Health care, social welfare and the common good, with Sophia Ikura

Transcript

Transcribed by machine from the recording.

Scott Chris, welcome back to the show. And we welcome Sophia, our first guest. We've never had a guest before.

Sophia We've never had a guest before. Now we're getting excited. I feel like we're in the big leagues.

Scott And we got a big league guest, Sophia Ikura. You are in Toronto. I am. And you work at the intersection of public health and social welfare and run a kind of, is it fair to call it like a think tanky kind of think lab where you're studying this stuff?

Chris It's less think tank and more lab. It's a lot of doing, lots of thinking, but a lot of doing, less writing. And the idea is just we're working in spaces where we don't have a lot of good solutions, so we have to kind of invent them as we're going along. And it's sort of an experiment trying to rethink how we do public policy using a lot of different tools and using the perspectives of many different disciplines that you don't necessarily bring into the policy process regularly. So, yeah, I would say it's more doing than writing, but it's everything else that you described. It's right at the intersection of sort of social welfare and public policy and healthcare.

Scott Chris and I have been talking in the last few episodes a little bit about just life in a pandemic and how part of the Basecamp community is about making maps together, seeking meaning together, about finding new paths, mapping a new world, and realizing we don't know all the answers, and we're doing this in a provisional kind of way together. I'm wondering, given what you're doing, what sort of... What maps have you seen that have been drawn wrongly in the pandemic, and what kind of new questions about meaning and purpose are coming to the foreground for you?

Chris Yeah, that's a great question, actually. I think that there's a lot of assumptions that we are expected to kind of accept whole, like whole hog. There's some actually amazing new maps that I love about the flattening of the curve and the story that that tells us about ourselves, about the way that we work and the fact that flattening the curve has been a really big social experiment. Everybody has to play their part and we have this social contract with each other where we are going to...

Sophia One of the big drivers of change that deserves to be recognized right up there alongside technology and all these other narratives we have about what drives change and progress and now we have this concrete evidence. How we can all transform the world if we all kind of have the same intent in our heads and bring it into our lives. But I suppose then one starts to wonder how applicable is this learning experience to sort of other challenges? And what was it about this?

Chris We will apologize, though, after we disagree.

Sophia Yeah, sorry, I didn't mean to interrupt you.

Chris Yeah, please, we could apologize. That would be great.

Sophia I feel so American right now. Shh!

Chris Apologize, Scott.

Sophia You interrupted my apology.

Chris No, so, I mean, I think that there's a little bit of fear, but I think what's more interesting is what we tell ourselves about what happened here afterwards, right? Like, I keep wondering whether or not there's an opportunity to redraw our maps about who we are as a society. Thank you so much for having me. If you can change behavior, that's the biggest hurdle. Because if you change behavior long enough and consistently enough, people don't like the dissonance that it creates between my mental model about who I am as a person and my behavioral change. And as a consequence, they will sort of realign their mental models and their frameworks about who they are. So if we've changed our behaviors for long enough and we've behaved in a very social way on a common problem for long enough, is there an opportunity for us to reimagine who we are as a society?

Is there an opportunity for us to say, like, we're not going to accept this idea that there's a basic level of human misery that we're going to accept as a given? The conversation around universal basic income is a really interesting one. We've been having that in Canada for some time. And generally speaking, some very smart people were written off as being sort of too earnest or too naive. And all of a sudden, we're having a very real conversation about universal basic income because governments are doing it and people are benefiting from it. And there's an opportunity to rewrite the narrative around that as being completely out of reach, as something that actually we can accomplish and could be useful. So I think it's the stories that we tell ourselves as we're coming out of this that I think are going to be really interesting.

Scott I'm curious. One of the things I'm noticing is that, I mean, I was astounded that the United States is 4% of the world's population and we have 30% of the deaths, which is astounding to me. I mean, but I think that what's happening in this country in a lot of conversations I'm following is there's obviously a kind of concern about our healthcare system, but it just gets politicized again. It's either, see, this is why we need to go to a socialized medicine

Chris I mean, I think what's interesting is how we have shifted, like in Ontario in particular, we've sort of elected a premier that's a little more on the populist end of things, who, you know, a short six months ago, like we could not have imagined that he would have turned to the public health experts and asked them their opinion about what we should be doing in this instance. And he's done a phenomenal job, actually, bringing the experts, listening to the public servants and the public sector around how to proceed. He's been cautious. He's also political. He's listening to people. Like, there's a lot of things that are happening that I would say would have been really, really sort of unexpected from the premier that we have in Ontario right now. And I think the opportunity is, you know, I listened to your podcast the other day about how many different mental models can we tolerate in the same space or how many can we expect should be allowed to operate at the same time. And I think the answer to the question you guys arrived at this is like as many as you care to connect through some points of intersection, right? Like what are the things that bring all those perspectives together? And one of the things that I find interesting about politicians on both sides of the spectrum is that if you go back to their origin story, usually it begins with an interest in

There was a poll that was done here in Canada, actually, asking Canadians about, like, on one hand, how quickly do they want to reopen the economy? And it was fast. And the other, like, what level of community spread would they tolerate? And their tolerance for that was actually really low. So there's clearly a dialogue there that needs to happen about how do we get to something that everybody can kind of accept.

Sophia Hard choices that need to be made. Yeah.

Chris Yeah. And then I don't think there's been a lot of conversation about the fallout of this, but it's going to be significant. Like the economic impact of the lockdown is going to be really dramatic. And I think it's going to affect communities very disproportionately. And it's going to take decades actually to come out of the long term implications of this for certain groups. So we need to have more of these conversations, I think.

Sophia Can I chime in on a couple of things there? One, the economic impact. So just a couple of days ago, I was on the phone with one of Europe's ambassadors to China. It's actually been a great time for the Foreign Service. You talk about sort of public goods that are kind of underappreciated. Countries that have had That have good teams on the ground in China. I mean, it's been so valuable because they've really been helping to, you know, source medical equipment that their countries need. And, you know, they've got the understanding of how things work on the ground to move things along. And anyway, we were talking about sort of the economic fallout for this. And one of the things he said to me that stuck with me is that like the bill for all this hasn't really come due yet. We're just printing money.

Chris I'm terrified.

Sophia Yeah, so we said, like, one, you know, across a lot of the developed world, you know, we're staring at maybe 35% or more youth unemployment for the next little while. It's going to be a really hard time for youth to find work, and that's going to create all sorts of, like, intergenerational tensions that we haven't yet really had to confront. And then his other point was just looking at the state of public finances. He said, like, yeah, like if this happens again in the next five years, we probably won't be able to choose to shut down the economy for a period of time because we just, you know, it will just hurt public finances too much to be able to sort of bail out the whole of society on this scale again. So so financially, we're all going to be really, really fragile for like not just until there's a vaccine, but, you know, for several years to kind of I love this word, Sophia, that you used, intersection.

This event is kind of an opportunity to connect worldviews and political perspectives and to connect in a very concrete way the I and the we. I'm actually a bit cynical about whether we will all come out of this being nicer to one another, sort of holding on to that kumbaya. Because depending where you look, we never really had it. I mean, the kind of the compassion that people expressed was wonderful, but it did hit against some pretty familiar limits within countries and certainly between countries. So, you know, the narrative that we've been really nice to each other through this is true, but the we is not everyone. But I do have more faith that we might all come out of this with a much stronger sense of our own fragility. Um, and how, how, you know, your wellbeing, uh, Sophia and mine are, are connected and, and not just in a sort of vague way, but in this kind of concrete way where there are some things that I, I can only have like, you know, health if other people are also resilient. Um, and I think. I mean, it'd be interesting to see how deeply that sense of connection goes. I mean, you do see it now in businesses or, you know, like if you're Airbnb, you're living the reality that, you know, you're only as strong as your customers.

In many ways, your business model is dependent upon a lot of public infrastructure that you take for granted. If you're looking for relief from your government, their capacity to provide that relief is dependent on if everyone's been paying their taxes or how...

Scott Well, I think it...

Sophia Sorry, go ahead.

Chris No, I mean, I think what I was going to say was I think that that's probably a matter of never having a real conversation about the trade-offs that were happening. When you don't have income tax, the assumption was that you would always have some ability to be able to pay for your basic needs. Like, if people are sort of buying into that model, that's the assumption that they're making, and there's not a lot of cushion in that kind of model, right? And there's a hubris that comes along with the way that we were living before that I think to some degree has been dispelled. Like, you're right, Chris, it has perfectly laid bare to us the nature of our fragility as a society, the degree of complexity and sort of the layering and layering of complex systems on top of each other and the reliance on each other.

And when one of those pieces goes, everything starts to fall apart. And at some point we should talk about the reason why I think the kinds of conversations that you're trying to have at Basecamp offer, I think, Maybe an early prototype for the way that we can begin to think about this kind of complexity that we've laid bare with Corona and with the pandemic response and what it's going to take actually to lean into the problems that are coming for us. Like that complexity has always been there, but I think we've been We've been either willfully ignoring it or we've been largely able to sort of remain ignorant of how fragile that system is. And it took something at the scale of the pandemic to force us to have a conversation about what do we need to do differently.

Sophia We're such an interesting species, aren't we? The complexity of our problems is only increasing, but it seems like our solutions are only getting simpler and simpler. Technology will solve all our problems. The complexity of our solutions has declined to zero.

Chris Yeah, I mean like we really like a reductionist view of it because it allows us to sort of ignore the difficult and messy parts of the problem. And it's really soothing. And I actually think that that has to do with how much information is constantly coming at us. Like how much information in a newspaper can you have enough detailed knowledge about to be able to accept anything other than a very sort of Basic platitude about it needs to be this thing or it has to be that thing. It's a binary in many instances. And that's not the world that we live in. We rely on complexity in a very big way.

Scott This is what's killing things in the United States right now. I think if you look at cable news, it's just the dialogue is, if you're, it's on one cable channel on the left, it's anybody that wants to reopen the economy, it just wants to kill people and that has no compassion. And then, you know, on the right, if you go to Fox, it's, well, anybody that wants to sort of, you know... Be cautious, doesn't love America, and doesn't have any compassion for all the people that are poor and suffering and are out of work. So little things are framed in a way that actually give us information, which is what we need, right? There needs to be some kind of consent of the governed where we realize, okay, we probably aren't going to get a vaccine in the near future. We're probably going to have to figure out how to live with this pandemic, live with the virus.

Thank you so much. But it seems to me that the kind of strategic thinking and the kind of information-based thinking and appreciation of complexity that that one nursing home owner was able to marshal, it just seems like our media discussion kills our capacity to have those kinds of conversations and come up with those kinds of strategies because we're just blaming everybody as if it's not the virus that's the problem, it's we're the problem. It's a debilitating kind of state of discourse.

Chris It's actually really interesting. You said a couple of things in there that I really liked, which is like, how do we actually think about how and when we will share the risks and with whom will we share those risks? And I think that there's like one of the things that's really, really debilitating to our ability to do that well is that we don't name those risks. We really name the specific components of the parts of risk that we're going to take on and share and spread and break it down in a way that puts it within reach. We've been spending some time at the lab thinking through reopening. And one of the core elements of reopening is sentinel testing, which is essentially you go in and do routinized testing of asymptomatic people. And typically, sentinel testing happens by sectors because employers can compel employees to be tested in order to be able to remain in the workforce.

Sophia This is called sentinel testing.

Chris It's called sentinel testing. It's a public health thing. Right. And it's and typically what you would do is you would say, OK, where are our industries that are most at risk and how do we want to do sentinel testing in order to be able to ensure that we can remain open? You want to do some hotspotting. It allows you to identify where there's an outbreak earlier and do quarantine. Those are all really important tenants of sort of moving out of lockdown. One of the things that tweaked for me was here in Toronto, we had ten deaths of airport limousine drivers in the last two months. Ten deaths is actually a lot for a city like Toronto. And what it told me was that it's sort of right in that sort of spot of people who are more vulnerable because they can't stay home, they must work. The kind of work that they're doing, the lack of access that they might have to protective equipment. And then I was like, where do those people live? And you can imagine that when you look at maps, we know that many of these characteristics of precarious employment or gig employment or low-income wage jobs, people who travel specifically using transit, people who may live in more congregate living spaces or multigenerational units where there's density, those are all really significant risk factors for the spread of corona.

And so there's a case to be made for not just doing sort of sector-based sentinel testing, but neighborhood-based sentinel testing. But for a whole bunch of reasons, that's going to be risky, right? Like there's a fear of stigma. There's a, I'm going in and taking something out, but I'm not giving anything back. I'm going to take your data, but I'm not going to offer you anything in exchange. There's, in Canada, there's certainly communities that have experienced that feeling of giving over my data and then having it be used in really negative ways. And that's true in the Indigenous community. And so I think that there's a whole bunch of reasons why we should be thinking about neighborhood-based strategies, but a lot of risk for those folks unless we do it well. And when I was thinking about the team that we put together to try and understand, how could you make sentinel testing feel safe and actually have utility for those residents?

It would be some combination of our epidemiologists who can think about numbers, think about frequency, and how many tests per 100,000 or 10,000 people in a particular neighborhood. You'd want sociologists and anthropologists who are very good at understanding the stories of people and how they influence their choices around whether or not they will participate. What are the historical experiences of those communities that you would need to understand in order to be able to put a good plan forward? And then you'd really want to be able to activate that community so they can ask you for what they need in order to make that tolerable. What are the neighborhood associations going to say to you about, like, yes, you can come in, but in exchange for that, when there's an outbreak, what we want from you is space. Like, how could we spread out? Or how could we safely quarantine whole families or whole floors of this sort of dense urban building? So I think, you know, to your point, you can understand the problem of sentinel testing from a mathematical perspective. That's the epidemiology piece. Public health would essentially say, well, we're just going to mandate it.

But if you ignore all of the aspects of the experience of that from the residents and the citizens' perspective, you're not going to be successful. And so I think we really need, like, new conversations, new tools, and very different approaches. And that's the kind of, I think, posture that we need to bring to many of these complex problems. Like a sense of humility.

Scott Is that what's drawn you to the Basecamp kind of community? For sure. Seeking that in your own discipline and connecting with other people who are seeking the same thing?

Chris Yeah, I mean, I think it's really fascinating. My first experience with Basecamp was a full day session where I was like, oh, not really anybody in the healthcare system compared to some of the folks sitting at our table. And like, just listening to these giants talk about some of the major challenges in healthcare with a real humility of like, I actually, I know a lot. I'm an expert in a lot of things, but I don't know enough to be able to do this on my own. And I think that that was a general attitude across the room, like just like these giants. And then other people who are in the earlier stages of this journey of trying to figure out how we innovate a path forward. Lots of curious people willing to have lots of curious conversations. It's incredibly energizing to have many different perspectives being lent to the same problem, looking at it from many different angles.

You can only know the part that you are an expert in. And even then, you need to have other people questioning some of your basic assumptions if it's going to go anywhere. So that's what gets me really excited about Basecamp, actually.

Scott Well, I appreciate your excitement. And Chris, Sophia, thanks for this enlightening conversation. And I hope that the Basecamp tribe increases.

Chris Me too.

Sophia Oh my God, we had an interview. Amazing.

Scott Thanks so much, Sophia.

Sophia Thanks, Sophia.