The Covid-19 pandemic was the best of times, the worst of times, for our healthcare system. We saw the ceaseless efforts of frontline doctors and nurses, working to contain an unprecedented plague. Yet, we also were reminded of the fragility of our medical system, buckling rapidly under the weight of a new disease, made worse by lack of access to quality care for many, and a population burdened by chronic diseases that have made Covid-19 so much worse.
Our healthcare system matters. How do we protect it?
We argue for three things.
First, we can adopt payment models which encourage health rather than sickness. We currently have a model which incentivizes providing ever-more expensive care for disease. It is a sick care system. We readily attend to people who present for care with symptoms; we are less skilled at improving health across entire populations. Models which shift the focus of market competition to keeping patients well have been explored in shelves’ worth of books and we here deflect away from specific ways to implement. But the fundamental concept: changing incentives from sickness cure to keeping health, seems to us indisputable. Put simply, the medical care system needs to embed public health practices.
Second, healthcare professionals need to engage with the social forces that shape health. Perhaps centrally, we can do this by incorporating foundational factors into medical education. During medical school interviewing courses, doctors have traditionally been taught to take family and social histories. An even wider focus on the socioeconomic determinants of health, on the forces that produce health—clean air, nutritious food, safe neighborhoods, and livable wages—can provide the perspective that lets doctors truly support health rather than just treat disease. Clinicians can see themselves throughout their careers as being part of the architecture that generates patients’ health, rather than playing a role only when patients are sick. A deeper understanding of our complex world can be accelerated by cultivating a more diverse population of physicians. How might care be better for people of color, for example, if doctors understood the Black experience from having lived it?
Third, healthcare providers can use their public voices to change the narrative about health. We can help communicate the fundamental role of context in shaping health. This means communicating the link between socioeconomic forces and prevention. Providers can tell the full story of health—not just the story of medical care. We saw, during Covid-19, how one of the most powerful forces shaping the narrative during was individual doctors speaking about their experiences. It is time for doctors to speak routinely about the full range of social factors that shape their patients’ lives.
We want an excellent health care system: after all we want outstanding doctors and nurses to look after us when we are sick. To prevent us as a country from living shorter, sicker lives, we need more than a health care system, we need a health system, one that generates health. Perhaps these three steps could start us on the way.
Michael Stein & Sandro Galea
As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.