A Bitter Pill - What Happens Next? podcast on digital health

SC: Tell me what the future will look like if we don't change the way that we think about health care or health care delivery. 

MC: Well, Susan, I think it's pretty clear that we're at the nexus of all of these sort of intersecting global challenges. So you know the very obvious ones, things like the global pandemic that we're facing. Then we have these environmental emergencies, like the bushfire disasters and climate change. And then there's all of these sorts of social injustices and inequities. Global poverty. We've got an entire global refugee crisis with millions of displaced people around the world. We've got ever increasing disparities between the health of indigenous and non indigenous populations and what we see at the moment is that there is this kind of very reductive way in which we deal with a lot of these challenges. We just take each one in its own little silo and we say, Okay, let's do you know, five things for this and five things for this, and then we've done our job. I think the problem is that unless we start to look at all of this as a complex system, that there is this big sort of matrix of factors which are interacting and causing the manifestation of these challenges. We're just going to see more and more challenges and, that is, I think, the sad reality at the moment is that we're just seeing more and more and more, and that's what will continue to happen.

SC: What is planetary health and why does it matter? Is it just about the environment. It sounds like we're just talking about the health of the oceans.

MG: Yeah, it sounds very Star Trek, doesn't it, planetary health? That's what I thought when I first heard it. But it's actually a really lovely way of articulating some of this complexity, which we deal with in health. So it's about the health of the human civilisation. But it's also about the health of systems on which that civilisation depends. So it's about environmental sustainability, it's about social equity and justice. It's about giving people that were traditionally silenced within a conversational discourse, giving them prominence. And it's about future generations. So we talk about this idea of intergenerational equity, which I think is such an awesome idea. It's this thing of ‘what are we doing for the people that will follow us, our children and their children and the legacy that we leave? So it really is about looking holistically and ecologically at health.

SC: So why is that important? Is it because, as you said, we've kind of been thinking about things too individually and too blocky and not focusing enough on how they connect. Or is it something else?

MG: What we know is that social disorder and environmental disorder actively generates and perpetuates biological disorder, and so often we in health care get really blinkered in our vision. We just look at okay here are symptoms of diseases and we'll address the symptoms and then move on to the next person because, our and often that’s to do with being time poor and resource restrained. You know those things lead us to look at health in that way, But we know, the science tells us, that unless you address the root causes, which are often environmental and social, you are only going to get more and more health challenges. And so that's why it's so important that we look at all of this disorder As part of our conversation around health,

SC: You might have noticed we're in a global pandemic and as well as the obvious health challenges that come with that, we see the cascade that comes from it - economic challenges, social challenges, medical challenges, environmental, the whole host of them that are ricocheting off that - has anything come from the the current crisis that we find ourselves in that is sort of presenting opportunities to us about the way we can be thinking about the future of healthcare, and how could we most make the most of this opportunity of the time that we're in when we think about health care, particularly?

MG: Absolutely. I think you know, pandemics expose all of this stuff that we try to sort of not think about on a day to day basis. It exposes the inequalities. It exposes the weaknesses within the health system, you know, so from a systems perspective, I mean just talking about the Australian health system. I mean, we are seeing, the issues laid bare, which, you know, people that are in the system have been talking about for decades but people outside the system aren't really aware of. And it's really useful because when we become aware of it, we can fix it. We can address it. So it's not just about addressing workforce shortages within the system. It's about looking at infrastructure, and the technology is the appropriate technology and about the systems which connect different parts of that system. And then also it's about understanding that pandemics, you know, we've always known that pandemics expose inequality because, unfortunately, people who are vulnerable, people who are marginalised are impacted by communicable diseases and non communicable diseases at much higher rates. So in America you're seeing 3 to 4 times the death rate for Covid patients in African American populations, it's just astounding. But it is something which we know, when people have structural discrimination, it affects their access to healthcare, which increases their rates of non communicable disease, chronic diseases. And when you have chronic diseases, you're more vulnerable to an infection, you know, and this is the same thing that happens here in Australia with our vulnerable communities as well. Our Indigenous communities in Australia have had a history of these disparities in health, and so often we just talked about them. As you know, it just exists not recognising that there is a history of, like in our country of systematic displacement and segregation and forced assimilation and then on this sort of ongoing structural discrimination, which has led to these differences in health outcomes. So we have the opportunity to take the blinkers off and say, hey, if we're going to fix this, we need to address all of this other stuff that is more upstream. 

SC: So how can we, then, better prepare for these types of situations in the future? Sadly we know pandemics will come again. What have we learned from this situation that we can do to prepare better? Like you said, it’s revealed some of these structural things. What didn't we know before that we can take with us into the future?

MG: What we know is that we live in a globalised world where there is an unprecedented rate of interaction between nations. So not necessarily net right now in this moment where we can't fly out. But, you know, as plane travel continues at these extraordinary rates, you are going to see pandemics. You are going to see infections which are not limited by the borders of a particular country. We know that every year at the World Health somebody in Berlin, , they talk about disease X being, what will the next big disease be, what will be the next Ebola or the next Covid19 this year? That's what it is. But what we do know is that it doesn't end with Covid19. There will be another, and all that we can do at the moment is to really prepare ourselves so that our health system is the most resilient it could be and our society is the most resilient it can be so that we can actually try to dismantle some of these structural vulnerabilities which leave us vulnerable to this disease. And it is by addressing those social and environmental inequities that we are able to better scaffold and strengthen and galvanise the system.

SC: What would it look like to you if you could create a really perfect healthcare system in the health delivery service? 

MG: Well, I think fundamentally what we want to see is that, at the same time that we are addressing health care delivery so that all people have optimal access to healthcare services, we would also be able to address these systems issues that we've been talking about, which means addressing the climate, issues, you know, making sure that we're reaching the Paris targets that were set out for us, making sure that we're addressing the homelessness issues within the country, making sure that we are looking at the engagement and the empowerment of Indigenous people within our country and looking at global global refugee crisis and displacement in the context of climate change. I mean, when you see the sea level is rising because the ice caps are melting because of increased carbon emissions, you're going to get more refugees. People don't have places to live, and we can’t turn our backs to that. We can't be blind to the reality of what's happening to our world. So I think in a utopian setting what we would be doing is opening our eyes to this complex matrix of factors and addressing all of them together. Now that is really that's why we call it utopian because it's, you know, it's so different. But I think what we can do is at least start with an awareness that this is how it works and then think about how we integrate our policies so that we are thinking about the climate. We are thinking about social injustice while we're thinking about health. 

SC: Maithri, this was so interesting. I really appreciate it. And it's always nice to have a Star Trek reference thrown into the podcast. Thank you so much for your time.

MG: My pleasure. Susan. All the best.

SC: Let's hear from Selina Lo.

Selina Lo (SL): I'm Selina Lo. I'm a senior research fellow at the Monash Sustainable Development Institute. In my other life, I'm a consulting editor to The Lancet Medical Journal based out of London and there I commission work on planetary and global health.

SC: Dr Selina Lo, thank you so much for joining us.

SL: Thanks very much, Susan, for having me.

SC: What does the future of healthcare and health service delivery look like if we don't change how we think about it?

SL: Yes. Thanks, Susan. I think that's a really big question, and it's probably for me not so much changing the way we think about health care and health service delivery. But more in terms of where we're taking the action, because we've recognised for a very long time that health is determined by much more than just by medical interventions in treatment or in hospital care, but also relies on social determinants of health, so our economic ability to access health, but also political, legal and now environmental determinants of health and even commercial determinants of health. So how industry, and choices that we make, affect our health care outcomes. If we continue on this current trajectory, we and our children, particularly children, are going to be living in a world four degrees hotter in a few decades time, affecting everything from the supply of food to the frequency of natural disasters and also new and emerging diseases with significant mental health burden, not to mention all of the plant and animal diversity loss. And while we've always known about the risk of a modern global pandemic for years, we haven't really implemented the messages or the assessments of those previous reports. For example, in 2015 The Lancet published an Ebola commission identifying that the world was not prepared, really, for the next pandemic or for a pandemic, and that was five years ago. On climate change, we've seen increasing understanding and also commitment in terms of the threat and the opportunities of linking climate change action to health outcomes. There's so many different direct consequences from flood and drought and heatwaves, but also indirect consequences of climate change, including this complex relationship of animal and human host. So, I mean, I'd argue that it's not so much that we don't have the understanding and the thinking because we've had very sophisticated scholarship around social, political, legal, ecological determinants. But what we're not so great at is acting to mitigate all of this in implementation in the type of funding action we do and kind of building up a new cadre of workers for the future. I would also argue that the future is actually now. That Covid, and also our summer that we've just seen passing in Australia is, in fact, the the stress test, or the stress future that has kind of revealed all of these inequities and our not so much inability, but perhaps neglect of direct action on these inequities, but also that with increasing understanding of these different links, that were coming to greater attention, at least within the health space, understanding of our inextricable links to our environment and what that means in terms of the urgent action needed to determine our future.

SC: What opportunities is this current crisis presenting? And how do you think we can make the most use of them when we think about health care and health service delivery?

SL: I think that Covid and the complexity of what we call planetary health have got a lot of commonalities. Addressing the pandemic and addressing climate change involve complex science to communicate, and that's not always so easy. But it also involves, and needs to have, global international cooperation. So both action on climate change and action on the pandemic need that. But the other commonality is that no matter what, both of these burdens will affect the vulnerable largely and more acutely, and the only real difference between them that I see is that it's actually in the action, in the immediate understanding of the threat and action on it, because the pandemic has actually really mobilised huge resources, and historically unpredicted responses from some governments in terms of how they're looking after their most vulnerable as well in protecting them during this period And one piece of legislation I find quite interesting right now is this, Welsh Act for the well being of future generations. They enacted this in Wales in 2015 and it was after a number of years of working on sustainable development in Wales. I think they're well prepared to understand the many determinants of health. But this act is so unprecedented because it, by nature, is protecting future generations by addressing health and well being and environmental challenges right now for the next generation. So opportunities like that are already here. And I would say, it's the system, this sort of system-building that we have to start doing. Another, in terms of to answer the question in terms of looking at the good, there's so many anecdotes of them, the good, different lifestyle behaviours at an individual community level that are coming out of our Covid experience, whether it's at an individual level, being a little bit more self sufficient - those of us who can, not traveling so much, which is better for the environment anyway, building a better sense of community - these are the positive stories coming out. But I'm obviously cynical, you know, we record these positive stories and really what we should be recording also is all the people that don't have those connections on a more sort of global or national level. There are opportunities for scientists to work together very quickly in real time. They coded the genome really quickly because of international cooperation, and that really has to be protected as a global public good, no matter our politics between countries. We have to protect scientists and their right to, and the worlds right to, access, collaborated data. Other opportunities are not so much in the, direct health space that just thinking of conflict and health. For example, in the last 20 years, 30 world heritage sites were destroyed by wars. And yet in the last few months, we've seen ceasefires, you know, in 11 countries because of the pandemic, and this has to be good, no matter how cynical we are. So UNESCO, for example, they have quite a beautiful campaign at the moment, talking about the next normal and it's essentially collecting such good news stories - less shooting in U. S. Schools and that different mobile operators in Africa are granting free online access to education resources - stories like that, I think, are just as important as the stories of, you know, whether cases of Covid are going up and down. And we need to kind of get together on that. I think as a global community. 

SC: How do you think we can better prepare for these types of situations in the future? Have we learned anything from this pandemic that we maybe didn't know that we could use in future situations? 

SL: We already knew that we are so globally interconnected both to our benefit and to our risk - risk of emerging diseases. And risk of I think, exploitation of certain markets that are not able to best protect themselves from more powerful multinational corporations. We also knew that the animal, han and plant natural world are interconnected on that in the last 10 years, nearly all or least a large majority of the newer diseases, infectious diseases that have emerged have come from the natural world. And so, just to disrespect the inherent relationship of how we are interconnected with nature is really to disrespect our own future at our peril. And many scholars are now, already pointing out that we should have, perhaps, invested in more trans-disciplinary research, perhaps around the one health network linking animal and human science. They had already, you know, predicted emerging outbreaks many years ago, and asked for assistance to be in place and investments to be in place before that happened. So we already knew that. We already knew also that some of us are more vulnerable to disease, whether it's chronic disease or infectious disease. But this pandemic has really revealed that correct hypothesis that the most vulnerable among us are the ones most at risk by nature of the kind of work that people have to do and then also their living conditions, whether it be migrants or people in very crowded refugee communities, for example. And then the other thing that we knew is that, really our health system and our health are the core back bone of individual and community thriving, and I'd argue, and many others would too, national prosperity beyond GDP. We have to start thinking about, you know, our concept, prosperity, what does that mean? It should really also mean health and well being and thriving. I think what we could have forced ourselves to see better, even as the first few months were coming, out is to maybe prioritize action around the tools and the importance of trust and the tool of communication because communication is still the very best vaccine in situations like this. But it's also at worst, and we've seen it in some countries, quite a dangerous weapon. And now that we're all in social media virtual space, we're kind of at the mercy of, you know, the ads or the clicks or the algorithms that come up, and depending on our own interest or fears, it just sort of feeds into our own inherent biases, unfortunately. Ands so the second area that, maybe we could have better prioritised some discussion or multidisciplinary discussion at the national level or international level around is, in the face of evolving evidence, which is what we still have with the actual disease of Covid, we don't know everything about it. We don't really know how it affects young children or adolescents we don't really know, even those people with mild disease or asymptomatic, do they have long term [inaudible] consequences and what they are, and then the mental health burden of living with all this uncertainty, there's so much we don't know, we don't even know, for example, when we closed down the schools, what would happen after that? Because largely in the Northern Hemisphere, they haven't really had their schools open in all this time. So it's not as though those studies were there in great number. So perhaps something we could have prioritised is to really examine as a given the precautionary principle in the face of poor or evolving evidence. And I'm not saying that we didn't do well in any country, but, I work in evidence based medicine in my other role outside of Monash is a medical editor and it is not, you know, perfect or strategic. really, how studies come out - they just come out because that's how researchers have done it. And the duty of you know, governments and people responsible for policy making in outbreaks, for example, is to take the best evidence and, you know, use the precautionary principle to make decisions in that. And I think we've kind of done the best we can. But some kind of scholarship examination of this method would be interesting. And then lastly, but most importantly, my lesson, and one that I always have been trying to promote in the last few months here, is that health workers really are our most precious resource and our most vulnerable in this fight. And you know, we see it now in Melbourne with a rising number of health workers affected. But we saw it months and months ago, in China and they need to be protected not just physically, you know, with the right PPE, the best protection possible, but I think they also need to be protected in their voice and from China to the States to UK to here, health workers trying to speak about their situation have not always had that freedom to do so And think to risk not listening is really a risk.

SC: Selina Lo Lots to think about their Thank you so much for your time today.

SL: No worries. Thank you so much, Susan. That was a pleasure.

SC: Some incredible ideas to consider from that discussion. More information on what we talked about today can be found in the show notes. Thanks for joining us. I'll see you next time.