BTO_Dr. David Nash: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Emmanuel Fombu:
Welcome to Bite the Orange. Through our conversations, we create a roadmap for the future of health with the most impactful leaders in the space. This is your host, Dr. Manny Fombu. Let's make the future of healthcare a reality together.
Emmanuel Fombu:
Good morning, good afternoon, good evening, ladies and gentlemen. Welcome to another episode of Bite the Orange. And today we have a very special guest. We have a very special professor and key opinion leader and someone I'm honored to speak with today, and I'm sure all of you will get to know him more. And this is no other than Dr. David Nash, who is an American physician, a scholar, public health expert, and known to be the founding dean emeritus and named chair professor of health policy at the Jefferson College of Population Health. With that being said, I don't want to, I mean, clearly he's a great expert in this space and I don't want to like, to kill it in my own terms. So I'll let him introduce himself to all of us. So welcome to the show, Dr. Nash!
David Nash:
Thank you so much, Manny. Great to be a part of this. And I love the title of your series, Bite the Orange, what a great idea. I think that says everything about healthcare that we need to know right there, the sour taste that it leaves in everybody's mouth and only the lucky few get to bite through to get the sweetness, so.
Emmanuel Fombu:
Exactly. I'll call you Dr. Nash, I respect that. And I know you asked me to call you David, but I'm not going to call you David. I'm going to call you Dr. Nash. Okay? All right. No, please. All right. I'm not call you David. You are, but, Dr. Nash .... Tell us about yourself, right? I think a lot of times population health is something that everyone studies. But who is that person behind? Who is David Nash?
David Nash:
Oh, boy. Well, so I'm a primary care general internist. I trained a long time ago. I had the real opportunity to go to business school after residency. So I also went to Wharton and graduated from there in 1986. So I did college, medical school, residency, Wharton, my children back then added up that I went through grade number 29. So obviously I liked going to school, but professionally, I've been at Jefferson on the faculty now for 33 years. It's just hard to even believe in years. At Sidney Kimmel Medical College, which was Jefferson Medical School back then, and then the last 15 years in the College of Population Health. And as you said, I was the founding dean. I stepped down from the deanship in July of 2019, pre-COVID, to hand it over to younger people after 11 years as dean. And now I've been working on all the things I care about most, especially finishing our book, how COVID crashed the System and doing my research and teaching. And most of all, Manny being with young people, that's what keeps me going. When you're my age, you're eligible now, it's really great to be with younger people all the time, so that's my story.
Emmanuel Fombu:
Okay, now this is quite fascinating. As a younger physician looking up to you, I like the idea of when you retire, it's not retiring, right? There's a lot more things to do, right? So when people, when I talk to people and people have this mindset of I do this, then I am done and I retire and I move to someplace and you don't stop. There's a lot more information that we could benefit from, right? So it's a physical work, but the experience you have, I'm sure we can all learn from.
David Nash:
Well, thank you. I feel like I still have a lot of gas in the tank, Manny. And even more important, there's still so much work to do. I mean, just look at our country and where healthcare is. Covid is the third leading cause of death in America, ri ght? Heart disease, cancer, COVID, and then preventable medical error. So just those two things alone, COVID and error, that's enough to get me out of bed every day and keep working and talking and teaching and doing research and so on, and crystallizing it all in a book was a great exercise during COVID. It was like my book report on the pandemic. Remember writing book reports in elementary school? Well, that was my book report on the pandemic because we wanted to sort of create the historical record because soon there's an old expression, a sad one, when the dying stops, the forgetting begins. And I'm not ready to forget, that's for damn sure.
Emmanuel Fombu:
You know, it's, interesting, Dr. Nash, to lay that baseline kind of foundation, right? So several years ago in my book, I made a best effort I could to explain to people what health system was like in the US Right right now, right? And.
David Nash:
It takes a good, Manny, just to explain what it's all about. Absolutely.
Emmanuel Fombu:
Exactly. And trying to put it in a chapter like a highlight kind, of kind of piece. And you have a lot more experience on more details about this. But what happened was I mentioned the idea that the US healthcare system was broken, okay? And I got a message from a buddy of mine that said, no, it's not broken. It's intentionally designed this way because it's so messed up that there's no way it could be that broken and people trying to fix it. So with that being said, you have a great book that I encourage everyone listening right now to get a copy of. I got myself a copy, now and I'm doing my readings. I like to have you back after I go into more details of that. And it's about how COVID crashed the system. A Guide to Fixing American healthcare. So with that being said, tell us what the healthcare system was like or looks like in general before COVID happened. Like what was it that it crashed?
David Nash:
Sure. So with Charles Wohlforth, my co-author, who's an amazing science writer, lives in Princeton, an awesome guy, we decided to base the book on what we know about airplane crashes. And we're like the National Transportation Safety Board experts, and we're at the crash site, Manny. And healthcare is the airplane that crashed, and we're walking through the wreckage, it's still smoldering, there's dead bodies everywhere, it's horrible. And we're searching for that black box. But here's the secret of the book. We know exactly what's in that damn black box, right? Here's what's in it. Pre-covid, American life expectancy in reverse gear, right, depression, alcoholism, opioid suicide, average life expectancy in 2019, pre-COVID, was in reverse for the first time since the Second World War. Also, we've got a nation, institutional racism, crime, lack of education, all of these social determinants now, maybe we should call them moral determinants of health, we're all in play and that's what we found in the black box. So whether it was COVID or something else, it was bound to crash the plane. That's what the theme of the book is about. And as you know, in your book, we spend half the book describing what went wrong, especially in communities of color in New York, in Philadelphia, in Chicago, in Los Angeles. And how did a million Americans die in the richest country in the world that devotes $4 trillion a year to a healthcare system? It makes no sense. So that's the first half of the book. And that's kind of a downer, no question. The second half of the book is much more upbeat, mainly about, well, what do we do to fix this mess before people forget what's happening? Look, 3000 people are dying from COVID every week, it's unbelievable. If one airplane crashed worldwide, we would ground the entire 737 fleet like we did a number of years ago. So the question for me is, well, what are we doing differently moving forward? Here's the punch line. I think our industry has its North Star, Manny, what business are we in? If we're in the business to improve health, as a professor, I would give us a barely passing grade, maybe a C minus or a D, And I'm an easy grader, because, we've lost the North Star. We're no longer in the business of improving health. And as you said at the outset, it's not really, ..., every system is perfectly designed to achieve exactly the results it gets in. This system is a disaster, so that's what the book is about.
Emmanuel Fombu:
But that being said, I know you're a globetrotter. I've seen, I've seen, I mean, recently I think you've been in India.
David Nash:
Yes, sir. I was in. Mumbai, India. That was my second visit there. Yes, amazing.
Emmanuel Fombu:
Correct. And as a globetrotter and you have a lot of experience about this, and it's easy to compare the US healthcare system to other health systems. So what are your thoughts? What is the ideal health system? Have you seen a health system around the world that you would say, you could point to and say, that's the model you should follow?
David Nash:
Well, that's a great question, Manny. The short answer is there is no such thing, unfortunately. Sure, there are pieces that we could emulate from other countries. Let's give some examples. So little tiny Israel, 9 million people, but they're all on the same electronic medical record. How do you think Israel has produced all the New England Journal of Medicine articles about vaccination and COVID testing and all the rest? That's because one medical record, that's one. Then there's countries like Australia, Norway, Taiwan, where the health minister has a huge amount of influence and power and is trusted by the people. So that's something we could emulate. Then there are gigantic countries like India with 1.5 billion people and there's free healthcare and access for everybody. Now, we could argue, sure, there's different levels, but India's taken a whole generation out of poverty in less than one lifetime. So there's lessons we could learn from everybody. Here's the problem, however, on the other hand, like the National Health Service in Britain, socialized medicine, it's gone bankrupt. Why? Well, there's unlimited demand for healthcare. So there is no single system. What we describe in the book is let's get the best attributes that we can, starting with changing the very fabric of medical education, nursing education, pharmacy education. I'm too old. We need a different kind of doctor for the future. That's a key part of the take-home message. And number two, we've got to change the crazy financial incentives. The number one challenge in American healthcare is price and price. Everything is way too expensive and it's designed that way. So we've got to realign those economic incentives. So to answer your question, there's no single best system out there. We would have to pick and choose attributes that make sense. And I'm not talking about a national healthcare system and a single-payer, that would never work in our very heterogeneous, multicultural country. That'll never happen in my view. What we need is better training, realign the economic incentives, and most important, find that true North again about what is the business that we're really in.
Emmanuel Fombu:
You talk about cost and going through your readings and doing research on some of your work. I looked at, you clearly mentioned that you're a reader of the AARP Bulletin, right? And you had like, ...
David Nash:
It's a great magazine, Manny. Yes, it is, you're not there yet.
Emmanuel Fombu:
Actually, you're not, they have an innovation center, aren't you, by the way, and actually follow the Innovation Center quite a bit in Washington, DC on the areas of innovation that it focus on. And the idea was the seven tasks that you just keep these tasks.
David Nash:
Right.
Emmanuel Fombu:
Right. And I think there's overtesting in that particular space. You want to talk about that piece and how overtesting and things that are not necessary?
David Nash:
Sure, sure. Well, of course. It's a great question. We talk about this in the book in detail. Most experts, and this has been published five different times, most recently October 2 years ago, write about one one quarter to one third of our spending, so let's just call it $1 trillion out of the 4 trillion, is of very little to no value. Oh, it might even also be dangerous. So another thesis in the book is, well, let's reduce that wasteful spending and reallocate those resources and let's improve housing, reduce crime, put people back to school, give people decent jobs. That's what drives a healthy society. Is that Pollyanna? I really don't think so. But as you know, Manny, it's really up to doctors more than anybody else to say, listen, we've got to cut down this waste, we have to realign the incentives, we have to work together to keep people healthy. It's incredibly hard job in the fattest society in the world, in a society where half the people have diabetes type one or type two. I mean, this is what we are up against. Oh, and in a society where COVID is the third leading cause of death. So that waste is all about doctor leadership. It's going to take doctor leadership to reduce $1 trillion of waste. Do you think we could do it, Manny? I'm not sure.
Emmanuel Fombu:
Which is quite interesting. And I'll give you a background story. So my family is from Cameroon, originally, in Central Africa, and grown up in Cameroon it was very interesting because the poor people had access to organic foods, right? So if you're poor, it's sub-Saharan Africa you could grow like tomatoes, seeds in the back of your backyard. You grow tomatoes, right? You have celery and you had healthy foods. And what happened over time was the rich eat canned food and the poor have access to organic foods, right? And if you look in the West, it's very interesting where you have whole foods like like the stores, like Whole Foods and organic Foods, it's very expensive. But it's very interesting how you look at it, where in the Western world you have people that are much richer actually trying to eat healthier foods or spending more money to eat healthier foods. And then in developing nations, you have the opposite thing happening where you have the poor people having access to organic foods, and the rich people are trying to eat like the junk food and like processed foods, right? So you have this different populations, but the same kind of issues that exist in these different worlds.
David Nash:
That's right.
Emmanuel Fombu:
... So in your experience around this, how do we manage these kind of perspectives in different worlds? Because if you look at socioeconomic determinants of health in the Western world and the developing world, they complete different kinds of ways of looking at.
David Nash:
Exactly. Well, as you mentioned in my most recent visit to Mumbai, K fried chicken and Pizza Hut were everywhere in every mall and all the fancy neighborhoods such as they are in Mumbai. And I'm worried that between the pollution and the eating Western food now India is going to face two epidemics, one of lung cancer from the pollution, and the other is Western style obesity and moving away from a vegetarian diet so ....
Emmanuel Fombu:
At that point, I was in Saudi Arabia last week in Riyadh, and going to Riyadh, I was literally trying to find like authentic Saudi food. I could not find it. I found McDonald's everywhere, Burger King everywhere. And everyone is eating this. And when I spoke to the health minister, I found out that diabetes is massive. It's like a massive thing, right? Heart failure, hypertension, like all these things, the population health is happening in those areas. So I think it's quite it's a critical moment for population health.
David Nash:
Yes.
Emmanuel Fombu:
Especially with someone with your expertise looking at this like it's a it's a crazy pandemic happened in real time with chronic illnesses. So what is your advice on how to go about doing it, like solving this problem? You mentioned something about the doctor of the future, right? So I want to get that vision from you. What is the doctor of the future look like and what does healthcare the future look like? What should we be concerned about?
David Nash:
Well, of course, there's no magic bullet, Manny. If there were, we would put it in the into practice immediately. But I think there are a couple of things that we talk about in part two of the book that we should be doing right now, which is changing medical education, nursing education, pharmacy education, connecting the dots, more people of color, better use of technology, more patient centric instead of training specialists. In most of the Western world, there's three primary care doctors to every specialist. In America, it's exactly the opposite, three specialists to every primary care doctor. I mean, it's totally crazy. So changing the whole training paradigm, that's number one. Number two, change the economic incentives. I'm all about bundled payment, capitation, global fee, whatever you like to call it. When you look at the evidence, a state like Maryland with a rate setting organization at the state level, here's your budget live within it, still has the best clinical outcomes at the lowest possible cost and the research evidence to support that is very solid. So whatever model we use, realign economic incentives, that's number two. And number three on my list is refocus on those social determinants, moral determinants of health. It's all about housing, reducing crime, better education, tackling the disparities and inequities in care. So one more time training, financial incentives and tackling the social determinants. That's what we found in the black box and how COVID crashed the system. And Manny, I should say, by the way, all the revenue from our book is going back to the Jefferson College of Population Health. So every time somebody buys a book, that's about a dollar, going to, back to our college, which is very important. So I'm awfully proud to be able to send the resources back to a place that has been my home for 33 years.
Emmanuel Fombu:
And that's quite incredible. So I advise everyone listening, right now, to please get a copy of the book, of course, right? And we'll put the link and push the book to make sure everyone reads it. But something that you highlight is about the element of crime. That's something that no one actually talks about, talks about in healthcare and population health, right? So, so what is the impact of crime on health?
David Nash:
It's terrible. Well, I'm so sad about, absolutely, but that's a critical part of population health. Manny, I'm sad about our great city of Philadelphia, the founding city of our nation. My office is three blocks from the Liberty Bell, Independence Place, Constitution Hall, I mean it's where it all started. And now we have terrible poverty and street crime, murder rate, all of the rest. I mean, it's just a terrible situation. And people are afraid to even come into the city for healthcare. So, look, we need a different model. And if we don't tackle the social determinants, we'll never be able to improve healthcare. That's the punch line. And what's even more upsetting is Philadelphia is the home to four great medical schools, including the two largest private schools in America. Jefferson and Drexel University College of Medicine, which is walking distance from Jefferson. So we have the wherewithal, what we don't have is the political will and the ability to pivot and refocus on what's the true north, what are we here to do? And that is why, as you noted, I am still working and still have gas in the tank, because how can we let this problem, how can we ignore this? I mean, I can't go to bed every night knowing that I'm not trying to fix what's broken.
Emmanuel Fombu:
We need you. We don't need you to go to bed. I'm sleeping ... We have all this wealth of knowledge that I'm sure we'd like to learn from. But with that being said, something you also wrote about in a book about life expectancy. Looking at 2017, for example, right? Which is quite interesting that you look at, life expectancy in the general population should be going up, which is the whole purpose, I hope.
David Nash:
Right.
Emmanuel Fombu:
Being the founding Dean, right, at Jefferson for Population Health to see life expectancy go down, that should be like clear failure.
David Nash:
Right? ... So that's what you need.
... here.
David Nash:
That's right, Manny. That's all you really need to know. I mean, that should be a warning bell, a fire alarm going off in everybody's head like you and me across the country to try to fix this mess. So, look, here's the good news. Lots of dedicated people are working hard to try to fix this. I really appreciate your podcast and the audience that you reach. I hope people will read the book. The whole idea is just to stimulate conversation so that all the smart people working together can get us back on a better track for the future.
Emmanuel Fombu:
Which is quite, quite interesting. So I don't know where we are in terms of life expectancy now, but I know in 2017, as we wrap this up, for the first time since the Second World War, life expectancy was actually going down.
David Nash:
That's correct.
Emmanuel Fombu:
Right. Like which is like the opposite trend. Where are we going? And I'm sure since then with COVID and how many people died during COVID, I'm sure the life expectancy actually dropped significantly.
David Nash:
Even further. That's right.
Emmanuel Fombu:
Further down. And so what is that? So when you see something like that happen, is there anything being put in place right now to actually improve that going forward?
David Nash:
Well, sadly, the answer is no. Let's make one closing analogy. So remember September 11th, 2001, right? 3000 Americans are murdered. We have a new cabinet level office, Homeland Security. Here we are 20 plus years later, we're still taking shoes and socks off at the airport. We have untold resources going to fight terrorism, all of which I totally get, but here's the challenge. We have no comparable effort to protect America from the next pandemic. In fact, we're working hard to take it all apart. So, Manny, we have a lot of work to do to make sure that when the dying stops, the forgetting doesn't begin, and that we're able to tackle these challenges. And great to have Bite the Orange as part of the conversation to make sure we don't forget.
Emmanuel Fombu:
Thank you. Dr. Nash was an honor having you on this podcast and would love to have you again. For everyone listening, please make sure you grab a copy of how COVID crashed the system.
David Nash:
And here's the great cover, look at that. Right. And it's got the radar and the virus. It's an awesome cover. So I appreciate your support very much.
Emmanuel Fombu:
And I finished reading and I would love to have you again to make sure that we will go deeper into it. And ...
David Nash:
... I look forward to.
Emmanuel Fombu:
.... and see what happened there. Thank you. It's an honor to have you on the show, Dr. Nash.
David Nash:
Thanks again. Manny. All the best. Bye now.
Emmanuel Fombu:
Thank you.
Emmanuel Fombu:
Thank you for listening to Bite the Orange. If you want to change healthcare with us, please contact us at info@EmmanuelFombu.com or you can visit us at EmmanuelFombu.com or BiteTheOrange.com. If you liked this episode and want more information about us, you can also visit us at EmmanuelFombu.com.
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