New Year's 2021 Post #1: The pandemic

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Re-dated from Saturday January 2nd to Monday January 4th, because of the addition of a new online New Yorker article, "What the San Francisco Bay Area Can Teach Us About Fighting a Pandemic," focused on the response of the San Francisco Bay area, and how long term commitment to funding public health, engagement of the UCSF medical campus in ongoing public health efforts, and experience that grew out of the response to the AIDs epidemic, in dealing with at risk segments of the population, were drawn on to make for a relatively exemplary response.

SF has 900,000 residents and 189 deaths from covid.  The 8+ million eight county Bay Area metropolitan area has fewer than 3,000 deaths from covid, which is about one-third of the overall US death rate from covid.

Additional comments interspersed below.

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Over the past decade, on many New Year's Days, I've written one or more posts, looking back with hope going forward.  For example:

-- 2016
-- "New Year's Post #3: More thinking on "return on investment" from different types of sports facilities and DC, and an Olympics in DC," 2015
-- "New Year's Post #1: Defining mediocrity up and the 2014 elections in DC," 2014

This year, it'll be more a set of pieces over the course of the next week.

Magazine long form writing on important issues.  When I was in England in 2018, during that time the London Review of Books published a full issue "article," The Tower," on 2017's Grenfell Tower disaster, where a fire killed 70 people and injured many more, and illustrated organizational and regulatory failures which contributed to the catastrophe.  

I picked up a copy but it was so overwhelming I never got through the article.

New Yorker's "The Plague Year".  In the US, the New Yorker has been known for its support of similar long form writing.  Pieces by John McPhee or the first publishing of John Hershey's Hiroshima, on the impact of the atomic bomb's dropping on that city.  And others.

Coronavirus Christmas ornament.

The current issue has a 40 page article on the pandemic, "The Plague Year: the mistakes and struggles behind America's coronavirus tragedy" by Lawrence Wright.  

We got the issue yesterday, I picked it up today, and spent the last couple hours reading it.  

I've touched on the pandemic in occasional writings since March:

-- "Rush Medical Center (Chicago) clues us into a gap in state and regional health care planning: planning for disaster and epidemic response"
--"More communities need to integrate health care and public health programming: Prince George's County, DC, etc."
-- "Blaming the victim vs. blaming the system: Federal officials blame pandemic deaths on poor health practices of individuals"
-- "How far has Brand America fallen? The US as a failed state"
-- "Memorial Day musing | Repositioning failure as success: pandemic; urban revitalization; voter suppression"
-- "Planning for winter outdoors in the wake of coronavirus"
-- "No we're not in this together: it should be obvious that people and places with more resources fare better,"
--"Coronavirus series in the Financial Times and the failures and successes of governance"

My primary interest is in systems and the quality of decision making, and what pandemic response communicates about needed changes to the health care "system."  WRT decision making, it's about how the quality of decision making has declined, that even in noncrisis situations a lot of people make bad decisions, and in crisis, few people are good at rising to the occasion.

This has definitely been proven the case as it relates to the pandemic.

The New Yorker article doesn't necessarily break anything new, but it's amazing that the author, was able to provide that kind of overarching coverage, reminding us of so many elements that are easily forgotten in the tsunami of news and reporting about the pandemic over the course of the year.  Like I'd forgotten about the soldier's home in Holyoke, Massachusetts, and the 75 deaths there.  And I had even written about it.

-- "Not that I want to defend management failure and unnecessary death, but that was an outcome determined by a corrupt system"

A different New Yorker article, "What the San Francisco Bay Area Can Teach Us About Fighting a Pandemic" discusses how SF's largest "old age home" is owned by the city and run by the public health department.  By contrast to the Holyoke operation, SF neither stints on funding nor staff (who are well paid) and the facility is run by the city public health department.  They managed the covid response excellent, and extended this approach to other nursing homes in the city (and area), resulting in relatively few nursing home related covid deaths, whereas nationally nursing home deaths comprise 40% of the total.

My thoughts about the pandemic and what the response should be have mostly been covered in earlier pieces.  And given the virulent disagreement between progressives and conservatives about health care, the idea of "Medicare for All" ("Medicare for All: What Is It and How Will It Work?," healthline), and the role of government more generally, I don't see much changing, despite the catastrophic failure of the federal government in addressing the pandemic.

The New Yorker article closes discussing the two elements that differentiated countries in their response to the coronavirus.  First, experience with pandemics and therefore a willingness to not think the coronavirus was just a bad flu, but something novel and deathly serious.

The second was the quality of decision making and management of the response.  For example, Wright contrasts successful nations like Taiwan to the US, but also within the US, states like South Dakota and Vermont.  Both have Republican governors.  But while SD is known for its laissez faire approach and rapidly rising infection and death rates, Vermont was an early actor applying best practice public health measures.  If all the US had the same death rate as Vermont, there would be fewer than 90,000 deaths, instead of 350,000 and climbing.

But at the very least, this should happen.  

1.  Change health insurance to health and wellness care.  Like I outlined in "More communities need to integrate health care and public health programming: Prince George's County, DC, etc.," which is an extension of the series on what DC should do when rebuilding the United Medical Center East of the River.  While they'll be doing one or two out of the many dozens of innovative ideas I suggested, mostly it's a missed opportunity at the cost of hundreds of millions of dollars.

2.  Relatedly, when building new hospitals, ensure there are pandemic preparedness facilities incorporated into the facility. ("Rush Medical Center (Chicago) clues us into a gap in state and regional health care planning: planning for disaster and epidemic response")

3.  Integrate public health measures, including the repositioning of the US public health system along the lines of how the US Agriculture Extension program is set up, linking federal agencies and research units with colleges of agriculture in every state, and "county extension units" providing technical assistance ("More communities need to integrate health care and public health programming: Prince George's County, DC, etc.").

The New Yorker article, "What the San Francisco Bay Area Can Teach Us About Fighting a Pandemic" discusses at length the public health response in San Francisco and the Bay Area, and how long term investment in public health systems there were leveraged to address covid.  The area's death rate is 1/3 that of the US as a whole.  NYC's death rate is 134x greater than SF.

The way that SF has continued to invest in public health, do great outreach, and engage the local university into the process is a model that should be adopted nationally.

4.  Address failures in urban and rural hospital economics, by taking over failing hospitals and keeping them in operation/Medical deserts I mentioned this in "What should a domestic Marshall Plan/21st Century New Deal look like?".  A model would be in the UK's railroad franchising system, where the state has the ability to take over franchises when run poorly or there is no bidder.

This is a problem in cities like Chicago and Philadelphia, and also many rural areas ("States with the most rural hospitals at risk of closing," North Platte Telegraph).  It's continued through the pandemic, when we need more health care options, not fewer.

There have been lots of problems with the Veterans Administration hospital network, because it's been underfunded and negatively impacted by neoliberalist approaches to government, and special interests trying to carve off part of the business of medical care ("The VA Is Privatizing Veterans’ Health Care While Launching a Campaign to Deny It," American Prospect).  

But in the 1990s and into the early 2000s it had been fixed and was considered a national best practice example of the potential for government provided care ("The Veterans Health Administration: An American Success Story?," Millbank Quarterly: A Journal of Population Health and Health Policy, 2007).

The first VA hospital I was ever conscious of was the one in Allen Park, Michigan.

The model of a successful, nonprivatized VA could be a model, and extended to operate hospitals that would otherwise go out of business in rural and urban areas.

5.  A public health and wellness approach would help us better address social determinants of health, disparities in outcomes and equity ("Covid-19 has shown us that good health is not just down to biology," Guardian; "Social Inequities Explain Racial Gaps in Pandemic, Studies Find," New York Times). 

I mentioned this in the Marshall Plan piece and it permeates the entries on the UMC, community health ("Community Health Improvement Planning"), on equity planning, and those cited above.

The New Yorker article, "What the San Francisco Bay Area Can Teach Us About Fighting a Pandemic" is particularly relevant to this discussion.  The SF Bay experience is that by far the people with the greatest risk for covid were "special populations," workers in food service and health care, primarily Latino and black, living in crowded conditions, without the means to take off work if sick, and not able to adequately quarantine if required.  The public health response addressed all those elements in creative, systematic ways.

6.  Creating a federal equity planning initiative.  Earlier this year, the Federal Office of Management and Budget banned training programs related to equity ("OMB calls critical race theory ‘divisive, un-American,’ orders agencies to cease training," Federal News Network).  The New Yorker article discusses Dr. Ebony Hilton, an anesthesiologist at the University of Virginia.  Last year, she and two colleagues wrote to the Biden Administration calling for the creation of a "Department of Equity" to address such matters.

While I don't think such a cabinet level agency would ever be approved as long as the Republicans control at least one branch of Congress, creating a formal equity initiative within the President's Office, the way that the Obama Administration created an Office of Urban Affairs to provide an Executive Office focus on urban issues.

At the city level, more places, like Toronto, are adding an "equity lens" to their policy, programming, and budgeting.  A similar approach applies a "women's lens" ("Gender Lens on the Budget," NFAW) or "children's lens" ("Assessing the Impact of economic trends on children," UNICEF) to policy and budgeting.

7.  We're going to have to figure out senior/nursing care and add it to a health care for all program.  Seniors have been disproportionately impacted by the pandemic.  People older than 70 are particularly at risk and have much higher death rates ("The plight of nursing home residents in a pandemic," Harvard Health Letter).

Various reports ("How government incentives shaped the nursing home business — and left it vulnerable to a pandemic," Washington Post; "Long-Term Care Policy after Covid-19 — Solving the Nursing Home Crisis," New England Journal of Medicine; "This Is Why Nursing Homes Failed So Badly," New York Times, not that they are really news, demonstrate that the nursing care industry stints on health care to increase profits.  This is true for for profit firms, and can be true even for nonprofits.  For example, a rural Utah hospital has purchased nursing homes throughout the state and uses the profits from them to subsidize losses at the main hospital.

By contrast, San Francisco's city run "old age home" is a model example of what happens when care is not stinted.  From the New Yorker article, "What the San Francisco Bay Area Can Teach Us About Fighting a Pandemic": 

Laguna Honda is by most measures the biggest skilled-nursing facility, or S.N.F., in the United States. It usually houses seven hundred and twenty residents, who are cared for by seventeen hundred staff members—as many people as one might find in all the S.N.F.s in a midsize American city. In January, therefore, when San Francisco began preparing for the coronavirus, it did so with one remarkable advantage: an unusually large proportion of its nursing-home residents lived in a facility owned and operated by the San Francisco Department of Public Health. 

Nursing homes vary widely in quality, and studies have found that a few factors combined can predict the level of care they provide. Size is important: facilities larger than a hundred beds tend to be harder to oversee and more prone to outbreaks. The percentage of patients on Medicaid is another indicator: because Medicaid reimburses care providers at lower rates than Medicare does, facilities that rely on it seek to cut costs. More than half of American nursing homes are owned by chains, and these tend to be worse than nonprofit, smaller for-profit, and government-run facilities. (Having been purchased by private-equity firms, many are under intense pressure to slash budgets.) But the most crucial determinant of quality is probably nurse staffing. Higher staffing levels, especially of registered nurses, or R.N.s, are consistently associated with significant improvements in care, while for lower levels the reverse is true.

Ironically, people live longer because of declines in tobacco use and other health care improvements such as cardiac care.  But before, smoking would kill off people before they got old enough to exhibit dementia and related ailments.  And taking care of people with dementia is hard and costly.