Lessons for a Post COVID-19 World: You Make the Call

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This is Part 2 of a three-part series on how our response to the COVID-19 experience did, is and will transform each, and all, of us. In Part 1, we renewed how we see – our worldview – to better inform our decision making on world health (this Part 2). In Part 3 we will discuss how to act globally (Part 3).

Part 1: Worldview; Part 2 World Health; Part 3 Global Action.

Part 2 – World Health: What Did we Decide?

“Earth provides enough to satisfy every man’s needs, but not every man’s greed.”
― 
Mahatma Gandhi

In April, 2020, deaths due to COVID-19 exceeded all U.S. deaths in the Vietnam War. Also in April 2020, this statement was released from World Health Organization Secretary-General’s SDG (Sustainable Development Goals) Advocates and SDG Advocate alumni on COVID-19: “World leaders agreed in 2015 to achieve the SDGs by 2030. We have only ten years to meet them. The Secretary-General called for a Decade of Action to deliver the SDGs. The COVID-19 pandemic has thrown into sharp relief the need to respond with urgency and ambition, to recover better for both people and planet.”

After SDG #1 Ending Poverty and #2 Ending Hunger, the third of these Sustainable Development Goals (SDGs) is “Good Health and Well Being – ensure healthy lives and promote well-being for all at all ages.” The last of the 13 targets for SDG 3 is: improve early warning systems for global health risks. Specifically, strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks.

So what?

As we plan to re-engage in a post-pandemic world, we have a choice: is our aim to merely recover? Or to rediscover?

It is natural to feel as if we need to resign to “picking up the pieces” and “getting back on track” with what we were doing – our prior “normal.” Especially if we did not learn anything new during our time, our lesson, sheltering in place.

But what if we resisted the tendency to return to what was and attempted to reinvent ourselves and rediscover what our only World could be? What might this look like?

Redefine: Freedom 

In quarantine, most of us felt significant restrictions on our freedom. Freedom to travel, work, socialize, etc. It was at least personally inconvenient for most and it threatened our sense of self-control, if not our livelihood, for many. 

But what if we re-examined our notion of “freedom.” Freedom for whom? From what? When? We have long recognized that freedom is not free – many veterans have made the ultimate sacrifice to assure our freedom. This understanding reveals (or should reveal) a deep sense of gratitude from those who have benefited from such sacrifice.

Now we are also realizing that freedom to be healthy – for each and all of us – also requires sacrifice. As noted in Part 1, our American culture exudes individualism, autonomy and impatience. But freedom from disease, as we are learning while physical distancing, reminds us that pathogens are agnostic to these values. To be free of such disease requires collective over individual decision making, community-interest over self-interest and that notoriously American contra-cultural concept “delayed gratification” over immediate gratification. 

But why? Because we are ONE – people, planet, world. Pathogens know no country, species of class boundaries, nor any other human-made division. What remains is for us to redefine or expand our own notion of freedom to recognize this reality – whether or not it is convenient to do so.

Refocus: Investment

In the U.S., capitalism, free-markets and economic self-interest work well for many purposes and industries. However, there is not yet a successful business model for improving health. In healthcare, payers (employer, private or government insurer, or community) have an economic incentive to prevent disease. However, healthcare providers have an economic incentive to treat disease. How would our society benefit if we realigned our obsession with a healthcare ‘system’ (now one-sixth of the U.S. economy, the equivalent expenditure of the fourth largest country’s GDP, and three times the median cost of all other countries) to become an obsession with a real health system? This redefinition would realign and reallocate investment from our expensive backlines, e.g., our health failure management system of ICUs and ventilators, to our high value frontlines, e.g., to community health workers (CHWs) and other disease prevention programs. Why? Because such a strong community-based primary healthcare “health” system would reduce the demand for healthcare, vs chase after symptoms and failures of health.* The World Health Organization has re-committed to community-based primary (CBPHC) healthcare as the most effective “frontstop” investment.

In short, we as a society need to decide to reallocate investment from healthcare to health. This sounds simple; maybe even obvious – why would we not invest in health to reduce demand for healthcare? But the politics of vested stakeholders who economically benefit from our expensive healthcare system can and will not allow this willingly. As a society, we have to break the vicious cycle of emergency backstop investment to address symptoms of the bigger problem. We need to get into a virtuous cycle of health investment to address causes at their roots. We need to redefine our focus by zooming out: we can only solve our healthcare system challenge by seeing the larger health system opportunity, by seeing the whole. From Part 1, this is the integrated, global view.

If we zoomed out, we would expand from merely adopting a high reliability organization (HRO) approach (e.g., reduce diagnosis and treatment errors in hospitals) to adopting a high reliability community (HRC) approach (addressing root causes of the pathologies that create the need for diagnosis and treatment). The more progressive healthcare organizations (as well as companies in nuclear power, chemicals and other high-risk operating industries), focus on the first HRO principle: ‘stay out of trouble**.’ For HRCs this means prevention. 

Snoopy advises high reliability principle #1: stay out of trouble (it is evidence-based that batters are not as successful with low pitches)

Return

This RoP (return on prevention) or RoSDOH (return on social determinants of health) investment in our frontstop far exceeds the RoI for any investment in our healthcare backstop. That is why we refer to these “stops,” respectively, as primary, secondary and tertiary care.   

Do we recognize that we have a blind spot? That what we can’t see – like the SARS CoV-2 virus spread – can kill us? Or do we have to wait until our backs are up against the wall – and the proverbial writing on the wall falls on us? Many payers and providers were slow to adopt (or even fought) telemedicine even though the technology has been available for some time. COVID-19 forced many in a change-resistant industry to adopt telehealth in a matter of weeks.

Decide: Community Leadership with a Global View

The most recent Global Burden of Disease (GBD) Report 2017, arguably the de-facto source for global health accounting, was described in Lancet as “disturbing” and “an urgent warning signal from a fragile and fragmented world.” In 2017, for the first time, the annual improvement in global adult mortality rates halted – adult mortality decreases plateaued, and, in some cases, mortality rates increased. Alarmingly, conflict and terrorism have become two of the fastest growing causes of death globally (increasing by 118% between 2007 and 2017). Alongside this alarming growth in violence, our era is characterized by epidemics such as opioid dependence, noncommunicable diseases, depression, as well as dengue fever. Crucially, GBD 2017 estimates that no country is on track to meet all of WHO’s health-related SDGs by 2030. For many of the 169 targets—including child malnutrition and violence reduction goals—no country in the world has attained the pace of change that is required to meet these goals. 

As healthcare executives with a renewed worldview (Part 1), we can all decide to become “world” leaders. A first step is recognizing that our organization and community are part of, and play a role in, a larger, interdependent world health environment. How does your strategic plan align with and refocus time and resource investment to address the targets in SDG 3? Consider including one target in SDG 3 that aligns with your community health needs assessment (CHNA). Given the reality of a pandemic, it is fair to ask “How does our plan help improve and respond to early warning systems for global health risks” (SDG 3D)? 

“A journey of a thousand miles begins with a single step.”

  • Chinese proverb

*Developed countries that get better outcomes than the U.S. for one-half the cost have a 2:1 investment ratio of social care vs medical care; the U.S. has a 1:2 investment social care to medical care ratio.

**The other HRO principles after this first principle, effectively all involve how to “get out of trouble.” 

Rob Thames serves as director of Global Health Administration Partners (GHAP), the consulting arm of Global Health Ministries (GHM).  GHAP partners in 14 low-resource countries to improve health by strengthening leadership, governance and financing. He writes about global health and healthcare leadership at robthames.com.

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