Sex, Drugs, and Public Health

“Hospitals are dangerous places.”

         This observation was all the more shocking to me because of who said it: one of the best physicians I’ve ever known. He was a soft-spoken cardiologist in Fresno. Someone who, like me and all U.S. physicians, was trained in and worked in hospitals.

         Many lives have been saved (or “prolonged” if you’re philosophical) in hospitals, of course. Babies have been born there, making everyone smile. And dramatic technological advances occurred inside their walls (face transplants, limb implantation). But all of us who work in these specialized facilities know that there are also dangers. Methacillin Resistant Staph Aureus (MRSA) was initially a hospital-acquired infectious disease problem before the organism escaped into the community. That’s why we have “Infection Prevention” (the newer, gentler phrase for “Infection Control”) programs in every hospital. The U S Health Care system rumbled along, providing care when people’s medical problems had progressed to the point of being intolerant or life-threatening. Meanwhile, the system did its best to monitor for unwanted errors and institutional infections.

         Early in the U S Covid epidemic, New York was hard-hit, you may recall. There, a prestigious hospital – just a few blocks from my Med School – fitted their physicians with Go-Pro cameras. Review of the videos was alarming. Harried doctors and other staff blew right past boundaries between Covid patients and others in their frenetic work. This glaring defect in Infection Prevention was rectified when a consultant group put doors, bright warnings and a place for donning and doffing PPE between the Covid ward and the rest of the hospital.

That’s just one example of how this epidemic in the U S (still the worst outbreak in the entire world) has uncovered weaknesses in our Health Care system. And it is my hope (and many others’) that this crisis will precipitate major changes to the system that almost all of us know is dysfunctional.

         I have lived, worked in and / or seen many countries smaller and poorer than the U.S. where health care is more accessible, higher quality and far less expensive. 

Many people in the U S use Emergency Departments for primary care. This is especially true in poorer neighborhoods (where, ironically, many Health Care Workers live). Travelling from home to a hospital – sometimes a long distance – for what ends up being a 20 minute exam is horribly inefficient. Especially if the wait in the E D is five hours. During which time you could be exposed to a communicable disease.

         Lots of people figured this out during this year, and avoided the E D.  but that’s potentially dangerous too, ignoring a medical problem (chest pain? numbness?) It’s also a financial blow to the hospitals, most of which depend on their E D’s for admissions.

         So what might the “New Normal” for the U S Health Care system look like, post-Covid?

1. A lot more telemedicine. Specialists directing care by video. Can you say “Zoom?”
2. 911 calls may be triaged, and some calls redirected to telemedicine. Not every 911 caller needs an ambulance or even an E D visit.
3. Extending from that, EMS responders will grow beyond radio contact to video / telemedicine, beginning triage before the patient arrives at the E D.
4. With this enhanced pre-hospital triage, less critical patients and those you want to protect from complications like infection, will be cared for in non-hospital facilities closer to home. Childbirth could easily fit in here.
5. These neighborhood Health Centers will also provide on-going care to Covid “Long-Haulers” whose symptoms recur and persist for months.
6. Architectural design of these neighborhood Health Centers will include more sunlight, gardens and informal, less clinical social settings. For an example, check out “Maggie’s Centers” for cancer therapy in the U K.
7. Higher Tech (and far more expensive) hospital care will be provided regionally. These tertiary care “motherships” will be connected to neighborhood Health Centers by telemedicine and will oversee quality of care.
8. Hospitals will be constructed with glass doors on patient rooms, whether in the E D or on the floor. This will allow controlled air flow to prevent spread of pathogens, yet Health Care Workers will be able to see the patients at all times.
9. Non-ICU and non-patient care rooms in the modern hospital – places like the lobby or conference rooms – will be designed to be convertible to ICU space if needed during a surge such as the Covid onslaught.
10. Each of us will be able (if we choose) to wear health monitoring devices. Advanced Fit-Bit, as it were, which can not only monitor our health, but warn us if we are near someone with an infectious disease. This tech has already been developed for Covid.
11.  Physicians and HCW’s will get their early training in neighborhood Health Centers, not hospitals, since this is where most will ultimately practice. Country X has been doing this for over 30 years.
12.  Medical training will emphasize Preventive Medicine. Success in patient care will be measured by keeping patients out of the E D or hospital.
13.  Most importantly – actually, this is critical – insurance companies will no longer be involved in financing Health Care. Which means they will no longer be ripping off 18 to 20% of your health care dollar. More money available for care. You won’t hear “your insurance won’t pay for the test your doctor ordered” anymore. We may not be able to achieve the cost efficiency of Country X (where Health Care costs are half of that in the U S, as a share of GDP), but any improvement will be good for the patients.

Covid has killed a half million Americans so far. It has crippled an estimated three million with “Long Hauler” syndrome damaging their bodies, and has been a gigantic pain in our economy and our butts. However, it has also pulled back the curtain from our dysfunctional Health Care system and has given us a once-in-a-century opportunity to re-build a better, more user-friendly system. 

I, for one, will do everything I can to see that it happens. 

What else has Covid taught us?

We’ve learned who our most essential workers are. Health Care heroes, for sure. As here in Mariposa County. But also, grocery clerks, agricultural workers, postal workers, and extended family members (now known as “teacher’s aides”).  NOT Wall Street investors, bankers, or corporate CEO’s.

Covid isolation has held up a mirror for us. Perhaps you have asked some of the same fundamental questions we explored in our 20’s. Like “what is basic and valuable in Human Nature?”

The way I wrestled with this is to compare us Humans to other animals to find what’s unique to us. My list:

1. we can see and enjoy Beauty
2. we can create Beauty
3. we can feel the pleasure of Love
4. we can feel the pain of injustice
5. we can believe in things that are so abstract that you can’t see, hear, feel or taste them. Things like Nationhood and Money (no, that’s not “money” – it’s a piece of paper with printing on it).
6. On the negative side, we can also believe lies. The consequences are obvious.
7. We can convert the Beauty of animals, plants and rocks into those little pieces of paper with printing.

So how about this for the post-Covid New Normal?

1. People leave the cement and glass world of cities to move closer to Beauty and work by electronic connection.
2. Wi-Fi is widespread, fast and free (as in many other countries).
3. Education is provided in significant part, by electronic connection.
4. We will withdraw from our encroachment and destruction of the parts of this planet where animals live. And where communicable diseases await.
5. We move rapidly from fossil-fuel based energy to renewables to enhance the Beauty and to de-rail the Climate Catastrophe (which will be MUCH bigger than Covid).