A Global Look at COVID-19 and Health Disparities
Editor’s Note: Cambia Grove is proud to partner with the innovation community to amplify their perspectives on topics applicable to the larger health care ecosystem. The views expressed in this article are solely those of the author and do not necessarily reflect the opinions or positions of Cambia Health Solutions, Cambia Grove, or any other entity or organization.
These reflections follow Cambia Grove’s May 21 event, “Paying for Health: A Global Perspective.” The second in this series, “Paying for Health: A Domestic Perspective,” will take place on June 3 and the third in this series, "Paying for Health: A Community Perspective," will take place June 16.
The World Bank estimates that the global economy will shrink by $4.2 trillion dollars from 2019 to 2020 due to COVID-19. Millions of people worldwide already live in extreme poverty, with no access to food, water, medical care, or basic sanitation. Imagine the ongoing devastation of this pandemic on Africa, then, where 80% of people work in the “informal sector,” beyond the reach of social services, infrastructure, and basic health care.
As Thomas Bollyky writes in Plagues and the Paradox of Progress, the working-age population in developing countries is expected to increase by 2.1 billion by 2050. But investment in public health in cities like Sao Paulo and Cape Town has not kept pace with medical progress elsewhere.
I thought about all this as I (impatiently, I admit) washed my hands (again) after carrying in a bag of groceries. An embarrassment of riches, from our still-abundant food supply to the flow of clean water at my sink to enough living space to practice social distancing.
The conversation about “paying for health care” has always perched uncomfortably on this barbed wire fence: the allocation of resources, with a growing population on one side and thinning funding on the other. Today’s fractured global reality makes this dialog much more urgent. Last week the World Bank’s president, David Malpass, estimated that COVID-19 could thrust up to 60 million people globally into extreme poverty. The current deaths from the virus worldwide – devastating as they are – are a miniscule tip of the iceberg compared with global health ramifications down the road.
In this urgent context, what can we learn from global experts about investing in health care? Ali Mokdad, PhD, Chief Strategy Officer for Population Health at UW and Albert Wettstein, MD, neurologist, geriatrician, and former Public Health Officer in Zurich, shared their ideas. Dena Morris, former President of the Washington Global Health Alliance, moderated.
COVID-19 Exposes Health Disparities
“COVID-19 came on top of existing health disparities, and mortality from COVID-19 in the US is higher among African-Americans and minorities,” said Dr. Mokdad. “I’m afraid COVID-19 will widen these disparities, and we’ll see even higher mortality among these groups, as well.”
Dr. Mokdad outlined four factors that determine health: socioeconomic factors such as education; access to health care; quality of medical care; and preventable risk factors such as obesity and diabetes. In his framework, “access” refers to health insurance in the US and universal coverage elsewhere. “We’re the only wealthy country in the world without universal health care coverage,” he said, “although now one of the mandates at WHO is to have universal health care coverage for all.”
“Quality of care” includes the time it takes from symptom onset to receiving care, with adequate follow-up to be sure treatment is working. But it’s the preventable risk factors, Dr. Mokdad said, that are most critical, referencing a JAMA study of health disparities in the US , in which preventable, behavioral risk factors explained 74% of variation in life expectancy.
“COVID-19 has already caused a $300 million deficit at UW Medicine,” Dr. Mokdad said. “It may be time to rethink how hospitals make money.” He suggests investing in chronic disease prevention and management, as well as giving incentives to people to change health behaviors, ultimately saving money and keeping hospitals focused on emergency care. “If we address the risk factors immediately as we are working long-term to address the socioeconomic factors,” he said, “we could get more return on our investment.”
The Swiss Model
“Switzerland has one of the highest life expectancies in the world,” said Albert Wettstein, MD. Everyone in Switzerland has comparable health insurance, he explained, with a welfare system that provides a basic level of housing, food, and medical care to all.
“Health insurance is not dependent on a job; everybody has it and has to pay the same amount,” he said, with state and national government helping to cover its costs. “If an elderly person needs a lot of medication and they can’t pay, they get the money from the government. Nobody goes without insulin or other medications; the government pays for those who cannot.”
Like the US, Switzerland has a three-level policy system of national, state, and local governments. “All three cover parts of the expenses of the health system,” Dr. Wettstein said, “and communities are responsible for caring for the elderly. Nursing homes are community affairs.”
The Swiss system of paying for health care, he said, is a “balanced system” with state and national government, local communities, companies, and the Swiss people themselves, with policies requiring Swiss companies to pay for pensions and contribute to unemployment, accident, and disability insurance. “Police, the medical system, and social systems have all learned to work together, for instance on substance abuse,” he said.
Innovation Can Be Low-Tech
Both global health experts believe in preventing and managing chronic disease as a top priority and retooling the ways health care is delivered.
“The primary question going forward is how to spread out the know-how of the medical system into the broader population,” said Dr. Wettstein. “The population at large doesn’t understand health beyond high-tech care, which is not a good ROI. It’s a better ROI with nurses as gatekeepers in universal health care.”
Nurses provide better case management, he said, so their role could be transformed to optimize their time and talent. “Nurses are less expensive than doctors and often do a better job on risk factors and underlying chronic disease,” Dr. Wettstein said. Working with patients who have chronic diseases such as COPD and diabetes require time-consuming, frequent, often lifelong support to support the behavioral changes that help them manage disease. Instead of expensive care in high-tech silos in the US system, Dr. Wettstein suggested “visiting nurses in the field going into patients’ homes every day, if needed, to keep people out of nursing homes.”
Dr. Mokdad emphasized the need for better chronic-disease management in under-resourced populations, so they aren’t as vulnerable to this and future pandemics. “Let’s build a system that will last a long time,” he said. Change can be simple: Give medical students free housing in older people’s homes in exchange for elder care. Or it could be a radical re-thinking: Quality hospitals defined by preventive care, with reimbursement mechanisms for prevention and case management.
That poverty correlates with mortality is not news. The pivot from this dialog is toward investing in person-to-person nursing, primary care, and public health strategies that can move the needle on health discrepancies and mortality. Investing in the social determinants of health is a clear direction for innovation and ROI – in this pandemic and beyond.
About Rebecca Buffum Taylor - Cambia Grove Member
Rebecca Buffum Taylor is the Founder of Prose Arts LLC, specializing in health and medical communications. She researched and ghostwrote The Healthcare Crisis: The Urgent Need for Physician Leadership, a look behind the scenes of our spiraling health care costs and failed attempts at reform. Congressman Adam Smith wrote of the book: “It offers a unique understanding of the factors driving costs in our health care system . . . It is the most objective analysis I have seen on this critical public policy challenge.” Rebecca has held senior editorial leadership roles in publishing, including Editorial Director for the nation’s largest patient education publisher and VP/Executive Editor for an international photojournalism book packager. She was Executive Editor of The Face of Mercy: A Photographic History of Medicine at War, a $1.3 million international photojournalism book project published by Random House. Her clients include the American Academy of Ophthalmology, EvergreenHealth, WebMD, Kaiser-Permanente, Amazon, GeneSage.com, HealthTalk.com, Glamour magazine, Warner Books, Chronicle Books, and Jossey-Bass Publishers. Her work can be seen at ProseArts.com.
• Cambia Grove’s audio recording of its May 21, 2020, event, “Paying for Health: A Global Perspective.” Quotes have been edited for length and clarity.
• Thomas J. Bollyky, Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways (2018, MIT Press and the Council of Foreign Relations)
• Laura Dwyer-Lindgren et al, “Inequalities in Life Expectancy Among US Counties, 1980 to 2014: Temporal Trends and Key Drivers,” JAMA Intern Med. 2017;177(7):1003-1011
• David Malpass, May 22, 2020; World Bank Blogs: “May 22, 2020: End of week update”
• Axel Van Trotsenburg, May 6, 2020; World Bank Blogs: “Broad, fast action to save lives and help countries rebuild”