Imagine a world in which a pandemic such as COVID-19 is not a once-every-100-years occurrence but a once-a-decade event. This is not a prediction; neither is it beyond the realm of possibility. A 500-year flooding event has a 0.2% chance of occurring in one year; Houston, Texas, experienced three such events three years in a row. In the past 20 years alone, we’ve seen 60.8 million people affected by H1N1 swine flu in 2009; a SARS-CoV epidemic starting in 2002 and again in 2018; a MERS-CoV epidemic starting in 2012; an Ebola epidemic starting in 2014; and Zika in 2015. Malaria kills several hundred thousand people per year, Dengue is spiking, and we’ve had an uptick in polio.
What makes an outbreak an epidemic, and an epidemic a pandemic, is a roll of the evolutionary dice and a particular expression of animal behaviors (including our own) that affect viral transmission routes, virulence, minimal host-virus co-evolution and evolvability of a virus itself. Combine genetics and human behavior just so, and we see COVID-19.
Examining the impact of more frequent pandemics on healthcare is an important thought experiment. How might the possibility of COVID-19 as a recurring experience change us in terms of how we deliver care, how we live and work, how we protect ourselves and move from fear back to active living? The possibility that COVID-19 could be a cultural catalyst for lasting change in healthcare and society at large makes this thought experiment all the more urgent. We must encourage and plan for policies that lead to better systems and lives.
Potent Conditions for Change
Climate change is usually cited as creating the conditions for more chaotic weather and dramatic shifts in rainfall. This results in some fundamental changes in biomes that lead to increased pandemic possibilities based on new species-to-species interactions. Some of these arise from behaviors such as mass migration that stress our water supplies and cause us to search out risky food supplies. This, in turn, increases the chance of the spread of infectious diseases. Additionally, viruses, once at equilibrium with their animal and human hosts, suddenly have new transmission routes, vectors and evolutionary pressures.
In the geopolitical realm, gene editing techniques like CRISPR, meant for good, could be used for faster and smarter responses to infectious diseases but also misused to create a ”plague bioweapon.” Shifting alliances, growing nationalism and increased protectionism could affect supplies of key raw or finished ingredients for pharmaceutical therapies and medical equipment beyond obvious threats to strategic supply chains. A country’s ability to quickly respond to infectious diseases could fast become a national security issue.
How the Future May Unfold
Cultures will adapt. Businesses, governments and individuals might treat pandemics as another recurring hazard to manage with the right supplies and contingency planning. Food supply will become a more strategic national value chain. More people may work from home or distributed remote locations, even to the extent that the nature of cities and work spaces might change from a pure physical notion to new physical/digital/virtual concepts. Smaller communities might pool their health resources. Face masks might become extremely effective at filtering viruses and be worn by everyone all the time – moving from safety to fashion statement. When AI agents start to uncover signals in medical records databases of an emerging threat, smartphones could light up with built-in tracking and warnings activated by health officials.
In this world, imagine:
- Healthcare will follow health consumers on their journeys and become centered on the consumer’s new environments and patterns.
- Regular telehealth check-ins, remote monitoring and in-home care will become routine. Wearables and home diagnostic devices will analyze at the edge of 5G-plus networks and stream relevant insights continuously. Algorithms will screen for new patterns and alert the health consumer, family and care teams to intervene when a notable and actionable anomaly arises.
- Similarly, nutrition advice, therapeutics and care will become personalized to one’s own genome.
- Physicians as care teams will be trained in holistic patient care, incorporating community interventions from social determinants of health, with anticipatory care that mitigates the chronic conditions to which a patient is ‘omically (e.g., genomics, microbiomics, toxicogenomics) predisposed.
The fear of infectious disease could become the catalyst to realize the vision of precision, contextual and holistic care. Healthcare might have the chance to finally transition away from episodic transactional models to a continual engagement in each person’s life.
But this is possible only if we are thoughtful in how we use the COVID-19 crisis as a catalyst for change
Sparking an Overdue Response
We don’t need to wait for a new pandemic to start building a more resilient, continuous, consumer-centered system of care. Take telehealth. Because most government and commercial health insurance plans limited reimbursements for virtual consults, health systems had little incentive to adopt that channel. When COVID-19 emerged, The Centers for Medicare & Medicaid (CMS) quickly expanded telemedicine reimbursements. Healthcare systems began promoting that option, and telehealth consults jumped dramatically. In a “new-normal” world, there’s no reason to reverse course, so long as we design for effective engagement.
Other measures we imagine taking to fortify our healthcare system are less familiar: machine learning, precision medicine and health engagement, in-home health tools, wearable diagnostics with seamless data tracking and bio-engineered foods. These are simultaneously intriguing, beguiling and disruptive. There’s also the concern about how much privacy we might have to trade for more protection against the next pandemic.
The Four Qualities of Change
To ensure these concerns don’t inhibit change, new healthcare services and solutions must express these four intertwining qualities:
- Authentic trust. People must be assured the information they give will be used for their benefit and not against them. Where authentic trust exists, people will more likely share data necessary to identify threats early and mitigate them soon enough to make a notable difference in outcomes, personally and for the community. For example, imagine the response from the health consumer when contact tracing is managed by a non-governmental organization such as the Red Cross or Doctors Without Borders or a trusted academic institution such as MIT or Johns Hopkins University vs. the NSA or a corporation with a vested interest. Contact tracing has a much greater chance of success where trust exists. Without trust, people will find a way to subvert the effort.
- Mutual value. People must receive an experience that provides value commensurate with the data and/or access they provide to enable that experience. PatientsLikeMe has been successful because people get direct value out of “donating” their personal medical information. “Give a little, get a little” goes a long way with information necessary to determine which health actions to take, when and how. Mandated altruism or zero-sum experiences have severe limitations in their long-term viability.
- Personal engagement. The service or tool must empower consumers to manage their health and wellness in ways that matter to them. Beyond primary and acute care, health journey dimensions to consider include spiritual needs, family support circles, career, financial and social journeys. People who score higher on the “Patient Activation Measure” are significantly more likely to engage in positive behaviors (e.g., preventive actions, adherence to treatment, self-monitoring) and avoid health-damaging behaviors, (e.g. smoking, poor diet). Imagine digital therapeutics programs for COPD or gestational diabetes that not only capture data in the home but also guide people – in their own context – to act in ways that allow them to realize their personal goals as opposed to using cold, clinical measures that have little meaning in daily lives. These positive changes in attitudinal behavior are necessary for both an effective pandemic response as well as delivering better health outcomes overall at a more sustainable per capita cost.
- Simplicity. Solutions must be easy and intuitive to use – “frictionless” is a useful metaphor. Imagine if we could walk into a convenient yet warm and personal retail clinic and get a quick and comprehensive health scan based on a drop of blood or a puff of breath, a video-pill and a comfortable cuff that captures ECGs and blood pressure. After a cup of your favorite coffee or a chai tea latte, you have a telehealth consult to discuss the results of the test and agree to immediately approved interventions that could very well prevent the occurrence of more severe problems later. Imagine if your phone were your personal care assistant, answering initial questions based on trusted health resources and personalized care pathways, scheduling health visits and interventions that fit into your life, with costs known in advance and prior approvals hidden and quick (and using the best payment path for your particular context).
Continuous healthcare delivery will involve a wide range of companies, from Apple and Google to CVS and Walmart. If traditional players don’t seize this opportunity to reinvent the industry, technology giants, national retail players and entrepreneurial entities likely will develop the alternative systems of care that the pandemic is priming our culture to accept.
Ongoing Ripple Effect
Clearly, other changes will be needed to support a pandemic-ready continuous health delivery system. These include physician training in leading continuous care teams focused on care in the home, new payment models such as Direct Contracting and other forms of risk-sharing and outcome-based pricing, subscription and freemium models, and perhaps even bidding.
What we’ve covered here is just the start of the thought experiment. While it looks forward, it is not science fiction. We have many of the tools in place to realize the vision but have been kept back by a fragmented and rigid system. What we need is to take advantage of a cultural catalyst and make sure we are designing for effective engagement and better outcomes. For all its horrors, the COVID-19 pandemic may be the agent that takes us to a better place.
This blog is part of our special report on the future of infectious disease. Stay tuned for more blogs on this topic.
Visit our COVID-19 resources page for additional insights and updates.
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