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Commons Health Care - Connecting Individual, Community and Planetary Health and Resilience

After fifteen years of working at the intersection of healthcare and the ecological health movement, I had begun to question whether “we” were really going to be able to figure out some of the challenging issues facing our planet. I believe in the sobering science of climate change and of the UN Millennium Assessment, yet I also believe in love and the wisdom and compassion of individuals. While not overtly optimistic, I am still hopeful. That said, in the context of a global economic crisis, an overwhelming global burden of chronic disease and interrelated climate change crisis I have wondered if there might be a new way to consider the role of healthcare and its relationship to health and community that would provide an opportunity to imagine new language, new relationships, and new models for change. The following are some of my ideas, in hope that they will initiate a conversation that may ultimately lead to a paradigm shift, a place that famed environmental thinker, Donnella Meadows, has identified as “the most important places to intervene in a system.” Let me know what you think……

 

About fifteen years ago, the EPA released a report documenting that the healthcare industry was one of the largest sources of dioxin and mercury--two known persistent, bioaccumulative, toxic compounds--discharge to the environment. Ironically, healthcare itself was making people and the planet sick! When the Center for Disease Control identified that 1 in 8 women were at risk of having learning disabilities as a result of mercury burden within her body, and that mercury contamination was limiting our intake of certain species of fish, it seemed obvious that we should eliminate mercury from commerce and find safer materials.

 

Since that time, I have worked with like minded colleagues to shift to a model that could make healthcare more environmentally responsible. Inherent in this idea was the recognition of the intimate link between the health of people, their communities, and the environment, and the belief in the benefits of prevention orientated approaches rather than downstream treatment. The idea is that through a systems approach to thinking, we might create multiple benefit solutions.

 

More recently, we applied this approach to food served within healthcare, based on the obvious relationship of food to health. Through a variety of lenses--environmental, social, nutritional and others-- it seemed intuitive that the healthcare sector would recognize these connections and model preventive action. For example, in light of our current obesity crisis, it seemed obvious that hospitals would want to model healthy behaviours by reducing or eliminating the sale of sugar sweetened beverages, which are linked to a host of human health and environmental problems. Similarly, it seemed apparent that administrators across the country struggling with the costs and consequences of multidrug resistance infections would link the fact that every major public health, nursing and medical association has called for the elimination of non-therapeutic antibiotics in livestock (because of their promotion of drug resistant organisms) and would work to purchase meat produced without antibiotics or support legislation which would regulate their use.

Though changing slowly, the business of healthcare remains siloed and fundamentally geared toward illness rather than prevention, while perverse incentives continue to reward healthcare for increased demand. Healthcare now represents 17% of the GDP and, without changes in law and policy, will reach nearly 50% of GDP by 2080 if current trends continue. Imagine the difficulty for both healthcare CFO’s and clinicians overwhelmed by the burden of chronic disease. In my community of Duluth, MN, a program was able to cut the readmission rate for patients with congestive heart failure to 7 percent compared with the national average of a 40 percent readmission rate. Ironically, though, succeeding in keeping patients out of the hospital wasn’t rewarding financially. “Every time somebody hit the hospital with heart failure, everybody got paid for taking care of that patient,” shared one of the providers. Clearly, our healthcare model is in transition, but the business of healthcare cannot maintain or increase much further without negatively affecting the economic health of individuals, communities and our nation. Moreover, reports from the Millenium Assessement and IPCC remind us that from an ecological perspective rapid change is essential.

 

Fortunately, many wise people have been thinking about this. The Institute for Healthcare Improvement is recognized as a national leader in this work and developed what they describe as “The TripleAim of Healthcare”.

 

Triple Aim

 

Not long ago, a colleague shared with me a link to a 2009 speech titled Squirrel”. After reading this now somewhat famous talk by Donald Berwick, M.D., then president and CEO at IHI, I had one of those “a ha’ moments. It was his metaphor of a Turkish fishing fleet that he used to explain important ideas on how to limit the “over-fishing” of health care resources that helped connect the dots. This fleet had somehow figured out rules to share their resources. Though “Squirrel” was focused on the triple aims of “experience of care” and “per capita cost,” I saw the connection to the third triple aim of “health of populations”.

 

Just weeks earlier, I’d had a conversation with friend and colleague, Diane Imrie, R.D, MBA , Food Service Director and thought leader behind Fletcher Allen Health Care’s nationally recognized healthcare food service model. She had developed a comprehensive sustainable seafood initiative for their hospital. She was helping their facility think about and put into practice the linkage between preserving fish stocks and the health of New England populations. Fletcher Allen was thinking about the Triple Aim.

Berwick went on to describe a seven-step process for containing healthcare costs across communities, applying rules developed by economist Nobel Laureate Elinor Ostrom a leading scholars in the study of common pool resources and human–ecosystem interactions. This reminded me of the work of Council of Canadians and their report Our Water Commons, and also of our local hospital, St. Lukes, that had worked to phase out bottled water so as to reduce the environmental health impacts and promote the public water system.

He further reminded us that ultimately it is the communities that are going to need to take responsibility to define their commons, set goals, develop metrics, and establish a healthcare solution. Though Berwick’s discussion was explicitly about cost containment and healthcare utilization, it suggested to me how we might incorporate an integrated commons approach to food, environment, climate and healthcare. Moreover, there were many parallels to the community driven healthcare model contained within the Sustainable Road Map (see below) developed by United Kingdom’s National Health Service.

Sustainable route map

 

I now see linkages and the importance of defining our commons, with the efforts of the ecological design leadership of the Cascadia Green Building Council working in the Cascadia commons and to the work of locally based food councils and networks.

 

On the Commons is an important effort working to draw attention to the importance of the commons in the modern world and to advance commons-based solutions.

 

I’m excited to follow Rethink Health, an effort involving Ostrom, Berwick and others, in which the focus appears to be thinking through a commons approach, with an emphasis on cost and quality of care, two of the three triple aims.

 

Commons healthcare is used to emphasize a commons framework to the population health triple aim and thereby distinguish, yet connect it, to a commons framework for cost containment and quality of care. Recently, I began to share these ideas through a presentation Commons Health Care. Many have responded favorably to the recent healthcare policy piece “The Case for Commons Health Care”. I’m curious about your reaction, similar work, and your ideas. Please send them along.

Jamie Harvie, January 2012

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