Fixing What Ails Us: A Modest Proposal to fix Healthcare and Education

Equanimity in American society depends on two giant engines of well-being that are currently struggling to sustain operations: healthcare and education.  Both have been severely damaged by the ongoing COVID pandemic, and public trust in both has sharply declined. The conclusions voters draw about their performance is likely to determine the outcomes of many races in 2022, 2024, and beyond. Both are facility-intensive, staff-intensive, capital-intensive, credential-intensive, highly regulated, highly politicized and very expensive—between them they account for about 25% of US GDP.

Both sprawl across the public and private sectors, urban and rural communities, and just about every other demarcation in America. Both are deeply consequential: they affect life, death, health, and children. Practitioners in both systems frequently view their work as a calling, not just a job. If we can’t upgrade both of them to a much better level of pandemic resilience, the negative consequences rippling across our economic and social fabric will exacerbate all our other problems for years to come. In short, if both are in crisis, let’s not waste it.

We all would much prefer that the pandemic end soon; we hate to hear experts predict that a transition to endemicity could be years in the future. Although we may well enjoy a welcome respite from high infection risk this spring, the odds are good that COVID is not done with us yet and may repeatedly rock our world for at least several more years, depending on how effectively we can tamp it down, both domestically and globally.

Meanwhile, odds of a new pandemic candidate appearing within a decade or so are uncomfortably high; we seem to be at the beginning of an era of global pandemic vulnerability. Whether or not we have more COVID-level catastrophes (and escape the one we’re in) depends on how well we can harden our major systems against such pathogens. The hardening process has legal, economic, moral, political, emotional and social components: six impossible things before breakfast.

It’s hard to get excited about endemicity because it means accepting the long-term presence of the SARS CoV-2 virus in our lives. Perhaps in another decade or so we can circle back and tightly control it with lights-out long-term childhood vaccines, as we have done with many diseases, but meanwhile, our task is to get past the crisis and settle into an endemic relationship with our new virus flat-mate.

In an endemic relationship, we will have achieved a stable, predictable balance between pathogen and host, such that our systems—personal immune systems, healthcare systems, economic and social systems—can function in new normal ways, rather than lurching from crisis to crisis. Most familiar causes of death are endemic: we haven’t cured traffic fatalities, lung cancer, or HIV/AIDS, yet the number of new cases each year is predictable within a narrow range, there are protocols for treatment, there is R&D, and life goes on.

Endemicity may not be exciting, but stability and predictability are the lifeblood of ponderous, complex systems such as education and healthcare. We have achieved it many times in the past: Confiscating Typhoid Mary’s pump handle worked, as did building modern water and sewer systems, and denying mosquitoes habitat by draining the swamps. The challenge this time is the toughest yet, because our urban, mobile, and global way of living has created a vast opportunity for highly contagious airborne pathogens.

Healthcare and education are two pillars of modern living. We can’t just turn them off to wait out pandemics, so we must make them functional under fire. What we learn from this difficult process will become best practices for other congregate activities—business, government, entertainment, worship, Zumba—the whole lot. Humanity is capable of greatly reducing its vulnerability to aerosol pathogens. Doing so will be approximately as hard as addressing the climate crisis, but these twin crises are related, and the solutions will also be related: both require a deep restoration of public trust in large institutions, a trust which can only be earned, not messaged into existence. Since Healthcare accounts for about 18% of GDP and is Ground Zero for the COVID crisis, let’s begin there.

Healthcare

An emerging Delta winter surge overtaken by a breathtakingly fast Omicron surge has hit our healthcare system hard, again. Omicron’s case fatality rate—the ratio of deaths to cases—is notably less severe than the rates experienced last winter and last September, but the total case rate is staggering, and is pulling hospitalizations and deaths upward in the US significantly more than happened in South Africa and the UK.

There are already more COVID cases in US hospitals than ever before (this did not happen in South Africa or the United Kingdom), pediatric hospitalization has more than doubled Delta’s peak, and the death rate is up over 40% in the past two weeks. In the US cities where Omicron exploded first, hospitalization rates are climbing steeply 14 days behind case rates, and death rates are climbing steeply 7 days behind hospitalization rates. At the same time, the case rates may have peaked in those same places, and the national in-hospital-with-COVID total has dipped slightly for the first time in over a month. We won’t know for a few more days whether this dip is a downward turn or a blip on the way further up: as the new case rates are dropping in the states Omicron hit first, they are rising steeply in other states.

Although Omicron appears to be less innately virulent in its impact on adults, there’s some evidence that it is more virulent for patients under the age of 5: hospitalizations of patients under 5 are five times higher than the highest previous level, and this has happened purely since Omicron became dominant. Age five is an arbitrary number set by data collection protocols—the actual age under which Omicron is more dangerous could be higher or lower.

Since the case rates are so much higher than at any previous time, even the “milder” Omicron is swamping hospitals, sickening healthcare workers, and driving another wave to the cemeteries: there have been 42,000 confirmed COVID deaths in the US in the past 28 days, reflecting a likely hybrid of Delta and Omicron cases. The average daily death rate today is close to 2,000. If that sustains for a month, we’ll lose another 60,000 people.

Peak rates of death in the current surge could exceed the peaks seen in the first Delta surge which peaked in September, and perhaps also the initial COVID surge in early 2020. This surge may be shorter, leading to fewer total new deaths than Delta has caused, but death rates have been elevated since last July.

Washington State is one of 14 states at the moment whose hospitals are (thanks to COVID) “forecasted to exceed capacity” (we are reportedly at 96% of capacity as of January 17 and have topped 100% several times in recent days), 2 states are “at capacity,” another 8 states are classified as “unsustainable,” 20 are “at continued risk,” and only 7 “have capacity” at the moment. Forty-three states, therefore, are at or close to circuit breaker status, where non-COVID procedures must be deferred.

The earliest places to suffer Omicron surges are reporting slowing new case rates, but they may be weeks away from the peak in deaths. There’s a bright spot: according to Kaiser in California, Omicron patients in their system leave the hospital significantly sooner than Delta patients and die less often, which suggests that the total Omicron impact-per-admitted-patient on hospitals will be lighter, even though the total daily patients-admitted data is breaking all records.

It is also becoming clear that the vaccines are doing an incredible job of saving lives: unvaccinated people account for a minority of the total population, but a large majority of those hospitalized, and a vast majority of deaths. The 10% of our population that is uninsured is also largely unvaccinated, meaning that the failure of the healthcare system to care for everyone is making the pandemic substantially more dangerous for all, and specifically damaging the healthcare system itself.

Our healthcare system has been repeatedly rocked by two years of COVID, with an estimated 20% above replacement of healthcare workers leaving the field, either by changing careers, taking extended time off, or dying of COVID. Now add to that the workers driven away from work by waves of breakthrough Omicron infections (estimated at 15% in some hospitals), and the system is in an unprecedented crisis.

It has also been weakened financially, as COVID waves have kept its “profit center” patients needing major surgeries and other treatments away. When COVID causes people to die at home who could have been saved in hospitals, these are not only unnecessary personal tragedies, they are also, in the healthcare system, lost high-margin revenue opportunities.

We have no idea yet what impact Omicron’s huge wave of cases will have on Long COVID in the future, but we know Long COVID will be a major ongoing challenge our healthcare system, since it is hard to diagnose and treat, is a notorious shape-shifter, and is a broad-spectrum comorbidity, increasing the challenges presented by diabetes, heart, lung, kidney and liver diseases, cognitive decline, and many other serious chronic conditions.

It may cast a very long shadow into the future. It seems to be a considerably bigger problem that the after-effects of other infectious diseases, but data is still scarce. There’s been a recent report that vaccinated people who are subsequently infected have a low rate of subsequent Long COVID, which is good news. It’s not yet known whether having been previously infected provides protection against Long COVID from a subsequent reinfection. The sheer scale of the Omicron wave makes the Long COVID question even more important for the healthcare system.

We are due (again) for a reckoning in healthcare. Our inordinately expensive system (18% of GDP, vs. 10% in other rich countries) is atrocious at caring for the uninsured 10% of our population, and now it is also burning through staff at an unsustainable rate. Our system maintains a chronic relative shortage of doctors, now aggravated by the pandemic. If the system holds together through the current surge, a major effort should be undertaken to help it prepare for multiple subsequent blows that will be delivered by our hyper-connected, pandemic-friendly world. As with so much else in our lives, healthcare needs to invent a new normal, not reconstruct the old one. Think of it as an opportunity.

We have, of course, been debating healthcare for years. COVID is resetting the terms of that debate. Not only will it batter staffs, leave a significant number of people with long-term health impairments, and create financial difficulties, it is also now driving a more generalized anti-vaccination sentiment which seeks to roll back ALL childhood vaccine requirements, setting us up for recurring measles outbreaks, etc. Meanwhile, we need to figure out how to prepare the system for a future in which new pandemics could be a recurring threat, and the need to treat a significant population of permanently impacted people will endure. With all that in mind, let’s turn to healthcare’s institutional sibling, education.

Education

I’ve been talking to educators. I’ve heard a strong, almost primal desire by K-12 teachers to teach in person, but also reports from the front lines that the COVID isolation and quarantine rates among teachers and staff are high enough in many places to push some schools back to remote learning, not because most teachers, parents, and students don’t prefer in-person learning (despite the risks and their anxieties), but because laws, not unreasonably in pre-pandemic times, do not allow classrooms full of kids without qualified teachers.

Substitutes are in short supply, and many of them are retired teachers, who are therefore older and at higher risk themselves. Schools without sufficient teachers able to be in the classrooms in person with kids won’t be able to let the kids come to school, no matter how much that frustrates parents, political leaders, and pundits. School districts are trying hard to stay open and avoid system-wide shutdowns, but the number of individual schools which closed abruptly for COVID reasons (over 5,000) set new records last week. In many classrooms, I’m told, about a third of students are absent on any one day, as they test positive or have been close to someone who has and must isolate or quarantine.

It’s clear that school boards and other political leaders with the authority to switch school systems to remote learning are extremely loathe to do so, for three reasons: 1) Remote learning works great for some kids, but not so great for many more, and not going to school damages a lot of kids and disrupts a lot of families with working parents; 2) It’s not clear that having kids in school is a much worse scenario from a disease transmission standpoint than having them at home, especially if schools provide good ventilation, have high rates of vaccination, and make appropriate use of masks and other protocols; 3) There is very little public support to send kids home—it’s political suicide. This last is probably reason number one in real life.

At the college level, the issues are fairly similar. As with secondary teachers, many professors vastly prefer in-person teaching, though many are not young and are therefore at risk. As with K-12 schools, if the Omicron wave sends faculty and staff into quarantine or isolation in large numbers, the instructional function of the schools cannot be realistically sustained through in-person learning. Schools can, however, keep the students on campus, and mix in-person with remote learning as best they can, and this is what will probably happen.

Colleges and universities really want those tuition/room/board checks to keep flowing, and remote learning from home stresses their revenue stream. Parents generally prefer to have their college student children at actual college, especially if they’re paying through the nose for it, and the students generally agree. As with K-12, the short-term disease/death risks to vaccinated & boosted students are quite low, and the Long COVID risks from Omicron infections are simply unknown.

A Modest Proposal

Scientists have warned us that humanity’s extremely global, mobile, urban way of living, combined with our push into the bush is an invitation to new airborne pandemics, sooner or later. Or, more likely, both sooner and later. Sooner is here now, and if we want to live through later, the sooner we prepare the better. Protecting our institutional engines of modern life, notably healthcare and education, would be a good place to start. How might we proceed?

I think decision makers in healthcare and education need to place less emphasis on just-in-time metrics and more emphasis on just-in-case planning. Just-in-time is a management philosophy which in its narrowest sense shaves costs by buying components as late as possible and managing supply chains very efficiently. More generally, JIT stands for maximizing financial performance by minimizing assets tied up in reserve positions, and then using those assets as productively as possible in the here-and-now.

In modern times, JIT management has given us marvels of high-speed efficiency, leading to lower prices on many things we love to have, and it has certainly delivered more shareholder value. However, it has built more and more invisible risk into many systems. To use Nassim Nicholas Taleb’s terminology, many of our systems have been made fragile in order to become maximally efficient. The efficiency is in part illusory, because the costs of fragility have been wished away. Fragility has potential costs that remain invisible until they suddenly appear, and they can be existentially large. We are living through proof of this now, as we have scrambled for doctors, nurses, teachers, bus drivers, syringes, coolers, tests, masks, gloves, refrigerator trucks, HEPA filters and so forth down an endless list.

Just-in-case thinking speaks more like a midwestern grandparent: better safe than sorry, an ounce of prevention is worth a pound of cure, bring a sweater. JIC thinkers are content with lower return-on-assets in the near term, in order to gain extreme value from those assets by having them available to thwart a great threat in the long term. Clearly, we could have used a little more JIC thinking in our essential institutions before COVID hit.

I’m not advocating a black to white shift, just an intelligent reset. Efficiency remains an incredibly good thing, and prudence should not be an excuse for giving up on it. But efficiency which ignores the need to prepare for not-fully-defined threats is false efficiency. It’s time to ask how we can beef up the JIC performance of healthcare and education to appropriate levels, and simultaneously persuade voters, patients, employees and investors that this is a smart, essential thing to do.

With that goal in mind, here are nine large-scale, long-term strategic initiatives to make our education and healthcare systems fundamentally more resilient in the face of pandemic disruption. They are not novel, but they are reconsidered in the light of our urgent need for a strong just-in-case infrastructure.

We need such initiatives because there’s a significant chance that if we don’t pursue them successfully this pandemic will linger for years, and the next one may come close on its heels. Since education and healthcare are similar in many fundamental ways, both benefit from the same efforts. Each of these initiatives in some way sacrifices some amount of peacetime efficiency to increase wartime resiliency. All of them depend on earning greater public trust. The JIC/JIT ratio will be increased. Resiliency is due for a comeback.

Nine Things To Do

1. Massively upgrade indoor air quality

Past pandemics have spread in a variety of ways: direct physical contact with an infected person, exchange of bodily fluids, mosquitoes, rats/fleas, contaminated drinking water, and the legendary fecal-oral (polio). Viruses evolve to take what’s given to them, and we no longer give them easy access through some of these old routes. What we DO give them, more than ever, is the opportunity for aerosol spread. We are numerous, and we cluster indoors. We cluster in cities. We whiz around the world clustered in planes, trains, and automobiles. We inhale each other’s exhalations far more than we used to.

One way to move the needle against aerosol transmission on a massive scale is to upgrade indoor air quality through better ventilation, filtration, and monitoring. Masking, which can be thought of as personal filtration, is fairly effective; done reasonably well, it seems to deliver about a 30% reduction in COVID transmission. Masking is quick to adopt at the individual level, but very hard to institutionalize. It’s a great emergency measure, and good as one more layer in a multilayered defense, but it’s burdensome over time, and last year it became a flashpoint in our individualist culture. To the extent that building-level improvements in ventilation and filtration reduce the need for mask-wearing, they’ll be popular. Increasing building ventilation pushes against the need to improve the energy efficiency of building heating and cooling, so ingenuity will be required.

We should be able to set and execute standards for ventilation, filtration and monitoring that will greatly reduce the risk of aerosol transmission in enclosed spaces. Such upgrades would benefit schools, hospitals, offices, apartment buildings, concert halls, movie theaters, arenas, and even private homes, where most transmission occurs. Taken to a high enough level, ventilation, filtration and monitoring improvements could significantly reduce the impact of the next pandemic (and the length of this one).

Safe, clean, energy-efficient indoor air on a national scale should be a high priority at every level of government. It’s a complex problem, because it impacts a welter of building codes, business practices, institutions, laws, lobbyists, and entrenched habits, and it will not come cheap. The sooner we get serious about it, the better. Robustly clean air is a just-in-case asset that also delivers just-in-time benefits—students and staffers think better when CO₂ levels are lower! Unlike vaccines, ventilation improvements are not pathogen-specific: they improve our defenses against anything airborne.

2. Solve the problem of vaccination hesitancy

We have paid a very high price for the fact that so many Americans have not yet chosen to be vaccinated. One estimate suggests that if vaccine acceptance had been nearly universal, so that vaccinations happened as fast as vaccines became available, the US might have suffered 200,000 fewer COVID deaths so far. The reasons for vaccine hesitancy or outright rejection are varied and complex, but they generally have their roots in distrust of the healthcare system, distrust of the pharmaceutical industry, and distrust of government. What’s needed is not a PR campaign to sell vaccination so much as a much deeper effort to undo the distrust problem. This is not going to be quick or easy, as it requires reforming federal and state public health agencies, the regulatory environment for the pharmaceutical industry, various international agreements, and our thoroughly effed-up healthcare system, not to mention toning down what passes for humor on social media. And then it will require persuading people that these reforms are real. As with ventilation, so too with vaccination: the sooner we get serious the better. Reducing vaccine hesitancy is a very powerful just-in-case strategy—the benefits are modest until there’s a pandemic, and then they are huge.

3. Ensure rapid global delivery of vaccines

We learned this time around that we have amazing technologies to rapidly develop vaccines. These technologies, such as mRNA and protein nanoparticles, are not limited to viruses, but can be deployed against any pathogen. We should figure out what’s working best this time and prepare to do it much better next time, and do it strategically from the beginning, so that we avoid the extreme differences between countries in vaccination rates. This means planning to overcome development, testing, manufacturing, distribution, financing, cultural, and last-mile challenges before they confront us again.

Pharmaceutical companies, pre-COVID, did not love the vaccine business: it was a long slow process to invent them, they destroyed their own markets in some cases, and then became commodified. Big pharma has had little incentive to tie up assets in order to be ready for huge-rapid scale-ups in vaccine production and distribution: where’s the profit in that? As we learned, vaccines require not only the bioactive agent, but also all sorts of other stuff to go in the syringes, the syringes themselves, the facilities to actually manufacture and assemble them, cold chain transportation, and so forth.

Getting the vaccines manufactured and distributed to loading docks doesn’t do the whole job, either: who is standing by to administer those vaccines to whole populations? Who is preparing those populations to accept the benefits of being vaccinated? The global impact of COVID may create an opportunity to gain global cooperation, which will be essential, but we’ll also need policy and money to maintain a system that is ready to rapidly vaccinate over seven billion people, not just those in the first world.

4. Master non-pharmaceutical competency

As we learned anew with COVID, if most people in a population quickly agree to wear effective masks, it can make a big short-term difference in transmission. The same is true to some extent for isolation (when you’ve been exposed but might not be infected), quarantine (when you are indeed infected), testing and tracing, social distancing, handwashing, and whatever else might work against a particular pathogen. Even done in a fairly half-assed way, these practices undoubtedly spared the US many deaths in the early days, and did indeed flatten the curve, though unevenly and at high cost. Thus far, the US has suffered about 2,600 confirmed COVID deaths per million people, 19^th-worst out of 155 measured countries, and worse than every other rich nation. We’ve had mask shortages and test shortages, deficits in political leadership, polarization, confusing rules, glaring inadequacies of relevant data, and we’re still struggling.

We need to be ready to quickly distribute a lot of masks, gloves, hand sanitizers, etc. We need to be ready for rapid test development, manufacturing, and distribution. These things need to be planned for, with playbooks, rehearsals, and stockpiles. We also need playbooks, rehearsals and stockpiles in high-risk environments, just like fire drills, so that concentrated populations know what to do when the pandemical alarm bell rings. As with vaccines, we need to address the deep underlying distrust many citizens feel for government, healthcare, and the pharmaceutical industry. This too is a complex challenge that will take time to address.

5. Establish a global early detection and containment system

At one time in the not-too-distant past, America’s CDC and its global counterparts cooperated to some extent in tracking possible disease outbreaks with pandemic potential. This system needs to be built back much better. China behaved very badly in the early days of the SARS CoV-2 outbreak, WHO did not cover itself in glory, a Trump-maimed CDC failed to provide good domestic or global leadership (and is still scuffling), and money for disease prevention is always harder to wring out of legislative bodies than money to respond to emergencies. We need a global pandemic sentinel system, to give us a chance to contain new pathogens before they can spread very far, and a chance to buy time to develop tests, vaccines, and treatment medicines and protocols early. This is pure just-in-case, with a huge potential upside in damage prevented.

6. Embrace schools as homes-away-from-home, not just education factories

We should recognize that our K-12 schools, just like college, serve a huge social purpose beyond instruction—they provide safe places for children to spend the day, socialize, feel some love, and get fed. K-12 education’s baseline function is as a childcare system for 55 million children, on top of which they enable learning. When they cannot perform that baseline care function, the harm falls disproportionately on children with less support at home, if they have a home. The states should change the laws and add funding to allow schools to become, when needed, giant daycare centers rather than closing for lack of healthy qualified instructional staff. Hire young, vaccinated daycare workers as necessary to keep the kids in school and looked after, even if instructional intensity takes a hit sometimes. Even constrained in-person learning is likely to be better for many students than remote learning, and for many children a lot of what they learn in school comes from the social matrix of school, not just the instructional curriculum.

7. Accept that some form of universal healthcare is essential

As resistant as rural Republican males might be to vaccination, they are not alone: the other group that is most vaccine hesitant are people without health insurance. Millions of Americans have no ongoing relationship with the healthcare system because they are not insured. When it comes time to get vaccinated, they don’t even know where to begin. They suffer the most from this, but they also increase the danger for everyone else.

COVID reminds us that there are benefits to everyone from having everyone else receiving basic healthcare. This isn’t the right place to launch into a comparison of healthcare alternatives, but it might shift the framework for that comparison in a productive direction to focus on the benefits everyone receives from universal healthcare during pandemics. The national healthcare systems in Europe have also buckled under the onslaught of COVID, but they have generally achieved higher levels of vaccination, and that’s paying off for them now.

8. Create much better real-time data collection systems.

The US has spent much of this pandemic flying half-blind, and the consequences are serious. We have much less information that countries such as Denmark or Great Britain about which variants are where, who’s dying of what, which preventative measures are more effective and less effective, and so forth. Without the data, we can’t fix the problems. Americans are wary of data collection (except when responding to stupid questions on social media), so political leaders are wary of proposing better data collection, but we’re paying a high price. If we want to systematically harden ourselves against future pandemics, we need the numbers.

9. Directly increase systemic resiliency

The same mentality that created just-in-time manufacturing also created the staffing version of that: employers hate excess headcount, because labor is often their biggest cost. Many hospitals and educational systems have tried to run “lean and mean” for years. This allows for greater efficiency in normal times but makes them fragile when stressed. Under assault from COVID surges, hospitals are unable to scale up their care as much as needed because they can’t increase staff fast enough (along with beds, supplies, floor space and everything else), and schools face an equivalent problem—they don’t have access to qualified instructional staff to fill in for those who step aside, and no “Plan B” for retaining their childcare function even when their instructional staff is depleted.

There is a model for what to do about this: the National Guard. The mission of the National Guard is to create reserve capacity that is quickly deployable to meet crisis levels of demand. It’s not as cheap as just-in-time when there isn’t a crisis, but vastly more effective during a crisis. The National Guard trains people to perform tasks normally executed by the active military, drills them periodically to keep their skills somewhat fresh, and pays them to stand by and stay reasonably ready to be called to active service as needed. Guard members are not expected to be quite up to the standards of those in active service, but close enough. Most of the time, they have a day job doing something else, and legally mandated job protection when duty calls. The National Guard is already providing some support in hard-pressed hospitals, but there’s been no program to create a bigger pool of people with skills in medicine and education who have been paid to keep their skills good enough and are pre-committed to a certain degree of availability. What would an equivalent program look like for instructional and medical personnel? What sort of recruitment, training, certification, drilling, remunerating and call-up protocols would be effective and appropriate?

The same question might be asked about other critical materials and supplies: how can we develop just-in-case reserves of field hospitals, oxygen, masks and gloves, injection kits, mobile HEPA filters, per-student hardware and software and so forth? What’s an appropriate process? Who specifies what’s needed? Who pays?  How is deployment specified, managed, and rehearsed? What does it mean to rebalance just-in-time with just-in-case?

Currently in hospitals there are many procedures which require full MDs, others which may be performed by Residents, Nurse Practitioners, Nurses, and so forth. How about cross-training down the ladder specifically in infectious disease protocols, so that, in a crisis, the shortage of full MDs is less of problem? Make it legal to grant the equivalent of what the military calls a “field promotion” in which, for example, a nurse practitioner with appropriate training can be promoted to perform as a doctor within a specified range of duties during an infectious disease crisis if doctors are in short supply.

In order to shift toward a resilience mindset, education and healthcare managers need to believe that their constituencies require it. Historically, they have not received this message except in brief windows when it’s too late. The process of transition to be more JIC and less JIT will be daunting, but the alternative is worse.

If we wish to avoid a delayed end to the COVID tragedy and perhaps a repeat, we should use the time and motivation we have gained with so much sacrifice to create a more resilient social and economic order, starting with our essential institutions in healthcare and education. The task is a lot harder than a mere Apollo Program or Manhattan Project, because it requires unprecedented participation by vast numbers of civilians, which requires a level of public trust that is currently lacking. Nevertheless, if we pretend education and healthcare don’t need to be substantially retooled, we are choosing to play whack-a-mole while playing the part of the mole.