America can move toward a transformed healthcare system accountable for our well-being and a new population health paradigm, led by healthcare professionals.
COVID-19 has wrecked America’s healthcare system and cast a harsh light on the social determinants of health.
In doing so, the virus – and more importantly, its consequences – exposed a truth that my colleagues and I have been preaching for more than a decade: the public health paradigm is outdated and insufficient. Its major tenets – including public health, epidemiology, behavioral science and the environment – are important but reactive.
We must also consider the quality and safety of the care we provide, the cost of that care, and a range of changing public policy considerations.
The healthcare profession
Healthcare is the biggest business in this country, but we rarely stop to consider what exactly that business has become.
Do health care providers have a mission to improve and maintain health? Or is our goal just to perform more procedures and fill all those beds?
The vast majority of physicians I know feel too disconnected from the system to respond. They see themselves as pawns or, worse, victims when they should be leading the charge in the population health paradigm, which balances treating the sick with keeping people healthy. The widening of disparities in care and the precariousness of SDOH require it.
Consider the social determinants in a city like Philadelphia, where I have worked for the past three decades. Ours is the poorest of the top ten cities in terms of population. A quarter of Philadelphians live in poverty and half are in extreme poverty, which means they cannot put food on the table. At the height of the pandemic, queues for food exceeded queues for medical aid.
It is therefore not surprising that the death rate for people of color is much higher than for other patient demographics. The inequality inherent in our system guaranteed a lack of access, a lack of resources and a lack of insurance for those who were constantly exposed to the virus because they had to work in jobs in contact with the public.
Lead from within
Doctors are not social workers, but we can always work to stop the disease at the source, when it’s still a drip, rather than waiting to tackle it downstream, when it’s became a flood.
Imagine if the people of Philadelphia were healthier before Covid; if we had less inequality, we could have reduced the incredible mortality rate of minority populations. If only we had paid attention to obesity, smoking, heart disease, exercise, nutrition – lesser issues that the system has largely ignored because there was no incentive to do otherwise. Indeed, the flood fills many beds.
As an academic, I have been advocating for a population health paradigm for over a decade. This means changing undergraduate and graduate medical curricula. Let’s bring the principles of population health to UME and GME.
Is it possible that the pandemic gave us a boost to finally get this information into the program? I hope the answer is “yes” and that we will soon see pharmacy schools, nursing schools and medical schools integrating the principles we preached before Covid. I also hope that we will see digital health care that continues to reduce marginal costs. These two changes will allow us to reach much larger populations at a lower cost than ever before.
There is a caveat: change will only come from within. The health system has become so large, so convoluted and so fortified by commercial interests that its revolutionaries, like my colleagues who defend population health practices, will have to build the equivalent of a Trojan horse to effect change .
Fortunately, and unfortunately, Covid has taught us that the system is not as solid as it seems. Leadership failures, racial inequities, public health mistakes, and institutional collapses — including in public health — have exposed a fragile core surrounded by thick, high walls.
Let’s get past those walls, assess the rot, and identify the root causes of how COVID-19 wrecked the healthcare system, killing over a million Americans. Even without new laws or government policies, I am confident that America can move toward a transformed healthcare system accountable for our well-being and a new population health paradigm, led by healthcare professionals. Failure to do so would be professional misconduct.
— David B. Nash, MD, MBA, is a member of the MediGuru Advisory Board, as well as Founding Dean Emeritus of the Jefferson College of Population Health and Dr. Raymond C. and Doris N. Grandon Professor of Health Policy, on the campus of Thomas Jefferson University in Philadelphia, Pennsylvania.