Your Face Is Not Your Own

I swear I'd been thinking about writing about facial recognition long before I discovered that John Oliver devoted his show last night to it.  Last week I wrote about how "Defund Police" should be expanded to "Defund Health Care," and included a link to Mr. Oliver's related episode, only to have a critic comment that I should have just given the link and left it at that. 

Now, I can't blame anyone for preferring Mr. Oliver's insights to mine, so I'll link to his observations straightaway...but if you're interested in some thoughts about facial recognition and healthcare, I hope you'll keep reading.

Facial recognition is, indeed, in the news lately, and not in a good way.  Its use, particularly by law enforcement agencies, has become more widely known, as have some of its shortcomings.  At best, it is still weak at accurately identifying minority faces (or women), and at worst it poses significant privacy concerns for, well, everyone.  The fact that someone using such software could identify you in a crowd using publicly available photographs, and then track your past and subsequent movements, is the essence of Big Brother. 

For once technology companies are at least pretending to be concerned.  IBM was the first, saying it was getting out of the facial recognition business entirely, including research, due to concerns about bias and potential for abuse.  CEO Arvind Krishna's letter to Congress urged: 

We believe now is the time to begin a national dialogue on whether and how facial recognition technology should be employed by domestic law enforcement agencies. Artificial Intelligence is a powerful tool that can help.   

Both Amazon and Microsoft subsequently put moratoriums on police use of their facial recognition software.  "We’re implementing a one-year moratorium on police use of Amazon’s facial recognition technology... We hope this one-year moratorium might give Congress enough time to implement appropriate rules, and we stand ready to help if requested," Amazon announced.  

Microsoft President Brad Smith echoed the call, stating: "We’ve decided that we will not sell facial-recognition technology to police departments in the United States until we have a national law in place, grounded in human rights, that will govern this technology."    

Of course, Amazon and Microsoft are still selling their software to other parties, and there are several companies still selling to law enforcement, such as NEC and Clearview AI. 

Credit: MediaJustice

The seemingly sudden (and narrowly focused) concern for our privacy rights has been spurred by the resurgence of the Black Lives Matter movement, in the wake of the nationwide protests about the George Floyd murder.  It made people uneasy that facial recognition might be used by the police to identify protesters, who were, of course, protesting the police.

There are at least two ironies here.  One is that the masks many protesters have been wearing due to coronavirus concerns make it more difficult for facial recognition software to identify them, although that is a technical challenge developers are addressing.   Masks have served a dual privacy/pandemic role in Hong Kong for some time, and there is an interesting design battle going on for masks and clothing that help defeat or at least confuse facial recognition, so it remains an open question whether they are a roadblock or just a speed bump.  

The other irony is it was smartphone video, another almost constant form of surveillance, that captured Mr. Floyd's demise.  In The Wall Street Journal, Joanna Stern wrote:

Many white Americans, myself included, failed until recently to grasp one of the biggest impacts of the smartphone: its ability to make the world witness police brutality toward African-Americans that was all too easy to ignore in the past. We could now see, with our own eyes, the black sides of stories that were otherwise lost when white officers filed their police reports.

One activist told her: The smartphone is a weapon that tells the story. This is going to tell what happened to me, this is what will tell what took place."

Technology gives, technology takes away.

Years ago I speculated that facial recognition could be used to identify when we might be sick, and perhaps be used to diagnose us, and this is now within reach of existing technologies.  We've got an array of surveillance measures that are tracking who we are, where we are, what we're doing, and even how we might be feeling.   

And we thought it was bad when we realized Google was reading our emails or Facebook was monetizing our interests. 

Credit: CPO Magazine

Whether we like it or not, whether we realize it or not, we not only don't know who is monitoring what we're doing on the internet, but we also don't know when what cameras are watching us, nor who is using which software to do what with those images.  Americans like to believe we have a constitutional right to privacy, but most would be surprised to find that such rights are more implied than explicit.

We should applaud the positions that Amazon, IBM, and Microsoft are taking on facial recognition, and we should welcome an explicit discussion about what the limits of facial recognition should be, but we shouldn't kid ourselves that the technology isn't going to advance faster than our privacy laws.  We've known that privacy has been an issue in tech for some time now, and despite efforts like the E.U.'s GDPR or California's Consumer Privacy Act, few of us would say we've become more reassured about our online privacy (and note how COVID-19 is pushing GDPR to its limits).  Facial recognition just adds to those concerns. 

Few of us would protest using facial recognition to reunite lost/missing children, to capture escaped killers, or perhaps even to isolate people infected with a deadly infectious disease.  Few, though, would probably be comfortable with third parties, whether they be law enforcement agencies or simply advertisers, always knowing where we are and have been.  There's a line to be drawn, but it's going to be a blurry one.   

I don't know exactly where the line is, but I'd start with cui bono: who benefits? 

As Ms. Stern wrote about smartphone cameras, "Like any technology story, what we do with them, and the world we want them to capture, is up to us." 

Defund Health Care!

In the wake of the protests related to George Floyd's death, there have been many calls to "defund police."  Those words come as a shock to many people, some of whom can't imagine even reducing police budgets, much less abolishing entire police departments, as a few advocates do indeed call for.

If we're talking about institutions that are supposed to protect us but too often cause us harm, maybe we should be talking about defunding health care as well.

Credit: Kyra Ching

America loves the police.  They're like mom and apple pie; not supporting them is essentially seen as being unpatriotic.  Until recent events, it's been political suicide to try to attack police budgets.  It's much easier for politicians to urge more police, with more hardware, even military grade, while searching for budget cuts that will attract less attention.

It remains to be seen whether the current climate will actually lead to action, but there are faint signs of change.  The mayor of Los Angeles has promised to cut $150 million from its police budget, the New York City mayor vowed to cut some of its $6b police budget, and the Minneapolis City Council voted to "begin the process of ending the Minneapolis Police Department," perhaps spurred by seeing the mayor do a "walk of shame" of jeers from protesters when he would not agree to even defunding it.

Let's look at the problem.  According to a Washington Post analysis, U.S. police fatally shoot about 1,000 people per year (and, bear in mind, George Floyd wasn't shot).  Police-related deaths are far higher, in absolute numbers or per capita, than other developed countries, as are arrests, use-of-force, and imprisonments.  All of this falls disproportionately on people of color, especially African-American men.

Not coincidentally, over the past forty years our spending on "law & order" has grown steadily, while our spending on social welfare programs has stagnated; they've gone from being roughly equal shares of national income to law & order being twice as much.  Even worse, there is no clear correlation between all that spending and crime rates.  As I've discussed previously, most of our arrests are not for violent crimes but for drug offenses as part of our "War on Drugs," even though our use of drugs isn't dissimilar to other countries while our treatment of drug users is.

We've cut social service programs and forced police to pick up the resulting problems, like drug addiction and homelessness.   As has been debated for years, we've turned our police into warriors instead of guardians.

If you haven't watched it yet, John Oliver nails the problems yet again:

On average, minorities have far less income and wealth, attend lower performing schools, are less likely to graduate from college, have lower rates of home or business ownership, and serve in fewer technical/managerial/executive roles.  We can't police ourselves out of the hole we've dug for many of our fellow citizens.  The question isn't why we have crime but, indeed, why don't we have more?

So, what does this have to do with health care?

We have the world's most expensive healthcare system, but one whose spending doesn't buy us better health or even longer lives.  A substantial portion of that spending is wasted at best and inappropriate or even dangerous at worst.  We have way too many medical errors, and those errors lead to a shocking number of injuries and deaths.

If you want to know why we should be angry at our healthcare system, read Elisabeth Rosenthal's An American Sickness, Cathryn Jakobson Ramin's Crooked, Beth Macy's Dopesick, or Jeanne Lenzer's The Danger Within Us, to name just a few recent exposes.

More of us suffer from our healthcare system than from the police system, with African-Americans having perhaps again the most to complain about, so, yes, why not call to defund health care? 

We can do better.

Ironically, the pandemic has effectively defunded large parts of our healthcare system.  For the first time anyone can remember, healthcare spending dropped.  Healthcare jobs, usually one of the major sources of new jobs, have been lost.  People are delaying care at astonishing levels.  Even ER visits for true emergencies, like heart attacks or suicide attempts, are way down.

With some exceptions, like increased use of telehealth, we're just not doing this defunding in any way that necessarily either improves our health or the healthcare system post-pandemic.

Credit: CDC

Start with public health.  If the COVID-19 pandemic has taught us anything, it is that we do not have a robust public health system, at any level.  We spend trillions of dollars on advanced medical care, but pinch pennies on public health, a pound foolish investment if there ever was one.  That has led to not only our slow, mistaken-ridden response, but also to the wide gap in African-American fatality rates from it, which are largely driven by the underlying health disparities, which themselves are both public health and socio-economic failures.

Focus next on social determinants of health (SDOH).  SDOH contributes much more to our health than medical care does, and investments in it produce outsized returns.  Better housing, a cleaner environment, better education, more income equality will result in a healthier population (and probably lower crime).

Then focus on primary care, which should be central to our healthcare system.  Over the past few decades, we've been funding institutions and sub-specialists more than primary care, and the pandemic has made that worse.  That is akin to the warrior versus guardian distinction for police.

Then, and only then, take a hard look at who we're paying for what care, with what outcomes.  There won't be enough money for everything our healthcare system is doing now, and that's OK; the goal is to need less care.

We're not going to get rid of the police.  As much as we rightfully decry some police practices, when it's your life or your property that is threatened, you're thankful for the police.  The issue is not whether to have police but what we should expect them to do and how to do that, and what we can do to reduce the need for them.

Same with healthcare.  When your loved one gets COVID-19, or has a heart attack, you want those ICUs and sub-specialties.  When the pharmaceutical companies develop vaccines for COVID-19, you'll be thankful for them too.  The issue is not whether to have a healthcare system but in how to make it less about medical care and more about health.

We should take this opportunity to defund healthcare, but do it thoughtfully.

We Can't Breathe

I was wondering what might crowd COVID-19 off the news.  The historic economic devastation caused by it has been subsumed into it, just another casualty of the pandemic.  In better times, perhaps SpaceX's efforts would inspire us.  But, no, it took the police killing of yet another person of color to take our attention away.

Now, let me say right off that I am not the best person to discuss George Floyd's death and the woeful pattern it is part of.  I have certainly been the beneficiary of white male privilege.  I've never been unjustly pulled over or arrested.  I haven't taken part in the protests.  But people like me need to speak out.  Writing about anything else right now seems almost irresponsible.

OK: you've seen the video.  You've heard Mr. Floyd protest that he can't breathe, that the officer was killing him.  You've seen other officers stand by and not do anything -- some even assisting -- even as bystanders pleaded for them to let Mr. Floyd breathe.  It's disturbing, it's distressing, and it's nothing new.

I saw a video from one of the resulting protests where another officer restrained a protester -- a black man, of course -- in exactly the same way, although in this case another officer eventually moved the officer's knee off the protester's neck.  He'd learned what that video looked like.

There now have been protests in over 140 U.S. cities, with the National Guard mobilized in almost half the states.  Most protests have been peaceful, but there has been looting, there have been shootings, and there have been deaths among both protesters and police.  It's a level of civil unrest not seen since the 1960's.

And we thought it was bad when we just wanted the grocery stores to have toilet paper again, when wearing a mask was considered a hardship.

It's a shame that some protests have ended up in destruction, and it's a tragedy that others have ended with violence.  It's possible that there are extremists who are seeking to use the protests as an opportunity to sow their own kinds of chaos.  But let's not use that as an excuse not to understand the justifiable frustration and anger that underlies the protests.

The New York Times profiled how Minneapolis might have a reputation as a diverse, liberal city, but "there remains an extraordinary racial gap for Minnesotans when it comes to education outcomes and health care."  Lawrence R. Jacobs, a professor at the University of Minnesota, explained: "

The racism has been around for a very, very long time.  You can see it in the redlining of neighborhoods, the education system, the transportation system and, obviously, policing.”

Similarly, The Washington Post called racial inequality in Minneapolis "among the worst in the nation," noting that:

The typical black family in Minneapolis earns less than half as much as the typical white family in any given year. And homeownership among black people is one-third the rate of white families.

It's not just Minneapolis, of course.  African-American and Latino populations dramatically trail whites in income and wealth across the country.  Those populations have long lagged in employment, and in the current recession are taking the biggest hits.  They're also more likely to be in low wage, essential jobs that can't be done from home, leading them to greater exposure to COVID-19.

Ironically, the very protests about police violence and the underlying inequalities may serve as fertile ground for further spread of COVID-19, and hit minority communities hardest of all.

Still, those are not the main reasons why minority communities are the hardest hit by COVID-19, especially African-Americans.  Dr. Marcella Nunez-Smith, director of Equity Research and Innovation at Yale School of Medicine, told NPR:

I've been at health equity research for a couple of decades now.  Those of us in the field, sadly, expected this.  We know that these racial ethnic disparities in COVID-19 are the result of pre-pandemic realities.  It's a legacy of structural discrimination that has limited success to health and wealth for people of color.  

Greg Millet, director of public policy at amfAR, agrees: "There's a structural issue that's taking place here, it's not a genetic issue for all non-white individuals in the U.S."  

One of those issues, sadly, is our justice system.  Here's a fact: police violence is a leading cause of death for young men in America -- and that is especially true of African-American men.  In research published last year, Edwards, et. alia concluded:

Police violence is a leading cause of death for young men, and young men of color face exceptionally high risk of being killed by police. Inequalities in risk are pronounced throughout the life course. This study reinforces calls to treat police violence as a public health issue . Racially unequal exposure to the risk of state violence has profound consequences for public health, democracy, and racial stratification.

Credit: Edwards, Lee, Esposito/PNAS

The problem goes beyond police violence.  We incarcerate far more people than any other country -- per capita or in absolute numbers -- and those prisoners are much more likely to be minorities (especially men).  Black men have a 1 in 3 lifetime chance of being imprisoned, Latino men 1 in 6, versus white men's 1 in 17.  Most of those imprisoned are there for drug offenses, and here the inequalities matter: whites are, in fact, more likely to use drugs, and about as likely to sell them, but are much less likely to be arrested/imprisoned for drug offenses.

Trevor Noah clarified the underlying problem: when Amy Cooper, the Central Park woman who called the police when a bird-watcher politely asked her to put her dog on a lease, she simply expected that, as a white woman, she'd be believed, and the African-American man wouldn't be.  We're all facing COVID-19, Mr. Noah reminds us, but African-Americans are facing COVID-19 and racism.  

President Trump wants to just lock up the protesters, while seemingly not to mind that COVID-19's disproportionate impact on minorities helps his election chances.  He and other so-called conservatives are happy to continue to allow the wide disparities that resulted in, among other things, George Floyd's death and COVID-19's impact on minority populations.  Even those of us who are offended, even outraged, by these inequalities have, for the most part, been too complicit in them.

The protests and even the pandemic will pass -- somehow, sometime, and with catastrophic damage.  But history will judge us by whether we took the opportunity to address the problems that underlie them.

The 2020 COVID-19 Election

Many believe that the 2020 Presidential election will be a referendum on how President Trump has handled the coronavirus pandemic.  Some believe that is why the President is pushing so hard to reopen the economy, so that he can reclaim it as the focal point instead.  I fear that the pandemic will, indeed, play a major role in the election, but not quite in the way we're openly talking about.

It's about there being fewer Democrats.

Now, let me say right from the start that I am not a conspiracy believer.  I don't believe that COVID-19 came from a Chinese lab, or that China deliberately wanted it to spread.  I don't even believe that the Administration's various delays and bungles in dealing with the pandemic are strategic or even deliberate.

I do believe, though, that people in the Administration and in the Republican party more generally may be seeing how the pandemic is playing out, and feel less incentive to combat it to the fullest extent of their powers.  Let's start with who is dying, where.

The New York Times put it bluntly: The Coronavirus Is Deadliest Where Democrats Live, as illustrated with their map:

Coronavirus cases in counties won by Clinton in 2016 on left, in counties won by Trump on right; larger bubble means more cases. Data is as of May 21, 2020. By Jugal K. Patel for The New York Times

The article explains:

The devastation, in other words, has been disproportionately felt in blue America, which helps explain why people on opposing sides of a partisan divide that has intensified in the past two decades are thinking about the virus differently. It is not just that Democrats and Republicans disagree on how to reopen businesses, schools and the country as a whole. Beyond perception, beyond ideology, there are starkly different realities for red and blue America right now.

Potential explanations for the differences include population densities, loci of international travel, and proportion of minority populations.

Nor is it necessarily true that the current trends will remain; coronarvirus is starting to surge in rural areas.  A Washington Post analysis indicates: "Rural counties now have some of the highest rates of covid-19 cases and deaths in the country, topping even the hardest-hit New York City boroughs and signaling a new phase of the pandemic."  

It's not only about red states versus blue states; it is also about who is dying in each.  People of color have been impacted much more.  African-Americans are dying at almost three times the rate of whites or Latinos; in Kansas, the rate is seven times, and five times in Michigan or Missouri.  And not all states are reporting deaths by race, so the problem may be understated.  Latinos and, to a lesser extent, Asian Americans have also been hit harder than whites.

COVID-19 DEATHS PER 100,000 PEOPLE OF EACH GROUP, REPORTED THROUGH MAY 19, 2020.  Source: APM Research Lab

APM Research Lab estimates (as of May 20):

If they had died of COVID-19 at the same rate as White Americans, about 12,000 Black Americans, 1,300 Latino Americans and 300 Asian Americans would still be alive.

Some of this has been attributed to underlying health and/or living conditions, but a new study found that, even controlling for differences in age, sex,income and chronic health problems, African-Americans are hospitalized with COVID-19 at nearly three times the rate of white or Latino patients. Co-author Stephen H. Lockhart told The New York Times:  "The important thing we found in this study is that even when we were accounting for all those things, race mattered."  

There's an economic toll as well -- as shocking as the jobless rates are generally, they are worse for minorities, and minority-owned businesses are being hit hardest.  This may be due, in part, because such businesses had a much harder time obtaining PPP loans.

Certainly not all minority voters vote Democrat, but African Americans tend to overwhelmingly do so and Latino voters also do, although not quite as monolithically.  A disease like COVID-19 that disproportionately impacts minorities hurts Democrats more than Republicans, whether outright through fatality or just in reducing turnout.   

Turnout by minority votes has long been a problem.  Going to a polling place during a pandemic will be problematic for some voters, and if you are a voter who is in a higher risk group -- such as African-American, it may be particularly so.  Many states are pushing for mail-in voting for any resident as a way to assuage such concerns, a tactic that President Trump fiercely opposes.  He cites potential for "massive fraud," although no evidence exists for this and many states, including ones controlled by Republicans, have allowed it without problems.  

The opposition to mail-in voting is less about safeguarding the integrity of the election and more about trying to control who ends up voting. 

Our reactions to the pandemic are very much splitting along party lines.  For example, wearing a face mask, as public health officials urge, is now seen as a political statement.  That brought North Dakota Governor Doug Burgum, a Republican, to tears in a recent press conference:

President Trump's 2016 election hinged on razor thin margins in a few swing states. No matter the impact of COVID-19, he isn't likely to win in hard-hit blue states like New York, California, or Massachusetts, but it might well make the difference in swing states like Michigan, Pennsylvania, or Wisconsin, and could even make a difference in purple states like Illinois, New Jersey, or Minnesota.  How many fewer Democrats able/alive to vote would it take?

The strategy is not without risks.  Polls show voters give former Vice President Joe Biden a wide lead on ability to deal with the pandemic, and support for Trump among senior citizens -- which had supported Trump in 2016 but who now at greatest risk of contracting and dying from COVID-19 -- is weakening.  Statements from Republicans like Texas Lieutenant Governor Dan Patrick suggesting seniors were willing to die from COVID-19 as a trade-off for restarting the economy don't help.

Let me be clear: I'm not saying President Trump or other Republicans want minority voters to die, and certainly not that they are intentionally trying to make that happen.  But, from a political standpoint, the pandemic is currently is hitting his supporters less hard, and there's a political calculation may come with that.  Democrats cannot be blind to that.  

COVID-19 is the biggest health crisis in a hundred years.  It has caused perhaps the greatest economic crisis in ninety years.  It would be unfortunate if we allowed it to also cause perhaps the biggest political crisis in our nation's history.  

Home, Sweet Work

If you're lucky, you've been working from home these past couple months.  That is, you're lucky you're not one of the 30+ million people who have lost their jobs due to the pandemic.  That is, you're lucky you're not an essential worker whose job has required you to risk exposure to COVID-19 by continuing to go into your workplace.  

Shutterstock/KornT

What's interesting is that many of the stay-at-home workers, and the companies they work for, are finding it a surprisingly suitable arrangement.  And that has potentially major implications for our society, and, not coincidentally, for our healthcare system.

Twitter was one of the first to announce that it wouldn't care if workers continued to work from home.  "Opening offices will be our decision, when and if our employees come back, will be theirs," a company spokesperson wrote in a blog post.  "So if our employees are in a role and situation that enables them to work from home and they want to continue to do so forever, we will make that happen."

Other tech companies are also letting the work-from-home experiment continue.  According to The Washington Post, Amazon and Microsoft have told such workers they can keep working from home until at least October, while Facebook and Google say at least until 2021.   Microsoft president Brad Smith observed: "We found that we can sustain productivity to a very high degree with people working from home."  

The tech industry, of course, had been famous for its unconventional workplaces, with open architecture, free/low cost food, games, rowdy atmospheres, and, more lately, futuristic buildings.  It also led to concentrations of talent in areas like Silicon Valley or Seattle, with corresponding soaring housing costs and commuting sagas.  

José Cong, a tech talent acquisition advisor, told The Wall Street Journal that, when it comes to increased remote work, the pandemic "is going to be the gasoline on the fire."  

It's not just corporate benevolence or concerns about public health.  It's also about the money.  Short term savings in office energy use/upkeep and business travel, and longer term savings in real estate costs, make work-at-home attractive to companies.  Entrepreneur Hiten Shah told Cat Zakrzewski of The Washington Post: "Everyone's doing the math.  Once you follow the money, it points to the fact that this is inevitable...The cost savings are just ridiculous comparing to have an office and all the things that come with that."  

Tech may have gotten most of the work-at-home press, but the trend is broader than that.  For example, think also about IT more broadly, customer service, HR, or finance.  Nationwide Insurance moved 98% of its jobs to work-from-home due to the pandemic, and doesn't see any reason to move them back.  CEO Kirt Walker told Fortune: "We've tracked all of our key performance indicators, and there has been no change.  We keep hearing from members, 'if you hadn't announced you were all working from home, we never would have known."  

He sees the change as part of a historic, permanent mindset shift: "We think the world is changing. We’ve got to take cost out of the system. We want to enable sustainable growth."

There are real questions about the shift.  "Companies will have to find ways to build culture remotely, which is really tough to do," tech analyst Gene Munster told the WSJ.  Zoom calls are all well and good, but "People like to come in and collaborate with and work with their folks," said Jennifer Christie, Twitter's chief human resource officer.  Professor Andrew Hargadon told The Post, "there’s still value in being together in person.  Those accidental interactions in elevators and cafeterias or when grabbing coffee can still spark ideas."  

In The WSJ, Rachel Feintzeig raises another consideration: when home is work, how do we separate home life from work life?  Harvard Business School Professor Leslie Perlow noted: “You can’t get away from your family, can’t get away from your work.  You have no excuse ever. Where can you be?”  

In her NYT op-ed, Jennifer Senior predicts: "But over the coming months, I suspect that those of us who spent most of our careers in offices will grow to miss them."  She mentions the camaraderie, the intellectual stimulation, even the prospect for romance as reasons.  

There are further ripple implications.  Business Insider reported how suburban office parks were already becoming more deserted, posing problems not just for their commercial real estate owners but also for the cities and municipalities that relied on tax revenue from them -- not to mention for the restaurants and other small businesses that served all those workers.  

We've seen a urban-suburban competition for jobs, but now that fight has a new contender -- workers' homes -- and no one yet knows all the implications of that shift.  

Healthcare is less able than most industries to work from home, but it is doing its best through increased use of telehealth.  Its problem is that its revenues are built around patients coming in for visits/treatments/procedures, and most aren't.  As a result, telehealth notwithstanding, hospitals say they are losing billions of dollars, and healthcare workers are, for the first time in decades, undergoing massive layoffs -- well over a million in April alone.  

When we think about all those deserted office parks and buildings, think also about hospitals and medical office buildings.  The healthcare system will need fewer of them both from the demand side -- patients preferring to use telehealth -- and from the supply side -- healthcare professionals able to do more remotely.  Mei Kwong, executive director of the Center for Connected Health Policy, warns of a long transition, telling mHealth Intelligence: "It’s going to take some time to sort things out...It’s going to get interesting."

"Interesting" indeed.

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This pandemic will not last forever.  Ready or not, we're already starting to reopen major parts of the economy.  Perhaps the sudden, massive work-from-home experiment will soon be just a memory, and we'll all end up back to our offices.  

But that's a sucker's bet.  The prudent business leader would seriously consider, as Mr. Walker said, that this is part of a once-in-a-generation/once-in-a-lifetime, permanent shift.  The prudent business leader would evaluate how much of their business could be done from home (or other settings), and how to best support that shift.  The prudent business leader would be trying to drive and support the changes, not react to them.

The question is, how many such prudent business leaders there are in healthcare?

Keep Petri Dishes in the Lab

COVID-19 is changing the landscape of our healthcare system, and, indeed, of our entire society, in ways that we hadn't been prepared for and with implications that we won't fully grasp for some time. 
As we grapple with how to reshape our healthcare system and our society in the wake of the pandemic, though, I worry we're going to focus on the wrong problems. 

Take, for example, nursing homes, prisons, and the meatpacking industry. 

Anyone who has been paying attention to the pandemic will recognize that each of these have been "hot spots," and have been called "petri dishes" for coronavirus (as are cruise ships, but that's a different article).  These institutions aren't the only places where masses of people congregate, but they seem to do so in ways that create fertile territories for COVID-19.  And that's the problem.

Credit: NASH JONES / KUNM

We knew early on that nursing homes were going to be a problem.  We knew COVID-19 was a problem in Wuhan, but that was far away -- until a few cases emerged in late February in a skilled nursing home in King County, Washington.   We know now that these were not the first cases, nor the first deaths, but we were stunned by how quickly it spread in that facility.  By mid-March experts were already calling nursing homes "ground zero," and that has been proven right. 

It is now estimated that as many as a third of all U.S. coronavirus deaths have come from nursing home residents or workers.  That is (as of this writing) almost 30,000 deaths, and over 150,000 cases. 

It took us longer to realize that prisons were also going to be a problem, although it shouldn't have.  The U.S. incarcerates far more people -- absolute numbers or per capita -- than any other country, and many of those institutions are overcrowded, dangerous, and less than sanitary.  Worse yet, they are disproportionately populated by people of color, who have been found to be disproportionately impacted by COVID-19.  It was a disaster in waiting and the disaster didn't wait. 

COVID-19 is "spreading like wildfire" in several prisons; one prison in Ohio has found eighty percent of inmates -- that's 2,000 people -- have tested positive.  Seventy percent of inmates in a California prison tested positive.  The Marshall Project estimates over 20,000 cases have been identified among prisoners nationwide.  States that are aggressively testing are, no surprise, finding mass infections in their prisons, including among the staff. 

Meatpacking also took us by surprise.  States that thought they were successfully avoiding the pandemic suddenly had major outbreaks tied to meatpacking plants, including ones in Iowa, Nebraska, Minnesota, and South Dakota.  Meatpacking plants across the country started to close, promoting the President to invoke the Defense Production Act to keep them open, despite the ongoing concerns from workers.  Plants are continuing to close despite the order.

Samantha Gillison described the dangerous working conditions of meatpacking plants in Think, and concluded:

But no one really paid attention to the brutal working conditions until it turned out that they also make the people who work there particularly susceptible to being infected with COVID-19.  

The fact that these jobs tend to be low wage ones, often filled by immigrants and definitely with no work-from-home options, add to the risk. 

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There are things that can be done to mitigate the spread even in these three industries, starting with much more testing, but the very nature of each industry makes them susceptible to this and other public health hazards:

Nursing homes: Nursing homes (and their cousins, assisted living and other congregate care facilities) are the stepchildren of our healthcare system.  They're generally crowded, understaffed, underpaid, without sophisticated personal protective equipment (PPE), and not well-versed in nor well regulated on infection control measures.   According to the CDC, out of 4 million nursing home residents each year, there are typically between 1 to 3 million serious infections every year, with some 380,000 deaths from them.  That's without a pandemic. 

We can, and we should, address the pay and safety issues inherent in the nursing home model, but those are bandaids.  The model itself is the problem.  Too many people who are in nursing homes and other facilities are there because they lack the resources -- financial, family, support options -- to stay in the community.  We need to invest in developing and supporting a 21st century approach to aging in place. 

Prisons: We may still use term "correctional facilities," but at best it is ironic: few get "reformed."  We imprison far too many people, for far too long, especially for substance abuse or mental health issues that in other countries would merit treatment and support.  Worse yet, after leaving prison many find that their lives can never be normal again, shut out of many professions, living options, even voting.  We say we're addressing criminal justice problems but we're actually creating  significant socioeconomic, racial/ethnic public health problems.

Norwegian prison cell.  Credit: Stringer/Reuters

Other countries - take, for example, Norway -- manage their society in ways that result in far fewer people being locked up and in safer conditions when they are.  Certainly the U.S. can do better than we are.   

Meatpacking:  We like our meat and we like it cheap, so as a result much of it is raised under horrific conditions and processed under equally bad ones.  We should be willing to pay more for more humane conditions for the animals and much safer conditions for the workers, and find ways to automate much more of the work.  If that means our meat consumption drops and our meat budget rises, well, how many lives is that worth to us?

As Ms. Gillison wrote: "Industries famously don't regulate themselves, and the meatpacking industry isn't going to be an outlier...Things won't get better until there is the real political will to change how the meatpacking industry handles worker safety."  Do we have that will?  

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It's not going to be enough to try to minimize the pandemic in these industries; in each case, the pandemic isn't the problem, but rather is the result of the problem.  We need new models for these industries that take advantage of available technology and safeguards, reimagining them for the 21st century...and, along the way, making us all safer.  

I'm all for petri dishes to help find new drugs or to teach science, but not as places to live or work.

Healthcare Starts to Zoom Along

A year ago, if you'd used or even heard about Zoom, you were probably in the tech industry.  Today, if you haven't used Zoom, your friends or colleagues must not like you very much.  COVID-19 has made most of us homebound most of the time, and video services like Zoom are helping make that more bearable.

And, thankfully, healthcare is finally paying attention.

Zoom was founded in 2011, poking along under the radar for several years, overshadowed by competitors like Skype or WebEx.  For the entire month of May 2013 it only had a million meeting participants.  Even by December 2019 it could boast "only" 10 million daily users.

Then -- boom -- COVID-19 hits and people start staying at home.  Daily users skyrocketed to 200 million in March and as many as 300 million in April (well, not quite).  Daily downloads went from 56,000 in January 2020 to over 2 million in April.  Zoom is now used by businesses and families alike, drawn by it simplicity and ease of use. 

By all rights, we should be using WebEx for business video calls and Skype for personal ones.  Both had been around longer, offered credible services, and still exist.  But both were acquired along the way, WebEx by Cisco, and Skype ultimately by Microsoft.  As with its acquisition of Nokia, once acquired Microsoft didn't quite seem to know what to do with it.  Each left openings that Zoom plunged through when the pandemic hit.

Zoom's success has not gone unnoticed.  Google introduced Hangouts in 2013, Duo in 2016, Meet in 2017, with Hangouts and Meet aimed primarily at businesses using its G Suite.  Late last month Google announced it was making Meet available for free to anyone with an email account.  Google claims Meet now has 100 million daily users, up 30 times since January. 

Meanwhile, Microsoft had been pushing its business collaboration service Teams, and in COVID-19 times is now trying to broaden its reach to consumers, extending Teams to its consumer Office 365 subscription service.  While Microsoft insists Skype is booming, with over 40 million daily users, it looks like Teams is the future.  A spokesperson told VentureBeat:

For now, Skype will remain a great option for customers who love it and want to connect with basic chat and video calling capabilities.  With the new features in the Microsoft Teams mobile app, we see Teams as an all in one hub for your work and life that integrates chat, video calling, [and the] ability to assign and share tasks, store and share important data with your group, [and] share your location with family and friends, whereas Skype is predominantly a chat and a video calling app platform.  

Then there is Facebook.  Last month it launched Messenger Rooms, which allows for up to 50 people at a time on a video conference call.  It is a direct response not only to Zoom but also to life in a COVID-19 world.  CEO Mark Zuckerberg said: "Video presence isn’t just about calling someone.  It is starting to be a fundamental building block of a private social platform with lots of new use cases."  The service is free and does not include time limits.  

Credit: TechCrunch

Zoom gave competitors some openings.  Its security measures left something to be desired (although Zoom claims to have now addressed), allowing "Zoombombing" to become a thing.  Google, Microsoft, and Facebook have all stressed the security features of their video platforms; e.g., Microsoft's new Teams ad emphasizes its security.

Healthcare hadn't ignored video conferencing.  Let me rephrase that: video conferencing hadn't ignored healthcare, with companies like TelaDoc, AmWell, Doctors on Demand, and MDLIVE doing their best to make telehealth a standard part of healthcare.  With certain exceptions like Kaiser Permanente, though, telehealth seemed like healthcare's stepchild, beset by reimbursement issues, licensing restrictions, and simple inertia.   

As recently as last year, it was estimated that only 1 in 5 physicians used telehealth, and even that reflected dramatic growth.    Only one-third of hospitals had a telehealth option.  But the coronavirus pandemic changed all that.  Any kind of "elective" visits or procedures were limited; The Commonwealth Fund found that in-person ambulatory visits dropped 70% from mid-February to mid-April.  

HHS has actively promoted telehealth, along with many private health insurance companies.  Not having potentially sick people come into offices, exposing both other patients and healthcare workers, seems like a very prudent thing during a pandemic, and as both clinicians and patients get used to telehealth visits, many believe they will persist after the pandemic.

Zoom saw the potential in healthcare long before COVID-19, introducing Zoom for Telehealth (now Zoom for Healthcare) in 2017.  It offers "HIPAA/PIPEDA enabled plans" for healthcare organizations, and claims customers such as Phoenix Children's Hospital and Magellan Health, although one suspects that not all patients who are using Zoom to communicate with their physician are doing so with a Zoom for Healthcare platform. 

Similarly, Google specifically mentions "hospitals supporting patients via telehealth" as one of the uses for Meet, and Microsoft boasts that "Microsoft Teams can help healthcare providers conduct virtual visits," enabling "simple, secure collaboration and communication with chat, video, voice, and healthcare tools in a single hub."  That new Teams ad includes a healthcare customer as one of its four featured Team clients:

Not to be left out, Epic is reminding customers that its EHR can also be used to provide video visits with patients, a service it had previously rolled out with several telehealth vendors, including AmWell.  Epic is now working with Twilio to build its own telehealth solution. 

Stay-at-home restrictions are already starting to be lifted (even if it is not clear we're ready), allowing more of us to get out more often, even for healthcare services.  We'll be able to see our friends and family again, go back to work (although whether we'll give up remote work remains to be seen), and start using the healthcare system in-person again.  It's possible that Zoom has reached its zenith already, and the competition between it, Facebook, Google, Microsoft is a zero-sum game on a declining customer base,

But I don't think so.  We've now seen more of the world that broadband promised us over a decade ago, and we like it.  With healthcare, though, all too often it is about the money, not our convenience or preferences.  I just hope that healthcare learns its COVID-19 Zoom lesson.