How long has it been since you felt comfortable standing less than six feet from someone who is not a member of your household? As you look forward to Memorial Day this coming weekend or past that to the Fourth of July, or Labor Day, is it possible for you to imagine how you will celebrate?  Have you been to a Zoom cocktail party, or attended a Zoom graduation? Can you imagine a Zoom wedding or funeral? When was the last time you had your haircut? When do you think that you will be comfortable getting your next haircut? How silly or strange would any of these questions have sounded last Thanksgiving when it would have been more than a month before the most alert among us would have known there was anything for all of us to worry about? 

 

Did you ever use the simple combination of words, “essential worker,” before March? If you had responsibility for an enterprise like a hospital, medical practice, educational institution, or if you were on the board of any enterprise before last March, did you spend much time thinking about the “resilience” of the enterprise? Before March, when you heard phrases like “no margin, no mission,” “maximizing shareholder value,” or “strategic plan” where did your thoughts go? Were you surprised to discover how vulnerable everything in your world was before March? If someone had told you on New Year’s Eve 2019 that before June 1, 2020, 100,000 Americans would die of a disease for which we had no effective treatment, that 40 million jobs would be lost, that schools would have been closed for the last three months of the school year, and that there was no basketball, no hockey, no baseball, and no Olympics, what would your reaction have been? Has your sense of what is really important in life changed over the last two months? Do you define “essential” in May any differently than you did in February?

 

The recession of 2008 disadvantaged many of us for a while. Most of us remember the uncertainty and inconveniences following 9/11. Many of us struggled with the unknown of the AIDS epidemic. Some of us remember the assassination of John Kennedy. Some of us remember the polio epidemic of the fifties. A rapidly diminishing number of us have personal memories of World War II or the Great Depression, but none of those events impacted as many of us in such a sudden and confusing way as we have collectively experienced with the shut down of our normal lives in our response over the past ten weeks in a collective effort to survive and minimize the human losses from the COVID pandemic. For an amazing moment, we have prioritized life over business and profits.

 

“Dazed and confused” is a succinct description of many of us. “Apprehensive and reluctant” also works. “Afraid and not sure who to trust” would also be an accurate label for many of us. In most of our previous national emergencies the majority of us have accepted the leadership of our elected officials, but now when we look for a leader, we see someone who inspires less confidence than a carney barker. 

 

In the past when the nation has been attacked by some human enemy or natural disaster, we have come together in a unified response. The COVID-19 pandemic has been “a first time in our lifetime” event for most of us individually, and as a divided nation. The most recent evidence of the difference of this moment compared to other stressful moments in our collective memory is that the majority of Americans are apprehensive about accepting the opinion of many political leaders when they tell us it is time to go back to work and back to barber shops, restaurants, churches, and even to our dentist or doctor. Last week the New York Times quantitated our reluctance to follow the advice of political leaders who discounted the advice of healthcare experts. The majority opinion of Americans was presented in an article by Giovanni Russonello entitled “The Government Is Ready to Reopen. Its Citizens Aren’t, Polls Show.” Russonello writes:

 

Two months after the coronavirus shuttered much of the United States economy, the outbreak’s impact — on jobs, health care, food access and much more — is growing only more severe, according to a growing body of polling and social science data.

But here’s what else the polls are telling us: Americans are generally uninterested in returning to normal, and they tend to believe federal health experts, who continue to warn against a swift reopening of the economy.

President Trump said this week that he was eager “to get our country open again,” adding, “People want to go back, and you’re going to have a problem if you don’t do it.”

But more than two-thirds of respondents said in a Pew Research Center poll out Thursday that they were more concerned that state governments would reopen their economies too quickly than that they might take too long — roughly on par with past responses to the same question.

 

The article goes on to assert that about two thirds of Americans are not interested in returning to the dance, and less than a quarter “said they definitely trusted Mr. Trump’s statements on the virus.”

 

There is nothing like an unexpected near death experience to change what you think, or to motivate you to consider going in a new direction. I have had such moments before. In 2008, I became CEO of Harvard Vanguard Medical Associates and Atrius Health about a month before the collapse of Bear Stearns and its ultimate sale to J.P. Morgan that was the prelude to the total financial meltdown that followed the collapse of Lehman Brothers on September 15, 2008. In 2008, Atrius was a loose confederacy of five medical groups held together by a shared medical record and joint contracting, but each of the groups retained substantial “reserved” powers that made any coordinated activity a negotiation. In a way we were like America. There was a lot of local autonomy and plenty of opportunity for each group to say “no thank you” to collective objectives. 

 

I was well aware of the issues, and had a deeply held belief that none of the groups could expect a long term successful future without much more clarity about how we acted together in a very tough market place where our most significant competitor was also the primary supplier of much of the hospital and specialty services that we obtained through contracts. We were into “coopetition” big time. If you want a current international relationship that shares elements of our dilemma think about America’s relationship with China. At best such relationships are difficult to maintain, especially if there is an imbalance of wealth and size. Maintaining the cooperation and trust that is required for coopetition to lead to something positive depends on both parties sharing some mutual objectives. Even when both parties work hard to make the deal work, external events beyond the control of either party can destroy the relationship. 

 

So, in February 2008 we were a marginally stable organization with internal differences trying to provide innovative medical care in a competitive market with a partner who was competing against us while selling us services. Everyone in the practice wanted things to get better, but no one wanted to be asked to change anything they did. There was a great reluctance within management to change anything in the business systems even though the management structure had many duplicate positions across the five participating groups. There was an even greater reluctance within the practice to change any of our clinical partners despite clear evidence that we were paying a high premium that could be measured in the tens of millions of dollars a year for the relationships we had. Some of our specialists felt a greater affiliation with our competitor than they did with our practice. As long as the money flowed, and a tenuous balance was maintained, we had the external appearance of  a medical group with a very positive national reputation. Our quality scores led the nation in many categories. We were innovative and admired. 

 

This meta stable situation was then hit by the market failures that precipitated the “Great Recession.” As a medical practice with substantial debt, and with the requirements that we hold reserves to cover our risk contracts, there was real “trouble in River City” [our corporate offices were at the Riverside Office Park in Newton near the Charles River] when the value of our holdings dropped like a stone. For good or for bad, the peril of our financial situation was of little concern to many of our clinicians and staff.  As a new CEO, I was getting a rapid introduction to the darker side of healthcare finance.

 

After becoming CEO, I still maintained a small connection to the practice. I would frequently see patients that I had followed for decades on Friday afternoons at our offices in Wellesley which are pictured in the header of this post. There is a large four level parking garage behind the building. One Friday afternoon, I was arriving late for my session after a morning of multiple meetings about the challenges that we faced. I was not surprised when I drove all the way to the top of the garage without finding a parking place. I intuitively knew that had I gone to any one of our offices it would have been the same. I knew that all of our parking garages, not just the Wellesley garage, would be full. There were plenty of people who wanted to see our PCPs and specialists. Patients and payers were paying a lot to see us. That was when it hit me. It made no sense that our schedules were full and our contracts were excellent, but our future was uncertain. Our measured quality was as high as that of any practice in our state, and was even better than most of the practices in the country. The collapse of banks and the stock market had revealed that being good was not good enough to guarantee our survival; it was time for us to change, whether we felt like it or not. 

 

The “Great Recession of 2008-2009” signaled a need for our practice to make some big changes that had long been resisted or never even considered. We suddenly were aware of our vulnerability in an unstable world.  Like a lot of “emergencies” in medicine, it was the acute recognition of a chronic problem. The COVID-19 pandemic has uncovered the need for substantial changes in the processes of government, the organization of commerce, and the organization and finance of healthcare in 2020.  We are told daily that this will pass, and it will pass. Perhaps one day we will look back on this moment and realize that our COVID experience revealed that without a doubt major changes in the status quo were necessary.

 

Perhaps the first change that we need to make is to build bridges across the very wide political divide that prevents progress on so many fronts. We will always have differences of opinion, but do those differences benefit by the deep contempt that we feel for many of our neighbors? Maybe, we will look back on this moment and realize that Abe Lincoln was right in ways that applied to us when he said, “A house divided against itself cannot stand.”  Slavery was the issue was in 1858 when Lincoln made his pronouncement about a house divided. We are divided in many ways now, including our views on how to protect and improve the health of the nation. The inequality and brutality of slavery has morphed into an economy characterized by deep inequality and a growing gulf between a small minority that have much more than they need and a growing majority that is dangerously vulnerable to unexpected events. We have exchanged the chains of slavery for a persistent financial bondage where more than forty percent of our citizens are slaves to a weekly paycheck that never grows adequately to prevent them from losing ground against the economy every year, and makes tens of millions dependent public and private sources of welfare like local charitable food banks and SNAP. 

 

The pandemic has revealed that we have been confused about what creates value in our lives. One would think that what is “essential” like the work of nurses, teachers, farmers, truckers, first responders, and the maintenance workers who remove the viruses from the surfaces around us before we touch them, would be considered “valuable” and that their efforts would be rewarded with a living wage plus a little “reserve for contingencies,” but that is not the way things have evolved. Who among us expects to be saved or served by a hedge fund manager? Did you know that our national measurement of the value we create, the GDP, does not count the work of mothers or those who provide care to their elderly relatives, but it does count the money spent for the clean up of the pollution created by a power plant? Maybe, after we begin to have conversations across the partisan divide, we could talk about what we have learned is of real real value, and how we can work together to insure that what is “essential” can be covered with less “sacrifice” from those whose value to the rest of us seems to arise from the fact that they must assume personal risk to exist. 

 

Another reality that COVID has revealed is that pushing “efficiency” to the limit to maximize short term profitability can compromise resilience. Efficiencies have driven how we manage supply chains. Redundancy and extra capacity have been sacrificed as costs that can be cut rather than resources that can be maintained as a form of reserve for unexpected contingencies, like natural disasters and economic downturns. Some of the things we have categorized as wasteful may be seen in the light of our experience to be necessary. Who among us would venture on a long automobile trip without a spare tire or the certainty that we will be able to buy gas when our tank runs low, but collectively we did not ensure that we had adequate PPE to provide care that could be delivered without compromising the safety of providers. 

 

Whose job is it anyhow? That question seems to have no clear answer in many situations. Who has the ultimate responsibility to coordinate a response to something like COVID-19? The president has implied that it is not really his job. Should management of an unexpected event always be a local issue in an era of interstate and international commerce? If we were attacked by the Chinese, would we expect that Georgia could determine when it withdrew from the attempt to defend the nation? If the enemy bombed New York would we expect life to be unaffected in Cheyenne, Wyoming? We maintain arsenals of ships, planes, munitions, and a standing military that is either always practicing or performing, and we have focused conversations about military preparedness while neglecting the primary needs of ten of millions of people who would never be able to realistically imagine going on a cruise, or spending a weekend at a resort, in any capacity other than as part of an undocumented workforce. When we reconsider what creates value, will we also reconsider the value of each individual?

 

They say that we manage what we measure. There are many “essential services” that we have not been measuring with as much enthusiasm as we have spent on measuring the performance of the stock market. I am not arguing that we should do away with efforts to clean up pollution, or that we don’t need venture capitalists, but I do believe we have good reason to try to catalog all of the things that the pandemic reveals that we have neglected. 

 

As we think about how to move from where we are to where we want to be, we need to reconsider how we think about leadership. Do we need leaders elected through an evolved process designed to protect the status quo, or do we need leadership that is elected for its ability to lead us toward a more secure and inclusive future? Has it occurred to you that in science and business the innovations that lead to advancements are usually the product of failure, but we don’t tolerate failure in our leaders even though we know that learning and improving are processes that are fueled by failures? 

 

We elect people who can never admit an error, and are fearful of accepting responsibility for any adverse outcome while rushing to put their name on anything that seems to succeed. Call it human nature, but could we not do better? We were not always so fixed on the status quo. The Articles of the Confederacy were a disaster that did not promote the best interests of the nation, and in about a decade that document gave way to the Constitution which was immediately improved with ten amendments, and over the intervening years since 1791 there have been 27 more amendments. The twenty-first amendment ending prohibition in 1933 repealed the eighteenth amendment of 1921. We have poof in our history that we can make real change. What changes will we propose that might make us a more “perfect union” with more responsible leadership after we process what the experience of the COVID pandemic has taught us? 

 

How we should change, and what we should change, should be a conversation that our next president is capable of leading. I would suggest for starters that we consider an amendment that makes the health of the nation, like the military defense of the nation, the explicit responsibility of the federal government. That does not change the ownership of our delivery system, or remove any choice, but that amendment would clarify that everyone is entitled to equal access to the same set of benefits. The mandate should also include  assuring the protection of a healthy environment. The quality of the air we breath and the water we drink has been a debate since the 70s. Teasing that discussion away from the influence of lobbyist requires much more effort, but is in our collective best interest.

 

Back in 1776 when we penned the Declaration of Independence we declared the individual right to pursue life, liberty, and happiness. We have come a long way, and it is clear that it is in our best interest to declare our collective right and responsibility to pursue the best expression of health for every human being. The fact that pandemics pay no attention to borders means that we would be wise to extend our concern to include what we can do to improve the health of the planet. The first step in that process would be an honest appraisal of the question, “What part of the world’s problem are we?” We require no new treaties or international agreements to stop our contributions to the destruction of the environment as an important, and self serving step, to the improvement of the health of every individual. 

 

These ideas may sound grandiose, but there is good evidence to believe that just as we are seeing more violent weather, we are also seeing the emergence of more dangerous viruses even as we suffer the continuing health consequences of a deteriorating environment. After AIDS, Ebola, SARS, MERS, Zika, and COVID what confidence do we have that there will not be a new and even more infectious virus before we have recovered from the damage that COVID-19 has done? We may have greater challenges ahead than trying to decide what to do without Major League Baseball or the NFL. Our conversations should be greater than how do we get back to normal because our experience with the COVID pandemic is proof enough that our old concept of normal was a dangerous and unhealthy place. We can dream and work for something that is much better, or accept the fact that the future could be about continuing loss. It’s our choice.