1. Ahern Gould, Kathleen PhD, MSN, RN

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As I write this, good news abounds on every front of the pandemic. Yet, the statistics remain frightening. The devastating surge that was predicted is here, as human behavior and political turbulence have complicated our containment of the virus. To stay safe, many are hunkering down to make it through the holidays and into the New Year.


Vaccines are on the way, as impressive results encourage early approval. Treatments have improved using monoclonal antibodies, inexpensive corticosteroids, such as dexamethasone, streamlined infection control protocols, and innovative care practices, such as pronation and new oxygen delivery systems. Home test and rapid testing are in use, and vaccine plans offer a return to a new normal. Continued success, and the end of the pandemic, is only a matter of time, and a matter of will.


We will start over at a new place with resolution, lessons learned from the darkest days of the pandemic, and inspired leadership. "Today, we are beginning to reflect on our postdisaster days, what we will remember is that it was a time when we really all worked together," says Douglas Starr,1 a writer for the New Yorker who reminds us what crisis leadership looks like. Essentially, it looks like unity of purpose, often using something called swarm intelligence, the ability to spontaneously work together in a crisis. Drawn from animal behavior, it is a latent force that biologists tell us is always ready to emerge, given the right circumstance and leadership. Often, it resembles the unselfish behavior seen in the military, and in health care, when people know that they must depend on each other to save lives. Starr1 describes how leadership functioned following the 2013 Boston Marathon bombing when leaders set the tone for swarm intelligence, which began to emerge almost immediately. Starr1 uses unique examples to describe swarm intelligence: the Boston Marathon Bombing, the unexpected World Series win (after an 86-year drought) for the Boston Red Sox, a tornado in Joplin Missouri, fire-ravaged California, and hurricane Harvey in Houston. During these turbulent times, people self-organized, guided by leadership models that encouraged innovations-allowing individuals to take responsibly, thereby creating opportunities to reset the course of each state, organization, and family. Health care teams exemplify swarm intelligence. Each day, and each emergency, requires this level of organized precision. Although each phase of the pandemic required significant rerouting, care teams and organizations responded with unified efforts consistent with swarm intelligence behavior. Recovery from this event will require the same level of unity and leadership, armed with new lessons.


Many of us have sheltered in place before, often at hospitals, at disaster scenes, and at home. This experience was different; it was sustained, and it affected our global society. COVID-19 provided many new lessons and perspectives that will change population health. It revealed that deep systemic changes are needed in our society and organizations. Alison Mudditt's2 words about our society captured this message: "Today's challenges reach far beyond discrimination and marginalization in the workplace. Yes, we are far more aware of the weight of systemic injustice and racism borne by our coworkers of color. But even if we do all of the right things within our organizations, it's not enough. We need to deliver a fundamental shift in the way we work internally and with all of our stakeholders in response to a watershed moment. It's about strategy as much as it is our people policies. COVID-19 has taught us many lessons about public health and the transmission of disease. It has also shed a stronger light on the deficiencies and inequities in the US health system."2


During the pandemic, racism and inequality were collectively called out, but it has been going on for centuries, and perhaps all of us have played a role in perpetuating it. Mudditt,2 like most of us, experienced a year of deep reflection. She realized that many of us have never faced the incredible burden of racial inequality, housing insecurity, and poverty. Her words inspire us to look more closely at things we have not seen or experienced. She encourages us to listen more closely to expressions of cultural pain, described by outpatients, families, coworkers, and neighbors. Her call to action includes the reminder that any new plan or work by individuals or organizations in a post pandemic world will require a new awareness, extensive resources, energy, and creativity.


COVID-19 has provided many other lessons about our health system that need to be taken to heart. As Mudditt2 provides reflection, COVID-19 era writers and leaders such as Starr1 and Butler3 provide examples and lessons, and Dr Donald Berwick4 provides the framework for a renewed moral law.1-4 In a recent JAMA network article, Butler3 suggested 4 COVID-19 lessons for achieving health equality. Lesson 1 is to provide health services where people are. This means decentralizing care by building up the infrastructure of health services within communities. Lesson 2 is to focus on improving interracial communication. Poor communication and distrust between providers and patients are common. The suspicion among Black individuals regarding a COVID-19 vaccine has deep historical roots, which must be reconciled. Lesson 3 is to strengthen the caregiving workforce for older adults. COVID-19 drew attention to the caregiver workforce, as the characteristics of this workforce increased the risk of virus transmission. We must address their needs. Lesson 4 is to say goodbye to employer-sponsored insurance. For millions of families, the shock of losing employment has been compounded by the temporary or permanent loss of health insurance. The double whammy of economic loss and health care insecurity was central to the COVID-19 experience. These essential lessons could guide our postpandemic restructure. The will to do this may be enhanced by Berwick's4 description of moral law.


The knowledge, reflections, and lessons earned during the COVID-19 pandemic will help us move toward a new agenda for health care. But this pandemic has inspired something more, something that the philosopher Immanuel Kant called "the moral law within."4 This philosophic view may refocus what Berwick4 describes as the moral determinants of health. Perhaps, it will offer an enlightened look at the inequities and injustices that were unveiled during the pandemic. Berwick4 tells us that there is something beyond the traditional: caring for illness. It is the belief that it is important and appropriate to expand the role of all providers and health care organizations into demanding and supporting societal reform. To achieve this, he proposes a morally guided campaign for better health, offering a rational to-do list as a framework that includes the following:


* US ratification of the basic human rights treaties and conventions of the international community. This includes the elimination of all forms of discrimination against women, children, migrant workers and members of their families, and persons with disabilities.


* Realization in statute of health care as a human right in the United States


* Restoring US leadership to reverse climate change


* Achieving radical reform of the US criminal justice system


* Ending policies of exclusion and achieving compassionate immigration reform, state-sponsored violence, child abuse, and family separation


* Ending hunger and homelessness in the United States


* Restoring order, dignity, and equity to US democratic institutions and ensuring the right of every single person's vote to count equally4



Postpandemic reform will reflect hard-fought lessons, inspired leadership, and perhaps a new moral compass toward population health. We are fortunate to have the lessons and insights of these committed professions to add to the knowledge of the capable and experienced workforce that has brought us through this challenging time. The will to achieve better health care has never been stronger as we start over at a new place.




1. Starr D. What should crisis leadership look like?The New Yorker. 2020. [Context Link]


2. Mudditt A. In search of equity and justice: reimagining scholarly communication-The Scholarly Kitchen October 28, 2020. Accessed December 1, 2020. [Context Link]


3. Butler SM. Four COVID-19 lessons for achieving health equity [published online November 5, 2020]. JAMA Health Forum. doi:10.1001/jamahealthforum.2020.1370. Accessed December 1, 2020. [Context Link]


4. Berwick DM. The moral determinants of health. JAMA. 2020;324(3):225-226. doi:. [Context Link]