Posted on May 28, 2020 at 6:18 PM
by Craig Klugman, Ph.D.
In 2009, after an outbreak of H1N1 flu, the Institutes of Medicine (IOM) issued a letter that encouraged all states to begin planning for a pandemic flu. Three years later the IOM expanded their call and asked states to develop crisis standards of care plans. Having worked on the ethical frameworks for pandemic flu for the State of Texas (2010), for crisis standards of care in the state of Illinois (2015), and conducted exercises with the Borough of Brooklyn (2012), these plans considered a number of scenarios from the length of the pandemic, to availability of supplies, to the type of crisis. However, they all relied on functional public health and medical systems that put plans into action, including leadership guidance, scientific expertise, and an availability of excess capacity for resources and response.
What few predicted was state departments of health and hospital systems adopting money-saving business management practices. For hospitals, this meant adopting processes such as Just-in-time ordering that saves money by decreasing the amount of material (think personal protective equipment and ventilators) that must be stored. For states, it meant saving money by not spending it: Ignoring the plans’ calls for investing in caches of PPE, ventilators, field hospital tents, setting up a reserve medical corps, and even having transportation to move supplies where they would be needed. For the federal government, using business management meant encouraging hospitals to adopt lean principles developed for the automotive industry which “focuses on the elimination of waste, with waste defined as any activity that consumes resources (staff, time, money, space) without adding value to those being served by the process.”
The result of these approaches is that when the COVD-19 pandemic hit the United States, it was far worse than our plans had expected and the health infrastructure of the country lacked the surge capacity and excess resources necessary to deal with a virulent infectious disease over a long-term. There were few stockpiles, no coordinated efforts, no extra beds, and few specially trained health care providers. COVID-19 hit the country in all its weak spots at once.
While the current crisis is on-going and will be for some time, there are already some lessons to be gleaned from this pandemic in order to be better prepared for the next one.
(1) Medical care should not be treated as a commodity for seeking profit. Models that work for automobiles and retail do not work in health care. Being prepared for crisis requires having excess capacity at all times. This necessity violates lean management principles and just-in-time cost savings, but having excess resources saves lives.
(2) When groups of experts and community members spend time and states spend the money to create plans, they should be followed. I spent two years on the Texas plan and five years on the Illinois plan, neither of which were followed until the pandemic hit, when it was too late. Because of a restructuring of agencies some of the Illinois plan components had been misplaced and copies were sought from task force members. The corollary to this lesson is the need for experts to lead efforts during the pandemic instead of navigating by elected officials’ “hunches”.
(3) Everyone needs to have good quality health insurance (or maybe Medicare for all) and paid sick leave (even for part-time and gig workers). With patients of COVID-19 being hit with unexpected medical bills and millions losing their employer-based health insurance, people may be reluctant to seek help when sick, which in a pandemic puts everyone at risk. Although the U.S. spends more of GDP per capita than any other nation, much of that money disappears into the private medical system in terms of profits and stock dividends.
(4) As someone who had 48 hours to move my classes from in-person to remote learning, the Internet must be treated as a utility to which everyone should have access, and not something reserved for those who live in cities and can afford expensive data plans. Response plans need to incorporate internet access since this has become not only how we work, but also how we socialize.
(5) There is a mental health toll on health care providers who are overworked, often seeing their pay cut, and have among the highest rates of infection with COVID-19. Consider also the everyday trauma being experienced by most of the people in the U.S. with disruptions to everyday life, shelter-in-place, and a level of sickness and death unknown in 100 years. Given that he U.S. has a lack of mental health providers and insurance coverage for these services, there needs to be equity in our approach to physical and mental health.
Lastly, (6) every nation needs to be prepared for the unpreparable. No matter how many reports expert write, and exercises health departments run, there will always be aspects of a crisis that were not predicted. Thus, systems have to be flexible and rely on experts being available (and listened to) to mount the best and fastest response.
None of this is cheap and none of this happens fast. Comparing the responses of countries that were prepared based on having faced epidemic in the last decade, their percent of population that were infected and died have been far lower than the United States: Singapore, South Korea and Taiwan have low infection and death rates compared to the rest of the world, in part based on their planning after confronting SARS and H1N1. The U.S. is ranked first in number of cases and number of fatalities and 17th (out of 83) in terms of case fatality rate. The cost of not preparing is the loss of too many human lives.