{"id":11101,"date":"2020-05-14T09:43:17","date_gmt":"2020-05-14T09:43:17","guid":{"rendered":"https:\/\/peacerep.org\/?p=11101"},"modified":"2022-01-29T19:19:50","modified_gmt":"2022-01-29T19:19:50","slug":"covid-19-and-health-systems-responding-to-unpredictable-predictability","status":"publish","type":"post","link":"https:\/\/gentest.cahss.ed.ac.uk\/dev-peacerep\/2020\/05\/14\/covid-19-and-health-systems-responding-to-unpredictable-predictability\/","title":{"rendered":"COVID-19 and Health Systems: Responding to Unpredictable Predictability"},"content":{"rendered":"

In an article originally published in Just Security<\/a>, Liz Grant<\/a>, Yina Lizeth Garcia-Lopez<\/a>, and Christine Bell set out 11 themes for health systems to consider when responding to the Covid-19 pandemic. Liz Grant is Director of the Global Health Academy at the University of Edinburgh, with expertise in Ebola crises.\u00a0<\/strong><\/em><\/p>\n

Health systems across the world have been tested by this pandemic, and many have been found wanting, surprised by the pandemic\u2019s ferocity and its unknowness, its seeming unpredictability. And yet pandemics are not new \u2014 the Black Death, cholera, yellow fever, smallpox, the Spanish Flu, HIV\/AIDS. We know a lot about pandemics and can even predict them.<\/p>\n

In an article for\u00a0Just Security<\/a>, Professor Christine Bell identified 11 baseline understandings likely to shape effective responses to the coronavirus pandemic in conflict-affected regions. Based on our experience with fragile and resource-limited health systems, we set out a further 11 themes that all health systems must consider in order to make effective decisions while battling the pandemic.<\/p>\n

1. Build trust<\/strong><\/p>\n

As we have seen in past crises, the effectiveness of responses depends on the\u00a0trust<\/a>\u00a0that people have in their clinicians, and in health systems, to protect them and have their best interests at heart. In the HIV pandemic, the move from fear and authority to a relational approach between patients and their clinicians changed outcomes. One male HIV patient captured the importance of trust when\u00a0interviewed<\/a>\u00a0about his care: \u201cI feel very confident [with my doctors in the infection consultations], because both he and the psychologist advise me. I thank them because they have always been extremely good, they are always aware of my mood and how I feel. Every time I come for a consultation, they take good care of me and I feel very at ease with them and with the whole team here.\u201d<\/p>\n

Yet, in a recent\u00a0comment<\/a>\u00a0in\u00a0The Lancet<\/i>, Robert Peckham quoted a physician who led the 2003 SARS response in Hong Kong: \u201cAt that time [the SARS era] society was more united \u2026 whereas now people feel they have to rely on themselves for protection. They have less trust in the government.\u201d If true, this will pose significant challenges in combatting the coronavirus.<\/p>\n

2. Ensure public access to accurate information<\/strong><\/p>\n

Organizations such as\u00a0Healthcare Information for All<\/a>\u00a0have a vision: \u201cA world where every person will have access to the healthcare information they need to protect their own health and the health of those for whom they are responsible.\u201d The most accessible, simple, and free \u201cmedicine\u201d is accurate health information.<\/p>\n

Lack of information kills. Misinformation kills.<\/p>\n

This lesson was felt acutely during the Ebola epidemics in West Africa and more recently in the Democratic Republic of the Congo. These saw health workers\u00a0beaten to death<\/a>\u00a0because of\u00a0false beliefs<\/a>\u00a0that they were bringing Ebola to the community, that injections given at health centers were full of the virus to kill communities, and that body bags for those who had died were not to protect against bodily fluids leaking and transmitting the virus but to take away body parts for sale elsewhere.<\/p>\n

The strategies to manage this coronavirus pandemic depend on individual and collective responses to a set of essential simple health messages, including wash your hands, stay two meters (or six feet) apart, avoid touching, and stay indoors. But the myths, misconceptions, and inaccurate information about coronavirus have placed thousands at people at risk of severe illness, and caused deaths.<\/p>\n

Social media has amplified a tsunami of misinformation. This includes\u00a0myths<\/a>\u00a0such as: herbal remedies or garlic can cure COVID-19; the virus is spread by 5G; it only affects older people; and spraying alcohol on your skin or gargling with salt kills the virus in your body. The health system needs to be at the forefront of the largest health information campaign in its history, while simultaneously working in tandem with Facebook, WhatsApp, Instagram, and the like, to stop rumors and myths.<\/p>\n

3. Widen the concept of stakeholders<\/strong><\/p>\n

Everyone is a stakeholder in the health of a community and its members. What happens outside the formal health sector is as important to health and wellness as the actions of formal health workers. Cultural, religious, and traditional spaces become even more powerful in times of stress and severe illness, and behavior in those spaces may need to adapt. When rituals, rites, and beliefs such as communal worshipping services, funerals, and religious pilgrimages such as the Hajj have to be abandoned, faith leaders have powerful roles to play in reconstructing communion and recreating spiritual space using the power of symbols and icons.<\/p>\n

Just as<\/a>\u00a0\u201caid modalities may themselves need forms of conflict diplomacy,\u201d health modalities may also need new forms of health diplomacy. And we are seeing a new form of health diplomacy in the public space of volunteering \u2014 informal workers offering their services. Across countries, many without formal health roles have created systems to backstop and safeguard the formal healthcare system \u2014 boda boda drivers in Uganda carrying food to hospitals,\u00a0taxi drivers in Spain<\/a>\u00a0carrying patients to the hospital for free.<\/p>\n

4. Be aware of the health worker gap<\/strong><\/p>\n

How are countries\u00a0managing<\/a>\u00a0the total\u00a0health worker gap<\/a>? We are not aware of any country that has a sufficient number of healthcare workers. The WHO\u00a0projects<\/a>\u00a0a \u201cshortfall of 18 million health workers, primarily in low- and middle-income countries\u201d by 2030,\u00a0unless<\/a>\u00a0significant efforts are made.<\/p>\n

This workforce shortage is across all areas of health workers, but it is particularly acute for nursing. \u201cThe State of the World\u2019s Nursing 2020<\/a>,\u201d which the WHO published on April 6, describes a current shortage of 5.9 million nurses and estimates that there will still be a shortage of 5.7 million nurses in 2030. This shortage overwhelmingly affects Africa, Southeast Asia, and the Eastern Mediterranean.<\/p>\n

Such shortages are further exacerbated in these fluid and uncertain times because some health workers have left their workspaces, and we need to better understand this dynamic. Which health workers have left their worksites for family, health, economic, geosocial, or geopolitical reasons? Who remains within their country, and who crossed borders before they closed? Health workers have become the social and informal political leaders of this pandemic as they, more than anyone else, know what is happening. But with lockdowns, quarantines, and, as\u00a0we have seen<\/a>\u00a0in India, mass movement of workers, many have moved back to their home states, provinces, and countries.<\/p>\n

5. Learn and implement lessons from past pandemics and epidemics<\/strong><\/p>\n

As we mentioned at the beginning of this article, viruses with wide-ranging effects are not new. Many countries have recent experience with pandemics or epidemics, and we should learn from them.<\/p>\n

In particular, Liberia, Sierra Leone, Guinea, Nigeria, Uganda, and the Democratic Republic of Congo developed processes to prevent the spread of and ultimately halt their\u00a0Ebola epidemics<\/a>. They also identified failures in resource utilization and investment made during, and in the wake of, the Ebola crises, and they used this information effectively to ensure that gaps are filled and loopholes closed. The lessons they learned include: work with communities; build on existing community leadership and coordination structures; and, from the very beginning, manage the crisis through the lens of a humanitarian emergency and build in national emergency response capacity.<\/p>\n

6. Understand and address inequalities in access to healthcare resources<\/strong><\/p>\n

Public, private, not-for-profit, and faith-based health services, as well as traditional healers, all provide forms of healthcare, but each has different access to resources and different remits and commitments. It is dangerous to assume there is equality and equity of access to each service and therefore that all members of society have some form of health coverage.<\/p>\n

In this period of pandemic there are\u00a0numerous reports<\/a>\u00a0of hospitals turning away patients too poor to pay and patients with illnesses other than COVID-19 being unable to access care with the disruption in the delivery of essential services. While the disease trajectory of this pandemic points to how essential intensive care units equipped with ventilators are, hospitals across the world \u2014 in New York, Madrid, and Moscow \u2014 do not have enough. Those in many low-income regions have none.<\/p>\n

But it is not just inequalities in high-tech resources; inequalities in access to services, particularly primary healthcare, are also critical. Getting the basics of care right will change the face of the pandemic, but this is only possible when the basic primary care systems are in place. In so many countries these are missing or, if present, unaffordable to the poorest. If ever there were a rationale for\u00a0Universal Health Coverage<\/a>, this is it; if ever there were a time for Universal Health Coverage, it is now.<\/p>\n

7. Understand who is being left behind<\/strong><\/p>\n

Health systems urgently must determine which communities, which groups with which illnesses, which segments of the population are being excluded from health care. As Robert Muggah, principle of The SecDev Group,\u00a0has noted<\/a>, \u201cWhile all populations are affected by the COVID-19 pandemic, not all populations are affected equally.\u201d<\/p>\n

Those living in informal settings globally are particularly vulnerable as their access to health systems was already fragile before the pandemic. Among the many groups identified as likely to be outside the care system, researchers have estimated that, in the U.K. alone, between 30,000 and 40,000 homeless people are living in hostel accommodation or on the streets. Children are also particularly vulnerable, and children in\u00a0fragile and conflict zones<\/a>\u00a0who have already experienced multiple shocks in their short lives are likely to be excluded from health care.<\/p>\n

Groups outside the care system are not only at risk of COVID-19 but also other common illnesses, and they may refuse to come into the health sector or find themselves excluded from it. Moreover, factors outside the health sector\u2019s power in many countries \u2014 crowded living conditions, lack and cost of running water, and protective measures intended to curb the disease \u2014 are the very factors driving the disease. These same factors are also often responsible for hunger, malnutrition, and the exacerbation of other deadly illnesses, including untreated non-communicable diseases.<\/p>\n

8. Address psychological dimensions as core to health<\/strong><\/p>\n

The silent psychological pandemic creeping alongside the coronavirus pandemic \u2014 fear, anxiety, isolation, and loneliness \u2014 must be studied, along with its influence on life and health. Victor Frankl\u2019s\u00a0statement<\/a>, \u201cMan is not destroyed by suffering; he is destroyed by suffering without meaning\u201d resonates across many countries as news outlets tell of patient after patient dying alone. There is a terror of the lonely death, and the unresolved grief of families unable to say goodbye.<\/p>\n

9. Understand disease interactivity<\/strong><\/p>\n

As with other contextual dimensions of this pandemic, the presence of diseases other than COVID-19 affects health systems\u2019 and patients\u2019 experience of coronavirus. For example, Clare Wenham, Gabriela Lotta, and Denise Pimenta\u2019s\u00a0powerful analysis<\/a>, published in \u201cMosquitos and COVID-19 are a ticking time bomb for Latin America,\u201d draws attention to the\u00a0syndemic<\/a>\u00a0that Latin America faces. With dengue, chikungunya, yellow fever, and Zika interacting \u2014 driven by poverty, overcrowding, poor housing, lack of access to water, poor sanitation, gender inequalities, and violence \u2014 the health sponge is already saturated to capacity.<\/p>\n

10. Maintain essential health services<\/strong><\/p>\n

While the focus of all health systems is understandably on tackling the coronavirus pandemic, failure to manage populations\u2019 ongoing healthcare needs could have a far longer, deeper impact on health globally. If child vaccination programs are stopped, if medication for non-communicable diseases such as cancers or heart disease and infectious diseases such as tuberculosis and AIDS are not available, if maternity services are absent, advances in maternal and child health will be reversed and the health of a country\u2019s workforce will rapidly decline.<\/p>\n

However, maintaining essential services is not always simple. The WHO\u2019s\u00a0maintaining essential services<\/a>\u00a0report explains, \u201ca system\u2019s ability to maintain delivery of essential health services will depend on its baseline capacity and burden of disease, and the COVID-19 transmission context.\u201d<\/p>\n

11. Expand valuable practices beyond COVID-19<\/strong><\/p>\n

In response to the coronavirus pandemic, numerous practices have been developed in the crisis delivery of services, such as rapid transition to telemedicine, nurse and doctor task-sharing, and guidelines enabling all clinicians to discuss anticipatory palliative care and end-of-life preferences. Some of these practices could strengthen health services in the future.<\/p>\n

Notably, integrating palliative care into mainstream healthcare could have an unparalleled impact on the global burden of suffering, which was already acute in many low- and middle-income countries. Half of the world\u2019s population \u2014 the 3.6 billion people who live in the poorest countries \u2014 have access to\u00a0less than 1%<\/a>\u00a0of pain medications distributed worldwide. Indeed, the editor of\u00a0The Lancet<\/i>, Richard Horton, has\u00a0described<\/a>\u00a0this great abyss of suffering as \u201can appalling oversight in global health.\u201d The coronavirus pandemic has further\u00a0increased demand<\/a>\u00a0for, and encouraged\u00a0recognition of the significance<\/a>\u00a0of, palliative care. This provides an opportunity to integrate this essential service into mainstream healthcare outside the crisis context.<\/p>\n

The pandemic has challenged to the core the systems that promote and protect our health. It has accentuated rather than initiated capacity failures, organizational gaps, and resource crises in almost all systems across the globe. However, the strategies for shaping effective decision-making and care to battle this pandemic could also be the strategies that will strengthen health systems in the future, making them more equitable, more responsive to needs, and more oriented towards health, rather than disease.<\/p>\n

For further reading, visit the PSRP\u2019s Covid-19 hub<\/a>.<\/strong><\/p>\n

Image: A medical support team augmentation class trains on JBSA-Fort Sam Houston, Texas, Nov. 18, 2014. Fifth Army \/ Public domain via Wikimedia Commons<\/a><\/i><\/p>\n","protected":false},"excerpt":{"rendered":"

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