finding led to hygienic measures, vaccination and improved health care for soldiers — at no cost to the soldiers themselves. They were critical to national security, after all. Other nations’ armies soon followed.

The Canadian military spends a lot on its soldiers’ health. This year’s budget calls for $143.4 million over the next five years and $28 million yearly thereafter.

It’s ironic that American civilians, who have nothing like Canada’s single-payer health care, fund a huge program for 9.6 million U.S. military personnel, retirees and their families. President Joe Biden has requested $55.8 billion for the Military Health System in fiscal year 2023. And that’s not even a very big chunk of Biden’s requested $773 billion military budget.

But military health care raises a question about civilian health care. The Americans fund their enormous military (not to mention hundreds of police forces and bureaucracies) on the grounds of national security. Without such spending, the argument goes, America would succumb to the many existential threats it faces.

Disease as existential threat

But suppose we defined disease as an existential threat, which it certainly has been to the at least 45,000 Canadians who’ve died of COVID-19 so far. At least four million of us, myself included, have been infected, and somewhere between 10 and 30 per cent of this four million are likely to experience long COVID.

Suppose we decided that our national security is also the personal security of its individual citizens and residents. We know that whether we thrive or sicken is rarely a matter of “personal responsibility”; the social determinants of health give long lives to the rich and short ones to the poor.

Let’s do a thought experiment. In a fit of collective madness, Ottawa and the provinces and territories declare a national security crisis. They say that to be truly secure, Canada commits to ensuring the health and well-being of all its citizens and residents — literally from womb to tomb. Apart from that, citizens and residents are free to do anything they please as long as it doesn’t harm other people’s health and well-being.

Countries like Australia and New Zealand already have “well-being budgets,” based on the concept that “citizens’ well-being drives economic prosperity, stability and resilience, and vice-versa, that those good macroeconomic outcomes allow to sustain well-being investments over time.” More briefly, good health is good business.

Save money! Don’t get sick

No doubt true, but the upfront costs of truly universal health care would be brutal. To keep those costs down, we’ll need to keep Canadians from getting sick in the first place. So the emphasis in Canadian health care will be on prevention.

Admittedly, prevention is a hard sell. When public health is working properly, nothing happens, so it lacks drama. It’s more exciting to have an outbreak kill a few people before intrepid doctors shut it down, but the pandemic has shown us that outbreaks don’t always follow the script. Better to live in boring good health than hope your local hospital has a bed for you — and staff able to give you the best care possible.

So Canada will ensure that every pregnant person gets excellent prenatal care and strong postnatal support, at no out-of-pocket cost. But that’s not all: Canada will ensure that families will have comfortable, hygienic housing no matter where they live in the country. That will help shut down tuberculosis outbreaks in First Nations and Inuit communities.

What’s more, every family will receive a substantial universal basic income to ensure it can afford to feed its children and itself, whether adults in the family are employed or not. UBI has been shown in Canada to improve physical and mental health. It could greatly reduce the costs of disease response, and even opioid mortality — which is chiefly a threat to the poor.

It’s called junk food for a reason

Some preventive measures would be unpopular: heavy taxes on junk foods and sugary drinks, for example. The same would be true of concussion-prevention rules in sports like hockey, football and soccer. But the health outcomes would speak for themselves.

It would also be politically challenging to reduce sickness and deaths from air pollution: Health Canada estimates 15,300 of us die prematurely from such pollution, while millions suffer from asthma and other respiratory problems, at a total yearly cost of $120 billion.

And that’s just from exposure to PM2.5 particulates, NO2 and ozone — all produced directly or indirectly by vehicles and power generation. Tire particles from battery-heavy electric cars are far worse exhaust fumes.

Tuition-free medical school

As for the worsening shortage of health-care workers, we might begin to remedy it by free tuition for medical school; in exchange, graduates would accept assignments to underserved communities for, say, a three-year hitch. They might then seek work elsewhere, or remain. Family doctors would be far better paid and supported than they are now. The same would be true of nurses, technologists and support staff. If public health is working, they will all have far fewer individual cases to deal with.

Of course this seems politically and economically impossible. Yet on grounds of national security we spend billions on fighter jets and the training of their pilots, not to mention all the infrastructure to support the military. (And we’re notorious free-riders on the Americans’ military spending.)

Killing ourselves for a living

But if we don’t see our own health and longevity as national security issues, we are implicitly admitting that our economy and politics are based on deliberately sickening and killing some of us to benefit some of the rest. That is an admission no politician is likely to make, just as no cannibal is likely to admit that eating people is wrong. It’s easier to blame the sacrificial victims for their lifestyle choices, or their poor decisions.

In the pandemic most governments tried, for a while, to protect their people from infection. But as COVID-19 mutated and mutated again, the idea of trying to protect our fellow citizens fell out of favour. Politicians quickly realized that saving lives wouldn’t pay off; on the contrary, removing mask mandates and reopening travel would make most voters very happy, however many might die in long-term care or the schools or on the floors of overcrowded emergency departments. Just like pre-pandemic life, we’ve gone back to killing ourselves for a living.

Florence Nightingale forced British generals to realize that their soldiers were more valuable if they were healthy than if they were dead. Until we think the same of ourselves, public health will not be regarded as a matter of national security.