America can move toward a transformed healthcare system, responsible for our well-being, and a new paradigm of population health, led by medical professionals.
COVID-19 has crashed the US health care system and shed a harsh light on the social determinants of health.
In doing so, the virus – and more importantly its aftermath – has exposed a truth that my colleagues and I have been preaching for over a decade: the public health paradigm is outdated and inadequate. Its core tenets — including public health, epidemiology, behavioral sciences, and the environment — are important but reactive.
We also need to consider the quality and safety of the care we provide, the cost of that care, and a number of changing policy considerations.
The business of health
Healthcare is the biggest business in this country, but we rarely stop to reflect on what exactly has become of this business.
Are healthcare providers in the business of improving and maintaining health? Or is our goal to just do more procedures and fill up all those beds?
The vast majority of doctors I know feel too disconnected from the system to respond. They see themselves as pawns or, worse, victims, when they should lead the charge against the public health paradigm that balances treating the sick with keeping people healthy. Rising inequalities in care and precarious SDOH call for it.
Consider the social determinants in a city like Philadelphia, where I’ve worked for the past three decades. Ours is the poorest of the top ten cities by population. A quarter of Philadelphians live in poverty and half live in deep poverty, meaning they can’t put food on the table. During the peak of the pandemic, lines for food exceeded lines for medical aid.
No wonder, then, that the mortality rate among people of color was much higher than among other patient demographics. The inherent inequality in our system guaranteed a lack of access, a lack of resources, and a lack of insurance for those who were constantly exposed to the virus because they are required to have public-facing jobs.
leadership from within
Doctors aren’t social workers, but we can still work to stop disease at the source when it’s still a drip, rather than waiting to tackle it downstream when it’s become a tide.
Imagine if Philadelphia’s population was healthier before Covid; If we had less inequality, we could have reduced the incredible mortality rate among minorities. If only we had paid attention to obesity, smoking, heart disease, exercise, diet – softer issues that the system largely ignored because there were no incentives to do anything else. Indeed, the tide fills many beds.
As an academic, I have championed a population health paradigm for more than a decade. This means that undergraduate and graduate medical education curricula are changing. Let’s bring the principles of public health to UME and GME.
Is it possible that the pandemic has given us rocket propulsion to finally get this information into the curriculum? I am confident that the answer is yes and that we will soon see pharmacy schools, nursing schools and medical schools embracing the principles we preached before Covid. I’m also confident that we will see digital healthcare that further reduces marginal costs. Both of these changes will allow us to reach much larger populations at a lower cost than ever before.
There is one caveat: change will only come from within. The health system has become so large, so convoluted, and so empowered by business interests that its revolutionaries, like my colleagues who champion public health practices, must build the equivalent of a Trojan horse to effect change.
Fortunately and unfortunately, Covid has taught us that the system is not nearly as strong as it seems. Leadership failures, racial injustices, public health failures, and institutional collapses—including in public health—exposed a fragile core surrounded by thick, high walls.
Let’s break down those walls, assess the rot, and identify the root causes of how COVID-19 crashed the healthcare system and killed over 1 million Americans. Even without new laws or government policies, I am confident that America can move toward a transformed health care system that is responsible for our well-being and a new paradigm of population health led by medical professionals. Failure to do so would be an offence.
— David B. Nash, MD, MBA, is a MediGuru Advisory Board Member and Founding Dean Emeritus of Jefferson College of Population Health and Ph.D. Raymond C. and Doris N. Grandon Professor of Health Policy The Thomas Jefferson University campus in Philadelphia, PA.