Pandemic and bureaucratic revolution. Volunteers did better than the state
Volunteers in the locker room before working in the intensive care unit. Photo: Vladimir Gerdo / TASS
Can the virus’s war on bad bureaucracy lead to a political modernization of healthcare?
How much travel restrictions, the closure of businesses, curfews and other government measures announced here and there have affected the final number of victims of the coronavirus, will be clear later. And understanding this is not only important for the future battles of developed countries and international expert and humanitarian organizations with future pandemics, but also dangerous for ineffective regimes. Like a lost war.
The global lockdown, which has become an expensive, almost like war, ritual of the commitment of society and modern bureaucracy to the value of human life, has shown growing gaps in the modern world.
First, between developed countries and the rest of the world. Advanced democracies have both the resources and the political need to save their citizens at all costs. But
there are no such resources outside the golden billion, and the value of human life suddenly turned out to be a very expensive cargo cult.
Secondly, the material and ideological gap is not just between the poor and the rich, but between those who, due to sufficient income, education and mastered social practices, can afford a full-fledged existence within technological ecosystems, with all the privileges arising from the status of the user, and those who who for various reasons, sometimes subjective, is left behind.
It is possible that the technology business, by expanding its user market, creating global ecosystems and local IT communities in cities in developing countries, is modernizing the periphery. Urban users of networks such as Facebook, with a significant number of them traveling the world and even working for international organizations or technology companies, are difficult to manage with primitive political technology and rubbing “Newbie” poison into the underpants of opposition politicians. It is no coincidence that the most sensitive blow to the reputation of the FSB of Russia was inflicted not by the special services, but by Bellingcat journalists working on the analysis of data available on the network, falsifications of the Belarusian elections were recorded using a specially designed application for this, and the lies of official statistics about the spread of coronavirus and deaths from it in real time analyzed in several communities on social networks.
Switching peripheral political elites from the TV and refrigerator party to the Facebook and coffee party may not only increase social inequality in developing countries, but even create a new design for it. But technology markets will become larger, new capitals will generate new political interests, the periphery will be tightened technologically, politically and economically, as it was as a result of the activities of the East India Companies in the distant XVII-XVIII centuries. Here we look at how the need to modernize healthcare can contribute to this exciting process.
Lockdown as a ritual
In those countries where statistics have not been turned into a propaganda tool, after some time it will be possible to accurately calculate or, at least, evaluate how administrative measures influenced the spread of infection, and how – the readiness and ability of citizens to maintain a regime of self-isolation. How many lives directly COVID-19 claimed, and how many – the termination of planned operations, the collapse of emergency medicine and the transfer of emergency hospitals to covid hospitals, which was actively practiced, for example, in Russia.
Looking at the data for New York and Washington during the first wave, household income, the number of family members, and possibly education, influenced the rate of spread. Where incomes were more than $ 100 thousand per year per family, there were less than 1.6 people under one roof and these people had a high level of education, the virus spread much slower, maybe twice as slow as where the annual income of households ended up less than $ 35 thousand, and the number of less educated than in the first case, family members exceeded 2.6. Mortality – the ratio of those who died from the disease to those who fell ill with it – depended mainly on how many people over 65 years old in the population. Where there are more than 40% of them, as in Bergamo, Italy, at the peak of the epidemic, the number of daily burials was many times higher than the norm.
The transfer of these ideas to the post-Soviet space is possible, but, of course, with the necessary amendments. The average disposable income of households in Russia, if we assume that on average families consist of 2.6 people, it turns out about $ 12 thousand (in the United States – more than $ 44 thousand), state and public institutions differ, and people themselves are arranged differently. However, we are dealing with one type of virus and one type of its carrier, homo sapience. There are social groups in the United States, the EU, and Russia that are ready to practice self-isolation, social distance and other restrictions associated with lockdown, and there are those who cannot or do not want to do this. Significant differences in the quality of government institutions, including health systems, business and professional communities, immerse these groups in different political contexts, but do not negate their similarities.
The lack of correlation between mortality and household income, or mortality and public health spending are indirect but alarming signs of public health ineffectiveness in relation to the pandemic. The lack of hospital beds during the second wave means that there were more patients than hospital beds, but it says nothing about how hospitalization affects the outcome of the disease. This remains to be seen.
The above is important for understanding how productive the government and insurance companies are at spending huge amounts of money on healthcare. Importantly, not only during, but also after the pandemic, healthcare-related officials, public figures, politicians and entrepreneurs will want to increase these costs. Of course, neither in Russia, nor in Ukraine, nor in Belarus there is no possibility to increase the share of healthcare to 17% of GDP, almost like the United States, and even to 11-12%, as the EU average. But this is still a lot of money now (in Russia in the amount of about $ 120-150 billion). It is difficult to object to any sacrifice to save lives. If these lives are saved and the sacrifices are not ritual.
In developed countries, the quality of the bureaucracy, the amount of money, and the influential medical community make it possible to count on an increase in the efficiency of health care depending on the cost of it. In addition, the new technological order, the formation of which the COVID-19 pandemic, according to many experts, has accelerated, involves the resettlement of citizens of developed countries to comfortable transnational ecosystems, the infrastructure of which will be provided by fintech, medtech, edtech, other hightech and unconditional income of residents. Modern national bureaucracies and technology giants will somehow come to an agreement, even already agree. This is how I would interpret the claims against Google, Facebook and Apple not only from American, but also from European institutions.
But for the corrupt state institutions of the post-Soviet space, even the lockdown ritual turned out to be a rather painful blow. To really learn from the experience of the current pandemic and restructure healthcare in accordance with the requirements of an enlightened and solvent stratum of citizens without modernization and assistance from developed countries and their technological giants, neither Russia, nor even Ukraine, in which society has a much greater influence on politics, apparently will be able to.
Virus instead of terrorists, volunteers instead of the state
In addition, the shift of elites from the fight against terrorism to the fight against viruses and other diseases changes the expert agenda and the beneficiaries of budget spending. Instead of security experts, specialists in epidemiology will be more in demand, and more broadly – in biotech. Along with manufacturers of military equipment, companies developing vaccines, tests, diagnostic equipment and new drugs will apply for budgets. The various ways of collecting data and spying on citizens, easily implemented within the framework of the above-mentioned ecosystems, are quite universal for marketing, tracking terrorists and monitoring the spread of infections. But if countering extremism and terrorism involves working with leaders like Vladimir Putin and even Bashar al-Assad, then in the fight against pandemics, these autocrats are not so useful to the international community. In general, the fight against the pandemic mobilizes society around the welfare state, creating a completely new conjuncture within the political elites.
This is another wake-up call for corrupt governments. The scheme “raw materials plus stability in exchange for legitimization, technological assistance and the possibility of capital withdrawal to the EU or the USA” is already being revised. Raw materials, even hydrocarbons, are losing political significance, and stability will be difficult to ensure without providing access to advanced ecosystems to at least an educated and wealthy stratum of its citizens.
Instead of oil companies, builders of global digital ecosystems are rapidly breaking into international politics. They will once again make the periphery pay for technology. The social base for this is getting stronger before our eyes.
In announcing lockdowns, the state in both Russia and Ukraine acted under pressure from fear and society. And, I repeat, not that stratum of society, which consists of state employees and pensioners, which politicians in the post-Soviet space are used to focusing on. Public opinion was formed on the Facebook network, the number of subscribers of which grew from 5 million in 2011 (protests at Bolotnaya and Sakharov) to more than 13 million (in Ukraine, according to some reports, there are also more than 13 million users), remaining mainly in Moscow.
The post-Soviet state failed to cope with the pandemic. Perhaps this has not yet become an obvious fact, but it will become in the coming months. The quarantine measures were not effective. Health systems have collapsed. In Russia, doctors had to be bought for an impressive, corresponding to the usual sixfold earnings
people better treat themselves.
Informal networks have been able to build expertise, organize consultations and even logistics of medicines and home equipment. This became possible thanks to social networks, modern technologies for the delivery of goods and services, as well as the availability of information (google-doctor).
The actions of volunteer movements in the first wave were aimed at supporting doctors in the form of purchasing PPE, sometimes ventilators and oxygen, and active campaigning for lockdowns.
In Belarus, the second wave, if there was any, went unnoticed due to mass protests. But before the August 9 elections, volunteers dealing with the pandemic were the vanguard of the republic’s civil society, which had no problems only with beds – Lukashenka kept the Soviet bed fund.
“My friends made masks … they went to SPACE [the IT community center] and sewed masks for doctors there for eight hours a day. Collected money. EPAM [the largest outsourcing IT company in the post-Soviet space with headquarters in Minsk] collected money from employees and matched dollar against dollar. In my opinion, the employees raised 200 thousand … and now EPAM donated 400 thousand to the fight against coronavirus – only one company. And many people donated on a voluntary basis … They bought PPE, bought shields and delivered. … There are activists who actually carried shields, antiseptics, masks to Belarusian regional hospitals in their own car. And the state did nothing … thank you for at least allowing hospitals to take it … The situation was difficult … everyone did not like the attitude, there was a question of insulting the people … ”(male, born 1986, Belarus).
One of the main “organizers” of the Belarusian protests, the telegram channel NEXTA gained momentum in February-May, covering the real situation with the pandemic, supporting volunteer initiatives and fundraising to help doctors. On March 15, NEXTA published a joint statement of 72 Belarusian telegram channels on the situation with the spread of COVID-19 in Belarus, in which the channel administrators told the country’s leadership about the need to “introduce
quarantine in all educational institutions of Belarus; introduce and carry out medical control as carefully as possible at all borders of Belarus with neighboring states and at airports; at the highest level, prepare a radio and television appeal to the nation explaining the seriousness of the situation with the development of coronavirus and, on the contrary, stop soothing statements, after which people weaken control over their own safety; timely and transparently inform the public and journalists about the situation with the spread of the virus in Belarus and new cases of infection: number, locality, place of work / study – without violating medical confidentiality. “
Several fundraising platforms in support of the fight against coronavirus have been linked to opposition politicians. They were closed.
The second wave, being more severe, pushed the volunteers to engage in direct rescue.
In Ukraine, informal networks, which once dragged the Maidan and ATO on their shoulders, have accepted the challenge of the second wave of the pandemic, showing themselves as a stable public institution, habitually replacing the state. It is the volunteers who in 2014-2016 purchased helmets, body armor and sleeping bags for the ATO fighters who are now purchasing oxygen concentrators and medicines for severe coronavirus patients. For example, here is one post from Lesya Litvinova’s facebook account dated 11/18/2020:
“Twenty hubs arrived on Friday night. A few days before that, we cut the leftovers and persuaded “Be patient. Right now. Now. We are waiting”. Two did not wait. Two people who could have lived died. Right in the hospitals. Waiting for oxygen, which is not enough for everyone …
… On Monday evening, out of 20 new hubs, only two remained. And five more old ones returned. One of those who returned, managed to survive two deaths of the owners and one recovery in less than a month.
… I tell myself every evening that I have to write. About those who got through. About those who died. About doctors who trade in access to oxygen. And about others – who run around the lonely heavy houses on the weekend.
About how a woman from the village tried to mortgage a house in order to buy a concentrator for her husband at the hospital for 90,000. And about how the supplier did not bring the device to a pregnant woman, because on the way they were offered twice as much. About a woman who sleeps in a barn because she suffocates at home. About a man who forbade his wife to take a concentrator from us, because he is strong and can handle it, but someone is worse. And about his wife, who understands what “saturation 75” is and cries into the phone for fear of losing him, the brave one.
We expect 50 more hubs by the end of the week. They have already been paid for and, apparently, are already in the country. “
In Russia, it happened a little differently – oxygen concentrators are looking for where they can, relatives of severe patients, and if someone got such a device, he tries to keep it for loved ones. The institute of volunteering, which has developed in Ukraine and cannot but take on this work – already has a reputation that obliges – in most Russian regions so far.
But there are public institutions that habitually perform the functions of a collapsing state in the Russian Federation in the North Caucasus, where rural societies in some cases even in the first wave, in April and May, took upon themselves the organization of quarantine, the purchase of medicines and medical equipment, and taking tests at home. , delivery of doctors to patients and funerals of the dead.
Against the background of formal and not always consistent actions of officials and law enforcement officers (no one has ever explained the meaning of the prohibition of walking in squares and parks), reasonable and well-grounded initiatives of informal leaders looked worthy. In Dagestan, “Salafi mosques closed immediately, without waiting for any
their [authorities] decisions. The imam at each mosque independently makes a decision on this issue, if he believes that there is a threat to the parishioners … They closed immediately after … people began to enter hospitals en masse, they began to get sick en masse … The imam of the Tangim mosque simply asked the parishioners for Hungarian fighters , they say, where are these, where are those, and why … “This one got sick.” “He got sick …” Information came from the parishioners that many people got sick, and on this basis he made a decision – in fact ”(male, born in 1962, Makhachkala).
At the same time, the SAMD (Spiritual Administration of Muslims of Dagestan) dragged on with the cancellation of Friday prayers until the last, waiting, as insiders say, for a special assignment or order from the regional governor, trying to emphasize its integration into the bureaucratic machine (male, born 1962, Makhachkala). Later, the networks of Sufi murids, which were oriented towards the muftiate, joined the volunteer movement and proved to be very effective.
The village of Gubden in Russia should be remembered for the protests of truckers against the Platon system: “No one was left on the sidelines – even the unfortunate trucker didn’t stay … And I can’t point to a single person that this person didn’t help … WhatsApp, shouting, talking …
Someone needs to carry, for example, an oxygen cylinder. An oxygen cylinder was brought to my father’s home personally when he found it difficult to breathe. Apparatus, sensors (pulse oximer) were supplied to him and nothing was found … [In Gubden, truckers already in April-May, at the suggestion of a rural private doctor, learned to measure saturation,
provided their patients with oxygen on an outpatient basis and used hormonal therapy]. Another WhatsApp group – they left at night, dug graves [during the crisis month from mid-April to mid-May, three to six people died in the village every day], buried people. They showed their courage by their actions. … Although they will come and kill me today for saying so, but I will stand by my word: these people, not the state, won the coronavirus … We collected money with all the people. And I personally threw money into the account, I personally bought medicines for my own money, brought droppers from Chelyabinsk, from Iran ”(male, born 1975, Gubden, Dagestan).
In another Dagestan village, Nizhnee Kazanishche, a slightly differently organized volunteer movement was observed:
“Everything was organized by the Salafi youth … All our students who study at medical universities and colleges, as soon as they were released on vacation, they all came, immediately made a detachment, gathered about 150 people … It was still mid-April. Immediately from Peter, they sent protective suits, glasses, respirators, all the boys and girls were dressed. Those who know how to work at least at the level of a medical orderly are taken to the hospital … and the rest began to walk around the courtyards with thermometers, to measure the pressure of the elderly. Those who knew how, took blood. The street, children run, people walk back and forth, and at one moment these guys appear in chemical protection, as in Chernobyl – in glasses, with spray knapsacks … And almost after that the acute phase began to subside. They began to distribute food – all this was done by the jamaat without any state …
We had an old hospital with 50–70 beds … And then a new one was built – with 150 beds. And when the flow of patients began, this old hospital was reactivated … and they did something like a dispensary … They organized the meals themselves – the head of the village with the youth.
Few people believe in the state and do not particularly expect anything from it … Basically, the communities actually worked ”(male, born in 1962, Dagestan).
Of course, there are examples of interception of the initiative by informal institutions from a state that is not coping with its responsibilities in other regions, for example, in Irkutsk (the movement “Take a doctor to a patient”): “All two IT specialists came up with this idea. In the city, the second wave of a pandemic was already beginning, hysteria began, there were patients in all the neighborhoods, and they went to them for two or three days, ambulances did not reach, the doctors did not reach them. They announced that the money will be collected on the card. A car costs 1,500 rubles per day, that is, 1,000 for gasoline, 500 rubles for washing – well, we have a dirty city, we need to wash it. When I drove around the first day of the doctor, they found out that he can serve about twice as many applications if he drives, and does not walk … I wrote a post on Facebook, an hour later a representative of the governor called at
legislative assembly. I have known him for 20 years … “Seryozha, I personally cannot carry, but tell me where to throw the money” … And the people very actively began to collect money. Four days after the beginning of this whole story, I received a call from the City Duma: come all yours, who are, we want to help. We come, the chairman of our Duma sits there, they say: “We want to give money.” They gave me 600 thousand rubles. That is, this, in principle, was enough for one and a half to two weeks of hard work “(Sergey Bespalov,
head of Navalny’s headquarters in Irkutsk, volunteer).
In the Irkutsk volunteer story, there is a contrasting case highlighting the problems of bureaucratic management. In response to the citizens’ initiative, the regional authorities allocated 68 vehicles for the delivery of doctors and paramedics on calls:
“… After two or three days, half of them did not go online. There was a scandal, the drivers either say they are afraid, or: we are up to five, we are home at five … All these people were immediately sent to work, conditionally, until eight in the evening. But all the same, at the same time, doctors constantly call and say: “Give us the cars, because those cars that the officials gave, we were tortured with them – either for lunch, then for maintenance, then refuel, then somewhere else.” And our volunteers, as a rule, are such that they arrived at 9 am and until the last patient, well, with a lunch break ”(Sergey
Bespalov, head of Navalny’s headquarters in Irkutsk, volunteer).
Conclusion: will there be a revolution?
Could the virus’s war against bad bureaucracy eventually lead to a political modernization of healthcare in countries where this bureaucracy is not as strong or as good as in the EU and the US? And how will this modernization affect the state, the doctor and the patient? In such a connected system, either everything changes, or everything remains the same. If medicine becomes a state corporation, assimilating budget and public money, but in private interests, what should ordinary people do?
The time has not yet come to answer this question unambiguously, but factors that can contribute to the medical revolution are already visible.
First, it is health education of citizens. Over the past few months, not only volunteers, but also ordinary people have become much more aware of their health in general and viral infections in particular. Many had to deal with basic diagnostic techniques, to acquire the habit of being interested in the oxygen saturation indicators from relatives and friends. We learned a lot about the structure and imperfections of the healthcare system, about private medicine, about the market for laboratory research and medical equipment.
Secondly, trust in public health care has been lost, which has failed. We have learned not to trust official health information and treatment protocols because they may not work. And in general, they are sometimes compiled not for medical purposes, but for some kind of perverse bureaucratic purposes. Often they just tried to make money on us, using the state as a sales manager.
Third, volunteers and other informal networks turned out to be the best operators of scarce resources, the best organizers of expert support and, in general, the organization of medical care.
Moreover, informal volunteer, fellow countrymen and social networks, primarily Facebook, have shown themselves as creators of an effective, mobile, constantly learning institution of public reputations of medical professionals, which, in combination and interaction with informal, but professional, self-formed the medical community, provide optimal navigation in the medical services market.
Fourth, this market of medical services, parallel to the official health care system, creates qualitatively different statuses for doctors and managers. Here they are not officials, but independent (professionally and economically) market participants who must make their own decisions, putting their reputation on the line. This incentive system seems to work better than any bureaucratic regulation.
Fifth, new technologies. Both communication and medical. Most of the dispatching functions, which are assigned to the outpatient link and partially penetrate into medical hospitals, can be automated. With the help of a Google consultant for this pandemic, many have learned to read CBC and biochemical blood tests, not to mention saturation, blood pressure and blood sugar. Primary health care system, which takes about 30% of total costs, can be replaced with a free app in your smartphone. Before the pandemic, this statement would have caused the righteous anger of some doctors, but after the complete fiasco that they suffered in the war with COVID 19, not even coping with the triage, this anger will no longer seem justified.
Sixth, business interests. For businesses, especially high-tech businesses, a huge new market is opening up with insane growth potential. These are medical home devices, new diagnostic methods, new treatment methods, but, first of all, this is a completely different institutional structure of healthcare.
The global technology business, the professional medical community and institutionalized networks of consumers that generate the reputation (capitalization) of specialists and are capable of flexible cooperation – this is a ready-made
“Coalition for reforms”. But how much this coalition will be able to convert its interests into political reforms – time will tell.
Text prepared as part of the Reforum project
The first text of the series: Pandemic and “military” modernization. How the coronavirus changed government and society
The second text of the series: Hippocrates against the bureaucrat. How the coronavirus changed the organization of medicine