Pandemics Are the Mother of Invention

If, as they say, necessity is the mother of invention, then you'd have to say that the COVID-19 pandemic is proving to be the mother of invention and innovation.  And, like Isaac Hayes sang about Shaft, it is a "bad mother...(shut your mouth)."

Many believe that the Allies won WWII in large part because of how industry in the U.S. geared up to produce fantastic amounts of weapons and other war materials.  It took some time for businesses to retool and get production lines flowing, during which the Axis powers made frightening advances, but once they did it was only a matter of time until the Allies would prevail.

Similarly, COVID-19 is making scary inroads around the world, while businesses are still gearing up to produce the number of ventilators, personal protective equipment (PPE), tests, and other badly needed supplies.  COVID-19 is currently outnumbering these efforts, but eventually we'll get the necessary equipment in the needed amounts. 

Eventually. 

What intrigues me, though, is how people are innovating, inventing new solutions to the shortages we face.  I want to highlight a few of these:

Hospitals: China received a lot of press when they built COVID-19 hospitals in a matter of days, and now that is starting to happen here. In New York City, the U.S. current epicenter, the Army Corps of Engineers has, within a matter of days, repurposed the Javits Convention Center into an overflow hospital with almost 3,000 beds, making it the largest hospital in the city.  It will serve primarily non-COVID-19 patients, allowing other hospitals to focus on COVID-19 patients.

Javits Center hospital

Governor Cuomo has set a goal of 1,000 bed overflow hospitals in each of the five boroughs, the other sites being Brooklyn Cruise Terminal, the Aqueduct Racetrack facility in Queens, CUNY Staten Island and the New York Expo Center in the Bronx.  

In addition, another field hospital is literally being set up in the field, in this case Central Park's East Meadow, across from Mt. Sinai Hospital.  It will have ICU capabilities.

Testing: When this is all over, there will be many analyses about how the U.S. botched coronavirus testing.  As of this writing, although testing has become vastly more available, it still is well below what is needed, and we do not have a good understanding of how widespread the virus has spread and who is currently spreading it.

Abbott Labs COVID-19 test.  Source: Abbott Labs

Part of the problem is that, even for those who can get tested, the results can take hours or even several days to get results.  During that time, they may be asymptomatic and further spread the virus.  All that may be changing. 

Abbott Labs has gotten approval for a point-of-care test that can give results in as few as five minutes.  FDA Commissioner Steve Hahn and former FDA Commissioner Scott Gottlieb both called it a "game changer."

Another game changer is the ability for individuals to self-administer diagnostic tests, alleviating the need to go to testing facilities, and risk exposure for health care workers.  A new study has found that such testing can be as accurate as physician-administered tests.  Such tests are awaiting FDA approval.

PPE: There similarly are not enough masks and other personal protective equipment.  Health care workers are being told to change them after each contact with infected patients, and, as a result, the numbers being used are skyrocketing.  President Trump might suspect that something nefarious is going on, but the need is real. 

Manufacturing of PPE is ramping up, but it will take time to catch up to need.  So Battelle Labs has developed a decontamination system that can allow masks to be reused up to twenty times.  It took intervention from Ohio Governor DeWine to persuade President Trump and FDA Commission Hahn to grant FDA approval in a matter of days, but now the system is quickly being ramped up to full capacity. 

Ventilators: Ventilators are one of the most troublesome bottlenecks in treating COVID-19 patients.  When such patients go into respiratory distress, as an alarming number do, it is quite severe and lasts for much longer than for other ICU patients.  As a result, the ventilator supply has been badly stretched.  Hospitals are having to make tough choices about who gets one and who doesn't. Governors are fighting over where additional ventilators get sent, and manufacturers are scrambling to increase production.

Some hospitals have innovated by using single respirators to serve several patients simultaneously, although the safety of this is unclear.  Others are using continuous positive airway pressure machines (CPAPs), more typically used to treat conditions like sleep apnea, although, again, the safety of this is in question.

Fortunately, the engineers are at it.  In Italy, some clever people started 3D printing badly needed respirator values, for free, when hospitals couldn't get them from the original manufacturers. 

Dyson CoVent ventilator

Never one to be outdone, James Dyson, of vacuum cleaner fame, developed an entirely new ventilator in an astonishing ten days, and is already producing them.  Virgin Orbit, which normally, you know, sends things into space, has developed its "mass producible bridge ventilators" and is hoping to begin production in early April, pending FDA approval. 

Not to be outdone, within two weeks an MIT team developed an "open source, low cost" ventilator design which it believes can be built for as little as $100 (a normal ventilator costs as much as $30,000).  They are waiting for, you guessed it, FDA approval, and warn that these "have to be manufactured according to FDA requirements, and should only be utilized under the supervision of a clinician."  In other words, don't try this at home.

---------

These are just a few examples.  I didn't discuss, for example, how new treatments and vaccines are being rushed through at a breakneck pace, or the countless innovations front line health care professionals are being forced to come up with every day as they face the crush of very sick, infectious COVID-19 patients.  

We are, indeed, at war with the coronavirus, and there are going to be casualties.  A lot of them.  The number of deaths will shock us.  But as shocked as we may become, as overwhelmed as we may feel, we're also going to be amazed at the creativity and innovation people are bringing to the fight.  In the end, though, that and the heroics of our health care workers are what is going to win the war.

The New Scarlet Letter

If you live in one of the jurisdictions that have imposed stay-at-home requirements, you're probably making your essential excursions -- grocery store, pharmacy, even walks -- with a wary eye towards anyone you come across.  Do they have COVID-19?  Have they been in contact with anyone who has?  Are they keeping at least the recommended six feet away from you?  In short, who is putting you at risk?   

Baidu coronavirus map app (Qilai Shen/Bloomberg News

Well, of course, this being the 21st century, we're turning to our smartphones to help us try to answer these questions.  What this may lead to remains to be seen.

We long ago seemed to shrug off the fact that our smartphones and our apps know where we are and where we have been.  No one should be surprised that location is of importance to tracking the spread of COVID-19.  No one should be surprised that it is already being used.  We may end up being surprised at how it will be used.

Last week Israel granted its domestic security agency emergency powers to track the mobile phone data of people who have (or may have) coronavirus.  The intent is for the health ministry to track whether such persons are adhering to quarantine rules, and possibly to alert others who had previously come in contact with them.    

China is using the AliPay Health Code to assign color codes to individuals based on their known health status -- green, yellow, red.  No one is admitting exactly what the codes mean or how they are determined, but The New York Times did an analysis that:

found that the system does more than decide in real time whether someone poses a contagion risk. It also appears to share information with the police, setting a template for new forms of automated social control that could persist long after the epidemic subsides.

Alipay Health Code 

The system is used in real time to determine, for example, who can board mass transit or use public housing.  It is being rolled out nationwide, despite the lack of transparency about how the codes are determined, used, or updated.  As one citizen told The Times: "Alipay already has all our data. So what are we afraid of? Seriously."

Seriously.  

Singapore has developed a tool -- TraceTogether -- that uses Bluetooth to track whose phones have been in close contact, and for how long.  If someone then tests positive for COVID-19, the health ministry can easily determine who has been in contact with them.  It supposedly does not collect name or even location, but the health ministry can identify individuals if deemed "necessary."  The government is making the technology freely available to developers worldwide.  

South Korea is using smartphone data to create a publicly available map of movements of known coronavirus patients, and aggressively message those who might have come in contact with them.  As The Times also reported:

South Koreans’ cellphones vibrate with emergency alerts whenever new cases are discovered in their districts. Websites and smartphone apps detail hour-by-hour, sometimes minute-by-minute, timelines of infected people’s travel — which buses they took, when and where they got on and off, even whether they were wearing masks.

Unfortunately, the information about their movements is having significant ripple effects, disclosing destinations users might have preferred not be public, or attaching a stigma to places they frequented. One person told The Guardian: "I thought I only had to protect my health, but now I think there are other things more scary than the coronavirus."

In the U.S., volunteers from several big tech companies built covidnearyou, which allows people to self-report such facts as any symptoms, travel history, or exposure to people who have tested positive.  Anyone can then use their map to determine if there are affected individuals near them. 

MIT's Media Lab has developed Private Kit: Safe Paths, "An app that tracks where you have been and who you have crossed paths with—and then shares this personal data with other users in a privacy-preserving way."  Unlike efforts in some other countries, the data is encrypted and does not go through a central authority.  MIT Technology Review says:

This lets users see if they may have come in contact with someone carrying the coronavirus—if that person has shared that information—without knowing who it might be. A person using the app who tests positive can also choose to share location data with health officials, who can then make it public.  

Oura smart ring.  Credit: San Francisco Chronicle

Going one step further, two San Francisco hospitals have developed a smart ring that is "able to detect body temperature and pulse."  It is aimed at health care professionals and workers, such as ER doctors, as an early indicator of COVID-19 exposure.  It's probably only a matter of time before laypersons demand a version.

One can easily imagine such a smart ring being connected to a smartphone app, perhaps even generating a color code, and broadcasting the individual's status and location to others worried about potential exposure.  I bet Alibaba would be happy to help.

Everything else being equal, it's good to know who represents a risk to us.  Typhoid Mary became Typhoid Mary because people around her didn't know she was a carrier.  It would be in the public benefit to ensure that people can get warning about other people who are most likely to be infectious with COVID-19.

That being said, everything else is not equal.  We don't have a good understanding of when people with COVID-19 are most infectious, how COVID-19 is most likely transmitted, or how exposure to such people increases risk of third-party transmission.  Tagging people and then broadcasting that tag, along with location and even identity, could put people at risk of discrimination (e.g., refused service or contact) and even attacks. 

As one privacy expert told The Times: "That could extend to anyone, to suddenly have the status of your health blasted out to thousands or potentially millions of people.  It’s a very strange thing to do because, in the alleged interest of public health, you are actually endangering people."

And we need to bear in mind that whatever technology we bring to bear on this public health problem could subsequently be used for other problems, public health or other.  We increasingly live in a surveillance society, and that can be to our benefit -- or to our detriment.  We don't always realize the slippery slope we're on until the slide has become irreversible. 

I'm all for using technology to address public health crises.  I'm just not clear what the ultimate price we're going to have to pay for that, and that makes me nervous. 

Not Another Twenty Years...

I know that everything is COVID-19 these days, but I don't know that I can read another article about it right now, and I certainly can't write one.  I need a break, and maybe you do too.  Instead, I'll talk about tech adoption and some lessons architecture -- yes, architecture -- might have for healthcare.  

Credit: Getty Images

The Wall Street Journal has an article Tech Disruption Can Take Decades -- Just Ask Architects.   Many of us knew that computer assisted design (CAD) had revolutionized the field of architecture, but until reading this article I did not realize that particular wave passed through the field in the latter  decades of the 20th century.  The wave that is currently passing through is something called building information modeling (BIM).  

BIM is 3D modeling on steroids.  AutoDesk, which I gather is to CAD and BIM as Epic is to EHRs, defines it as: "BIM is an intelligent model-based process that helps make design, engineering, project and operational information accurate, accessible and actionable for buildings and infrastructure." GRIFTISOFT, a competitor, says "BIM is the use of 3D virtual models of buildings, as well as a process of managing and collecting building data."  

In its BIM 101 article, engineering.com stresses that BIM is not just for architects and not just for design.  Instead, "BIM is all about the information. It doesn’t just create a visually appealing 3D model of your building—it creates numerous layers of metadata and renders them within a collaborative workflow."  

Keep that in mind for later.  

BIM didn't really start to take off until the last recession, when layoffs or fewer active projects gave architects more time to earn the software.  Not surprisingly, younger workers picked it up first, either then teaching other workers or assuming more duties and shunting older and/or less tech proficient workers to tasks less connected to design, "sometimes creating a complex generational dynamic."  

Phil Bernstein, a Yale architecture professor, told the WSJ this about BIM adoption:

I’m surprised by how slowly this is all happening.  When we first proposed the idea that Autodesk would shift from drafting platforms to modeling platforms, if you told me that almost 20 years later we’d finally be at the point where it was normal everyday practice, that’s a long time."

As one architect told the WSJ, "The promises of technology are oftentimes extremely exciting and encouraging when you hear the sales pitch.  The reality is that it’s a much longer and more complex process than originally envisioned."  

The article goes on to note:

The phenomenon holds lessons for other industries and trades, as digital tools offering more efficiency and precision replace older, more manual technologies. The barriers to adopting costly automation or technology can be significant, especially in fragmented fields with many small players.

Architecture has gone from a field marked by emphasis on drafting skills and reliance on reams of architectural drawings to one reliant on shared, dynamic, interactive 3D models infused with various types of relevant information.  In short, everything we should expect EHRs to be.

EHRs and telehealth are the two obvious parallels to CAD/BIM in healthcare.  Neither is a new technology.  Epic, for example, has been selling EHRs for forty years, and the VA's VistA has been in existence about as long.  EHRs have finally gained broad use, due in large part to the HITECH stimulus payments, but not deep satisfaction among clinicians.

Similarly, companies like Teladoc Health and American Well (Amwell) have been offering some form of telehealth for over fifteen years, and it is only with the COVID-19 crisis (darn -- I should have known I couldn't avoid it altogether!) that we are finally lifting some of the many barriers -- e.g., licensing, reimbursement -- that have kept telehealth from becoming mainstream.  

Of course, the fact that we have separate EHR solutions and telehealth solutions is an example of not fully embracing technological change (although some vendors are starting to integrate).  Similarly, the fact that we have telehealth solutions that are distinct from commonly used messaging/video services is another example that we're not fully maximizing available technology.

Healthcare has had many barriers to technological change.  Until fairly recently, most physicians worked in solo or other small practices.  Most hospitals were single location, nominally non-profit.  Home health agencies, nursing homes, dialysis centers, even drugstores were largely "mom-and-pop."  Most of that has changed to larger, more vertically/horizontally integrated models, but mindsets and technologies have not adopted as rapidly as business structures.   

And, of course, reimbursement has been a factor in healthcare technology adoption: there is a multiplicity of third-party payors using a byzantine medical coding system to pay an array of payment levels.  It can be tough to introduce new technology that doesn't fit existing molds and that may, in fact, slow processes during the learning curve.  

When you think about those older architects who struggled to learn CAD and then were forced to adopt to BIM, think about physicians spending hours trying to catch up on their EHR documentation.  A recent article in Harvard Business Review claims: "Estimates of physician productivity suggest that 20% to 30% or more of a physician’s available capacity is absorbed by clinical documentation, electronic medical record (EMR) inputs, and other compliance-related work."

Right now, you might say that healthcare is at the 2D CAD level.  Yes, we're moving away (ha!) from paper and more fully utilizing computers, but we're a long way from the 3D, interactive, information-embedded BIM that architecture uses.  

Imagine, for example, an EHR that:

• has a 3D model (digital twin!) of patients, annotated with pertinent images and information;
• is accessible and updateable by other clinicians as appropriate;
• is accessible and updateable by patients and patient devices;
• can be used as a communications vehicle with patients and clinicians

None of that technology is beyond our current reach, but I hate to think that it might take another couple of decades for such an approach to be in wide use. 

A Healthcare System, If We Can Keep it

We are in strange days, and they are only going to get stranger as COVID-19 works its way further through our society.  It makes me think of Benjamin Franklin's response when asked what kind of nation the U.S. was going to be:  "A Republic, if you can keep it." 

SAUL LOEB / AFP VIA GETTY IMAGES

The versions of that response that COVID-19 have me wondering about are: "A federal system, if we can keep it," and, more specifically, "a healthcare system, if we can keep it."  I'll talk about each of those in the context of the pandemic.

In times of national emergencies -- think 9/11, think World Wars -- we usually look to the federal government to lead.  The COVID-19 pandemic has been declared a national emergency, but we're still looking for strong federal leadership.  We have the Centers for Disease Control, infectious disease experts like Dr. Anthony Fauci, and a White House coronavirus task force.  But real national leadership is lacking. 

Credit: Dayton Daily News/Marshall Gorby

States and cities are forming their own responses.  Schools are being closed.  Other types of businesses -- e.g., malls, movie theaters, gyms, casinos -- are being closed.  Bars and restaurants are only allowed to do carryout/delivery.   Curfews are being imposed.  Primaries are being delayed.  But none is being done on a national level, and, in many cases, not even on a state-wide basis. 

As Gerald Seib said in The Wall Street Journal:

Put differently, Americans have learned they can’t really count on Washington to deal with this crisis for them. Local leaders, businesses, churches, sports leagues—all have taken up the task, and done so more effectively than the political leadership in Washington.

The House passed an emergency coronavirus bill last week, and now the Senate is  coming up with its own ideas.  When Congress finally passes what bill remains to be seen, after how much further damage has been done to our health and our economy. 

Anne Applebaum minces no words in her article in The Atlantic:

The problem is that American bureaucracies, and the antiquated, hidebound, unloved federal government of which they are part, are no longer up to the job of coping with the kinds of challenges that face us in the 21st century.

"The United States," she says, "is about to be proved an unclothed emperor."  Derek Thompson, also writing in The Atlantic, is equally blunt: "...executive branch of government—drained of scientific expertise, starved of moral vision—has taken on the qualities of a failed state."  In New York Magazine, David Wallace-Wells says: "America is broken...This is not how a functioning society responds to a crisis." 

These are descriptions of the United States, and it's hard to argue with them.

Pandemics are, by definition, catastrophes.  They're going to cause damage.  The question is how societies prepare for them, and respond when they hit.  So far, the U.S. is failing on both counts.

In our federal system of government, we delegate many duties to the states, which delegate many to localities. Public health is one such duty.  Michele Barry, senior associate dean of global health at Stanford University, told The New York Times:

We have a completely decentralized public health system.  It is difficult to mobilize a large containment strategy. That’s what Singapore did, or what China did. We don’t even work from the states up. We work from the counties up."

Unfortunately, as The New York Times also reported: 

A widespread failure in the United States to invest in public health has left local and state health departments struggling to respond to the coronavirus outbreak and ill-prepared to face the swelling crisis ahead...Many health departments are suffering from budget and staffing cuts that date to the Great Recession and have never been fully restored.

Our failure to have testing done earlier, and then quickly made widely available, is a public health failure, and it means we are still in the dark about many key questions. 

Credit: Getty Images

Now we're worried about COVID-19 patients overwhelming our entire healthcare system.  Elective surgeries are being postponed.  We may not have enough ICU beds.  There may be a shortage of ventilators for those ICU patients.  People are stealing personal protective equipment, posing additional risks to medical personnel. 

When COVID-19 hit Wuhan, China scrambled to build new hospitals in little over a week.  I don't have much faith in our ability to accomplish that (although there are calls for the Army Corps of Engineers to try). 

The pandemic didn't create the problems in our healthcare system.  The failure to prioritize public health is longstanding.  Worry about how people pay for testing is symptomatic of the problem people have paying for healthcare generally.  Our inability to determine how to prioritize where necessary supplies and equipment go reflect the fact that our healthcare system is, for better and for worse, a largely capitalistic system where money rules, not need.  We decry pharmaceutical company profits but look to them to quickly develop COVID-19 vaccines.

Charley Grant of The Wall Street Journal says: "The issues exposed by the crisis are likely to linger far beyond the worst of the outbreak."  He goes on to predict:

How effectively the U.S. can beat back the novel coronavirus, and what parts of the system shine or disappoint, may well determine whether the federal government expands its role in the system or reduces it.

I'd go further: how we get through this crisis may well determine what kind of healthcare system we want to have, and perhaps even how much power the federal government should have.  

We're going to spend a lot of money on the pandemic.  Not all of it will be spent as it perhaps should have been.  Many people will get infected and many of them will die.  Parts of the healthcare system will flounder; some will fail.  There will be heroes and probably a few villains.  These are all in the nature of pandemics.

The key questions with the current crisis are how quickly we can act, how effective that action will be, and, perhaps, most importantly, what lessons will we learn?  How much power should the federal government exercise in such crises, or over healthcare generally?  What problems with our healthcare system are unique to pandemics, and which need broader fixes?  How best to ensure public health on an ongoing basis? 

There are no easy answers.  The next few months are not going to be pretty.  We're going to make some decisions that, in retrospect, will seem like mistakes.  But we will get through this.

But, as economist Paul Romer once said: "a crisis is a terrible thing to waste."

Let's not waste this one. 

What If We Had a Pandemic and No One Came?

I wasn't going to write about COVID-19/coronavirus; too many other, more knowledgeable people are already doing that.  It is a rapidly developing situation, and we're still learning about how it is going to impact our lives.  I won't even try to get into the testing debacles in the U.S. or our confused "official" attempts at guidance and reassurance. 

Credit: Politico/iStock

But I am intrigued about how it may be impacting our healthcare system and, indeed, our society, in ways that may actually end up being positive. 

Right now, we're in a bit of a panic mode.  Conferences are being cancelled.  Businesses are curtailing travel and urging many workers to work from home.  Schools and universities are switching to online options.  St.Patrick's Day parades are being cancelled.  Sporting events are being hold without crowds, or cancelled outright; major events like the Tokyo Olympics are at risk.  The National Guard is being called in to set up "containment zones."  Whole countries are being put on "lockdown."

As former HHS Secretary Michael Leavitt said: "Anything said in advance of a pandemic seems alarmist. After a pandemic begins, anything one has said or done is inadequate."

Some of our responses will be short-term or even, in retrospect, prove ill-advised.  But here are a few that I hope gain traction:

Telecommuting: We spend  lot of time commuting.  We use a lot of gasoline in the process, contribute to air pollution, wear down roads.  Ever since the Industrial Revolution moved jobs away from the home, we've been all-in on going somewhere to work, but many -- not all, but many -- 21st century jobs can be done from home or off-site locations, at least some of the time.  

As many as 24% of private workers teleworked at least some of the time in 2018, but many employers, as well as the federal government, were in the process of curtailing such options until COVID-19 hit.  

Come on, it's the 21st century.  Telework is healthier for workers and for the environment.  We should use the current crisis to figure out when and how it makes sense to embrace and encourage it.

Rational cost-sharing: A recent report found 14% live in families who struggle to pay healthcare bills, although some would argue the number is much higher.  With a contagious disease like COVID-19, though, delays in getting tested or treated can help spread the disease, which is leading some states -- such as California, Colorado, New York and Washington -- to limit such cost-sharing, at least for insured plans under their regulation.  

Cost-sharing can serve a purpose, but when it is punitive or prevents people from getting essential care, it is ultimately self-defeating.  Let's hope COVID-19 teaches us to finally stop being penny-wise, pound-foolish.

Testing: Typically, when you need a medical test, you have to go to a healthcare facility.  That adds a barrier to getting the test, not to mention either exposing you to others who might be contagious or them to you.

With COVID-19, though, people are realizing the problem this causes.  Some countries -- England and South Korea -- have instituted "drive-though" testing, as has at least one Seattle hospital.  Next on the horizon, courtesy of the Gates Foundation, are home tests.  

We have drive-though restaurants, dry cleaners, coffee shops, even pharmacies; we have home delivery of meals, groceries, and everything Amazon can sell.  Why not extend these expected conveniences to health care testing as well?  It won't work for all tests, but probably can work for more than COVID-19.  

Telehealth: Telehealth/telemedicine remains the next big thing; it just hasn't quite taken off the way many expected.  Reimbursement and regulation issues remain barriers.  But COVID-19 is forcing us to realize how important it can be for possibly contagious people not to go out in public in order to get medical advice.  

The recently enacted emergency pending provisions for coronavirus included provisions to extend Medicare's telemedicine services, and many doctors, hospitals, and health insurers are also trying to expand its use.   American Well reports a surge in use, both from people worried they might have COVID-19 and from others who want to avoid those who do.

Telehealth makes sense.  Sick people don't want to have to travel needlessly, and everyone would prefer to avoid contagious people.  We're urging self quarantines and, in some cases mandating them, but we still need such individuals to get medical advice.  In the 21st century, why isn't a telehealth visit our usual first option for most health issues?    

Paid sick leave: When workers think they might have COVID-19 -- or the flu, or even a cold -- they face the inevitable decision: to go into to work or not?  If they are lucky, they have a job they can do from home, but if most do not have that option, especially for the retail and service industries (including, of course, health care).  

As a result, many go to work until they are too sick, and some act as vectors to spread whatever they have.  It's bad for them, bad for the other workers, and bad for the employers.  But many employers lack robust paid sick pay programs (if any at all).  

The U.S. is one of the few major economies not to require paid sick leave, although some states do.  A new study on state laws found that, yes, fewer workers worked when sick, they didn't have many such days, and the overall cost to employers was small.  What's not to like?  

COVID-19 is forcing the issue.  For example, Darden Restaurants Inc., which operates such restaurants as Olive Garden and Longhorn Steakhouse, is now offering paid sick leave to all workers.  There are efforts at both the state and federal level to require it, although whether those can overcome traditional business resistance to such requirements remain to be seen.  

Sick people do not belong at work.  Most sick workers can ill-afford to not get paid when they are sick.  If COVID-19 teaches us anything, it might be that paid sick leave is an investment we can't afford not to make.  

--------

We will get through COVID-19.  We don't yet know how many will get sick or die, how much it will cost, or how significant an impact it will have on world economies, but we will get through it.  I just hope we'll learn the right lessons from it, including the above.  

Still Fighting the Wrong Wars

What do the coronavirus and Navy ships have in common?  For that matter, what do our military spending and our healthcare spending have in common?  More than you might think, and it boils down to this: we spend too much for too little, in large part because we tend to always be fighting the wrong wars.

Workers trying to sterilize coronavirus.  Photo by STR/AFP via Getty Images

I started thinking about this a couple weeks ago due to a WSJ article about the U.S. Navy's "aging and fragmented technology."  An internal Navy strategy memo warned that the Navy is "under cyber siege" by foreign adversaries, leaking information "like a sieve."  It grimly pointed out:

Our adversaries gain an advantage in cyberspace through guerrilla tactics within our defensive perimeters.  Once inside, malign actors steal, destroy and/or modify critical data and information. 

This is the Navy, after all, that proudly tried to modernize by installing touch screen technology on some of its ships, only to have the disaster that hit the USS McClain.  Its vaunted Integrated Bridge and Navigation System was, ProPublica found, "was a welter of buttons, gauges and software that, poorly understood and not surprisingly misused, helped guide 10 sailors to their deaths."  And that wasn't the only technology-enabled naval disaster in recent years.

But don't just blame the Navy.  We've got a next-generation stealth fighter which, after over $400b of development, is still having major problems.  Elon Musk, who always seem to be living in the future, bluntly said: "The fighter jet era has passed.  Drone warfare is where the future will be."

We spend more on defense than the next seven largest militaries combined, spending trillions on advanced aircraft carriers, stealth fighter planes, and fancy personnel transports, and our adversaries are investing in cyber warfare, drones, IEDs, and other low cost, modern tech options.

We also fight with traditional tools like financial sanctions, which similarly are proving ineffective.  A new report concluded: "Our sanctions system needs a radical update."

It is no wonder that a recent report from the National Counterintelligence and Security Center warned:

The ever-changing technology landscape is likely to accelerate these trends, threatening the security and economic well-being of the American people and eroding the United States’ economic, military, and technological advantage around the globe.

We may be fighting the wrong wars, but at least we win the spending prize.  Just like in healthcare.

The coronavirus outbreak helps illustrate our misguided focus.  Yes, when we identify someone is critically ill with it, we've got the doctors, hospitals, and technology to help deal with it.  But that leaves a lot to be desired.  As Matthew Herper wrote in Stat News, "It is an invisible threat, and it is making vivid the shortcomings of our health care systems."

He noted:

We tend to overreact to problems that are facing us right now but underreact to long-term threats that build slowly...We panic, but we don’t prepare.

 Our public health system is fragmented, underfunded, and only appreciated in times of crisis like this.  We lack a solid tracking system to identify and swiftly respond to outbreaks.  We can't even seem to manage producing the diagnostic tests to help identify this outbreak.

Credit: CDC

Dr. Michael Mina, a Howard epidemiologist, told The New York Times: "The incompetence has really exceeded what anyone would expect with the C.D.C.," causing The Times to wonder: "Why weren’t more Americans tested sooner? How many may be carrying the virus now?"
Our system is creaky even -- or especially -- when someone is diagnosed with the virus.  We urge people who are or even may be sick to stay home, but, as Christopher Ingram pointed out in The Washington Post, 

The United States is one of the few wealthy democracies in the world that does not mandate paid sick leave. As a result, roughly 25 percent of American workers have none, leaving many with little choice but to go to work while ill, transmitting infections to co-workers, customers and anyone they might meet on the street or in a crowded subway car.

Mr. Ingram cites research on the effect of mandatory paid sick leave on flu rates, which found that they caused a major decrease.  In other words, he says, "at the population level, cities with paid sick leave policies are considerably healthier than those without them."  

Public health pays off.  

New York is trying to require health insurers to waive any cost-sharing for testing for the coronavirus, but, even if the requirement proves to be legal, it would only cover a small portion of associated costs, and would not apply to ERISA plans that are exempt from state regulation.

And, of course, for those unfortunate enough to be hospitalized or even just quarantined due to the virus, they're likely to be stuck with big bills, even if they have insurance.  One health law professor told Sarah Kliff of The New York Times:

The most important rule of public health is to gain the cooperation of the population.  There are legal, moral and public health reasons not to charge the patients.

But, of course, that is not the healthcare system we have. 

A couple of years ago I asserted that our biggest health problems are public health problems, which are ill-served by our current medical care system.  I concluded then:

We need to stop viewing public health as a boring, not glamorous, small part of our healthcare system, but, rather, as the bedrock of it, and of our health.

Mr. Herper urged that "outbreak should be a wake-up call...about infectious threats that we face together and that exploit vulnerabilities associated with income inequality, health disparities, and our slowness to recognize threats."  I agree with that, but do not think it goes far enough.

We need to stop fighting the wrong wars in healthcare.  We're arguing about universal coverage, surprise bills, transparency of pricing, the high price of prescription drugs, and, now, the coronavirus.  Each is a real problem, but none is the right war.

The real war facing us is a public health war.  Whether it is this or the next pandemic, or whether it is obesity or gun violence, the biggest threats come at the public health level.  We're spending plenty of money on healthcare, but we're not spending nearly enough on these wars.

If the coronavirus outbreak teaches us anything, let it be that we'd better be investing much more heavily in public health, as broadly defined as we can make it.