We’re navigating out of the pandemic with a new perspective on long-term wellbeing – both of healthcare workers and the communities they serve, writes Alex Kazemi.
The politics of health has seen some careless words spilled out over the last two years. So when, around the world, politicians have confidently stated that their healthcare services are coping with the demands of the pandemic, the words sting for those in healthcare because they are missing a crucial sub-clause. Healthcare services are “coping”, because they have to. They always have. Access to healthcare is profoundly inequitable but it was supposed to be a fundamental tenet of universal healthcare that nobody in need of it should be turned away.
Whatever the argument for the reduced relative severity of omicron, its highly increased transmission means that it still causes more sickness overall. A lot more. And the recurrent desperation of not being able to meet standards of usual care, together with exhaustion, has meant that globally many healthcare workers are leaving their posts. Epidemics of viral illness have become epidemics of burnout. It reminds me of something I learned recently about the Titanic. Had the ship hit the iceberg head on in a single impact it would have stayed afloat. Instead, the iceberg scored along the side of the ship, puncturing multiple flotation compartments along the way, ensuring it sank. The analogy doesn’t fully hold though because, by force of necessity, healthcare systems don’t sink. They are being held afloat by slowly unravelling workforces. What happens from here depends on learning the lesson from the pandemic, of looking beyond its edges, both backwards into our history and outwards into our society.
Separating a healthcare system out from the society within which it exists is a mistake. The practice of medicine and the study of health have drifted apart, such that the medical narrative of what makes us healthy or unwell has become rooted in some mixture of microbes, genes, individual choice and plain luck. But to ascribe all this disease to seemingly random occurrences like viral evolution is to look only at the small part of the iceberg above the waterline. The pandemic has become an uncomfortable searchlight illuminating the darker waters of our world – poverty, racism, inequity, the practice of profit from the creation of disease. The part of the iceberg that is doing the damage is beneath the surface.
The usual rejoinder is that medicine and politics shouldn’t mix, that we should stay within our lanes. Frankly when you examine the full accounts of those making such statements, you usually find them veering between the lanes themselves, much in the manner of an inebriated driver. From where I sit, it’s all politics. And if it’s true that politics is really nothing but health writ large, then there’s a mandate for the voice of those dealing with health and ill-health to be present in that conversation, as well as an imperative to use that voice thoughtfully. And in a way that does not dismiss sections of our society.
All of this should have become icily clear during the pandemic, but consequences are still labelled as individual choices, a population-level health crisis continually reframed as one of individual risk. Inequities remain kindling for the pandemic inferno. Here in New Zealand, repeated advice that the vaccination rollout last year would be inequitable was ignored. While the pandemic is a marathon, it was rapidly turned into a sprint for Māori communities as the delta outbreak sparked a race of vaccination versus contagion. And a race where colonial history, and the racism that it has left woven into our structures, meant that Māori were denied their place at the start, leaving them behind in vaccination rates and at the sharp end of that outbreak. The repercussions continue still in this one.
Politics has changed the delivery of healthcare too. Despite regular appraisals that purely market-focused healthcare, such as that seen in the US, performs badly on all measures in comparison to socialised systems, the prevailing neoliberal sentiment has been to try to shapeshift one into the other. In a country that spends billions on its military, a virus that crept unseen past its borders has caused far more deaths than any recent war (nearly a million at last count). At least part of that sad record has been because adequate healthcare has become inaccessible for far too many Americans, and particularly for the non-wealthy and non-white.
I used to believe that the relentless focus on healthcare marketisation, without the ability to see the areas in which it was failing, was in itself just a failure to appreciate the enormous complexity of healthcare systems. Watching the current UK Tory government has changed my mind. The adage runs that you should never ascribe to malice what could be reasonably ascribed to incompetence. But in their policies, they seem to have plenty of the latter and, depending on your viewpoint, a fair bit of the former too. I’ve come to believe that, as illustrated by the Immensa testing scandal and the more recent one around PPE, the incompetent bumbling is actually a systematic chiseling away of the NHS to sell its parts to the highest bidder, or sometimes just to old chums.
That aside, it’s still true that healthcare complexity is both underappreciated and the source of much hope for how to fix the malaise that afflicts it. If healthcare were a structure made of bolts and struts we would stand in awe at it, the way we do with modern skyscrapers. But it remains intangible. It’s mess and blood, grief and hope, made of all the same things that make us human. Even in the dead of the night it’s furiously alive, more fluid dynamics than Newtonian mechanics. And what’s happened over decades of neoliberalism is that, in service of the twin gods of productivity and micro-economic efficiency, the space around the edges of this invisible life, the room that allows people to breathe, has been excised until the knife now scores directly into its human heart.
I’m not arguing against the need for improvement. There’s much to do better, everywhere. But it’s no small miracle that the dedication and ingenuity of the everyday people within the system has meant that, worldwide, enormous numbers of patients have been treated in the pandemic, and vaccinations have been rolled out at huge scale and speed. The convenient narrative is that there is some overarching grand plan, a top-down structure that keeps it all rolling, but that’s not the truth. The extraordinary grows out of the ordinary. That it copes in any sense to navigate, however heavily, through something like a pandemic comes not from the edicts of those at the top but the rapid reconfigurations of those on the ground.
Viewed only as one large ship, national healthcare systems have a large turning circle. What’s able to pivot more quickly, and to reconfigures, are the smaller groups of people doing the work they have become expert in. It’s in this sense that pandemic healthcare responses have worked at all, but that’s not the conventional story told of individuals and leaders, nor does it fit with the production-line symbolism of the last few decades. We need not be paralysed by this complexity either. There isn’t a need for a theory of everything for this to work; that it could work now, in the midst of all this, is a phenomenon of emergence from self-organising units of people, real humans delivering real care.
Healthcare is also well used to crises. What even is the meaning of the word crisis if it is a continuous state of affairs, the dismal normal that no one in health wants to return to once the pandemic subsides? Healthcare workers will find what The Atlantic journalist Ed Yong calls the “panic-neglect cycle” depressingly familiar. That see-sawing between, on the one hand, the hurried patching up of the fabric when it tears and, on the other, the long periods of inattention when the same fabric is stretched and stretched until it rips again. These cycles have occurred everywhere in the pandemic but existed beforehand too. Driven by the focus on the immediacy of matters at hand rather than the long-term view, there’s a tendency to always plump for the quick fix of cash sums for building modifications or equipment purchases. It’s not that those things aren’t needed but nor are they the core solution. People are.
The quick-fix approach reached its nadir during the pandemic with the establishment of the Nightingale hospitals in the UK. Intended to soak up sick Covid patients spilling out of the conventional hospitals, and expensively assembled, they were unable to be adequately staffed, such was the load on the the NHS and the preceding attrition in staffing. The lesson is that responding to immediacy in a way that only addresses physical infrastructure and not human resource is highly likely to be unsuccessful.
The perspective shift then is fundamentally about long term wellbeing, both that of the workers and, importantly, that of the communities they serve. All of them, not just some. The latest round of health reforms here in New Zealand hold promise of a broader vision. The scaffold they provide will need to be filled in by those who do the work in partnership with the communities they work for. The wider social and economic determinants, the politics of health, will hopefully be brought to the fore, as this is essentially the core of public health in the longer term. In the shorter term, what has become over decades a heavily under-resourced system that only works for one part of society needs significant course correction. It would be better if people did not continue to be load bearing elements too, something that requires both valuing the quiet work (and by valuing I don’t mean the performative gratitude of a nightly clapping ritual) and resourcing it appropriately. The realisation must surely come that all these requirements are incompatible with both boom-time tax cuts and austerity era pay freezes.
The biggest worry for many in healthcare now, as the pandemic response seems to shift to yet another phase, is that once the searchlight finally moves on all this will be forgotten, locking us into the same old patterns. For Covid-19 itself, the approach of governments like the UK – trying to exit the pandemic room and asking the last person out to switch off the lights – creates a void. We could never see the virus anyway. At best we had some measure of its impact on society. Without even that, our knowledge of it disappears but the virus doesn’t. Once the frequent distress flares that have emanated from healthcare systems in many countries are no longer seen, what do we return to? In one of the more probable of the many blurry interpretations of the term endemic, Covid-19 could actually become a seasonally epidemic disease, potentially compounded by the return of influenza and the threat of the large vaccination gap that has opened up for childhood diseases like measles. The prospect of a return to yet more winters with healthcare services teetering on the edge is grim.
All this needn’t be inevitable. Beyond the patching up of the rips lies the possibility of a more all-encompassing reimagining, where healthcare lies within a much larger, and much more inclusive, consideration of the health of our society, as well as how much better we could look after the wellbeing of those who work in it. An approach that is not rooted in wrong-headed political and economic ideologies that only serve to further entrench inequity, ill-health and the malaise that afflicts healthcare services. It’s not enough just to be trying to stay afloat. That’s too low a bar. Because, in the long term, coping and thriving are two very different things.