This week I am talking to David Nash, MD (@nashpophealth) the founding Dean Emeritus and Professor of Health Policy at Jefferson College of Population Health. David like me have family working in front-line healthcare and struggled through the pandemic response and the enormous challenges this placed on our healthcare system and the staff who work in healthcare.
We dive into his book: How COVID-19 Crashed the System: A Personal Journey and Policy Prescription and discuss the opportunities to fix what’s broken. We talk about American individualism, exceptionalism, and federalism, which contributed to the challenges during the pandemic.
We discuss the shocking nature of supply chain disruption and the consequent shortage of medical supplies that induced astounding protective measures such as armed guards around PPE. We dive into the failures in the response to the pandemic including the slow adoption of basic medical procedures like proning and steroid use. The conversation touched on some positives that came out of the pandemic as well. And the disproportionate impact of COVID-19 on poor people of color, with some people denying the impact on minority groups.
On the positive side, we saw the acceleration of science and the development of the new mRNA vaccine, which was made possible by basic science and research that had been taking place over the preceding years. Without this ongoing investment, we would not have had such impressive options to help combat the pandemic
Listen in to hear our discussion on improving population health and the need to focus on improving health rather than just healthcare delivery, and to shift towards a more preventative approach and helping leaders achieve the “true north” of improving health. We end by discussing the issue of burnout in the medical profession and the need for a shift toward humanism and communication rather than heroism.
Listen live at 4:00 AM, 12:00 Noon, or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
And this week, I’m delighted to welcome Dr. David Nash. He is the dean emeritus of Jefferson College of population health, and a practicing internist. David, thanks for joining me.
David Nash
Great to be here. Thanks again.
Nick van Terheyden
So we’re talking how COVID crashed the system. I’m just gonna say that’s a great title. Obviously, I think we’re all aware of the experiences, the challenges, you’ve put this all into a book. And I had a little bit of time to sort of review this. So I want to sort of focus on several things. But first of all, tell us about your personal experiences through this pandemic, from the initial phases if you weren’t
David Nash
sure. So, Nick, great to be here. Great to be together face to face. Thank goodness, we’re able to do this. Yes, exactly. It’s just take a moment, right. So look how COVID crash the system. This is my labor of love. My guilt trip my exorcism. During the almost three years of the pandemic, I live in suburban Philadelphia, been a faculty member at Jefferson for more than 30 years. My wife’s a doctor, I’m a doctor, and we have a daughter, who is a hospitalist, and attending hospitalist. And at the very beginning of the pandemic, she was going to work wearing a garbage bag over her white coat, didn’t have enough gloves, you get the idea? Oh, yeah. And so my wife and I were worried that she was going to die. And I was safely at home, doing my thing. Charles wolf Werth my co author of super good guy, science writer in Princeton called me and said, You need to put a voice through your work. And I said, Oh, man, you know, I’m not sure I could do that. But Charles prevailed. And together 18 months of work, another six months at the publisher, and here we are. And I’m thrilled to tell you that this book, which is not about COVID, the virus, but about what COVID did to the healthcare system, and what opportunities we have to fix what’s broken, was a very personal journey for me and for Charles, and as it turns out, for my family.
Nick van Terheyden
So I think, to be fair, I think it did a number on all of us in a variety of ways. We all sort of experienced it in different forms, obviously, you know, and your images is not lost on me. I actually lived a little bit of that when I was doing some support work. And, you know, a total travesty of a whole range of issues. Unbelievable. And yet, I just want to confirm we are living in the United States of America. Right? That’s this is where this is coming from,
David Nash
as it is. And so you you hit it on the head, of course, Nick. So look, when Charles and I started the journey together, where do you even begin, right? When we started the book, 50,000 Americans had died. And you remember the outrage that that was equal to the number of casualties in the Vietnam War. Right, right. So now we’re at 1.3 million more than any other country on a per capita basis in the world. And I’m counting and counting. It’s roughly 3000 deaths a week in the United States. So, you know, look, let’s make an analogy. September 11 2001 3000, Americans die and two attacks, right? When 30 plus years later, we’re still taking our shoes off at the airport. We have a cabinet level secretary, we’re still talking about it. We’re still fighting terrorism. And now the current administration for all kinds of good and bad reasons has essentially disbanded the entire COVID apparatus at the White House level as she’s just going back to being dean at Brown, Medic brassy.
Nick van Terheyden
Oh, I had no hug.
David Nash
So, look, there’s amazing but the three things that Charles folk and I focused on easy to think about American individualism, American exceptionalism and American Federalism easy, let’s take it 123 Right. So American individualism, look, we’re still in the covered wagon, heading out onto the, you know, getting to the Oregon Trail to see the Pacific Ocean meaning, you know,
Nick van Terheyden
can I just interrupt you for a second? I just watched one of the Yellowstone prequels and I actually know what that means now. Oh, my God, that’s awful.
David Nash
Right. So it’s, you know, we’re surrounded and so not in my backyard, and I know and you can’t tell me what to do because I’m a survivor. So that’s the individualism exceptionalism was, hey, my unbelievably courageous doctor, colleagues at Jefferson were on the phone with doctors in Italy. Free Christmas 22. Because those Italian doctors were saying to us, hey, get ready, you have no idea how bad this thing is. An American exceptionalism was well not invented here. I don’t have to pay too much attention. Then federalism. You know, you remember when governors were getting the national guard to protect the ventilators at the Maryland airports? I do, right? Or if you had a New York State license plate, you could get arrested driving to Rhode Island, right? Yeah. Anybody remember? Right.
Nick van Terheyden
So there was checking yourself checkpoints going into Florida?
David Nash
Point, Charlie. Right. So individualism, exceptionalism, and realism. That’s what we went through.
Nick van Terheyden
So. So let’s, let’s focus for a second if we can on some of the positives that came out, because I think the we’re and, you know, you highlight so many areas that I think it’s easy to forget, but we shouldn’t, and, you know, we’ll come back to the whole issue of that decommissioning of the capability as important, sadly, but before we do that, I want to just highlight a couple of things that I recall, as a clinician, one of the things that was set up really quickly was two things. It was a WhatsApp group for clinicians. And it was a Google doc of here’s what, when we will know and learn. Yeah, just to be clear, WhatsApp, yeah. And Google dogs, and they were highly effective, thankfully.
David Nash
So we actually have a term for that in the book. Let me tell you, yeah, and yes, and Google and all the rest. But we described it as the Incident Command culture. That’s what you’re really saying. And let me give two minutes on what that so about. So every hospital that has Medicare paying patients in covered by Medicare has to have an incident command, I n, C, E, an incident occurs, pandemic being a great example. So there’s a whole structure that stood up to handle the emergency. And there’s protocols that every hospital in America to enjoy big community hospital 800 bed, Jefferson University Hospital has an incident command. But what did that evolve into was some really powerful cultural change in our business, specifically, the ability to say, hey, this disease is evolving on a daily basis. We want feedback from the people who are at the front lines, we want to know what’s working and what’s not. And then here’s the punchline, we’re going to close the feedback loop with doctors, nurses, and pharmacists. And we’re going to do it on a daily basis. And that if we could perpetuate the Incident Command culture, that is listen to the people who are on the front lines, it’s a tenant of quality improvement, close the feedback loop, give doctors good information about what they could do better, and then get out of their way. That’s what Google and WhatsApp were doing on a global scale. But in every hospital, they had a little taste of that in the Incident Command culture. And we demonstrated that we could do it, we could make changes, we could create guidelines. Yes, we drove a lot of people crazy, because science is messy. disease was messy. The virus didn’t follow anybody’s instructions. Right? Well, and to be clear, we didn’t understand I didn’t understand it, and it was life threatening. Right. And look, you know, after the Second World War, a lot of historians coined the phrase, maybe you’ve heard it, Nick, when the dying stops, the forgetting begins. Right. And I hope we don’t get to that stage. And one of the reasons that Charles and I wrote this book was to tackle the idea that when the dying stops, the forgetting begins, I am not going to let that happen. And I think we all especially doctors, nurses, pharmacists, especially people who are on the frontlines, not me, but people like my daughter, they deserve to not be forgotten what we went through, and then what are the implications for our great country? Look, just look around where we are today. advisor’s soup, super exciting, where the biggest business in America, right health care, or 20% of the GDP. Nobody even comes close. The entire military industrial complex is roughly six to 8% or three times that size. So we have an obligation, I think, to look in the mirror, see how we could do a better job that that’s the thesis of it. COVID crashed the system in a nutshell.
Nick van Terheyden
So thinking back to some of the positives, so, you know, move past the black garbage bags. And you know, the shortage is very, it was. And, you know, it’s certainly been the topic of a few conversations I’ve had subsequently, I think we saw, or we remember certain specific things like, as you described, the sort of protection of there was armed guards around PPE. So it was even believable, almost raids, I think, by governments on testing equipment were
David Nash
essence of National Guardsmen from opposing states facing each other at the airport. I mean, like the Civil War kind of receives support, receive supplies, medical supplies, to be clear member, Governor Cuomo, right. He was a superstar every day on television, as opposed to other leaders on television. Right, let’s not forget, yes.
Nick van Terheyden
So we learn a tremendous amount. I mean, I think, again, one of the Silver Linings that I would say about this was the incredible acceleration of science, our capacity exactly in under 12 months, I start to finish from the point of identification to the point of a release of a viable, not sorry, viable, that seems that’s just unfair factor eight, phenomenally affects
David Nash
vaccine, let’s give credit to two relatively obscure scientists working at the University of Pennsylvania, our arch rival at Jefferson, who is very generous of you had been told multiple times that they’d never get anywhere with that work. And that mRNA research was in two years, you know, a road with no end. And, you know, hopefully both of them are going to get the Nobel Prize. Let’s hope so. Right. I agree. They have deep Philadelphia roots are an amazing team, a guy and a gal. They had 20 years of work. Right, right, which had we not had that likelihood would be you and I would not be sitting here today having this conversation.
Nick van Terheyden
And and I think to amplify that point, it’s about the basic science that we don’t always know is going to work out right, that is essential to the foundation of building all of those blocks that we
David Nash
manage another reason why you and I agree, science is messy. You don’t know what’s going to succeed and what’s not. And the original clinical trials on both the moderna and Pfizer vaccines, were a homerun far better than they expected. Right.
Nick van Terheyden
So I’m just going to say, from my perspective, a little bit of a downside to that was that it changed people’s expectations as earnings of vaccines to oh, that’s what I expect from a vaccine, which wasn’t the norm. Right? So for those of you just joining, I’m Dr. Nick the incrementalist today. I’m delighted to be joined by Dr. David Nash. He is the Dean founding dean emeritus for the Jefferson College of population health, we’re just talking about his book, how COVID crashed the system, some of the positives that we saw and experienced, I think, let’s talk a little bit about the negatives and you know, some of the failures, I think the surprise, a lot of failures never was to be clear, and you know, a million other than just in this country plus that we can talk about, but when you think about some of the things that we learned, we were we were a little bit slow in some instances, or to share or even understand some basic things. Airborne, airborne. proning, in intensive care, I was gonna say steroids, which I’m gonna say as a an old guy from medicine, me, but what was it? Wasn’t that the most obvious thing?
David Nash
Maybe not, right? No. So let’s also remember, I mean, imagine if you were an intern or resident Elmhurst Hospital in Queens, ground zero, right, and you’re an orthopedist and training or a psychiatrist and training and now you’re intubating patients, one after another, they’re dying in front of you. You’re risking your life. I mean, we forget the intensity of it. And look, let’s be straight for our listeners. The fact that it was in a hospital that serve poor people of color, a good part of the country said, well, going to look the other way. Let me tell you a story, Nick, you know, I’ve been since the book came out right after Labor Day of 22. It’s a good and fantastic opportunity. No one ever thought it would be best seller. All the money is going to Jefferson. We’re selling 1000 copies a month. I’ve been all over the country back and forth. And I had incredible stories of people coming up to me at a book signing, sharing what they went through. And to your point. I’ve had other stories of people in my face. Oh, I bet we’re example. Don’t you think those million people would have died anyway? I mean, come on. And this is with highly educated individuals, right? So I’ve lost twice as often. I believable and then I’ve been in environments where no the fancy dinners over, and I’ve signed books and most of the waitstaff who are minority come up and give me a huge hug. Now, so I’ve had both those experiences. I
Nick van Terheyden
mean, those essential stuff that we know are essential stuff. Right, right.
David Nash
Who died at huge disproportionate levels in our own great city. The people kept the trains running in the subway, so the nurses and doctors could get to Jefferson. They were dying at 3x 4x and 5x, the general population. So if we throw that shame on us true,
Nick van Terheyden
truly no laughing matter. So let’s talk about the future. So we’ve had our pandemic, for this century, we won’t be having another one for another century.
David Nash
Let’s hope you’re right. No, I’m
Nick van Terheyden
I don’t, but I’m not let’s. Let’s be clear. Even if we don’t have one as bad, we’re certainly going to see more of this. It’s, it’s absolutely inevitable. I just I think
David Nash
most of the best scientists in the country would agree with you. You know, personally speaking, I was very happily surprised that during the great Chinese holiday migration back in January, I was petrified. A mutation would emerge when 800 million people decide to go on vacation. So far invited an unvaccinated country locations are so far, so good. I hope I don’t have to eat my words one day, but Right.
Nick van Terheyden
So we’re going to see something. And yet, to your point earlier on of once the fighting is over. We start forgetting we are forgetting
David Nash
course we are. Why right. So part of it is wrong.
Nick van Terheyden
I know. I’m sorry, can I just reaffirm we’re still in the US we haven’t moved again.
David Nash
So I’ll tell you what we learned in our work and being absorbed in this every day for months on end. And Charles and I had a 90 minute zoom call every other week for 18 months to make this work. So you know, we talked a lot about COVID. So I think when you interview the experts, the philosophers and sociologists, the anthropologist, all of which we did, a couple of amazing things emerged. So in countries where they had trust in the government, just let that hang in the air for a moment, right? Where there was which country was this? Australia, New Zealand, Israel, Germany, Sweden, Norway, where they had trust in the government. That was the key characteristic. And the second characteristic was what the Aussies call, mate, ship, Ma, te mate, ship your mind mate. As truth? Yeah, I’ll get that. And what happens to you, I care about and happens to me. So between trust and mate, ship, those countries, you know, they figured it out. They did the tough decision making, they did the quarantine, they wore the mask, they did all the things. Look, trust and mate ship that does not describe our country. It doesn’t sadly, right. And so I think that conquered everything. It culture eats science for breakfast. And I think we saw an awful lot of that going on. That’s the other thing we wanted to call attention to. And then look at our own industry, right? Billions of dollars, hundreds of billions of dollars pumped into healthcare for good reason. The thing of float here we are at five, you know, but lifespan in the United States is in reverse gear. Right? Despite all the amazing technology you see surrounding us right here at this moment, for the last two years, the last two years, and the four horses of the emotional apocalypse, right alcoholism, suicide, opioid abuse and depression, pre COVID. We’re driving life expectancy in the reverse direction. Now Yad isolation, domestic abuse, violence. Okay, education, a whole generation of children trying to play catch up all including my own grandchildren. Come on. So these are the forces that we have to contend
Nick van Terheyden
with. So all compounded by that particular pandemic. Absolutely. Absolutely. Oh, look, you’re an expert. Let’s be frank, this is this is your area of expertise in terms of management and dealing with population health. You set up the original training institutions
David Nash
a school of its kind in the country. Right, right.
Nick van Terheyden
What does David do? Yeah,
David Nash
well, it’s a great question, Nick. Surprise,
Nick van Terheyden
there’s no waving a magic wand.
David Nash
There’s no waving a magic wand. Look, I’m on the other side of the work mountain now, you know, 33 years on the faculty and still counting, my goal is to get to 35 years of service. No single person is going to change the system. But if this book stimulates conversation for the current leaders to start to think differently, and achieve what others have called the true north for our industry, which is of course, improving health, right, that’s our true north. And sadly, sadly, we’ve lost sight of the core goal, to improve health. It’s not about health care delivery, it’s about improving health for the population, we like to say, you know, for the last decade in our college, we want to go upstream and shut off the faucet instead of what we do every day in health care, mopping up the floor, right? And I’m tired of mopping up the floor. That’s a very expensive, ineffective, not safe way to run 20% of the GDP of the biggest economic engine in the world. So are we going to wake up and do things differently? Essentially, that’s what the last couple of years of my career is going to be focused on.
Nick van Terheyden
So you’re going to create the new welfare system that I’ve created,
David Nash
I’m going to pester the people in charge to start thinking more broadly about the issues.
Nick van Terheyden
So where would you start it? Who would you start pestering?
David Nash
Let’s do it right at home, our great city of Philadelphia, it’s been my professional home for 42 years, birthplace of our country, five medical schools, one out of four doctors passes through Philadelphia, at some point in her training in America, you win
Nick van Terheyden
the occasional football game. Yes,
David Nash
occasionally, too, right? Yes, the Eagles, it was a disappointment. You had to bring that up. But seriously, healthcare is the biggest business talking about football. Healthcare is the biggest business in Philadelphia to write. And if you took Sidney Kimmel, Medical College, Jefferson Medical School, and Drexel, those are the two largest private medical schools in America. And yet, our county where these schools are located, is the least healthy county in the state of Pennsylvania. Let me make sure everybody gets that. Right. So how can we claim that we’re improving health? I mean, the sad truth is, we got a lot of work to do. And in my closing years, and it’s great to be Medicare eligible, you know, I want to continue, is it though? Yes, yes, sure. It is. Sure it is. And great to have the, you know, 40 year perspective on the problem, but it’s not going to be you and me, Nick. It’s going to be my doctor daughter and her peer group, who are going to be saddled with making the changes that we call for in how COVID crash the system, so
Nick van Terheyden
I’m just going to call out most of my daughter’s PGY one. Medicine. Oh, great. And she is in the top burnout. Yes, sadly, profession, you know, specialty, already suffering extraordinarily. And, you know, I worry day to day well,
David Nash
why don’t we spend the last minute on that since we share this with our two daughters? Pretty amazing. Right? Right. So look right across the way, Byron Scott and the team we’re talking about, I’m not your hero. You’re damn right. Yeah. Okay. So let’s get over that. It’s not heroism we want it’s unionism, not heroism, heroism is stoicism, individualism or autonomy, lack of teamwork. everything that’s wrong with American health care is heroism, heroism equals burnout and suicide. Yes, it does. We want humanism and communication and an ethical allocation of resources and things structural racism, all the other issues. That’s what we want. We don’t want here. Oh, doctors. We want you minister doctors. Big difference.
Nick van Terheyden
So, David, I trust you. And I want to be your mate. Alright man. Strewth, it’s yeah, you got that. We’ve got makeshift. All right, unfortunately, as we have each and every week, we’ve run out of time just remains for me to thank you. Thank you a tremendous pleasure, David. Thanks for joining me on the show to be
David Nash
together. Thanks again.
