Tag Archives: health care

Weak Links in the Chain

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Resilience has become almost a buzzword with regard to how communities handle adversity and disasters, albeit a very useful buzzword. It focuses our attention on how we can better prepare for and cope with such events. The question of the moment is how the concept of resilience applies to our response to coronavirus.

One of many hospitals in Chicago, all of which have visitor restrictions in place due to the coronavirus pandemic.

I am not and never have been a public health expert, though, as an urban planner and adjunct planning professor, I have often worked with such people. I say this because I want to be clear about the prism through which I am viewing the coronavirus pandemic as a public health disaster. What I bring to the task is decades of work, particularly as a research manager, in the subfield of hazards planning. I am known for deep expertise in hazard mitigation and planning for post-disaster recovery. In this article, I am reaching into that toolbox to help identify what we need to learn from the current crisis.

Specifically, part of what has become the standard approach to hazard mitigation planning is vulnerability analysis, the process of identifying what in plain English are weak links in the chain of community capabilities and capacities to manage and recover from a disaster. Every community, every nation has strengths and weaknesses built into its systems, which are really an ecosystem of economic, social, institutional, environmental, governmental, and other elements of the community that comprise the way the community functions in both sunny times and days of turmoil and dysfunction. How well can that community or nation restore itself, rebuild, adapt, and learn from its experiences? One of the most fundamental elements of success, for example, is trust in government and community leadership, something that is being tested right now in the U.S. That leadership can either greatly enable and empower or greatly hinder the capacity for effective response to, and planning for recovery from, a given disaster.

But my focus here is on what a vulnerability analysis of our response to COVID-19, the disease caused by the novel coronavirus, might include. I say “might” because I do not pretend that what follows is comprehensive. It is merely suggestive. A more comprehensive list would best emerge from a summit of leaders and experts when it is time to decide on the lessons learned from this disaster. For now, leaders are rightly focused on using existing authorities and capacities to control the spread of the disease.

The main point of a vulnerability assessment is to identify potential points of failure relative to the hazard under consideration. For instance, with hurricanes or floods, we would want to know what roads or bridges would collapse or become impassable. We would also want to know the locations of substandard housing that might suffer damage or destruction or endanger its occupants. There are dozens of other examples of potential points of failure that I could list here, but presumably, you get the idea.

With the novel coronavirus, we are dealing with an invisible hazard that inflicts suffering and death on people, not buildings or structures, and—most importantly—for which there is not yet an identified cure or vaccine. Most people do not die, and many suffer only mild symptoms, but the spread of the disease is of radical concern in part through the slow rollout of testing kits in the U.S., which exacerbates an existing inability to know precisely who is infected, especially since many people test positive who are asymptomatic, that is, not exhibiting clear symptoms of the disease. Vulnerability depends on various factors, most notably, but not exclusively, age. Respiratory and other existing conditions can elevate that vulnerability, while some older people may be tough enough physically to weather the assault. Thus, identifying and classifying real and potential victims is a business fraught with uncertainty.

Given all that, where are the weak links in our communities? Many can be readily identified from the more routine aspects of vulnerability assessments, starting with governmental capacity:

  • To what extent has the city, state, or the federal government prepared and established capacity for anticipating the problem and quickly enabling the appropriate responses? It is perfectly logical to expect that greater capacity should exist at higher levels of government that have greater resources at their disposal.
  • What is the level of political maturity among the electorate, and the political will for undertaking and enforcing difficult but necessary decisions in a crisis?

The biggest questions surrounding coronavirus seem to relate to institutional capacity, some of which can obviously be enhanced or supported through governmental capacity, for example, in procuring and distributing the personal protective equipment, ventilators, and temporary hospital beds needed by the regional “hot spots” for virus outbreaks, which at the moment include New York, but also a frightening spike in confirmed cases and deaths in the last few days in Louisiana, possibly tied to the huge crowds attending Mardi Gras in New Orleans. These have led to Gov. Jon Bel Edwards issuing a stay-in-place order similar to those in effect in California, Illinois, and New York. Among obvious questions in a vulnerability assessment going forward:

  • What hospital capacity exists for treating large increases in numbers of patients in a future pandemic? This includes emergency room capacity, intensive care units, and other essential elements of the treatment process, as well as the ability to expand access to protective gear. It also involves the adequacy of skilled professionals to work with this increased patient load.
  • What capacity exists to monitor, work with, and even thin the population of crowded jails and prisons, where social distancing is effectively an oxymoron, and the potential for rapid spread of disease can amount to a death sentence for those confined behind bars?
  • What are the sanitary and patient care conditions in local nursing homes, and how effectively are they regulated? Nursing homes and similar facilities for elderly medical care have in some cases become virtual incubators for the spread of coronavirus, leading to situations where relatives can no longer visit.

Many of these questions also lead us to questions of economic vulnerability, which also pertain to social equity. Restaurants in states that have instituted closures of public places where people normally congregate in large numbers have laid off thousands, possibly millions of workers—the numbers change by the day—who often work for hourly wages and need every hour to pay the rent. Workers in the gig economy, the tourist economy, and the travel industry are all similarly vulnerable in varying ways. One result, even under normal circumstances, is that many of these workers, some of whom are also undocumented immigrants, are reluctant to take sick days because they have no paid sick leave. Often, they also have no paid health insurance, or cannot afford it.

That, in itself, needs eventually to be recognized by the United States as a source of pandemic at worst, or a threat to public health, at best. Take, for example, the story of a McDonald’s worker who shared the news that he went to work ill, vomited when he ran to the restroom, but was afraid to call in sick because a missed paycheck was a threat to his economic security. How often does that happen, and how reassuring can it possibly be to customers who even think about the potential consequences? Is anyone attempting to gather data on this problem? A worker rights organization, Arise Chicago, has been fighting for better protection for workers on this front for several years, and won passage of a Cook County ordinance in 2016, but the battle continues. At the moment, these workers either are laid off because of restaurant closures, or are adapting to the temporary new world in which their employers can sell takeout, drive-out through, or delivery.

But whether it is hotel, restaurant, or transportation workers (such as taxi and Uber drivers), among others, the vulnerability lies in the harsh facts that drive them to show up for work despite illness because of their lack of paid sick leave or medical coverage. Nowhere in America can an honest vulnerability assessment of future pandemics ignore these socioeconomic imperatives. Economic facts drive health impacts, which in turn drive at least some of the questions surrounding health care capacity. In this sense, one can see how identifying all the weak links in the chain of vulnerability means recognizing the interrelationships between the various categories of vulnerability I listed initially.

This description of the process could go on for many more pages, but it may be more important to let the complexity and interdependence of it all inspire further thought. With that in mind, let me offer a few other items for consideration:

  • Given the inability of some parts of the population to accept the necessity of temporary restrictions, how well prepared are we to control the wayward behavior of the few, even as the majority of our citizens show adequate consideration for others around them? What are we prepared to do about them?
  • In the event of a lockdown, what are we prepared to do for victims of domestic abuse who are suddenly trapped inside their homes with abusive partners, parents, or relatives? Do we have institutional capacity to remove them to safer quarters and the ability to answer their calls for help? Sheltering in place is hardly likely to make an abuser more sympathetic.
  • How well are we positioned to assist those suffering from mental illness, for whom isolation may increase propensity for depression and suicide?
  • In what ways can we respond to the needs of homeless people, for whom the spread of a pandemic disease may increase due to proximity and unhealthy circumstances?

There are some very hopeful signs of creative thinking on these issues in local and state governments, if not in the White House. For example, the City of Chicago has reached agreement with several hotels to use hotel rooms as isolation rooms for victims of COVID-19, with the city paying for the capacity in advance. This relieves hospital capacity, to some degree, but it also provides some employment for hotel workers who would otherwise be idling at home because of the shutdown of the hospitality industry as both leisure travel and conventions grind to a halt. The workers will provide food in the kitchens and undertake other safe duties, while trained public health personnel deal directly with the quarantined patients. The hotels stay open, some workers stay employed, and some strain is removed from medical facilities. Some members of the Chicago City Council are now calling for the use of vacant public housing units for the same purposes.

Likewise, some otherwise closed YMCA facilities will begin accommodating the homeless while providing necessary social distancing. All of these are creative solutions that can emerge from identifying the weak links in the chain, and can provide cornerstones for sound planning for resilience in the face of future public health emergencies.

In short, let’s all keep our thinking caps on. We’re going to need them not just this time, but for the future as well.

Jim Schwab

Aligning Planning and Public Health

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Just nine days ago, on November 15, I stood in front of two successive audiences of long-term health care practitioners to present workshops at a conference in Wisconsin Dells discussing, of all things, “Fundamentals of Planning for Post-Disaster Recovery.” Where, some might ask, is the nexus between these two subjects?

Patients who survived evacuations from New York City area hospitals, six in the city itself and one just outside, during Hurricane Sandy would know. People with disabilities, the elderly, the ill are especially vulnerable during disasters, and moving them out of harm’s way is no picnic. They cannot just grab the keys to their cars and drive out of town ahead of the storm. Evacuating them is a major undertaking that must be well-planned.

And so, our fields of expertise converged. I discussed what I knew from urban planning, but I invited input from their experiences in handling such situations. Some had not yet experienced a disaster, but others had, and their numbers in the health care field are growing, as doctors and nurses find clinics and hospitals impacted by wildfires in California, and hurricanes, floods, and tornadoes elsewhere. Mine was not the only presentation related to such concerns. The keynote by Desiree Matel-Anderson, founder of the Field Innovation Team and a Federal Emergency Management Agency (FEMA) advisor, detailed personal interactions with disasters. Others focused on emergency management. The audience needed to know about new regulations and laws, such as those promulgated in 2016 by the Centers for Medicare and Medicaid Services (CMS) or the Disaster Recovery Reform Act (DRRA), passed in October as a

Photo by Kristina Peterson

rider on the FAA Reauthorization Act. DRRA outlines new responsibilities for the FEMA administrator in providing training to local officials and utility providers in planning for emergencies for nursing homes, clinics, and hospitals, and for the Federal Highway Administration regarding evacuations for these facilities, prisons, and certain classes ofdisadvantaged persons. I told the nurses and administrators in my audience they needed to prepare for these new responsibilities. There seems to be a growing conviction in Congress and federal agencies that health care institutions need to be better prepared to protect their patients during disasters. In the light of events dating back to Hurricane Katrina, that does not seem unreasonable.

To some extent, I believe it is the growing engagement of the urban planning profession with natural hazards that is facilitating a re-engagement of the profession with public health practitioners. I say “re-engagement” because the two fields grew up together, at least in North America. In the late 1800s and early 1900s, industrializing, rapidly growing American cities were often festering incubators for diseases because of pollution, overcrowding, and fire and other hazards. The Great Chicago Fire of 1871 laid the groundwork for major reforms related to building codes, helping to create the largely masonry-based architecture now predominant in the city. Activists like Jane Addams inveighed against oppressive health conditions for the working class. There was an urgent need for both better planning and public health measures that would prevent the spread of disease, and the two professions matured accordingly. At the same time, civil engineers took growing responsibility for developing the sanitary infrastructure cities needed, such as sewer treatment systems and effective drainage, a topic I addressed in a keynote in September 2015 in Boston for the American Society of Civil Engineers’ Coasts, Oceans, Ports and Rivers Institute (COPRI) annual conference. All three professions grew up in the same cradle, addressing urgent societal needs for health care, better urban design, and public sanitation.

Scene on the Jersey Shore after Hurricane Sandy.

All of this is a long, but I think crucial, introduction to a book by Michael R. Greenberg and Dona Schneider, Urban Planning & Public Health: A Critical Partnership, published by APHA Press. I had planned to review it earlier, but recent events expanded the context for its importance. Greenberg, a long-time planning colleague and professor at Rutgers University in New Jersey, previously authored Protecting Seniors Against Environmental Disasters (Routledge, 2014), a book inspired in part by his own experience with elderly parents during Hurricane Sandy. He is certainly familiar with the territory. Schneider, also at Rutgers, brings the perspective of a public health expert.

The book reads mostly like a textbook and thus may be of most valuable to instructors willing to acquaint students in both fields with their organic relationship to each other and why the partnership is important today. Admittedly, the problems are not the same. We no longer face the scourge of tuberculosis, and smokestacks no longer belch particulates as freely as they once did. The water is less polluted. But our society is creating other problems of a momentous nature, including climate change and the resulting increased severity of weather-related disasters. Under the Trump administration and various less environmentally friendly state administrations, there have been concerted efforts to retreat from previous initiatives aimed to clear the skies and foster environmental justice. It is thus imperative that we have trained, knowledgeable, and articulate professionals who can advocate for the public interest when powerful political forces push in other directions.

The book makes powerful arguments in this context for the salience of a collaborative assault on the threats posed to our communities by natural hazards, using the tools of both public health and planning to analyze the threats and identify meaningful solutions. Not everything needs to happen at a macro level, either; in fact, planners and public health officials often are at their best in examining trends at the neighborhood and community level to find very geographically specific solutions to localized but persistent problems.

The authors are methodical, laying a groundwork in the first three chapters for understanding the building blocks of the two professions and their integral relationships. One can easily detect the influence of Greenberg’s long and distinguished career on both a practical and theoretical level as he discusses the impacts of various approaches to zoning, such as the use of downzoning to protect open lands and natural resources and the use of special districts, as in Austin, Texas, to protect the environmentally sensitive Edwards Aquifer through measures such as integrated pest management practices, which reduce the use of toxic chemicals that can enter the water supply. And the connection to natural disasters? Even recent history has revealed the vulnerability of Texas to prolonged drought, making the protection of water supplies essential to public health and welfare.

Recognizing the modern context for their focus on this “critical partnership,” the authors have included significant material on the role of risk and hazard mitigation analysis in planning, with a whole chapter on “Keeping People Out of Harm’s Way.” As with much of the book, it leads students on a path through the critical minutiae of planning and public health analysis, including case studies at various levels of analysis—for example, a brief but close look at the Galveston City Hazard Mitigation Plan.

Other sections address critical current issues such as the availability of healthy foods in poor communities, and how that can be addressed through laws, community organizations, and better resources; how to redevelop safe community assets from former brownfield sites; and potentially evaluating the benefits and drawbacks of major regional development proposals. In short, this is not bedtime reading for most laypeople, but it is solid instructional material for aspiring young professionals and may be useful as well to community advocates who are willing to learn the nuts and bolts of using planning to achieve better public health results in their neighborhoods and communities. As such, it is a timely and needed addition to the literature.

Jim Schwab

Primary Physicians React to Affordable Care Act Repeal

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Just two weeks ago, I posted a story on this blog about public rallies against repeal of the Affordable Care Act, aka Obamacare, including one I attended and observed here in Chicago that day. That article discussed patients’ reactions to the prospect of ACA repeal under the Trump administration, noting that just 26 percent of Americans currently favor wholesale repeal—far from a majority—while substantial majorities favored almost all the major provisions of the current law. But what about the primary care physicians who treat those patients and serve on the front lines of medical care? How do they feel?

Well, the New England Journal of Medicine apparently decided to find out. It turns out that an even smaller minority, just 15 percent favor wholesale repeal, including just 38 percent of those who voted for Donald Trump. The journal notes that the adjusted response rate to its survey was 45.1 percent, and that the views of primary physicians are not necessarily the same as other physicians. It also notes that about three-quarters favor making changes to the law, but that option is not at all inconsistent with favoring its continued operation. Many such laws are amended over time as a result of experience with their strengths and weaknesses. One potential change favored by those surveyed is that of providing a public option, such as Medicare, in competition with private coverage. Creating such an option for consumers runs counter to current Republican dogma on the issue.

That said, 95.1 percent favored the prohibition on denying coverage based on pre-existing conditions, and majority support for other key provisions of the current law, with the exception of the tax penalty for noncompliance, although even that support was higher than for the general public, at 49.5 percent, almost half. However, the prohibition on denying coverage depends on the mandate for individual coverage. One makes the other possible.

Jim Schwab

“For God’s Sake, Don’t Repeal It”

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Overflow crowd attends health rally at SEIU-HCII hall.

Overflow crowd attends health rally at SEIU hall.

“Six weeks ago,” said Sen. Dick Durbin, the Illinois Democrat who is assistant minority leader in the U.S. Senate, “I got a call from Burlington, Vermont.” It was Sen. Bernie Sanders, who told him “we need to rally in cities across the U.S.” to preserve health care for Americans. Sanders, though falling short of the Democratic nomination last year against Hillary Clinton, showed a noteworthy capacity as a prescient organizer. He clearly anticipated the assault that the new administration and congressional Republicans have now launched against the Patient Protection and Affordable Care Act (ACA), popularly known as Obamacare. And so today, five days before Donald Trump will be inaugurated the 45th President of the United States, rallies to preserve the ACA took place. Durbin spoke in Chicago at the overflowing hall of the Service Employees International Union (SEIU), Health Care Indiana-Illinois (HCII) unit.

Line forms at the back of the building. It got much longer.

Line forms at the back of the building. It got much longer.

My wife and I arrived about 15 minutes before noon, parked our car in the lot behind the building, and joined a long and rapidly growing line of people seeking to attend the 1:00 p.m. rally. Limited by fire code, the SEIU staff had to cut off the number of people entering, directing the rest of the crowd to a Jumbotron behind the building. We were lucky, among the last 25 people allowed inside, and the line behind us stretched around the corner. Clearly, the Republican attack on health care had stirred a hornet’s nest, at least here in Chicago.
Durbin was the leadoff speaker following an opening by Greg Kelley, executive vice-president of SEIU-HCII. With

U.S. Rep. Jan Schakowsky posing with followers.

U.S. Rep. Jan Schakowsky posing with followers.

him were several Chicago area Congressmen—Reps. Mike Quigley, Jan Schakowsky, Brad Schneider, and Raja Krishnamoorthi, all Democrats, along with Cook County board president Toni Preckwinkle. Durbin cited the statistics that reveal the origin of the angst driving the overflow crowd. He noted that some 1.2 million people in Illinois stood to lose their health insurance coverage if the ACA is repealed, roughly 10 percent of the population. The ACA saves seniors in Illinois an average of $1,000 per year on prescription drugs. People stood to lose the ACA’s protection against lifetime limits on coverage, which in the past often led to bankruptcy for people with catastrophic illnesses like cancer.

“The Affordable Care Act was the most important vote I have ever cast as a member of Congress,” Durbin concluded. “If the Republicans can’t replace it with something as good or better, for God’s sake, don’t repeal it.”

A true citizen uprising needs more than politicians at the podium, and union leaders, such as SEIU president Mary Kay Henry, health care consumers, representatives of Planned Parenthood and a small business alliance, and others, including the Rev. Jesse Jackson, kept the standing-room-only crowd revved up. Tracy Savado, introduced as a health care consumer with a story to tell about lifetime coverage caps, shared that her husband had been diagnosed with an acute form of leukemia. Fearful of lacking enough insurance, she inquired of her insurance company representative about this point, and, she said, was told that President Obama’s health care law had done away with such limits. Prior to the ACA, she noted, about half of all insurance policies had lifetime caps on coverage. She added that she had recently attended a farewell for outgoing Health and Human Services Secretary Sylvia Burwell. Asked what might happen in the new administration, Savado said, Burwell paused and noted that the biggest obstacle to the GOP plan for repeal is “people sharing their stories” about the benefits they have enjoyed from the new law. “When people understand what’s at stake, they aren’t going to want repeal,” she concluded.

Many of the other speakers essentially made many of the same points in different ways for almost an hour and a half, until William McNary, co-director of Citizen Action Illinois, ended the rally on a boisterous note with a rousing speech in which he declared that “the only pre-existing condition the Republicans want you to have is amnesia.”

His comment is a powerful point that is worth remembering in considering how matters came to this pass. More than a few Americans who voted for Trump in the recent election are also benefiting from Obamacare. While people clearly can and do vote on issues other than health care, it remains undeniable that this constitutes some form of contradiction that requires explanation. Even amid the 2010 debate that ended with the passage of the ACA, Tea Party rallies often featured protesters with signs that read, “Keep your government hands off my Medicare.” What sort of stunning ignorance is required to fail to understand that Medicare was and is a creation of the federal government by a vote of Congress in the 1960s and that, absent the “government hands,” it would never have come to be in the first place?

Recent polls have shown overwhelmingly that voters favor virtually all the key features of the Affordable Care Act even as many nonetheless oppose whatever they perceive as “Obamacare.” A post-election Kaiser Health Tracking Poll found public support at 80 percent oDSCF3283r above for ACA provisions allowing young adults to stay on their parents’ insurance plans, eliminating most out-of-pocket costs for preventive services, subsidies for low-income insurance purchasers, and state  options for expanding Medicaid, as well as 69 percent for prohibition of denial of insurance because of pre-existing conditions. Only 26 percent want the law repealed. What we have faced since 2010, and must confront now, is not a real plan to replace Obamacare with something better, but an incredibly slick campaign of propaganda to associate the word Obamacare with something evil.

People who come to terms with the origins of such contradictions may find themselves in a better position to understand the remarkable political gall required for the Republican majority in the U.S. House of Representatives to pass repeal in recent days without offering a clue as to what will replace Obamacare. “Repeal and replace” was Trump’s campaign mantra, yet even he has offered no details of consequence about what that will mean even as he insists Congress will somehow do both within the next few weeks. Anyone who believes that can be done by a party that has failed to define an alternative for the last six years is truly prepared to believe in political miracles.

It would be more realistic to look closely at Trump’s nominee for Secretary of Health and Human Services, Rep. Tom Price of Georgia, a man who advocates replacing much of current Medicare coverage with a voucher system and is devoted to dismantling Obamacare. Read his intentions closely, get angry, and organize.

Jim Schwab