Fixing Our Health System After Covid-19 | The Turning Point

The Covid-19 pandemic was the best of times, the worst of times, for our healthcare system. We saw the ceaseless efforts of frontline doctors and nurses, working to contain an unprecedented plague. Yet, we also were reminded of the fragility of our medical system, buckling rapidly under the weight of a new disease, made worse by lack of access to quality care for many, and a population burdened by chronic diseases that have made Covid-19 so much worse.

Our healthcare system matters. How do we protect it?

We argue for three things.

First, we can adopt payment models which encourage health rather than sickness. We currently have a model which incentivizes providing ever-more expensive care for disease. It is a sick care system. We readily attend to people who present for care with symptoms; we are less skilled at improving health across entire populations. Models which shift the focus of market competition to keeping patients well have been explored in shelves’ worth of books and we here deflect away from specific ways to implement. But the fundamental concept: changing incentives from sickness cure to keeping health, seems to us indisputable. Put simply, the medical care system needs to embed public health practices.

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UFOs, COVID, and the return of radical uncertainty | The Healthiest Goldfish

Imagine it is 2024. For the last few years, it feels as if the world has largely moved past the COVID moment. There is a widely-shared sense that we have successfully dealt with our generation’s big challenge, and can now resume a calmer life. COVID was the worst pandemic in one hundred years, so we allowed ourselves to believe it would be at least another century before we faced anything so disruptive again. Unfortunately, this turns out not to be so. A new pandemic emerges, shutting down the world again, this time for a full two years.

Such a scenario likely seems farfetched. Not because it imagines a global pandemic shutting down the world—while that may have seemed farfetched two years ago, we now know it to be all-too plausible. No, it seems farfetched because imagining another pandemic so soon after the last one violates our bias towards thinking the world is much more predictable than it actually is. Within the framework of this bias, there is room for unprecedented challenges, but only with the unspoken assumption that, the world being predictable, unprecedented challenge will be followed by a long period of relative tranquility, giving us time to collectively regroup. That another global pandemic could conceivably follow COVID in the next three years speaks to a reality of our existence we do not like to acknowledge—that it is deeply uncertain. Regardless of whether or not we see another pandemic in 2024, the possibility that we could is indeed an uncertainty we must each day face.

Earlier this month, The New York Times ran a story with a headline which spoke to the uncertainty with which we live, “U.S. Finds No Evidence of Alien Technology in Flying Objects, but Can’t Rule It Out, Either.” The story concerned an upcoming government report on Unidentified Aerial Phenomena (UAPs), an updated term for what are more commonly referred to as UFOs. The article contained this eye-catching line:

“[S]enior officials briefed on the intelligence conceded that the very ambiguity of the findings meant the government could not definitively rule out theories that the phenomena observed by military pilots might be alien spacecraft.”

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Defining Out Goalposts | The Turning Point

During April of 2020, the in-hospital mortality rate from Covid-19 was at 19.7%. By November, it had declined to 9.3%. That is a remarkable testament to the triumph of clinical medicine in the face of a previously unknown disease. The drop in mortality was due to many factors, including the use of non-pharmacological approaches such as patient proning, the use of pharmacological therapies in hospitals such as remdesivir and steroids, and perhaps also due to lower viral loads seen in hospitalized patients because of more universal embrace of mask wearing. Regardless of the explanation, it is clear that our handling of Covid-19 got better quickly, changing dramatically the risk of what should be the ultimate outcome of concern: death.

But this dramatic improvement in mortality did not do very much to change our broader public narrative of Covid-19. Our impression—legitimate as it was—of a new deadly disease that was to be avoided at all costs was fixed quickly in March of 2020, and it did not budge much when the risk of the disease’s feared outcome changed substantially. We were seeing the same dynamic a year later as the widespread introduction of vaccines provided protection for those most vulnerable—the elderly and those with underlying medical conditions—lowering mortality rates and leaving cases to be driven by younger people who have had much less risk of contracting severe Covid-19. Despite this dramatic change in disease profile due to widening vaccination, the public conversation about the state of the pandemic remained driven, largely, by fluctuating case numbers, and state-by-state decisions were informed primarily by case load, even if these cases were milder and posed less risk.

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Too far, or not far enough? | The Healthiest Goldfish

The business of creating a healthier world is, fundamentally, the business of pushing for change. This means pushing against a status quo which often does not serve us well. This can require us to oppose systems, and even people, that are invested in entrenching the drivers of poor health. This is all to the good. However, while we are quite familiar with the reasons why this pushing is necessary—an awareness informed by our understanding of the drivers of poor health—less discussed are some of the ways this pursuit of change can, at times, undermine itself, leading in counterproductive directions. This is well-illustrated through a story told by the conservative political theorist Kenneth Minogue, one which he used to critique the development of liberalism:

“The story of liberalism, as liberals tell it, is rather like the legend of St. George and the dragon. After many centuries of hopelessness and superstition, St. George, in the guise of Rationality, appeared in the world somewhere about the sixteenth century. The first dragons upon whom he turned his lance were those of despotic kingship and religious intolerance. These battles won, he rested for a time, until such questions as slavery, or prison conditions, or the state of the poor, began to command his attention. During the nineteenth century, his lance was never still, prodding this way and that against the inert scaliness of privilege, vested interest, or patrician insolence. But, unlike St. George, he did not know when to retire. The more he succeeded, the more he became bewitched with the thought of a world free of dragons, and the less capable he became of ever returning to private life. He needed his dragons. He could only live by fighting for causes—the people, the poor, the exploited, the colonially oppressed, the underprivileged and the underdeveloped. As an ageing warrior, he grew breathless in his pursuit of smaller and smaller dragons—for the big dragons were now harder to come by.”

I acknowledge that this story, excerpted from Minogue’s book, The Liberal Mind, may strike some readers of this newsletter as perhaps unfair. Where Minogue sees “smaller dragons,” a different perspective might see normal-sized dragons to which we are only just now applying the correct measure of attention.

Yet it is hard to deny Minogue’s story raises some necessary, though perhaps uncomfortable, questions: is there a degree to which we, too, need our dragons, even if certain challenges have diminished or changed over time? Can we know progress when we see it, and, if not, what are the forces which may be clouding our vision? In today’s Healthiest Goldfish, some thoughts on these questions, on what form our pushing for a healthier world might take, and on how we can better calibrate our efforts so they will always be in proportion to the “dragons” of the moment.

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Part 2: Recognizing, and moving beyond, our collective grief | The Turning Point

There have been few moments in the country and the world’s recent history when we have collectively grieved for so many. Over the course of the Covid-19 pandemic, nearly . 00,000 Americans have died, and over 3,500,000 people have died around the world. The dead are our family, friends, neighbors, colleagues, and all are mourned. Recent data suggest that 33%of Americans know someone who died during Covid-19; that would be a total of about one hundred million Americans who are, in the moment, grieving personal losses, grief that in and of itself has implications for their health.

As we look past a global pandemic and move to rebuilding, the first step is acknowledging and recognizing the grief of many. This starts with our personal lives, in the opportunities we have to share grief with loved ones, and to acknowledge and make space for the sadness of the moment.

Beyond sadness, the science on the mental health consequences of grief should be sobering. In a study conducted in 2014, it was shown that the bereavement period is linked with greater risk of new onset of multiple psychiatric disorders, regardless of when the grief happens during the life course. We already know that with Covid-19 there has been a dramatic increase in anxiety or depressive disorders, with roughly four in 10 adults in the US reporting symptoms, an increase from one in 10 in January through June of 2019.

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A case for good faith argument | The Healthiest Goldfish

A healthy world is a world founded on good ideas, and good ideas are founded on a process of open, rigorous, even heated, debate. Yet such a debate is not always what we see in our public discourse. Polarization has informed a public conversation which does not always support a healthier world. Conducting a better public debate, it seems to me, is trading the cynicism that often informs bad faith arguments for the healthy skepticism which informs the generative conflict of ideas that truly advances progress. Some thoughts on how we can support such a conversation, towards the goal of a healthier world.

The last several years have been a contentious time. Polarization, informed by political divides, has come to characterize much of the public debate. The below graph reflects this, showing how opinion has migrated away from the center and towards extremes on the left and right.

Source: Pew Research Center. October 5, 2017. The Partisan Divide on Political Values Grows Even Wider. From: https://www.pewresearch.org/politics/2017/10/05/the-partisan-divide-on-political-values-grows-even-wider/. Accessed May 18, 2021.

The time of COVID was no exception—it was, if anything, an intensification of the division we have seen. It did not take long after the emergence of a novel coronavirus for the existential stakes of the political debate to migrate to conversations about masking, lockdowns, social distancing, the origins of the virus itself, the means of treating the disease, and, eventually, vaccines.

These divides have done much to undermine our response to the pandemic, just as they have done much to add dysfunction to our political process and fray our social fabric. Having said this, I would also add that I do not regard emotional, deeply felt, debate to be a uniformly negative influence. I have long argued for the importance of a diversity of perspectives and for creating space for these perspectives to be aired and debated, even when such debates are uncomfortable and contentious. This discourse, when it is conducted civilly and respectfully, is necessary for advancing the ideas that support a healthier world, and, ultimately, a culture and politics capable of meeting the needs of the moment.       

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Part 1: Grief and Loss | The Turning Point

Covid-19 has brought 18 months of grief. More than half a million have died from the virus in the United States, day after day, relentlessly; although we can almost see to the end, this dark moment has not seemed temporary. So much has been precarious for so long. But the grief we’ve felt has come from more than death. Grief has swept through us. All around, there is tremendous suffering.

Grief is always individual. Multiplied across a country, these individual griefs leave a great sadness. Grief is loss—what have we sadly lost, collectively? Years of life, years of health; our actuarial tables have shifted. Prolonged grief has had the expected effects: depression, anxiety, cardiovascular decline. Also countable and fallen: jobs and income.

But we’ve also lost confidence. We couldn’t quite control or command Covid-19. We looked for solace in uncertain science. We clung to changes in graphs and curves. With our data and models, we believed we could control and predict Covid-19. But viruses do not obey. We continue to reset and retime our goals. We have lived in uncertainty. Suffering causes humility.

We lost, for a time, our habits. We withdrew. We stayed still, indoors. We have, many of us, been emotionally paralyzed, fearful. We’ve been busy trying to survive. We’ve been consumed by this effort, while pretending to do the work we have, and caring for our children. We have said goodbye on video cameras. We have watched funerals rather than attend them. Our rituals have been interrupted.

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Why health? | The Healthiest Goldfish

Earlier this month, the CDC announced that fully vaccinated people need no longer wear a mask or physically distance to prevent the spread of COVID-19 (with the exception of places where such measures remain required by law). There are undoubtedly a large number of factors—from the political to the scientific—that informed and influenced this decision. But, leaving aside etiology for the moment, the unexpected announcement does present an opportunity to interrogate why we have done what we have done during the pandemic, and what we want, or perhaps should want, to guide our decision-making during these times.

There seems little question that implicit in the CDC announcement is a greater tolerance of some risk; a move away from saying that we are doing everything possible to reduce all risk, to accepting that some risk is acceptable—maybe desirable—as we move to more freely engage with those we have missed this past year. At the same time, I am also aware that the trauma of the pandemic has made it difficult for some to immediately embrace a future without the protective measures we have all become used to, with some amount of risk, even as these measures become less necessary. This is understandable, and those who are processing these feelings deserve compassion and time to adjust. It is clear that returning to something like “normal” will be a journey rather than a single step. So, as we embark, collectively, on this path, I wanted to reflect today on a first principle that informs much about what we have done this past year and will do going forward: why health? Why does it matter that we spend so much time working to generate health? Come to think of it, what is health anyways, at its core? What is it for? Perhaps in better understanding these questions we can better think how to factor in the risks we are, or are not, willing to take, to better address the steps necessary for getting to health; and to think better about the tradeoffs inherent in any decision about the health of populations—now and in the post-COVID future.

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