Photo by Nishant Kulkarni | Unsplash
A few weeks ago, I was speaking to a colleague of mine, Professor Leonard Berry. Len is a distinguished professor of marketing at Texas A&M University and an IHI Senior Fellow. Some years ago, Len published a seminal book about Management Lessons from Mayo Clinic, and more recently he completed an extensive study into the successes and failures of modern cancer care.
As with every conversation I have these days, Len and I began by talking about our families and how the pandemic has affected our personal lives and our work. And then Len said something that completely disarmed me. He said, “I’m not sure if I will live to see the end of COVID. COVID may well be our system’s chronic disease.” He was not referring to “long COVID” or the long-term clinical sequellae of the coronavirus infection. Instead, he was saying that it was possible that COVID was here to stay.
Until as recently as July of this year, many people here in the US were forecasting the end of COVID. This is an acute infectious pathogen after all, and we were nearing the 70 percent immunization threshold. Case rates had plummeted, and many believed the end of COVID was near. But with the rise of the Delta variant, climbing case rates, and hospitalizations at all-time highs, the days of early July feel like a distant memory now. An unsettling feeling has crept into the national psyche.
Most experts now agree that we are likely headed for endemic infection. In this scenario, almost everyone has some form of immunity either from vaccines or from infection, and their immunity lasts long enough so that people do not get seriously ill when they are infected. A few weeks ago in The Atlantic, Sarah Zhang noted that we are probably heading toward a situation in which SARS-CoV-2 will likely circulate in our world with the other common coronaviruses.
This may sound scary. I know it unsettled me as I thought about it. Like many of you, I long for the days when we see friends again and host family gatherings without uncertainty and doubts. But what I had initially failed to grasp was that the transition to endemic COVID is not only an epidemiological one, but also psychological one. As Zhang wrote, “When everyone has some immunity, a COVID-19 diagnosis becomes as routine as diagnosis of strep or flu — not good news, but not a reason for particular fear or worry. Endemic COVID-19 means finding a new, tolerable way to live with this virus. It will feel strange for a while and then it will not. It will be normal.”
No one would have wished COVID-19 upon our systems, but now that it is becoming increasingly clear that we are likely to be dealing with it for the foreseeable future, it makes sense to view COVID not as something temporary, but instead as a force that ought to reset our health systems. This means incorporating the hard-won lessons of the pandemic into how we create and provide health and health care going forward. Based on what I have learned about what is working and what is not, I believe a health system shaped for the better by COVID-19 would:
- Prioritize workforce and patient safety — A system shaped by COVID would treat the safety of the workforce and of the patients that come into it as its top priorities. Workforce and patient safety would not be ancillary activities handled by a small team whose main purpose is to complete reporting requirements. Safety would be fundamental for all who pass through our hallways.
- Build in equity from the start — A system shaped by COVID would build health equity into all our structures and would not treat equity as an afterthought. A system shaped by COVID would not require reams of documentation to show how systemic racism and oppression plays out in health care because it is readily apparent in how vaccines are distributed, how they are accessed, who gets into the hospital, and who does not. COVID has thoroughly demonstrated the need for more equitable distribution, delivery, and access. Such a system would invite all of us to think differently about how we listen and how we take care of each other. A system that recognizes that there can be no quality without equity partners with people in our communities to co-produce the best ways to deliver care and services.
- Identify the best locations for care delivery — A system shaped by COVID determines which essential services must be provided inside an acute care institution and which ones should be willingly and ably offered in alternative care locations, including in the home or a community-based environment. It would define what is most appropriate for a face-to-face clinical engagement and what can instead be done through alternative means, including virtual or phone visits. A system shaped by COVID emphasizes the use of modern technologies and works to make them as accessible as possible.
- Develop strong partnerships between public health and health care — A world in which we are living with pandemic infectious disease for the foreseeable future forces us to renegotiate the connection between health care and public health. A system shaped by COVID would build a fully integrated and interdependent relationship between public health and health care. Future pandemic readiness plans must involve a deeper and more meaningful link between public health and health care that involves a shared language, shared aims, and possibly also shared resources and assets. A system shaped by COVID would redefine what we think of as a “health system” to include the public health apparatus within a particular geography and all the delivery vehicles that are present inside the system, including those that are not institutionally based.
As Chief Medical Advisor to the President Dr. Anthony Fauci said at a recent White House press briefing, “It is going to be very difficult — at least in the foreseeable future and maybe ever — to truly eliminate this highly transmissible virus.” COVID may become a permanent feature of our health ecosystem. If we drop our guard and think it will just go away, we may not make the needed investments to prevent the worst of this pandemic from happening again. If we heed the lessons that this contagion is trying to teach us, we can create a system that prioritizes equity, safety, and preparedness and provides care when we need it, how we need it, and in the form that we need it in. A future system shaped by COVID-19 and its cousins could be something we are proud of and inspired by. I hope what we have learned during the pandemic motivates us to change our systems fundamentally for the better.
Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.
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