health care PPE

Seven months ago, AcademyHealth transitioned to virtual work, joining thousands of other organizations adapting to the COVID-19 pandemic. However, I do not believe that we had yet grasped the enormity of the situation, nor the extent to which the pandemic would reveal and accentuate the existing, deep failures at every level of our health system. Like the proverbial ‘boiled frog’, we have tacitly and incrementally accepted these failures for far too long -- despite years of study and documentation from the field of health services and policy research (HSR) that confirmed their existence.

At least four challenges demand immediate attention so that we may begin to repair our fractured and failed health system.

First, the devastating impact of the pandemic on communities of color and low wage workers has made the inequality that has always existed in America evident to even the most [willfully] blind observer. America can no longer look away. These inequalities are not unfortunate byproducts of our society – they are the natural consequences of decades of policy choices and private actions, many driven by overt and systemic racism.  Sustained disinvestment in low income communities, barriers to economic mobility, and bereft physical environments that are not conducive to health put individuals and communities at greater risk of illness and death due to COVID-19, both directly and indirectly.

Second, the pandemic has forced us to think about our health workforce, its composition, its skills, its resilience, and, sadly, its basic safety in ways unimaginable just a year ago. I never thought I would see images of nurses in this country using garbage bags to protect themselves due to a lack of PPE.  We also cannot ignore that this direct threat to the workforce’s safety comes on top of a growing epidemic of burnout among frontline clinicians that has left them emotionally exhausted. Here again, the dual tolls of burnout and basic safety do not fall equally on all. Health professionals of color and underrepresented members of academic faculties continue to be subjected to overt and covert racist behaviors and systems that reinforce biases rather than address them. Recently, the AAMC released its framework to eliminate racism which outlines four pillars of work that will “create a shared vision of the AAMC and academic medicine institutions as diverse, equitable, inclusive, and anti-racist organizations.” Health services research and its institutions must do no less.

Third, the decades long financial starvation of our public health infrastructure nationally and at the state and local levels has left health departments and their partners struggling to respond in a timely or robust way. The funding for the nation’s leading public health agency, the Centers for Disease Control and Prevention (CDC), has remained essentially flat for more than a decade (adjusting for inflation). State health departments have seen similar funding stagnation and declines while local health departments have 55,590 fewer staff due to layoffs or attrition. To compound matters, we have moved from a lack of recognition of the contributions and value of public health agencies, and the dedicated professionals who work in them, to the outright targeting of public health leaders who speak up and speak out, applying science to protect their communities.

Fourth, we have seen an almost complete failure of our health data ecosystem despite billions of investments from the federal government and private sector since 2009 and the HITECH Act. Most significant is the failure of the public health data infrastructure, which received no comparable investment as part of HITECH. Indeed, the fragmentation is astounding; American’s more than 3,000 local, state and federal health departments often set their own rules and exhibit incredible variation in their ability to send and receive data electronically. In her recent book, Democratizing our Data: A Manifesto, Julia Lane argues that the steady decline in data quality produced by the government is a threat to an information-based economy and to the very foundations of democracy itself. Meanwhile, digital health is on track to have its largest funding year ever, with U.S. digital health companies raising $5.4B in venture funding through the first six months of 2020. What have these investments bought us? How many of those ventures are tackling public health data? We need to shift public and private investments to redesign our public health data ecosystem and connect it to healthcare and other data.

Of course, these four challenges do not exist in a vacuum. They have been reinforced by the critical interplay of federal, state, and local policies. The failure of federal leadership, despite valiant and sustained efforts by scientists in federal agencies, must be called out, as it was in the recent New England Journal of Medicine editorial, unprecedented in its 208-year history. This failure has left states and communities to grapple alone and at times compete with each other for basic needs. This is shameful.

What can we do? Stay tuned for my next post tomorrow, which will highlight how this lack of leadership has led to wide variation in the degree of disruption, disproportionate impact, and decision-making capacity across states and localities and propose three responses from our field

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Some years ago, Annetta Miller's collection of aphorisms was published in Kenya (2005), its title: AFFRICAN  WISDOM  FOR  LIFE.  Here is one of my favorites: "If you want to walk fast, walk alone; if you want to walk far, walk with others."  Thinking about improving our nation's population HEALTH and its healthcare, it's hard to ignore our institutional codependency and its effect on the use of our national resources.  With each institutional "silo" of entrenched endeavors commited to its own survival, aka "walking/bolling alone," our nation's health spending continues to inexorably follow Parkinson's Law, as it has since 1960, AND our nation's population HEALTH continues to worsen. Hans Christian Anderson's aphorism described as the "Emporor's New Clothes" applies to our nation's maternal mortality, early childhood adverse events, pre-adolescent obesity, adolescent mentorship deficets (maternity, STS, suicide, homicide, addiction), homelessness, mass shootings, midlife disability/preventable deaths, and senile dementia.  They all add up to our nation's annually 'stagnant' level of life-long longevity at birth since 2010. Considering the portion of our nation's economy allocated to health spending as a "Common-pool Resource," the Design Principles that are known and well-validated for successfully managing a Common-Pool Resource are known. Unable to hang together, our healthcare institutions are left hanging separately. The phenomena was succinctly identified by Benjamin Franklin long ago during the occasion of a Continental Congress.  Our excess health spending for 2019 could reasonably be identified as 5% of our GDP, viz $1 Trillion.   For our population HEALTH, its ultimate improvement will depend on a nationally constituted strategy to mobilize and focus local stakeholders for preventing, mitigating, and ameliorating each community's heritage that has led to their own neighborhoods' adverse determinants of unstable HEALTH. This strategy whould include national provisions for establishing equitably available, ethographically accessible, justly efficient, and reliably effective Primary Healthcare within every community for each of their resident persons. Since 1914, the Cooperative Extension Service for agriculture could be a fundamental model. The process will require a generational perspective. See reference by Erik Landry and John Sterman (MIT) below regarding Capability Traps in Human Systems.  

Submitted by Paul J Nelson MD on Friday, October 16th, 2020 at 11:52 am