Commentary
I Have a Dream
by Issam Makhoul, MD
Professor and Director of Hematology Oncology, Department of Internal Medicine, UAMS, Little Rock, Ark.
For the first time
in our lives, it appears
that there
is a global opening
in the continued
flow of
time. COVID-19
forced everybody
on the
planet to stop
and think. Many
lessons can be learned from the pandemic; as
someone once said, “You never let a crisis go to
waste.”
In the U.S., the crisis hit every aspect of our
health care system, revealing many weaknesses.
Non-urgent procedures and “routine” visits
were canceled in preparation for COVID-19 patients.
Overnight, the patients disappeared but
their health problems did not go away. We were
not prepared for that. But, as we were looking
for a new model of care delivery, telemedicine
emerged as the solution to the new reality of social
distancing.
Again, COVID-19 acted like a midwife delivering
a new model that had been in gestation for
decades. Prior to March 2020, telemedicine
appeared as a remote possibility; technical and
administrative hurdles seemed insurmountable.
But as “Humanity solves the urgent problems
that life places on its agenda,” we saw the obstacles
disappearing by miracle. Many institutions
are now back to almost full operation with
some patient encounters happening in person
and many more using telemedicine. The patients
seem to like it; but this form of patient care has
its limitations. Its reason to be, social distancing,
is also its Achilles heel.
The physical exam is impossible and the healing,
compassionate touches of the doctor and nurse
are gone. Meaningful proxemics have been lost.
Establishing trust and having difficult conversations
might be complicated and often undermined
by the distance and technology. What will
be the shape of our medical care after COVID-19?
The future will tell, but this form of health care
delivery is here to stay. We have swiftly adapted
and will continue to do so.
The other weakness of our health care system is
the exaggerated focus on medicine for the individual
– who can pay – to the detriment of public
health, which deals with populations. Public
health tackles the fundamental components of
a population such as job, food and housing security,
screening and prevention of diseases, life
style, and mental health. The common thread to
social determinants of health is the availability of
publicly funded programs and universal health
coverage for the entire population. All developed
nations and most developing nations provide
universal health care coverage, with strong public
health components, to all their citizens. The
U.S. is the exception. Although the virus did not
discriminate between poor and rich, the heaviest
burden landed on the shoulders of the poorest
and most vulnerable amongst us. This magnified
preexisting deficiencies. This pandemic should
close the debate on whether universal health
coverage is needed and whether public health
programs should be funded. The costs of these
programs dwarf when compared to the cost in
lives, quality of life, and financial impact when the
crisis hits.
Our medical education programs quickly adjusted
to this new reality and moved to an “all-distant
learning” model. Virtual learning is not new, but
COVID-19 gave it new, unprecedented dimensions
that will impact our educational institutions
for years to come. We are still struggling to find
the right format to teach and assess knowledge
and redefine a new collective graduate education
experience that, in the past, benefited from the
live interactions between a diverse student body
and its teachers.
Starting in mid-January and for several weeks
afterward, COVID-19 synchronized billions of
human lives into a state of immobility in their
homes; the result was a shutting down of major
economic activities across the globe. A few weeks
later, specialized centers recorded a drastic drop
in daily global CO2 emissions (–17% by early
April 2020 compared with the mean 2019 levels),
with just under half from changes in surface
transport. This ‘global social experiment’ proved
that we are responsible for what happens to our
planet and we can effect a change if we decide
to do so. Of course, nobody is talking about any
form of lockdown or confinement. But, imagine
what would happen if we replace half of our fossil-fuel-powered
cars with electric cars powered
by renewable energy. Would we not get the same
results? The answer is a resounding yes.
As we are working our way out of the muddy
COVID-19 territories, racial injustice against our
black citizens has flared up. Four centuries after
the beginning of slavery in the U.S. and more
than 155 years after its abolition, our nation has
not yet come to completely eradicate racism. Institutional
racism leads to weak social determinants
of health, which explains the heavy burden
paid by our black communities to the pandemic
(blacks represent 13% of the population in the
states that reported COVID19 race data and about
34% of total COVID-19 deaths in those states.).
To correct the effects of this historical injustice,
we need to acknowledge and dismantle the social,
economic, cultural, legal, and political underpinnings
of discrimination.
We’ve gotten used to our life with all its deficiencies,
but our ‘normal life’ isn’t that normal. I have
a dream today that we will take advantage of this
seismic event to peacefully reinvent our health
care system, society, economy, and governing
structures to be more just and in harmony with
nature and to respond to our deep human needs
for life, love, and peace for ALL. COVID-19 uncovered
our vulnerabilities and abilities. History
is tolling its bell. Are we ready to answer its resounding
tone?
28 • The Journal of the Arkansas Medical Society www.ArkMed.org