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The current coronavirus pandemic has threatened the lives of the most
vulnerable, ravaged global economic systems, and altered patterns of
everyday life in ways that even at the beginning of the year would have
been unrecognizable. At the same time, it has also reinforced the
importance of reliable and robust health care systems as key threads of
the social fabric. Here in Canada, like many other countries, one need
only look back upon the frenetic shifts in governmental priorities, the
media attention directed onto public health officials, the countless
times when we have been exhorted to flatten the curve to give our health
care system a chance, and widespread public support of health care
workers that have characterized these last few months. These instances
remind us that as “the maintenance of human life and the reduction of
physical suffering have become paramount”1 in Western
societies, health care systems are popularly viewed as powerful agents
of deliverance holding the line against the virus and the anxieties of
sickness, finitude, and death that travel with it.
Until there is a real threat of that social fabric unraveling, however,
one might not consider what comprises the threads that constitute it.
While I draw upon the Canadian example here, the particularities of its
experience have significant parallels in contexts beyond its borders.
Prior to the coronavirus pandemic, we might have considered our health
care system, despite its imperfections,2,3 one that
operated more or less seamlessly, or
“ready-to-hand”.4 That is to say, the relationships
and interactions that enabled our system to deliver health care in
spaces such as acute care hospitals worked such that their complexity
was not readily apparent on an everyday level. Health care professionals
could be easily forgiven for not consciously recognizing the myriad
nuances of the tapestry in which they provided safe and high-quality
patient care.
The pandemic’s effects in these recent weeks, however, have changed all
of that. Stresses upon the health care system have thrown a spanner in
the gears of our reasonably well-oiled machine, threatening to make our
system “unready-to-hand”. Yet, paradoxically, it is in anxious moments
of crises like these where fluid activity slows down to the point that
we can consciously distinguish the myriad elements of our system –
including those easily overlooked – and how they actually
articulate.4 Otherwise put, the effects of the
pandemic have rendered our health care system “present-at-hand”: a
disorienting rupture in our usual taken-for-granted patterns, of course,
but also an opportunity to better understand the collection of roles,
relationships, and interactions that are principally used to realize
health care.
Significant stress upon the overall network of the health care system
has congealed within one of its principal nodes, the acute care
hospital. Placing it under the microscope, we know that its ability to
function is contingent upon the determined efforts of medical personnel
such as nurses, physicians, and respiratory therapists. Yet it is now
glaringly evident that non-medical workers are also indispensable in
realizing health care within its walls. For example, it is impossible
for those of us with predominantly clinical duties to assess or care
safely for someone with coronavirus without an appropriately cleaned
room. It is impossible to safely enact health care without having
necessary personal protective equipment (PPE), hand sanitizer, and
equipment wipes restocked outside patient rooms and in emergency
departments. It is impossible to have the scripted choreography of
efficient patient flow from triage to emergency department to CT to
intensive care without the work of porters. That PPE is available to be
worn in the first place necessitates that it be made ready for
distribution by those who staff the hospital’s receiving department.
That a sufficient number of ventilators are available to care for those
needing advanced respiratory support demands not just sufficient
production, but the skill of those in hospital engineering and
maintenance departments able to service these pieces of lifesaving
equipment at a time when they are in recurrent usage. The information
technology infrastructure and those who maintain the enormous demands
upon it render results and necessary patient care data available on a
continuous basis. In our current reality, these workers, like other
essential services, deserve the full gratitude of society.
Yet it is not just the complexity of the networks of personnel within
the hospital that have been illuminated. While initial concerns about a
massive shortage in ventilators and a critical steady supply of PPE have
now abated to some degree, those needs cast an unexpected light upon the
sustainability of the outside supply chains that power the hospital’s
daily health care activities. In large part due to laudable efforts made
by domestic companies to re-purpose their manufacturing infrastructure
and governmental coordination, Canada has now moved into a phase where
its ability to maintain PPE supplies domestically has grown
dramatically.5 Yet the process of getting to this
point was a massive scramble at a time when the potential for
miscommunication and missteps with catastrophic consequences was high.
Further, the domestic supply line is still not yet robust enough to
avoid the need to get in line with the rest of the world for
internationally-based PPE suppliers or to mitigate the effects of
political decisions made by other countries upon PPE orders that had
already been placed. 6,7
Some countries now find themselves standing in the midst of a first
wave, while others are imminently bracing for a second. Here, we are
more or less between waves, with a small amount of time to reflect upon
the lessons of the last few months before we find ourselves quite likely
back in the maelstrom. Rather than waiting – again – for the point in
which our health care system is in danger of being overwhelmed and our
society left vulnerable, we need to consider broader ways of thinking
that may attend proactively to the complexities that have been revealed
by coronaviral stresses. This becomes all the more important when we
recognize that, like many other jurisdictions, our system’s optimal
functioning demands an alignment between myriad stakeholders, including
federal funding and standards setting, provincial administration, and
delivery through multiple health authorities and a multitude of
different hospitals, all of which have different considerations and
responsibilities in realizing our social right to health care.
Drawing upon metabolism offers a shared conceptual frame that is
accessible to those who attend primarily to health care in a clinical
fashion, those who consider the system’s administration, and those who
are responsible for financial and material inputs and outputs.
Originating as a physiological concept in nineteenth-century organic
chemistry,8 metabolism has also been used as a
philosophical approach to consider the relationships between humans, the
natural environment, and social phenomena.9Highlighting process, flow, and dynamic change,10 a
metabolic view suggests that the solid appearance of the physical plant
of the acute care hospital belies its reality as a locus of an
ever-moving complex set of interactions and patterns that reproduce
themselves on a continuous basis. As such, the reassuring stable
appearance of day-to-day appearance of health care delivery is actually
a dynamic equilibrium, a constant balance to which we must attend.
Appreciating that there is “an inside and an
outside”10 to the acute care hospital organism,
metabolic thinking transcends the walls separating its inner workings
and its outer supply chains necessary for its ongoing activity.
Specifically, it enables those who design health care systems, develop
policy, administer health authorities, and manage hospitals to align
their considerations in order to consider more widely how health care is
enacted, how personnel come together to realize it, which materials are
necessary to sustain it, and which effects – both intended and
unintended – may be produced as a result. As such, discussions on
topics as wide-reaching as providing just living wage and benefit
offerings commensurate with the essential roles of non-medical workers,
ensuring the safety of working conditions during pandemics, rendering
the supply system far more resilient to global disruptions, and
guaranteeing the material and social sustainability of the health care
system writ large may be made part of a broader and ongoing proactive
conversation rather than thwarted by jurisdictional or philosophical
silos.
COVID-19 has consumed much of the oxygen of 2020 thus far, burning
through norms of the global order with a ferocity and a velocity that
has left governments and institutions from across the world struggling
to catch their breath and respond in an effective and cohesive manner.
In placing our health care systems under duress, however, it has allowed
us to better understand their complexities and illuminated key
components that have been, until now, overshadowed. As the smoke slowly
begins to clear, a metabolic approach gives us an opportunity to
re-consider how we may attend to the myriad interlocking pathways of
health care systems in a sustainable and proactive manner, such that our
society and its leaders at all levels are able to more readily respond
to both subsequent waves and other major events no doubt awaiting us in
the future.