The real challenge: Climate change

Our focus may be on Ukraine or in Gaza for obvious reasons, but the list of ongoing emergencies according to the UNHCR goes from Afghanistan to the Horn of Africa, and from Bangladesh to Venezuela. A large percentage of those emergencies are man-made, whether they be the Myanmar expulsion of the Rohingyas or the forced displacement of almost 2 million Palestinians by the Israeli army. But a good number of these emergencies are due to what used to be called “Acts of God” and which, more recently, we have come to identify as “Climate change”.

It may be the case that climate change does not exist, but what is obvious is that the Horn of Africa is entering its sixth rainy season without rain, affecting the populations of Ethiopia, Kenia, and Somalia (UNHCR). It is a fact that December 2023 started with one of the biggest snowstorms on record from Munich to Moscow (Washington Post, 4 December 2023), while in Spain records were set for the hottest December since records exist (Mail Online 13 December 2023).

Climate extremes affect disproportionally the most vulnerable population strata: infants and older persons. While infants are the future, older persons are the present, and finding the balance between one and the other is the conundrum of today’s policies: limited resources have to be shared between future and present. It may be unfortunate, but the present (older persons) vote, and the future (infants) do not yet have voting power. The result is that there is a funding bias prioritizing older persons.

There are almost 30 million persons 65 years of age and older in the EU. That is a big chunk of the voting population and, not surprisingly, there is quite a lot of attention directed at them. In that respect, I have to confess without shame that, I am partially guilty of following that trend. I have recently coordinated a proposal for the HORIZON EUROPE call. The proposal intends to develop a system involving older persons living alone in the prevention and preparedness to unexpected systemic health events, such as heat and cold waves, and pandemics, aiming at the preservation of their living environment. I have had the luck of collaborating with a fabulous group of partners that have given their best in order to produce what we hope to be a winning proposal.

The fact remains that climate change is producing and will produce systemic climate and health events that will test, to the limit, the possibilities of the social-healthcare systems. Designing a procedure to prevent the effects of those climate changes in older persons, will allow us to dedicate more resources to our future: the infants of today.

Heatwave last summer killed 61,000 people in Europe

This happens in a part of the world that, we tend to think, is quite advanced. However, such a figure indicates that Europe is not ready for the heat: neither its infrastructures nor its population are ready.

Start with the infrastructures. Here in Spain, where I live, the Moors knew how to deal with heat. They built cities with very narrow streets, so that the sun would not hit the pavement. They made abundant use of water fountains and gardens. We have forgotten those teachings. Our new cities have wide avenues so that cars can zoom in and out without problems. Although I live in a city with sidewalks full of trees, which helps to keep the temperatures down, new remodeling of most plazas is done with complete lack of vegetation. As proof, go to the famous Puerta del Sol, now in the last stages of remodeling, without a single tree.

And now for the population. Again, we have forgotten the teaching of our ancestors. They knew that you open your windows at night and close them during the day. More to the point, they knew the importance of water to stay cool. Drinking water was at hand in all rooms. Remember the famous “botijo” or the “bota” in Spain? They knew that from noon to six or seven in the evening, the only activity you should do was to take a “siesta” and stay indoors. And finally, they knew that dressing was all important: cover yourself to avoid the sun hitting you.

But there is still a more important thing that the new world has forgotten. It is the importance of the extended family. The fact was that when one aged, there would be a younger generation that would take care of you. You would never be alone. So if you needed a glass of water, somebody would be at hand. Today almost 30 million people live alone in the European Union. Those 30 million rely for their safety on the public health network. But public health care cannot be a substitute for friends and family. The only way forward is that those living alone need to take their care into their own hands.[i]

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[i] https://www.theguardian.com/environment/2023/jul/10/heatwave-last-summer-killed-61000-people-in-europe-research-finds?CMP=Share_AndroidApp_Other

HORIZON EU – Disaster-Resilient Society

Which market for ehealth

Digitalisation of the healthcare system will continue, but the use of health data will come under stricter regulation in the US, Europe and China.[i]

The optimism about the digital health industry is slowly declining in 2023.[ii]

Keeping the above in mind, now it is up to you and your team to assess and identify which niche market you are aiming at. The first step is to know who your client is, because your client is not necessarily the user of your product or service. Your client is the organization or person who will pay for your offer. If, as is frequently the case when dealing with ehealth services or products, the payer is different from the user, you must confront a double challenge.

First you must be sure that there are enough users of your product/service to make production on a large scale viable. Second you must be sure that the payer will find your product/service advantageous compared to the current alternative, be it digital or analogic.

This double aim is probably the main challenge that anyone working in the healthcare sector must deal with. The payer will mostly focus on the efficiency side of your product/service, the user will value other aspects such as comfortability, usability, and other aspects not necessarily related with the efficacy of its use.

Before going further in your quest from project to start-up check out, preferably with people or organizations unrelated to you and your team, whether your idea meets the needs of both payer and user.

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[i] Healthcare outlook 2023. The Economist Intelligence Unit Limited 2022

[ii] Global Digital Health Business Outlook Survey 2023. Research2Guidance 2023

The basic ingredient is humans.

In your quest for putting together an e-health start-up, or for that matter, any start-up, you should not take for granted that the team of professionals, the group of friends and colleagues you have put together, will ride the quest with you unhindered.

Therein lies the first mistake of your long journey towards success. Humans are fickle, they are more like the “donna è mobile” of the opera. You, as the de facto leader of the group, should know your team and the people who make it up.

Since your ultimate aim is to demonstrate that your project is fundable, your first concern is to be able to say to prospective investors that your team is committed to the vision of your start-up.

You should be sure that the profiles and expertise of the professionals match the needs of the project. It is difficult to tell a long-time friend or colleague that his/her inclusion in the team does not add any value to the vision of the project, but that is your role.

Once you are sure that you can cover the most important aspects of the market you are aiming at, the next step is to confirm that the key partners will be able to commit their time to the project if and when the necessary funds are raised.

On your way to tap the well of venture capital, a first step is to be able to show that your team is the best possible team to fulfil the needs of the market. Remember, at this stage, the only asset you have are your professionals.

Venture Capital is not Adventure Capital

Type “Venture Capital” into The Encyclopedia Britannica and you will get “funds provided by wealthy individuals, investment banks, or other financial institutions to relatively new and small companies that appear capable of exceptional growth and long-term success, including nascent private companies, or ‘start-ups’.”

Reading it carefully, you, a “start-up” entrepreneur, will get the first glimpse of what venture capital IS NOT. Because venture capital is not ADVENTURE CAPITAL.

It is not an adventure because “wealthy individuals, investment banks, or other financial institutions” are not adventurous. They are wealthy, and they have funds, because they have managed their portfolios sagely and thoughtfully and, what is worse for you, they plan to keep it that way.

So, they will mobilize their wealth only if they can see “exceptional growth and long-term success”. Who should provide the basis for such a positive appraisal? You, the “start-up” entrepreneur.

You must be prepared to convince a skeptical investor that you have a unique product or service, that there is an entry barrier that will allow you to be the first on the field now and in the future, that there is a demand for said product or service, that you know your product or service and the way to replicate it, and that you … are not a fake.

If you believe in your idea, you had better start thinking about how to convince a skeptic of the merits of your idea. My advice is to do the exercise even if you are not looking for external funds, because if you are not able to build a selling point, your idea probably has too many flaws and will end up, like most brilliant ideas, in the bin.

Prepare for the unexpected

Life is full of unexpected events and being prepared for them makes the difference between success and failure. This is true at any level: individual, local, or governmental. Responding to unexpected events successfully involves improving preparedness by, among other things, clarifying roles and responsibilities around management of risks.

Most research has focussed, so far, on management of risk at the local or governmental levels and very little has been dedicated to the individual level. If that is true at the response stage of an unwonted event, almost nothing has been done at the preparation stage.

Making individuals living antennas for the detection of an incoming event may be too ambitious, although there are examples of it. For instance, in Spain there is a network of volunteers that measure weather conditions throughout the territory and are a source of daily information to prevent climatic events. Creating such a network for any type of event could reinforce the resilience our society dealing with high impact events. Such living antennas could be trained to lead their neighbours in the early response to a high impact event. For such network to be effective, the components have to be deployed across the territory, making in-person training very expensive. E-learning could be the answer for training a vast number of living antenna volunteers to manage High Impact – Low Probability (HILP) events.

Involving citizens in EWS

An anthropogenic approach is needed when designing a system directed at diminishing the effects of an emergency, be it human made or natural. Most Early Warning Systems (EWS) have been designed by professionals and, in most cases, designed around a specific threat. Vulcanologists are worried about telluric movements, maritime scientists regard tsunamis as the biggest threat, and firefighters are concerned about the consequences of forest fires during the hot summers.

But there is a point of contact in all those EWS that is not involved in their design: people. People are at the center of any emergency and yet they are the forgotten link in any EWS system.

It is easy to involve people living on the slopes of Etna into participating in a EWS designed to save their lives. Etna is a live entity that constantly reminds the people living nearby that it can erupt anytime. It is more difficult to do the same with the two million people living in the vicinity of Vesuvius. The memory of its last activity is long forgotten. And what about making people aware in Barcelona that tsunamis exist in the Mediterranean and that they are just few centimeters above sea level?

The challenge then is to get the general public involved in being part of the EWS. To achieve that, e-learning and gaming in particular are tools that have to be explored; these have had positive results in other areas. A well-structured and simple e-learning system has to be devised to complement any EWS. The challenge is that it has to satisfy all kind of persons. It cannot be forgotten that the population is made up of old people with limited ICT skills, disabled people that have to be involved in their own survival, kids that have to be taken care of, and nerds who think they know better. The success of the EWS relies on the ability to cater for all those people at the same time.

Primary care for today

Most disasters or crisis-related emergencies involve a migration problem: the bigger the emergency, the bigger the number of displaced populations. Lately, Europe has been shielded from big emergencies involving huge population movements. The last such event originated in its territory dates to the Balkan Wars; that changed with the Ukrainian crisis, bringing in almost 4 million displaced persons. Those in-born crises do not take into account the on-going crisis and constant inflow of people originating in the East and South of the continent. Thousands if not millions of Middle East and Sub-Saharan individuals are ready to jump over the Mediterranean as soon as the autocrats governing the countries east of Europe or Northern Africa decide that their role as gate keepers is not worthwhile for them.

Focusing on the healthcare sector, Europe has been able to deal with the recent flow of Ukrainians mainly because those arriving had a relatively high standard of care in their country. But what would happen if the gate keepers opened the door for those trapped in Turkey or the southern shores of the Mediterranean?

So far the response, in a most peculiar if not plainly hypocritical way, has been to ignore their health needs and process their cases as expeditiously as possible, so as to make their return to their point of origin the main objective of the European policy. Ignoring the fact that they have migrated because their existence in their countries is unbearable and without any future does not make for good policy. Ignoring the fact that Europe is in the midst of a demographic crisis and a good flow of immigration and new blood could help to alleviate the crisis does not make for good policy. Ignoring the fact that all the available research suggests that migrants pay more in taxes than what they receive from the state does not make for good policy. It seems then, that the only policy guiding our policymakers is the appeasement of the far-right groups and their focus on immigration as the root of all evil.

But suppose we in Europe change gear and decide to incorporate the flow of immigration into our societies? One of the aspects that would have to be considered is their healthcare needs. Primary care, as the entrance to the healthcare system, would be where the pressure would most be felt. And primary care has been overcome by the Covid-19 pandemic, even more than hospitals and ICUs. My question is: have policymakers realized the importance of strengthening primary care? Even without the change in immigration policy, primary care needs a boost. Europe cannot attempt to survive without a strategy to absorb millions of newcomers and without a strategy to make a healthcare provision fitted for the future: an older population together with a younger migrant population.  

High-Impact events preparedness

There are multiple factors to consider when testing the level of resilience of a society in the event of a crisis. The well-known model of “prevention – preparedness – response – recover” for risk management summarizes the basic steps for an efficient answer to an unwanted event that puts in jeopardy the well being of a group or of an entire society.

Most people in the developed world have been fortunate not to have been faced with a war. Since WWII, Europeans and North Americans have not been involved in a war affecting their homes. But that placid world has been shaken since the start of the twenty first century by several high-impact events that have disrupted the well-being of large chunks of western society. First was the financial crisis of 2007-2008. With some countries still recovering from the damage, the Covid-19 pandemic struck in 2019, turning the world upside-down. And in the midst of recuperating from the effects of the pandemic, the Russian Federation decided to attack Ukraine, disrupting the energy market, fostering inflation and sending, yet again, many families below the poverty level.

Those three high-impact events have something in common that could serve as a model for well designed “preparedness” management. I have pointed out the common denominator of the three events: sending many families below the poverty level. That common denominator is present in many unwanted events; for instance, floods or earthquakes. When a big disruption occurs, some layers of society – mostly those at the bottom of the social pyramid – see their living standards directly affected. These are the ones which rely more heavily on public social and health provision.

We can see clearly that the socio-health sector is the one that has to come to the fore when a high-impact event occurs. Dimensioning the socio-health sector for “normal” times is not sufficient. Dimensioning the socio-health sector for early response, e.g. emergency response, is not sufficient. The socio-health sector has to be ready for medium-term action since the effect of a high-impact event is going to be prolonged in time. Many of the families who lost everything during the financial crisis have been in need of assistance for many years, and the same is true for those most affected by the pandemic or the inflation shock of today. Societies have to dimension their socio-health sector taking into account that, once the shock is absorbed by the early “response”, the “recovery” phase is a long undertaking, and for that reason, “preparation” has to be clearly and sufficiently dimensioned. If in doubt, see the effect of Covid-19 on primary health care, which two years later is still struggling to cope with the increased demand on its services and is now being asked to cope with a new demand caused by the wave of refugees from Ukraine.