September 4, 2020
Dear Interested Readers,
Our Biggest Threat Is Our Incompetence
This is a week when we get a treat. Atul Gawande has published another insightful article built on a position that he has expressed before. On several occasions Gawande has as much said that our problem is not that we are ignorant or without resources. In speeches and in previous articles he has contended in a gentle way that many of the problems in healthcare can be explained as being derivative of operational incompetence. In his post this week he comes out and says it in a way that can’t be missed. We are fragmented, self serving, unwilling to be aligned toward achievable objectives, and we have always thought of ourselves first, individual patients second, and the general public, not so much at all.
The new article which appeared online from The New Yorker where Gawande is a regular contributor has a title that demands your attention, “We Can Solve the Coronavirus-Test Mess Now—If We Want To: The key to taming the pandemic will be both a new commitment to “assurance testing” and a new vision of what public health really means.” That’s a lot of title and the “Now…If We Want To” part is a challenge because it suggests that we can have what we want soon, if only we would…The “if only we would…” is explained in the article. But before Dr. Gawande tells us how to get where we want to go, he subjects us to a painful in depth description of all the wrong roads we have taken trying to get back to what we once had.
Thinking that thought reminded me of one of my many “favorite” Kris Kristofferson songs, “The Pilgrim, Chapter 33.” The connection in my mind between Gawande’s paper and Kristofferson’s song is a little allegorical and a little metaphorical. They make a similar point, and both speak to a desire to be back to a better place. Here are the lyrics if you want to read along while you listen to Kristofferson sing his song by clicking on the link above. In my formulation the people of America, are the pilgrim. The shrine we’ve never found is the dream that Martin Luther King.Jr. described for us in 1963 that was a vision of equality and justice that was the objective of our founding documents. Home is an America where “these truths” are the core of our collective existence. It’s a place where ideals like the Triple Aim and universal access to care are accomplished objectives. As our history has evolved, we have often been a “walking contradiction” to all the values we claim to honor.
THE PILGRIM, CHAPTER 33 – Kris Kristofferson
See him wasted on the sidewalk in his jacket and his jeans,
Wearin’ yesterday’s misfortunes like a smile
Once he had a future full of money, love, and dreams,
Which he spent like they was goin’ outta style
And he keeps right on a’changin’ for the better or the worse,
Searchin’ for a shrine he’s never found
Never knowin’ if believin’ is a blessin’ or a curse,
Or if the goin’ up was worth the comin’ down
He’s a poet, he’s a picker
He’s a prophet, he’s a pusher
He’s a pilgrim and a preacher, and a problem when he’s stoned
He’s a walkin’ contradiction, partly truth and partly fiction,
Takin’ ev’ry wrong direction on his lonely way back home.
He has tasted good and evil in your bedrooms and your bars,
And he’s traded in tomorrow for today
Runnin’ from his devils, lord, and reachin’ for the stars,
And losin’ all he’s loved along the way
But if this world keeps right on turnin’ for the better or the worse,
And all he ever gets is older and around
from the rockin’ of the cradle to the rollin’ of the hearse,
The goin’ up was worth the comin’ down
He’s a poet, he’s a picker
He’s a prophet, he’s a pusher
He’s a pilgrim and a preacher, and a problem when he’s stoned
He’s a walkin’ contradiction, partly truth and partly fiction,
Takin’ ev’ry wrong direction on his lonely way back home.
There’s a lotta wrong directions on that lonely way back home.
We have been up and down over the past 244 years, and once again through the pain of racial disharmony and the confusion of what might come next we seem to be inclined to take ev’ry wrong direction in the pilgrimage back to that home that exists in our dreams, if not quite ever in reality. And, as Kris says, “There’s a lotta wrong directions on that lonely way back home.”
Atul Gawande is writing to remind us of several of the wrong directions we have taken over the last six months. He sees a super highway to where we want to go, and he will chid us for our inability to work with one another to achieve what other countries have achieved, and what should have been so easy for us to do. His thesis is that with our current resources it should not be that hard to get on with a return to a more reasonable existence that is free of the economic and medical challenges we have experienced if only… “If only…” can cover a lot of possibilities and a lot of lamentations. Gawande used over 7000 words to make his case. I will try to transmit the key points to you in fewer words with the hope that I can still be true to his thesis. He begins by stating an objective that should be a slam dunk.
To get out of this pandemic, we need fast, easy coronavirus testing that’s accessible to everyone. From the way people often talk, you might think we need a technological breakthrough to achieve this. In fact, we don’t have a technological problem; we’ve got an implementation problem. We could have the testing capacity we need within weeks. The reason we don’t is not simply that our national leadership is unfit but also that our health-care system is dysfunctional.
Wow! I think Dr. Gawande has decided that it is time to speak directly to all parties. Yes, our leadership has been terrible, but we all have been complicit in putting up with a terrible system of care for all too long. Why have we been sluggish, more than sluggish, almost adamantly against the reforms that we have known we needed to make for more than a quarter century? I have written several hundred thousand words trying to make sense of that painful reality. He continues by doing what almost ever paper begging for improvements in American healthcare has done. He points to the fact that our peer countries do a lot better for a lot less.
Many developed countries have met their testing needs, and ready access to speedy tests has been key to containing outbreaks and resuming social and economic activity. Whether you live in England or South Korea, scheduling is straightforward. No doctor’s order is required. Tests, where indicated, are free. And you typically get results within forty-eight hours.
In other articles over the years Dr. Gawande has offered Texas as an example of our maximum dysfunction, and he does it again. Almost 20% of Texans lack coverage for healthcare. Their approach to the management of COVID has been irresponsible and the testing has been done so expensively and inefficiently that it is of little help in attempts to control the pandemic. After chiding Texas for a few hundred words, he gives us the business realities of testing.
Appointments can take days, results days more. Most testing in the United States is done by four companies—Quest Diagnostics, LabCorp, BioReference Laboratories, and Sonic Healthcare. Through early August, results routinely took four days or more, making the tests essentially useless. Times improved only when testing volumes declined, because many people gave up on getting tested. The vast majority of infected Americans, including those with symptoms, never get tested. And we have not even reached the fall, when flu season will hit and coronavirus-testing needs and demand are expected to rise substantially. As the saying goes, it’s as messed up as a pile of coat hangers.
He goes on to explain all the difficulties paying for tests. They are expensive and who will pay is controversial. Insurers don’t want to pay unless they consider the tests medically necessary for a symptomatic patient they cover. He goes on to say that controlling the spread of the virus in a population is really a different problem than diagnosing an individual. In the care of a population, a positive test that comes back 4 to 6 days later is next to useless since the CDC says that forty percent of spread occurs from individuals who are not yet symptomatic. Using the clinical criteria of insurers to determine “test worthiness” will never adequately address spread in a population.
His discussion moves on to the utility of “assurance testing” and refers to the suggestions of the economist Paul Romer, which I included in a post last spring. Rohmer suggested testing every person in the country about every two weeks. Assurance testing has worked in other countries.
The economist Paul Romer has argued for going further, saying that regular testing for every person in the United States should be our lead strategy for getting society back to normal. Those with a recent negative test would have permission to go without a mask; those with a positive test would be required to isolate for two weeks…
But is any of this remotely feasible when we can’t even make sure that sick people can get tested in a timely way? The lunacy of our testing system is the lunacy of our health system in microcosm. We are now paying the price of our long, uniquely American resistance to making sure that everyone has proper health-care coverage, and to building an adequate public-health infrastructure. We have not fully grappled with the difficulties we’re up against. But, if we do, we have a chance to fix the problem before the worst of flu season hits.
I would hope that you peruse the article because Gawande considers every issue from multiple angles. He spends some time discussing factors related to false negatives and the benefit of repeated testing
A negative test is, however, an indicator that a person is unlikely to be contagious at the time the test was done. As a rule, infectiousness is directly related to viral load, and so are positive test results. Still, each day that passes after a negative test reduces its value. A one-time test is not an adequate solution… If a group is going to work or live together on an ongoing basis but can’t take the necessary restrictive measures, or wants to relax them, repeated assurance testing is necessary to avoid outbreaks.
The next point that Gawande made was a surprise for me. He asserts that we have substantial unused testing capacity. What he is contending after the issues of cost, access, and effective use, is that we have a totally disorganized operations process. This is not a surprise when one thinks about the lack of coordination at the federal level and the very independent nature of practice all layered on top of decades of disregard for public health and the coordinated efforts necessary to protect the health of the public. He proceeds to give us the mechanics of how things should work. There are several components of flow which should suggest to us that Lean engineering would be an effective tool to improve the process. Any bolding in the quotes lifted from Gawande’s article is my addition, and meant to emphasize a point.bolding in the excerpt below.
To fix testing, we have to accelerate two lines of operation: test collection and test processing. The primary challenge of test collection—sticking a fifty-cent swab in someone’s nose—is last-mile logistics, which can be more intricate than most realize. You’ve got to manage people flow; it can be a challenge just to find locations where potentially infectious people can turn up without infecting others. Then there’s the flow of supplies, which involves having adequate quantities of the swabs and tubes that your particular lab requires, plus the personal protective equipment required for the staff. There’s the information flow—gathering and linking a patient’s information, the provider information, and the bar code on the specimen tube in a way that the laboratory can deal with. And there’s the financial flow—figuring out the billing system required to get reimbursed by the correct payer, which, for a particular person, could be Medicare or Medicaid, a private insurer, an employer, the state, the patient herself, or any number of other sources. Running a test-collection operation can be a nightmare for scores of reasons. You have to navigate supply shortages, neighborhoods that object to having lines of cars turn up at a pharmacy or clinic parking lot, business-insurance plans that may not cover you if you provide testing, and building owners with liability concerns. You may be unable to use your label printer and computer system if there’s no Wi-Fi in the parking-lot drive-up location you’ve picked.
Processing tests is a very different enterprise. It is exacting. Most diagnostic tests are performed by putting a sample into a device and getting a result. But large-scale molecular diagnostic testing—in which segments of genetic material are read—isn’t done with off-the-shelf kits; these are laboratory-developed tests, meaning that running them is less like operating an appliance than like doing a procedure, with multiple steps requiring precision and tight controls… the whole process, from receiving a sample at a lab to sending a result, typically takes between six and twelve hours.
Gawande tells us that the big commercial companies have upper limits to the number of tests they can do because of operational issues. The solution to developing the capacity to do the number of tests need in a timely fashion is to take advantage of hospital and health systems labs, but the bureaucracy and regulations have made it difficult for this to happen. This “control” and the associated errors early in the pandemic at the CDC explains why we had no effective testing through much of the spring and early summer. In previous papers, like his “checklist articles” Gawande has looked to other industries for guidance. In this paper he offers the example of the “electrical grid.”
Decades ago, electric companies were organized in the same way that laboratory testing is organized today. They were vertical monopolies that ran their own power plants, transmission lines, and customer operations. That arrangement got the job done, but it meant that many communities endured brownouts and blackouts from a shortage of capacity, while others had an oversupply. And the companies impeded innovation such as cleaner and cheaper energy. The creation of a national electric grid that physically connected the electricity supply, plus the Energy Policy Act of 1992, which required transmission-line owners to allow electric-generation companies access to their power lines, opened the door for load balancing, increased supply, lower costs, and alternative energy production.
He envisions a “national grid” of labs to ramp up the testing to levels that would allow the quick detection, isolation, contact examination, and follow up that would allow large segments of the economy to move to a pattern of interaction that is less damaging to the economy, and causes less human isolation. This “grid would also help distribute needed supplies as well as testing capabilities.
We have no national grid for the generation, transmission, or distribution of our testing supply—or, for that matter, the supply of ventilators, masks, intensive-care beds, or almost any other health-care resources. Now we’re paying the price. In power generation, the worry is that our national grid is aging; in health care, the worry is that we have no grid at all.
South Korea and China do have the equivalent of grids, and their experience on a population adjusted comparison has been substantially better than ours. Gawande spends some time comparing their success to how we stumbled and failed.
I have never heard Atul Gawande participate in a direct political discussion. Usually one must read between the lines to get an inkling of his political stance. He now becomes a little more direct. A reader gets the hint that he does think that political philosophy is part of the story of how we got to where we are.
Conservatives have long opposed the government’s playing a direct role in addressing major gaps in the supply of health-care services. A third of U.S. counties have no childbirth facilities, and shortages of psychiatric beds are even worse. So maybe we should not be surprised that we have no such system for testing. It’s not just that we lack a national grid; we haven’t even agreed that we need one.
After that brief comment, he is back to mechanics. He approaches the subject of getting better with a question, and a quick answer before discussing some promising innovations and insights like testing groups rather than individuals by examining wastewater, point of service testing, and in home tests done by the individual much like a pregnancy test.
Will improvements in techniques and technologies get us out of our testing debacle? They can help a lot—but only if we fix the underlying problem we have with delivery.
After a lengthy discussion of innovative options, he comes back to the reality that testing is necessary but insufficient to control the pandemic. It must be combined with a new emphasis, understanding, and support of public health policy and action. Have you noticed the difference in the number of cases in LA and Southern California compared to San Francisco and the Bay area. Dr. Gawande has, and offers an explanation:
San Francisco’s leaders recognized the importance of universally available testing; residents needed to have an easy way to get tested regardless of what insurance they had or didn’t have, regardless of what relationship they had or didn’t have with a clinic, and regardless of whether or not they had a doctor’s order. The city’s hospitals, labs, and clinics were not going to meet that need, because that isn’t their job. In America, health-care systems are responsible for the care of individuals, not communities. So the city’s public-health department decided to step in.
…Officials worked with local providers and laboratories to establish a network of free drive-through and walk-in sites, open to anyone who lives or works in the city. The city established a scheduling system, which people could access online or by phone, and outreach testing for nursing homes and other vulnerable communities. Public-health officers signed standing orders for each site, eliminating the need for a doctor’s referral. The city negotiated and paid most test costs. And officials made sure that they could enlist a network of labs to provide adequate capacity and keep turnaround time low. They established, in effect, a public option for testing… Elsewhere in California, places like Los Angeles have exploded with covid-19 cases. San Francisco has kept the coronavirus contained.
He uses the San Francisco success to underscore the importance of public health competence.
Historically, the work of public health has been separate from the work of health-care delivery, using measures outside the medical system to address controllable diseases like cholera, tuberculosis, and food poisoning. But even before the coronavirus crisis hit, the separation was making less and less sense. A wide range of diseases are now controllable with the modern tools of diagnostic testing, treatment, and prevention. As the coronavirus pandemic has demonstrated, the population-level distribution of medical tests, ventilators, and drugs matters as much to disease control as non medical measures such as masks and social distancing. Success requires integrating the systems focussed on individual care and those focussed on community needs.
We didn’t integrate, and we didn’t cooperate, and now we are left with over 6 million cases, with almost 200,000 fatalities, and a damaged economy. We need to ask ourselves what went wrong. Why did it turn out this way?
We’ve long resisted that integration, though. The clearest indication is how we’ve spent our money. Spending per person on medical care was seventy-nine hundred dollars per American in 2008; it climbed to an estimated eleven thousand six hundred dollars in 2019. By contrast, the average spending per person allocated to state and local health departments was a measly eighty dollars per person in 2008, and fell to fifty-six dollars in 2019. Public-health agencies that are supposed to look after communities’ health have been forced to expand tattoo-parlor inspections while shrinking their programs to assure adequate maternal- and child-health services or screen for chronic illnesses like high blood pressure and diabetes…Talk to city and state officials about what San Francisco accomplished, and you typically hear: “Just can’t do it.” …
Gawande thinks that San Francisco’s experience with AIDS prepared it to confront COVID-19. He believes that there is still time and much benefit to be gained from putting together programs of testing and public health to augment wearing masks and practicing social distancing that could hasten the return to a more “normal” existence, but it will require funding and cooperation.
A serious national strategy for coronavirus testing—including universally available assurance testing for essential workers, travellers, students, and others—is clearly needed. Such a strategy would entail a major injection of funding, which would pay for itself many times over by getting the pandemic response, and therefore the economy, back on track. It would have the F.D.A. supervise the validation process for laboratory tests, but with a simplified and speeded-up process. And it would build our national grid for monitoring, distributing, and accelerating testing capacity, whatever technologies emerge.
After that assertion, Gawande takes off his political gloves while saying that the president alone was not the whole problem. We took a long time getting to this level of incompetence as we headed down a lot of wrong roads looking for success without ever considering the importance of public health and dealing with the issues of the social determinants of health.
President Trump, backed by the Republican politicians who have protected him, is clearly uninterested in pursuing such goals. But even the most committed Administration would have struggled to overcome the effects of the long, collective neglect of our public-health systems. Hospitals and clinics have had the resources to spend tens of billions of dollars installing electronic medical-record systems. A whole industry has developed to deliver such capabilities. Yet our thinly staffed public-health departments, which are expected to compile thousands of diagnostic-test results per day and follow up on outbreaks, have nothing of the kind. Some still receive test results by fax and must manually enter them into databases. They lack the means to readily measure, let alone manage, a community’s availability of coronavirus tests, ventilators, hospital beds, or personal protective equipment. Not a single state in the country reports coronavirus-test turnaround time and rates of mask wearing—two of our most critical indicators for shutting the virus down. They’d like to; they just don’t have the ability to collect the information.
The pandemic has given us all a master class on infectious disease, diagnostics, and the reality that individual health is inseparable from community health. Polling shows that an overwhelming majority of Americans want the government to cover the costs of not only testing but also treatment for the coronavirus. In turn, support has grown for expanding Medicare to cover all Americans for their medical needs, and for investment in public health.
Step by step he has been closing in on his most pointed recommendation which is to use the election to select better leadership
Epidemiologists expect us to encounter one of the worst falls and winters in American history. We will have more American dead in a single year from the pandemic than we saw during any year of war we’ve faced. On Election Day, we’ll have a chance to turn out a President who has sacrificed tens of thousands of American lives—and undermined essential government institutions—to serve his own desires.
That is step one. But, despite the “carnage,” there is still much that we can do.
And yet, amid the carnage, there’s a lot we can still do to advance the essential work of collaboration…
Such efforts aren’t a replacement for national leadership, but they start the work that must be done to make ordinary physical interaction safe again, and to begin creating the public-health system we deserve.
He finishes this incredible offering with wisdom from C. Everett Koop, and a recognition that the pandemic has shown us where changes need to be made.
As the former Surgeon General C. Everett Koop once said, “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.” The pandemic has brought Americans a further lesson: our best chance for long, flourishing lives in the future requires that we build the foundations of our public health now.
Will we take the road Gawande advises, or will we continue on like Kristofferson’s pilgrim, taking all the wrong direction on our lonely way back home? Remember:
There’s a lotta wrong directions on that lonely way back home.
I would also remind you that Winston Churchill remarked that you could always count on America to do the right thing, after it had tried all the wrong things. I think Gawande is telling us that we have a chance of getting on a better road toward home eight and a half weeks from now. I hope that he is right, and I sure appreciate his effort to tell us about the better way back home.
It’s Fall, Almost
I am writing to you from Point Judith, Rhode Island. My wife and I are on our second “shake down cruise” before heading out across the country in search of adventure and the renewal of relationships. Once we get going there are many other family members and friend whom we want to see going to and coming from Santa Cruz where our son and his family have been allowed to return to their home following their evacuation from the path of the recent fires.
They live about ten miles north of Santa Cruz in the thick of the coastal redwoods. The fires were coming down the mountain toward them, and got to within a mile or two of their home in Felton. The whole area was evacuated. The progress of the fire was blocked by the good fortune of having a quarry between them and the fire, and the efforts of the quarry operators working with the firefighters. I will never complain again about the extra local traffic of the big trucks carrying crushed stone from the quarry. In the end the quarry was a life saver. Now there is ash to clean up, and the slow return to life that was already complicated enough by the challenges of COVID-19 and working from home with two energetic little boys aged six and almost three.
It’s been a rainy and cool week, with a chill in the air at night which led to the first fire in the fireplace which I enjoyed while writing last Tuesday’s post. On my walks I am beginning to see summer fade to fall. I have long contended that summer is the shortest season. It ends abruptly with Labor Day, no matter what the temperature or weather will be in the weeks that follow.
A couple of times a year, usually in the late summer after some rain, there is an unusual kind of “road kill” that I observe on my walks where the road is close to the shore. There is mostly conservation land along my path that is a mixture of forest and wetlands on the side of the road away from the lake. The “road kill” victims are little two inch orange newts. I see them smushed flat by the dozens. I am pretty sure that something is telling them to cross the road. It seems that they are migrating from forest to lake since I was able to see a few that were still alive and moving in that direction. I don’t know if the little fellow or gal that you can see in today’s header made it across the road because a few minutes after I snapped the picture and was already several hundred yards further down the road a couple of cars passed me headed toward my tiny friend. I did not have the courage to see if it made the final few yards of its slow trek across the pavement. I would like to think that it did.
As I pondered the situation it occurred to me that all the dead newts in the road suggested that few made the journey successfully, but the truth was that the little bodies on the road had accumulated over a few days. They were a “numerator” for which I did not know the denominator. I would like to think that the denominator of their population was quite large and the bodies on the road represented a distinct minority. That thought got me thinking about the pandemic, the Gulf Coast Hurricanes, and the California fires. The reality is that every life lost is a tragedy to be regretted. Any loss of life should lead us to use the pain we feel as motivation to work to minimize the risks for everyone going forward. We are warned by many that we are vulnerable to events either self induced or by an act of nature that may lead to a “great extinction” like the one that wiped the dinosaurs from the face of the earth. I don’t know about the newts and whether the survivors pass on tips to the next generation, but I do know that enough of them make the trip successfully to keep the migration going year after year, and within that reality there may be hope that we might avoid extinction by luck and grace, if not by foresight and effort.
Be well! Have a great Labor Day weekend! Still stay home if you can. When you are out and about, wear your mask and practice social distancing as best you can. Don’t try to outguess the virus.Think about the America you want for yourself and others. Reject leaders who will not be accountable and who distort facts as they ignore science. Look for opportunities to be a good neighbor. Let me hear from you. I would love to know how you are experiencing these very unusual times!
Gene
