interviews
An Introduction to Care | Part Two
by Dr. Kali Cyrus
February 13, 2020
Dr. Kali Cyrus is our February co-editor. This is part two of our conversation.
There is a lot of off the clock work happening, and out of pocket spending. So much of the care falls on staff after hours.
I would call it the out of pocket / out of office hours commitment. In terms of the costs to me, if I happen to be a doctor who gets bothered, a doctor who works in the public system, what ends up happening is most of my time is not actually spent treating the person's mental and physical health. It's mostly spent trying to figure out case management issues.
If we know this person doesn't have any food at home and they need to be taking their meds with food, or this person doesn't actually have a primary care doctor and they're smoking half as many cigarettes, which is usually the case, or their blood pressure is 200 over 120, or they keep getting hospitalized for medical reasons, if they're in a house dealing with trapping every night, they can't get sleep, it worsens their depression, and they're in a crisis and calling the cops, I can't do my job.
It isn’t really monetary, but as a team, we spend most of our time trying to figure out how can we get this person food when they may not be eligible to get free food from the state district, how can we actually try to get this drug dealer to forgive a debt – which is like, how can we do that?
What we end up doing instead of focusing on what kind of medications can I give you, or how can I meet with you on a weekly basis and talk through what you need to change, what is a path to recovery, is trying to manage the social stressors. It more so impacts social workers or people who've gone to school who want to be therapists, they end up being case workers. They end up doing these kinds of things, you can talk to them and use your therapeutic knowledge in that way, but it's a very different job that requires a lot more patience because you're dealing with systems that are so non functioning.
It's like going to the post office every day and getting in line for eight hours.
It's essentially what that part of the job has become. I think the other end of it, if you think about teachers who end up spending their money to buy supplies, that type of stuff, I don't necessarily end up in that position because I'm the physician. That's something a lot of us have very strict boundaries about. If I have a patient asking me for food, I'm at a clinic or I'm at their house, I'm not going to. No one would expect me to go run to the grocery store. That's going to fall on my staff. If my staff goes to see them three times a week, they're the ones who are going to get asked for money three times a week.
Think about people who work in group homes, where you have mental health patients with people who have other physical or mental disabilities, staffed by people who are not necessarily nurses. One, you're not making a lot of money and you're supposed to be in house with them all day, those are the clients saying, "I need a cigarette, I need a cigarette" when they've already used up all their cigarette money. But if they're going to flip, they're going to punch you in the face because they have a psychotic illness and they don't have the insight into knowing that you can't just give them cigarettes, cigarettes, cigarettes – they'll go buy them cigarettes if that's the thing that's going to keep calm.
Thinking through the costs in that way, is something I've learned from, and the way I've tried to help my staff out is however I can apply to services for them. I have some people in D.C., once I find out that they're at an age where they could potentially qualify from a home health aid, I apply to everything. I try to get them meals on wheels. I try to get them this thing, that thing. Many of them have been denied in the past, maybe they haven't really tried, or maybe they aren't eligible, but the main way is to try to get them as many services as possible, which then leads to complicating the treatment because you have four or five different agencies involved, and you're trying to figure out who's doing what, which is a different problem, but a better problem to have.
For the most part, the out of the pocket comes from my case workers. You end up spending a lot of money to help the system function to help your patient.
What needs to happen for these systems to work more cohesively?
I think about it as large group solutions and smaller more immediate solutions. In terms of the large overall solutions, I think crisis, I think crisis settings. I really believe in the urgent care system. If you're having a crisis right now people come to the ER and there's no beds to send them to. No long term hospital spaces. Not everybody needs to be in the hospital for seven days a week, 24/7 to be monitored.
We can move them to this middle unit where they can be kept safe for a little while. Some of them just need to get through the weekend. Observation units that aren't hooked up to all the expensive hospital bays are really great places, and then a lot of people can go home after that. They might not need the five days, they just need a couple of days. And I've found that that's a good workaround of not having inpatient beds.
I've also found that outpatient urgent care settings are good. It's a nine to five clinic, with staff, social workers, usually one physician, some peers. You can walk in off the street. It's an outpatient model, imagine how much money you save in that.
You can deal with the multitude of crises by having some place where you know you can go that's not waiting in the ER for eight hours.
In terms of the large system, it's groups. If you're not going to magically be able to reimburse every psychiatrist or every outpatient, why don't you have more groups of people, who once they leave the hospital just need something from six to nine. Think about AA in terms of mental health treatment, they need other people who are going through the same things they are that are staffed by social workers or staffed by psychiatrists who can provide ongoing care for them, in a model that's in a community center somewhere. That's not expensive and something the state can pay for.
Imagine the quality of what you could have at that time. It's not one reimbursable, so it's not there. Obviously the other individual level solution, you need a meals on wheels program or functioning transportation to help people get to appointments. You could even put a psychiatrist or psychologist in primary care offices.
My simple answer is how do you incorporate mental health players in these spaces? Making sure you at least know there are places that you can go. That takes investing in social services not just mental health centers. It's investing in the community itself.
interviews
Impact Investment For The Circular Economy
by Rob Kaplan
December 23, 2019
Rob Kaplan is Founder and CEO of Circulate Capital, an impact-focused investment management firm dedicated to financing innovation, companies, and infrastructure that prevent the flow of plastic waste into the world's ocean while advancing the circular economy.
This article was originally published in our January Issue on Plastics.
How do you define a circular economy?
I think a circular economy is one where commodities and resources are managed in perpetuity. So that there is no waste, but instead it's a resource for future innovation and product manufacturing.
In transitioning from a linear system to a circular one – who becomes responsible for the end of life? Especially in a time where goods are globally dispersed.
Well, I think the answer is that everybody's responsible. There's no single entity that is responsible for how it's managed at the end of its life, in my opinion. That's why this is a systems challenge that requires a systems solution.
Part of the challenge you're noting is the aspiration of a circular economy with the reality of where waste exists today. Because, circular economy in many ways is an aspirational concept. Especially within consumable products. It doesn't really exist. As we look to invest in companies that can prevent plastic pollution and instead drive towards more circular opportunities, it is a matter of degree. It's not, we'll get there tomorrow in that perfect ideal. It's more about, we've got a lot of waste that's not being managed appropriately. How do we improve that in a way that can create value for those communities? And also prevent the pollution at the same time.
What do some of those solutions look like in practice for you and the companies you work with?
We've been looking at how to invest in South and Southeast Asia for the last couple years. I'd say most of the opportunity that’s "shovel ready" today is in the waste and recycling sector. They are usually startup recycling companies that are generally the first line of formality. Where they're buying materials from waste pickers as well as municipalities in some cases. And then adding some kind of value to it. We also see a number of recycling facilities. They're a little bit further downstream from the collection aggregation. We have started to see a little bit of reusable and returnable systems, but they're in a very early stage at this time.
When you work with a large multi-national company, such as PepsiCo or Coca-Cola, what does their commitment to this process look like?
They have two different levels of commitment. The first is they are committing to improve their own operations and supply chains. Almost all of our investors have direct commitments about what they're doing to increase the amount of recycled materials they use in packaging and design for recyclability. Then, they are also committing capital to our strategy to allow us to invest in companies that can increase the amount of recycled material available for their use and the use of others.
They are also providing expertise and resources, and network. They are providing essential off-take and the ability to buy the material after it's collected and sorted. That's a big part of the challenge. The market that's available to buy this material. Needing that kind of surety of off-take.
We’ve discussed circular economies from a variety of perspectives and backgrounds. Science, academia, advocacy. You approach it as a business. Why is your work a necessary part of the puzzle?
The particular slice of the problem we are looking at is plastic pollution in Southeast Asia. We quickly realized it was going to take many billions of dollars of capital to build the infrastructure required to really stop the flow of plastic leaking into the environment and the ocean. We started to look at where would that capital come from? And we realized that it's not going to come from necessarily consumers or companies, but really, institutional investors that are financing the future of infrastructure in Asia. The only way to get those folks involved in this space is to show them that it's an investable marketplace. That there is a track record. That there is a pipeline of opportunity. And that you can make money doing this. We want to demonstrate that investing in waste recycling is as boring as investing in roads and bridges, for which there is a lot of capital allocated.
Our approach to this was “How do you turn this from a waste stream and a cost center into a profit center as a way to unlock that capital?”
When you say infrastructure, are you talking landfills, incinerators? What is that infrastructure?
Our focus is certainly on the recycling and reuse side. I think there is a reality that they need to have improved landfills in Southeast Asia too. But we're not particularly able or interested in financing landfills and incinerators are out of our scope.
Has the China recycling ban affected your day to day?
Oh yeah. I mean National Sword basically turned the entire recycling industry upside down globally. In the markets that we're particularly focused on, they were exporting waste to China too. They hadn't invested in their own domestic processing. That has caused big problems for them and has created great opportunities for investors, who are trying to build those companies within those countries, under those infrastructure projects.
I think most of the countries we're working in in Southeast Asia have also started to follow China's lead and stop accepting imported waste. The US and Europe are not contributing as much to ocean plastic these days as we used to. Because the exporting markets have dried up.
I think there's probably a shifting in the future where more of that will go to Africa, right? Because they haven't started those bans. But most of Southeast Asia has already either halted imports or is talking about halting imports.
Does all of this help move the agenda of circular economies further?
Absolutely. It was so cheap. No one had any incentive to invest in domestic circular economy opportunities because if you were in Los Angeles it was cheaper to ship a container of waste to China than it was to Chicago.
That's crazy.
One important point that I've been trying to communicate lately is that there is no silver bullet for these solutions. It's incredibly complex. People really look for elegant, simplified solutions. But a circular economy is complex. We're not going to be able to reduce our way out of this problem just like we're not going to be able to recycle our way out of this problem. You need both and many more solutions. I worry about absolutists that are trying to push agendas rather than really trying to drive environmental progress.
Our approach is very much, how do we deploy capital as much and as quickly as possible to stop this pollution and make triple bottom line in the process of doing it? Rather than, you know, any political perspective or point of view, it's really just the view of the investor that we're looking to bring to the conversation.
All or nothing doesn’t work here.
Yeah. It's really complex. How can anyone say that there's a single solution to something? If it were that easy, we would have figured it out already. And I think we're also starting to see, because of the topic getting so hot and everyone wanting a piece of it, they're all saying, “Well, what's my contribution?"
Right.
My contribution is activism. My contribution is lobbying or my contribution is X, Y, and Z. And so they're all sort of piling on without a really clear theory of change about where they think they're trying to drive the progress.
Has the re-upping of investment from petrochemical companies into the production of plastic affected your work?
Yeah. One of the interesting things about plastics and circular economies is you actually want that feed stock, right? If you start removing feed stock opportunities, like PET plastic, which is what most beverage bottles are made of, for example, that's really problematic from a circular economy and recycling perspective because PET is the most recyclable plastic that we have today. You'd want to see more of that recyclable material out there. Right now it's cheaper to make plastic out of petroleum or natural gas in the US. It could be cheap to make it out of old plastics. That's where I think the big unlock towards the circular economy comes in. How do you tap into those market forces of building massive chemical facilities and use that as your off take for recyclables? That's the opportunity to change the game and that's your supply and your demand.
Are you optimistic that that will start happening?
I think the petrochemical industry is starting to show that they're really interested in that idea. I think it's really complex and hard to do. There's a lot of barriers. But it's not a technology barrier necessarily.
Is it a political barrier?
It's not so much a political barrier, I think but... Why do you think it's a political barrier?
Because of the political and financial incentive to produce and frack natural gas. How do you switch where incentive lies?
Yeah. I think you're right there. Policy is a huge part of that. Especially in the US where natural gas is so cheap thanks to policy incentives and new technology. It's not so much the same thing in some of these emerging markets we're working in, which is where energy is very expensive and most of that additional capacity is coming online.