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"As we’ve become more aware of the needs of the society we allege to help, we can’t call ourselves invested in quality unless we move effectively toward improving the social determinants of health."
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Division, Cooperation, and the Opportunities Presented by COVID-19

By Donald Berwick | Wednesday, November 25, 2020
Division Cooperation and the Opportunities Presented by COVID-19Photo by Étienne Godiard | Unsplash

In the following preview of his IHI Forum 2020 keynote, IHI President Emeritus and Senior Fellow Don Berwick talks about health care’s role in addressing deep divisions amid the COVID-19 pandemic and makes a bold recommendation for the future.

A large proportion of the US population either doesn’t believe COVID-19 exists, or they don’t believe it’s as bad as some people claim. How can we address this pandemic fully if we can’t even agree it exists?

A foundational characteristic of any successful society is solidarity. We need leadership that can build trust so we can start to listen to each other. We’re paying as a nation for the immense political divisions among us: for example, wearing a mask to prevent the spread of COVID-19 has become politicized instead of accepted as common sense guided by science.

This kind of divisiveness drains energy and diverts attention. I hope we can find our way back to science and facts as the basis for shared action. We can differ, of course, on tactics and what needs to happen, but we better have respect for the facts. Nature is unforgiving. This coronavirus doesn’t care which side of the political divide you’re on. We need to build on our ever-growing scientific knowledge about this threat, or the virus will win. It will help to have leadership that’s honest, transparent, consistent in its messaging, and admits when we don’t know something yet. 

I believe that there is a role for the professions and health care organizations in these discussions. We in health care should come forward and express our shared belief that it’s better to work together.

What kind of participation do you mean? At the federal level?

We need it at the federal level. We need the federal government to handle logistics, science, development, communication, and a range of other tasks. The states also have a role and we’re seeing good gubernatorial leadership in some states.

But, as much as we need federal and state leadership and global leadership with the World Health Organization and others, I’m a fan of local-level consolidated action. I’m interested in what can happen in communities, municipalities, and small regions. At those levels, people have a different level of investment in solidarity. We know each other. We play soccer together. Our kids go to school together. This creates a social bond, which may be a precondition for compassion and mutual action.

For example, in the city I live in, Newton, Massachusetts, we have a mayor who has been able to create a sense that the city is a coherent, functioning unit in which we’re responsible for each other. Boundaries are porous and nobody’s building a wall around the city, but she has encouraged a sense of being in it together, which I value. That feeling may be more easily recoverable at the community level than at the national level.

This approach also creates a special opportunity for professions and organizations to act, because many people know their local hospital and the people who work there. The hospital may be a great place to think about positive action. We can all see the local roads and say, “Let’s fix the potholes.” Shared goals can lead us decide to act together.

The COVID-19 pandemic has highlighted many of the problems that already existed in the health care systems of many countries. Where do you see the key opportunities for improvement?

This tragedy has opened many opportunities if we have the courage to go through the door. Maybe the simplest ones are technological. After more than two decades of talking about telemedicine, telehealth, and virtual health as a force multiplier without a ton of progress, suddenly, bang, we’re there. We are using immense amounts of virtual care, and so far, it is paying off in multiple ways.

It’s worth reconsidering the very design of health care as a system by using virtual care and home-based care. For example, there is growing evidence that telehealth for mental health services is both effective and preferred by many patients. We’ve seen a surge of interest in "hospital at home," which is a very exciting redesign idea. Our payment mechanisms, licensure, and certification mechanisms, and our training supports will all have to catch up — they are largely lagging now, but I’m excited about much of what I’ve seen so far.

More difficult are the issues related to who is suffering most during this pandemic. We’re seeing ever more vividly the socioeconomic gaps and their consequences for people’s opportunities, economic security, and health security. I hope we can move toward the compassionate public policies and anti-racism activities that we need to close these gaps. We have a real choice: we can just lament them, or we can do something about them.

Given the disproportionate impact of COVID-19 on certain communities and populations, what kind of motivation have you seen to fully address health equity?

It’s hard to think of a conversation I’ve had in the past few months that hasn’t included health equity. It came up during the US presidential campaign. We are having a lot of discussions about equity and social justice that we probably wouldn’t have had even a year ago.

I get the chance to help coach the IHI Leadership Alliance, a group of health care executives from over 50 organizations devoted to advancing the IHI Triple Aim in their work. The will among the members to make health more equitable and inclusive has soared this year. They are investing in many important, equity-oriented initiatives. The University of Arkansas for Medical Sciences, for example, advocated for and implemented a policy to pay all their full-time employees a living wage.

This is important because we know that the same equity issues that plague our country are embedded in the health care world. Why would they not be? Health care is one sixth of the US economy, so one sixth of the equity problems are with us.

During this pandemic, I learned that there are over half a million health care workers in the US who don’t have health insurance. Almost two million health care workers are paid so little that they are on Medicaid. We’re contributing to poverty in the health care world. That’s not right. And there is a racial element to this. If you look at the death rates in the COVID pandemic, and the vulnerability of health care workers, you’ll see that wealth and race are related to vulnerability.

Many of the issues you addressed during your 2019 IHI Forum keynote — including the lack of universal health care in the US, climate change, racism, poverty, and the undermining of democratic institutions — have been huge factors in what has happened in 2020. What gives you hope that the quality movement is ready to address what you call the “moral determinants of health”?

The nature of quality itself — the definition of quality — is the meeting of need. As we’ve become more aware of the needs of the society we allege to help, we can’t call ourselves invested in quality unless we move effectively toward improving the social determinants of health. Anything less is, in a way, dishonest if we purport to be healers.

The data I quoted in my speech last year are solid data. There’s no question about the consequences of the social determinants of health. There’s no question about the consequences of racism, climate change, failures in immigration policy, or the lack of food security and housing security. There’s no question about the need to rely on science when we choose what drugs to use or how to take care of a patient or how to prevent illness. It has all become so much more vivid in the COVID pandemic.

Ending hunger or addressing climate change, or assuring that science is the basis for policy isn’t the job I signed up for when I became a doctor. I didn’t sign up for the job of assuring reform of our criminal justice system. But, if we’re oriented to health, it is the job. The job got bigger. We have to realize that the enormously hard journey of aligning our professional activities, institutional frameworks, infrastructures, financial models, payment systems, and training so they address these social needs is enormous, but it is the job.

Now we’ll have to come up with pathways for this alignment. Quality improvement should be able to help us do that. Improvement is all about change. It’s all about design and redesign. It’s a set of tools we can use to address the true causes of illness, injury, and disability, if we choose to.

How do we address these moral determinants of health systematically or collectively? These aren’t issues that can be tackled solely on the individual level.

You can do some things as an individual, but you’re right: organizing to tackle systemic problems involves more than oneself. We have to do this together. And we have to do it with government.

One of the challenges I’ve put forward is something that I guess one could fairly call outrageous, but here it is: We have organizations. We have the American Hospital Association and the American Medical Association. We have our specialty societies and our guilds. These organizations have lobbyists. What if all these organizations, for two or three years, agreed to suspend lobbying for more money? No lobbying about payment or income levels. Instead, they devote all their lobbying energy to ending hunger, homelessness, and the opioid epidemic in America, to reform criminal justice in America. I think things would change.

Now, that’s probably a bridge too far. It’s an extreme idea. But couldn’t all the leaders of these organizations and professions use their collective voice and will of clinicians to solve these problems?

The real tragedy — and the real opportunity — is that these are solvable problems. We know what to do about criminal justice. We know what to do about hunger. We know how to give people homes. We know how to use science as a basis for policy. We know how to address a whole host of systemic issues. We have the answers. We are just not yet using what we know.  Isn't it time that we do so?

Editor’s note: This interview has been edited for length and clarity.

Donald M. Berwick, MD, MPP, FRCP, is President Emeritus and Senior Fellow, Institute for Healthcare Improvement.

 
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