Some people are using the pandemic to explore all the ice cream flavors. Some are using it as a way to avoid street clothing (honestly, I haven’t put real shoes on in 7 months). And some of us are reaching down deep and finding a level of thoughtfulness and productivity that I don’t quite know how they muster. That latter person would be my friend and sister-from-another-mister, Jane Sarasohn-Kahn. Rather than join me in a trip down the rabbit hole, Jane has been inspired to write her second book in a year, this time documenting how the triple threat of the pandemic, the Black Lives Matter movement and the global environmental breakdown has resulted in what she terms, “The Holy Grail of health citizenship.”
Jane’s New book is called, “Health Citizenship: How a Virus Opened Hearts and Minds.” In it, Jane weaves together six months of new data – including consumer market research, health policy developments, healthcare industry updates, clinical evidence, biostatistics and pop culture – to point out how Americans’ lives, health, health care and the even their social contracts are changing. What was abnormal may well persist and become normal; we definitely know that what used to be normal is all out the window (Hey, is that an ice cream truck out the windows? Inquiring minds want to know).
For those of you who don’t know Jane, she is a health economist and appropriately refers to herself as a “trend weaver.” No one I know has the ability to identify important data, synthesize it and turn it into useful information in as fast or engaging a way as does Jane. Because of this, Jane is asked to speak and advise companies all over the world, and especially those that sit at the intersection of health and consumer behavior. She turns her big thoughts into practical strategic advice for companies like Adidas, CVS, Microsoft, Pfizer and Walmart. I will be extra super impressed when the Ben & Jerry’s folks get the memo and hire her.
So while I’ve struggled to parlay what has become my own attention span, which is that of a hyperactive gnat into reading just one book, even the kind that has big type, Jane has written one that captures all of the last 7-8 months into a coherent set of thoughts and ideas for how this may affect the world we live in on an ongoing basis. I asked Jane a bunch of questions about the book, which you can buy HERE, by the way, and I figured I’d document her answers because they are, like her, fascinating. Here we go (yes, it’s a long post, but you hopefully you have a lot of ice cream, so enjoy). And note: All italics that follow this paragraph are my words – the rest are Jane’s.
Me: You just wrote a great book, HealthConsuming, about a year ago. What inspired you to write the new one?
The pandemic and the Great Lock-down compelled me to reach into my creative self for my own mental well-being. The tagline for “HealthConsuming” (Note: this was the title of Jane’s last book) was, “from health consumer to health citizen,” where I asked the question at the end of the book, “what if people in America were health citizens, where the government ensured health care as a social and civil right, health informed public policy, and people controlled their health data?” A few weeks into the pandemic, my gut told me that COVID-19 was accelerating the concept for people in the U.S. We certainly did not feel like empowered health consumers, let alone “consumers” during the Great Lock-down and physical distancing. In the crisis, there is this opportunity for people in America to express our collective need to put the “public” back in public health, which has eroded for far too long.
You started the book talking about the confluence of difficult events that have happened in 2020 (pandemic, George Floyd’s murder and resulting BLM demonstrations. It has also been a year of global warming disasters, and political turmoil where the rule of law has been called into question. Do you think all of this has changed healthcare consumers in any fundamental way?
The pandemic occasioned the lock-down and that spawned economic recession and that has wreaked havoc on Main Street – all that has led to one key pandemic side-effect: financial toxicity. Then there have been all our personal mental and behavioral health responses to pandemic: The Fear Of Going Out (FOGO), self-medicating through super-sized purchases of alcohol for our “pandemic pantries,” and resuming a tobacco smoking habit, for example. On the stress front, we know from a recent study by the American Psychological Association that most Americans feel this is the lowest point they can remember in U.S. history. Finally, the devastating fires and floods capping off the summer and early autumn of 2020 remind people that clean air and safe housing and neighborhoods are part of our overall well-being. Together, people – consumers, citizens – have been overwhelmed with signals reminding us that health takes many forms, and so many factors that shape our well-being fall well outside of the healthcare delivery system.
If you had to pick one, and there are so many, which has been the biggest health impact of the pandemic?
We mourn the devastating losses of lives among our fellow U.S. health citizens. As we have this conversation, the tally is 200,000 and rising. In terms of health, I think the mental health impact will be the epidemic that persists beyond the virus pandemic. The stressors on everyone are many, and they translate in different ways for each of us. But the democratizer of COVID-19 is anxiety and stress, and that will translate into physical/medical impacts for many of us – through sleeplessness, heart issues, negative health behaviors, and exacerbation of chronic conditions that haven’t been managed during the crisis.
So that’s a downer and I need more ice cream. Has any good has come from the pandemic, healthcare consumer wise?
For some people, there’s a greater awareness of our homes as our health hubs, and how we can make health where we live – in the kitchen through home-cooking and baking, through spending more quality time with our families playing board games and assembling jigsaw puzzles, and of course, taking advantage of digital health connections – telehealth and apps, for physical and mental health access. And we can’t underestimate that, while on the health “care” side, we joke that we stood up 20 years of telehealth adoption in 2 weeks on the supply side. On the demand side, it was important to see older people use Zoom and adopt social convening platforms to meet with doctors – and then adapting that new behavior to read to grandchildren or play distance bridge with each other — literally bridging social connections which they hadn’t done before. We have seen some closing of the older vs. younger digital divide and that’s a plus. In this way, the ever-present blur between work and home has yielded a positive outcome.
It is interesting that grocery stores have shot to the top of consumer sentiment surveys and social media has fallen to the bottom. To what do you attribute this social media fall from grace and how does that foot with the concept of digital citizenship you discuss later in the book?
We entered 2020 already with a declining opinion of Facebook in the aftermath of Cambridge Analytica. In the book I talk about how all our Maslow Hierarchy of Need pyramids sort of flattened down to our physiological safety, and social needs. The grocery store became our go-to place for that bottom, base level of need – food, hygiene, and our home-making for sheltering (and ice cream). Beyond that it’s all about reliable WiFi and connectivity so we can work, attend school at a distance, be entertained through streaming services, and even pray with our faith-based institutions despite their remaining closed.
Social media fanned the flames of “fake news” around both to science and politics over the last year and has lost a lot of trust-equity in the pandemic. For health citizenship, a key pillar is “digital citizenship” which must be underpinned by trust and contemporary privacy laws that America’s patchwork quilt of HIPAA, CCPA, GINA, COPPA and other fragmented slices of protection don’t address how we live today and have been especially tortured during the pandemic.
For health, specifically, useful data comes from many places but our activity information–retail encounters and mobile phone geo-location data–can inform 360 degrees of our health and well-being. As good as that sounds, we want to ensure our personal data is used for good and in the context in which we choose to share it. We know that so many Americans do not trust either big tech or “the government” with their data, yet in a public health emergency, sharing data is a good thing. Despite that, without trust and a comprehensive privacy regulatory framework, the U.S. health consumer cannot be a complete health citizen.
Zoom – good or bad?
During the Easter and Passover holiday, families and friends came together around the world to share in faith, food, and fun to celebrate the holiday seasons. Zoom-meetings are how we now meet as friends and as work collaborators — all good there. But after seven months of five-days-a-week plus weekends on screen with friends and family, we are now part of the “Zoom-bie” Club – overdosed on virtual meet-ups. Your question will be the root of many future Ph.D. theses looking at worker productivity, family dynamics, and whether Zoom and other meeting platforms have been good or bad for mental health. In the short-term pinch of the pandemic, good. Longer-term, let us wait for the theses to be published.
You talk about hygiene/cleanliness becoming people’s biggest priority, but there is certainly controversy about this topic- it seems that some have equated masks and hygiene requirements with loss of freedom. What do you think about this?
A key pillar of Health Citizenship in my new construct, which I refer to as the new social contract, is “Love (wear the mask)”. I grew up in Detroit, where both the Michigan state seat belt law and motorcycle helmet law were both very much part of that ethos of “choosing not to wear my helmet is my freedom.” This is the tension of public health vs. individual rights. I fall on the side of public health, which I see as the side of loving my neighbor. I wear the mask for you, and you wear it for me. I want you to wear a seat belt to save your life, and I want you to wear a helmet when you are out there playing Easy Rider. We are in a Commons. I am not giving up on that idea. It is the same for climate change. (But seriously, keep your hands off my ice cream – it is not part of the Commons)
What are the most surprising consumer trends that have resulted from the pandemic? (and a follow up question: can you imagine the rioting if we were short on ice cream? Toilet paper is one thing, but ice cream shortages would likely end civilization as we know it, or at least in my house – but I digress)
I have been analyzing a ton of retail sales data throughout the pandemic that various folks have shared with me. Early on, there was fascinating data from Stackline looking at the fastest-growing categories in e-commerce. Number one: disposable gloves. No surprise there. Number two? Electric bread makers. Then in the Nielsen grocery shopping data, we found yeast to be out-of-stock everywhere, in brick and mortar grocery stores, on Amazon, and on the suddenly popular King Arthur Baking Company site. The sourdough bread baking phenomenon, with people sharing their resulting loaves on Instagram, was a surprise. I loved it. (what idiots – they should have bought electric ice cream makers!)
Another consumer trend that makes me smile is the Jekyll/Hyde story of Peloton, which last holiday shopping season took such flak for its ad featuring the scenario of a man buying a woman a Peloton. Some observers of that campaign saw it as an insult to the woman (the real question: does this ice cream make my butt look big if I eat it on a Peloton?). Fast-forward two months when millions of people were stuck at home in the Great Lock down seeking exercise opportunities to do indoors. Peloton has become a fitness darling to the point where the company has a wait list and has developed new business models for products and services. I loved that pivot, too. It is all about context and all about “us” in the moment. That is Maslow in action!
A third important example, and one which we need to monitor to see if it persists, is that consumers’ grocery shopping began to turn to food-as-medicine, and in particular to foods that could boost immunity (wow! I didn’t know ice cream could have that effect…). In the shopping data from the Food Marketing Institute, we saw this as a major trend, the larger headline is that the grocery store is a health destination – especially stores with embedded pharmacies. We will see the rapid evolution of the pharmacist as an extension of primary care, either formally from the health system collaborating with local stores, or from the demand side through consumers reliance on pharmacists as care providers where they live and shop. You well know I have been tracking this for a while, and the pandemic has clearly solidified this for mainstream consumers.
It seems that anti-vaxxers are growing in number and maybe for good reason given all of the controversy around whether the COVID-19 vaccine will be properly vetted. Is anti-vaxxing the ultimate manifestation of health consumerism – even if it is exercising the right to make bad choices?
I recently wrote on my social channels that my head is spinning around and upside down on this issue. I got my flu shot at Wegman’s 2 weeks ago, somewhat early, to get it off my checklist. I believe in the flu shot every year. My GP wants me to have it, and so do I. We believe in the science of the flu shot, year after year. But the SARS-CoV-2 vaccine? If we are science-based people and not fans of “warp-speeding” development in a politically charged environment, it is difficult to want to be first in line for that. Thus, the new anti-vaxxer might be science-based – flipping the script. Ironically, much of President Trump’s base are people in the anti-vax camp, so he, too, is flipping the script that way. As I said – mind-bending.
In a normal world, where you and I used to live, we are pro-vaccine based on sound science published in peer-reviewed journals. And just to be clear in full transparency mode, I have a button that says I am a member of the Dr. Fauci Fan Club. (I have a theory that there will be hundreds of babies born and given the name “Fauci” – mark my words)
Some people are thriving in the work from home world and others are suffering from loss of socialization. Who is better off right now – the extroverts or the introverts—and why?
I have had a home office for over 20 years as my sole place of business, and #WFH is getting to me. That’s because in my normal work-flow, I could leave the house mid-day, head to Wegman’s or the post office or Barnes and Noble, and have a chat with my fish-monger, my postal clerk, or the chap who works the customer service desk and shares my love of magazines. That is not so easy to do in the pandemic. Whether intro- or extrovert, I think it depends on that Maslow Hierarchy and how we feel at the top end of the pyramid: that is, self-actualization and self-esteem.
To survive the pandemic-marathon we need resilience and to feel connected even when we are not physically so. That is why I use the word “love” as part of our social contract: because even if we are alone at home, if we feel love we are connected. Technology can help and scale that; I love hearing the stories of people meeting up in a post-Tinder world in the pandemic, finding friendship and sometimes real love in the crisis. I have a younger friend who is experiencing this, and it is a beautiful thing. The bet her mom and I have is that she will marry her new true love before her two cousins will marry the people they have been “with” for several years. The pandemic is spawning some love stories we will hear more about in years to come. (and just watch, their children will be named Fauci…)
Will the healthcare system be changed forever or is the elastic that has held it together in its dysfunctional form too strong?
We should not add more layers on top of the dysfunctional system: let us not waste the opportunity in a crisis to learn, re-imagine, and re-build, right? Virtual care has indeed been helpful, but it has been launched on top of a largely fee-for-service system with a lot of waste, administrative burden, medical errors, and redundancy. It reminds me of the fax machine: we still use them on top of EHRs and apps and email and texts. We have never gotten rid of them, this dysfunctional Band-Aid. If we use the pandemic moment to accelerate toward value-based payment, we can address some of the waste and the redundant technology, and deliver care to people at home, in the community, in lower-cost settings that are more accessible and culturally convergent with our personal values. But that is a huge re-think of things, like the future of hospitals, for example.
Will the flight to the suburbs exacerbate the social divide, the financial divide, the divide generally?
I think of this a lot, referring to a cover of The Economist from earlier this year mapping “Main Street versus Wall Street.” The future of The City is on the line. I read a lot of Jane Jacobs in college studying urban economics — “The Death and Life of Great American Cities,” for example. The significance of sidewalks, the role of the public park and green space, crime prevention through environmental design – all of these issues speak to health. I also worry about the flight out of the city’s impact on culture – from the role of the museum to the livelihoods of crafts people in cities who earn their keep as artists and artisans and who inspire energy and color and creativity in our cities. And of course, there’s the social divide – because if culture, and our food-life, and good-paying jobs disappear from urban centers, then indeed, the financial divide exacerbates. Having grown up in suburban Detroit, your question resonates with me, haunts me even. That question informed my early studies in urban economics.
Have you seen any examples of solutions to the terrible racial challenges we are seeing come to a head? Any positive signs that point towards improvement?
I am encouraged by some of the business efforts that, so far in this very early moment, feel authentic. We pray and hope they will persist and “take.” In my book, I re-visit the Business Roundtable principles for doing good business by attending to more than just shareholder interests. In this model, we also attend to community stakeholder interests, neighborhoods in which companies operate, the environment, the infrastructure. The ESG principles for Environment, Society, and Governance around sustainable investing give me hope. I’m encouraged that Standard and Poor’s say they will look at sustainability principles in assessing credit ratings – is the kind of action that can move us toward greater inclusion and social wealth.
One slice of business is sports, and we have seen some moving moments there with the NBA suspending playing, and then NASCAR “cancelling” the confederate flag. (the NBA action is included on my COVID-19 U.S. timeline in the book). COVID-19 revealed the structural racism that has haunted health care in America for so long. Let us not waste this moment to address health in all policies – yes health care, but also fair wages and income inequality, education, environmental justice…it is a long list.
What are the “moral determinants of health”? What do you mean that this concept is a derivation of the SDoH?
The phrase, “moral determinants of health,” comes from the great Dr. Donald Berwick’s essay in JAMA published in June 2020 in the midst of the pandemic – his reaction to the unequal outcomes, namely mortality rates, among black and brown people in the U.S. vis-à-vis white people. Berwick has been involved with social determinants for many years; he’s a longtime fan of Sir Michael Marmot’s social equity research in the U.K. In his JAMA viewpoint, Dr. Berwick titled his piece “The Moral Determinants of Health” due to the outrage he is felt about the health inequities borne of the pandemic.
So many things have gone poorly for people during recent times – is there any silver lining? Can you name something going well?
In reading through all the data I’ve absorbed since the start of the pandemic, I think we humans can be proud of adapting so dramatically and quickly to this very unnatural circumstance of the lock down, followed by wearing face coverings, washing hands, and distancing (but not from ice cream). The data show me that under the normal curve, a majority of people would lock down again to crush the virus if we had the political will to mandate that and inspire a nation.
On the social front, there is also evidence that more white people are accepting the fact that health disparities are real and must be addressed. That APA survey cited earlier was re-fielded in June 2020 following the death/murder of George Floyd, and found that most people believe the movement against racism will lead to meaningful change.
Will life “go back to the old normal” when the virus is under control? What will be permanently changed?
In the book, I point to five changes that are transforming us as consumers: digitization of the individual; DIY-everything that we can do for ourselves; the home as health hub; financial stress, and finally the impact on our mental and behavioral health. All of these life-flows are changing in us and will persist to greater or lesser extent in all of us post-pandemic…or at least as our “next normal.”
What question do you want to answer? What is the message do you want to leave people with?
The call-to-action is to never let a good crisis go to waste, as Churchill is quoted as saying. The COVID-19 pandemic is a crisis that has impacted every man, woman and child in most of the world. In the U.S., the virus-crisis is converging with the toxic effects of an eroding economy and personal financial challenges, mental and emotional health impacts, and societal stress. Health in all forms is at the convergence of all these factors. The opportunity is for us to claim our Health Citizenship in America and secure access to care; digital citizenship and data rights; inspire trust in science and each other; and, finally, establish our new social contract of love. We have the opportunity to believe and act as communities for well-being. Audacious? Maybe. But if not now, when?