A global health consultant and top TED Talk presenter comments on how healthcare around the world has responded to COVID-19 and suggests practical steps for avoiding a future pandemic of the same scale.
As a global health expert, what do you think some of the best measures against the spread of COVID-19 have been around the world? Which have been lacking?
What the data has been showing us is that the travel restrictions and quarantine worked. What has been lacking is timeliness and making the decisions faster. Europe and the U.S. got those measures in too late.
I think Germany’s high testing rate is an example of a measure that has been very effective because the more you test the more data you have on how the outbreak is moving and the better able you are to allocate resources and make decisions. I would also single out New Zealand and the extraordinary speed they put their travel restrictions into place.
What is the most discouraging thing you think this crisis has revealed about the machinery of healthcare systems? The most encouraging?
It’s an interesting question because it reveals the degree to which a severe shock can make a healthcare system stronger or weaker. If you look at the East Asian healthcare systems, they faced SARS 17 years ago and learnt from that. They recognised that they were unprepared for such a highly infectious virus and they put systems in place so that when COVID-19 showed up they were ready and they responded.
The flip side is we had H1N1 and we got lucky with this because it just wasn’t that dangerous in the end. It spread tremendously but it didn’t have a particularly high mortality rate so we were able to feel we dodged a disaster there. There was an opportunity for the U.S. and Europe to learn from that and recognise they needed to build up their systems. To some degree, the U.S. did but then they let it go to waste. So, for me, the most discouraging thing is how quickly you can lose your readiness and capacity.
Some have argued that, in terms of numbers, the figures on COVID-19 contagions and deaths are low compared to the annual figures for illnesses like seasonal flu. Has there been media hype over this virus spread or is the focus justified?
I think this is an issue people focus on because they don’t want to face the truth. In the OECD, hospital occupancy rates run from about 60% to 90% capacity. That means when they face a seasonal outbreak like influenza they have enough hospital beds for patients with the infection. But when you have an outbreak like COVID-19 you have vastly more people than the system can absorb and you rapidly run out of the hospital beds that you need. People are dying who wouldn’t be dying if decent care was available and then you start running out of supplies and you get healthcare staff getting sick who wouldn’t get sick if equipment was available. Part of the problem is the total number of patients but part is about the speed at which that number hits you. When we talk about flattening the curve, influenza is the flat curve. People get influenza over a period which means they never overwhelm the hospitals. Anyone who has watched the news coming out of Spain, Italy or New York City knows that’s not what’s been happening with COVID-19.
Has the move towards lean management contributed to the above shortages?
Outpatient care is cheaper: it is about having a leaner, more efficient system and conducting minor surgery without paying to keep patients overnight.
But a lean system is a system without reserves or surge capacity. The kinds of expensive inefficiencies like extra beds are also a capacity for resilience. In effect, we have prioritised efficiency over resilience. What we did not prioritise was resilience or surge capacity.
However, I don’t think budgeting has to take an either/or approach. I think you can build in more resilience without losing efficiency. You can run pop-up treatment centres by adding temporary capacity when you need it.
I’d also like to add that, at the end of the day, I think this is a situation about equity. In the U.S. for example, you can see it’s people already marginalised who are dying from COVID-19. I think it is a real wake up call about how we treat every member of society and not just the rich.
What is the most disappointing point you think this crisis has revealed about international health bodies like WHO?
In my view, most international health bodies bungled the messaging around COVID-19 and in particular around staying home and not getting the disease. I think a lot of people in their 20s and 30s were left with the false impression that it was no big deal if they got this disease and the appeal to social solidarity to stay home to protect the elderly didn’t click. They should have focused on the fact that even if it doesn’t kill you COVID-19 is a deeply unpleasant infection to have. Having this disease is a horrible experience and even if you have the mild version, all this means is that you weren’t hospitalised. If they had focused on this rather than social solidarity they might have got social isolation faster.
I also think the phrase social distancing was a poor choice as it doesn’t have any emotional resonance and isn’t immediately understandable.
There has been a lack of coordination and standardisation across, not only the world but different regions in combatting COVID-19. Are you surprised at the lack of unity in Europe, for example, or do you think the staggered response has been inevitable given the involvement of different health systems?
Based on the low level of coordination before the pandemic, I was not surprised by the lack of unity. There is this idealistic view that we’ll all pull together in the face of a crisis but what usually happens is that when systems are under stress we get worse at cooperating on that international level.
I’m sure we could see more multi and bilateral cooperation across healthcare systems once this crisis passes. This situation has pointed to the need of that and it probably will happen.
What is your advice to governments to ensure that a pandemic like COVID-19 can be avoided or at least mitigated in the future?
First you have to think beyond your own national borders. You have to pay attention to what is happening in other countries and when you see a virus outbreak in another country, you have to assume it will come home to your borders rather than assuming it will stay somewhere else.
When it comes to mitigation, you can train your healthcare providers on personal protective equipment (PPE), infection control and how to treat whatever infection is coming. You can learn from the countries that already have it. You can ensure your supplies are in place such as PPE. What is your hospital capacity and how can you rapidly increase it if you need to?
In the area of avoidance, it is necessary to make sure every country in the world is able to recognise an emerging infection when it occurs so that it doesn’t go global. Every country has some kind of healthcare system and is capable of scaling it up with the right help. They’re capable of doing the basics of epidemiology; the simplest epidemiology is very old school. You can do the math by hand if you have to and you can certainly do it in an excel file. A healthcare system is also capable of implementing contact tracing after diagnosis of a patient through literally going and finding everyone they have talked to and testing them. Everybody can do that if they have some support and some funding.
If you could tell health authorities what to do right now to continue dealing with this crisis, what advice would you give them?
It is important to have a plan to transition out of self-isolation. You need infection level benchmarks where particular action can take place, for example, when new infections are under a certain level, people can go out again.
What would you like to see happen once this crisis has passed?
There should be a reckoning on a national level. Every citizen should think seriously about how their leaders handled this crisis and make the correct judicial and electoral decisions based on this. This isn’t something people should forget.