by Carlo Alfredo Clerici, MD, Tullio Proserpio, PhD, Costanza Raimondi, PhD candidate
The COVID pandemic has exposed us to our own fragility and has forced the entire world to confront a condition with no cure. We have all been forced to use ancient practices, such as isolation and quarantine, waiting for better, clearer solutions , while demonstrating renewed solidarity within communities. This in and of itself would be a great lesson for us all, but we must also look at how healthcare structures have responded to the crisis to see what experiences can be carried over as we go back to rebuilding our wounded society and medical system. Our considerations come from the Italian setting—where the right to health is Constitutional— but the contents of which can be shared by readers and professionals all over the world. In fact we believe that the topic calls for an open and constructive discussion at a global level.
The current pandemic has focused new light on the value of work in the healthcare sector and has also brought about reflections on economic costs and values involved in the process. These topics, while certainly not new, have seen a spike in public interest (perhaps temporarily) in the efforts of our health care system that is mortified after decades of cuts in technologies and personnel.
The pandemic has uncovered many key realities. First, there has been a shortage of technological tools and healthcare personnel. The fact that our healthcare system has been bent but not broken while under the immense pressure of thousands of COVID patients, coupled with a dire lack of protocols is simply due to an extraordinary number of health care providers going above and beyond their duties. They put their patients’ (as well as their country’s) well-being above all else. The COVID emergency has also brought to light the value of relationships within the context of illness, and the desolation that a lack of relationship can lead to. Let us pause and think about those who have died alone, deprived even of a proper goodbye to their loved one. On the other hand, in those hospital settings in which COVID patients were not treated, doctors and nurses were asked to reduce the number of patient visits per day, in order to comply with the general guidelines of avoiding large gatherings in small areas such as waiting rooms. The situation allowed many health care professionals to experience a significant change in their work: Patients were given the time they truly needed to enter into a relationship with their healthcare providers. Many claim to have discovered a new way of being physicians, probably closer to the idea of the profession that brought them to study medicine in the first place. And yet, the sad reality is that in a normal “COVID -free” context, such relationships between doctors and patient are considered solely at a formal level by rhetorical claims such as ‘the time of relationship is a time of care’ (according to the Italian deontological code) but are not given the weight that they deserve. We are still lacking the necessary acknowledgement that delivering good care must include forming valuable relationships, capable of accompanying the sick and nurturing their hope.
What we must face is that at the basis of our healthcare system there is a focus on economic value, which, with the great advancements in medical technology, represents a growing cost. The more successful medical practices of the Western world are clearly also more expensive medical practices. Of course, it would be naive and wrong to think that this aspect can be set aside, but it begs the question of whether it is appropriate or not to treat medicine as business. This time of crisis has also shown that health is made of many different factors. Health has to do with the conditions in which we live, both as healthy and as sick people and includes the economic stability of society, the wellness of families, and the social determinants of health.
What has our healthcare system invested in? While in a large part of the world people are still dying from very curable diseases, in our Western societies treatments are so highly technological that they likely will not be sustainable in the long-run. This leads us to another important consideration: The pandemic has shown in an unequivocal way the meaning of health as a good for all humanity, and the great disparities among healthcare systems of different countries. Since we are all part of the same human family, we feel even more compelled to help each other.
Health care is at the crossroads of fundamental rights as well as biological, psychological, social, spiritual and anthropological dimensions of health. Healthcare systems should balance rights to medical care—in Italy granted by the Constitution— in an ethical way, looking at individual needs. Lately, the intent of putting the patient at the center of the medical practice and organization is always claimed in theory, but how is it really, in practice?
Starting from the mid-90s, the DRG approach (diagnosis-related group), introduced by the American insurance system in the early 80s, has been applied in our country as well. The risk of a system based on DRG is that the healthcare centers will structure themselves based on the most profitable services rather than looking at the real healthcare needs of their population, leading to care settings that are more focused on monetizing services rather than assisting and curing. For instance, those services that operate in the direction of the so-called ‘humanization of medicine’, such as clinical psychology, psychiatry counselling, social services and spiritual assistance are too often supported by outside nonprofit organizations, since their original vocation is not that of offering an ultimate profit that can be weighted in economic terms.
Even with a bottom line focus, we acknowledged that there are some settings in which this patient-oriented approach to medicine is carried out. Palliative care and some pediatric settings have the ability to take care of the person as a whole, with their loved ones, from the moment of the diagnosis while also taking care of healthcare providers.
So, given all these considerations, what is our hope in the post-pandemic era? The challenge will be to define and maximize the potential of the healthcare system, universal and free care in emergency situations, and learning how these can become the pillars of the new systems that we will build. The interaction between public and private sectors will be crucial in this. Developing multidisciplinary collaborations between those services, mentioned above, that do not make any tangible profit, as well as academic multidisciplinary studies that support said collaborations in a true, organic and holistic way will also be key.