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Harry Rakowski: After COVID-19, we need to jumpstart health-care innovation

Commentary

COVID-19 has exposed the world to a deadly pandemic that has killed millions, crippled health care and stifled economies. Yet in every disaster there is a learning opportunity and we need to take advantage of the lessons learned on how to ensure a better future.

The Liberals have again won government in a costly election that achieved little change. It is not a mandate for expensive, inefficient policies, but rather should be seen as a wake-up call for changing the paradigm of politics as usual. During the campaign both the Liberals and Conservatives promised to invigorate innovation by funding a DARPA-like program.

DARPA is the Defense Advanced Research Projects Agency in the United States that is tasked with developing emerging technologies initially planned for use by the military, but with major spin-offs for civilian use. It was started in 1958 by President Dwight Eisenhower as a response to falling behind Russia in the space race.

DARPA funds important research in collaboration with industry, universities and government agencies. This collaboration was critical to the rapid development of mRNA vaccines as well as the antibody therapy given to former President Donald Trump to counter viral infection.

The Economist has called DARPA the “agency that shaped the modern world.” Its contributions have helped with the development of GPS, weather satellites, drones, stealth technology, the internet, and computer technology. A number of other countries have now tried to emulate DARPA’s success.

A Liberal campaign promise was to establish CARPA to create “a public-private bridge for research that helps develop and maintain Canadian-led technology and capabilities in high impact areas.” The agency is to be established with an initial endowment of two billion dollars.

There will be many election promises not kept. This should not be one of them. Creating CARPA is a bold idea that needs to be fulfilled and rolled out in a novel way. There should be lessons from previous failures.

The Canada Infrastructure Bank was a $35 billion project founded in 2017 to promote public-private investment in much-needed infrastructure. Four years later it has been slow to invest in projects, failed to find the expected private partners and is challenged by the limited scope of its projects.

CARPA needs to truly be bold and innovative without politicization of how the funds are distributed, and with nimble and visionary allocation.

Unlike DARPA, Canada does not have the need for the development of military applications. The focus of CARPA should be on technology and innovation that will drive improvements in health, environmental safety, and business development that will lead to healthier Canadians and more well-paying jobs. Whatever one thinks of the single payer model of health care, it’s one of the few industries in Canada that has the scale to bring these new breakthrough technologies to life.

We need to get away from expensive health care with a focus on prevention and early disease recognition and management. The hybrid of virtual and in-person care will persist long after COVID-19.

An area of focus can be the expanded creation of data from wearable devices that assess physiology and function, informing physicians and nurses and also providing important patient feedback. Business and Venture Capital partnerships will be readily available. The Apple 6 watch already has the ability to record a high-quality single lead electrocardiogram and your oxygen saturation.

The ability for the watch to track blood sugar measurement will hopefully be added soon. One of DARPA’s current projects is the implantation of a tissue like gel under the skin, engineered to continuously monitor your blood and report on problems.

Medicine is also being transformed by the use of artificial intelligence to evaluate big data pools to better manage disease and improve outcomes. Canada can be a leader in the application of AI to healthcare and business. Potential public-private partnerships will be further enhanced by the $100 million gift to create the Schwartz Reisman Institute for Technology and Society affiliated with the University of Toronto. There will be 750,000 square feet of new space built which will also house the existing world class Vector Institute for Artificial Intelligence.

CARPA needs to fund seed grants and mentor outcomes in a robust, supportive model similar to DARPA. Israel can again teach us lessons on how the strong support of technology-based universities, research incubators, and strong VC partnerships lead to world class discovery. It is actually important and to be expected that a number of projects fail, because it will show the agency is being ambitious. However as Joan Baez sang Bob Dylan’s words in Love Minus Zero “There’s no success like failure, but failure is no success at all.”

Canada has the talent, infrastructure, excellent universities and collaborators to succeed on a large scale. We need to seize the opportunity by CARPA Diem.

My father, tempered by the Holocaust, proudly believed in doing things economically, quickly and effectively. His life long motto should also instruct how CARPA will function: the difficult I can do by tomorrow; the impossible just takes a little longer.

Shawn Whatley: How to get Canada off the health-care teeter-totter

Commentary

Liberalism works when you are healthy but fails when you fall ill.

Classical liberalism emphasizes autonomy, individual freedom, and free markets. These ideas have fuelled centuries of wealth and prosperity.

Modern liberalism, in contrast, pursues central decision-making and equality of outcome. Despite similar names and obvious differences, neither type of liberalism provides arguments for everything patients need.

When classical liberalism fails in patient care, it creates space for modern liberalism. Modern liberalism then applies central decision-making which creates inefficiency and bureaucracy. This in turn creates a call for efficiency, deregulation, and policy based on economic liberalism.

This seesaw creates a policy teeter-totter with each type of liberalism pumping furiously at either end.

The failure of liberalism cannot be solved by more liberalism. Only a coalition of classical liberalism plus conservatism will allow Canada off the health policy teeter-totter.

How Liberalism fails

Successful ideas explain reality and suggest solutions to life’s messiest problems. Political ideas fail when they do not reflect reality or cannot explain human experience.

Given liberalism’s dominance in Canadian politics, we should ask how it performs for patients. Does it make sense when patients need it most? Classical liberalism delivers advanced technology, therapeutics, and almost magical cures, but can it deliver care to patients?

Classical liberalism fails to fit patient care in two areas. First, it fails in trauma and acute care. Car crashes and strokes often create dependent, comatose patients. Free agents lose control, and agency passes to a third party.

An unconscious patient is not a rare or special case of information asymmetry, common in professional relationships. Unconsciousness is not a theoretical gap market thinking can overcome; it is an infinite and insuperable knowledge gap. And it occurs hundreds of times each day across Canada.

In an emergency, agency does not pass from patient to friends or family. It passes to emergency medical services, hospitals, doctors, nurses, and a host of others. The coordination required to guarantee a seamless net of tertiary care inevitably involves central authorities. Government monitors performance, upholds standards, and maintains order, even in health systems which embrace private care.

Liberalism’s second failure occurs with chronic disease. Chronic disease is more common than acute, impacts more people, and requires care over decades. In between visits for medical care, patients need help with everything from scheduling and transportation to buying groceries and changing cat litter. Even with extensive formal community care services, isolated patients struggle. Informal social supports often determine how long patients live independently.

Hospitals provide services and are filled with caring people, but institutions cannot care. Only individuals care for other individuals. Patients need connection to individuals inside the bonds of social obligation: friends, family ties, or social groups.

For people who become acutely incapacitated or chronically debilitated, classical liberals offer solutions like designating a power of attorney for care or making prior arrangements with friends and family to act on an individuals behalf. But these good ideas sound less like classical liberalism and more like organic groups and social fabric found in conservatism.

These patients are depending not on large institutions but on something like Edmund Burke’s “little platoons,” which conservatives have always identified as the key to a healthy life.

Symbiosis

Liberalism and medicare share a symbiotic relationship – each benefits the other. This is obvious for modern liberalism: medicare needs a big state, which requires the central decision making favoured by modern liberals. But symbiosis also applies to classical liberalism.

In acute care, free agents need rescue – not rights, property, or the contracts liberalism provides. In an emergency, the only agent obligated to help is the same agent which sustains the liberal order (Hobbes’ Leviathan). Thus, maximizing liberal freedom creates a mandate for a robust welfare state to rescue individuals when they fall ill.

However, the symbiosis falters in community care. Individuals with chronic illness need connections liberalism cannot promote, and no state can provide.

Extrapolating government involvement

The need for central authority in acute, traumatic, and rare advanced treatments invites the same assumption for chronic care. If the sickest patients need government, shouldn’t government help with everyone else?

Framed in this way, modern liberalism has led the discussion on medicare. With deference to central control, it assumes that the solution for the first failure of liberalism will solve the second also.

Conservatives find themselves in a similar bind. They support what works. If central control helps patient bleeding at the side of the road, why oppose it for non-acute and chronic care?

Too often, Canadian conservatives claim a “Tory touch” and the assumption that big state solutions are part of their true blue identity. Or they suggest a dab of economic liberalism here, some tightened accountability there, but offer few ideas which reflect anything rooted in philosophical conservativism.

Conservatism defined

Some people reduce conservatism to nostalgia. Others paint it as protection of privilege, status, and power – a European conservatism. However, Canadian Anglo-American conservatism has too little history for robust nostalgia and no aristocracy to protect.

The historic alliance between classical liberals and conservatives also creates confusion.

Anglo-American conservatism is founded on an appreciation for traditional institutions, civil associations, and moral norms which have arisen over time. These time-tested ideas have been ratified by experience.

Where liberalism favours freedom over social obligation, conservatism sees social obligation as an inescapable fact of life (e.g., family). Classical liberals often assume aspects of conservatism, without explicit defence.

Conservatism takes a skeptical stance towards theoretical or grand ideas such as equality or social justice. Conservatism prefers facts and events – real things and real people. It seeks to improve what works, which means conservatives often support liberal or progressive policies.

Fostering connection

Little platoons can happen by accident, but most do not survive without support. Everyone is born into a family, but it takes effort to keep one together. The state could make things easier.

For example, many families place relatives in long-term care because they have no other choice. The current policy environment makes life hard for families to keep Grandma home. Could we reverse incentives, so it becomes attractive and easy to keep Grandma where she wants to be, at home with a family who loves her?

Every citizen needs the opportunity to be part of a social network of his own, regardless of how he defines it. But this will not happen without a policy environment which fosters the formation of those connections.

A conservative solution

If we won agreement to let Grandma stay at home as long as possible, we would still face the policy teeter-totter. Classical liberals would seek aligned incentives, crisp key performance indicators, and clear lines of accountability, from the ground up. Modern liberals would want the same, from the top down. Classical liberals might offer incentives and tax breaks to keep Grandma home; modern liberals might suggest more homecare or social services – each liberal pumping furiously.

Both kinds of liberals love modern theories of public management almost as much as they love drafting new policy. They both view social problems in generic terms – an aging society, isolated seniors – instead of specific, local problems. Generic terms justify grand, one-size-fits-all policy solutions. Solving the specific needs of Grandma’s living alone north of Sudbury holds less appeal.

Conservatives worry more about creating new, bad policy than winning support by ‘fixing’ old issues with the newest management theories. Complex social problems mean trade-offs and imperfect solutions.

Conservatives would start with the (painfully) slow process of understanding the problem. Instead of discussing generic Grandmas, we need to know more about Grandma herself. Is she one person or three: an ambitious woman in her early 80s; a slightly confused one in her late 80s; or a demented lady with papery skin and chronic wounds in her mid-90s? Or none of these? One individual could be all three in the span of a few years.

We might start with issues facing young Grandma(s) living north of Sudbury. In her early 80s, Grandma has the wits and plans of a younger person but not enough strength to see them through. She needs a bit of help but not so much it impedes her style. She is too healthy for homecare, but too poor to hire help. If she lets out a room in return for low rent and yard work, she might find herself worse off with OAS clawbacks on top of bigger grocery bills, blocked toilets, and the bother of having a renter around. She could barter material resources for required help, but government does not make it simple. Or she could take in family to help. But at her young-ish age, it might mean more nuisance than help. Of course, all these concerns would change by her late 80s.

A policy approach based on conservatism might look more like local, organic problem solving than grand, one-size-fits-all policy solutions. Conservatism starts from a view of society as a complex whole requiring long-term investments instead of quick returns based on annual budgets.

Conservatism plus classical liberalism

Little platoons are just one of many conservative ideas. Smart people should be able to use conservatism to suggest many other policy options.

This raises a bigger question. Aside from so-called “socially conservative” issues, why have so few conservative ideas been tabled in healthcare?

If not lack of knowledge, perhaps it reflects a lack of belief. Perhaps modern conservative are mostly just classical liberals? Maybe most self-described conservatives are just liberals who lean right? Or perhaps conservatives and classical liberals have become competitors, each vying to dominate centre-right discourse, not working together as well as they might?

Medicare does not struggle for lack of ideas or funding. It struggles from funding thrown at the same tired ideas rooted in similar political traditions. Classical liberalism offers many good things, but it fails patients in important ways. Absent outside input, liberalism guarantees stasis in Canadian healthcare: a furious teeter-totter between two kinds of liberalism. A partnership with conservatism would help.