Nothing in recent memory has tested healthcare systems across the global north (higher income and developed nations) the way the current pandemic has. I use the word ‘systems’ specifically in this case, for it is the way we view the delivery of healthcare as a system that determines our local and national responses.
In Rwanda, President Paul Kagame recently launched emergency food rations to be distributed to over 20 000 families in the capital city Kigali to assist citizens in adhering to and surviving through the strict lockdown (Dano, 2020). The Rwandan government understood that this was required to prevent spread of the virus beyond the capital city, where healthcare is scarce, and controlling the spread of the virus may have been impossible. Food therefore formed part of the public health response and was ‘part’ of the healthcare system.
In the early 1990s, the internationally renowned global health physician, Professor Paul Farmer—who was at the time a young infectious disease doctor—found that he could achieve a tuberculosis cure rate of close to 100% in the central plains of Haiti. His ‘secret’ he joked, was the simple combination of community health workers, anti-tuberculosis medications, and a monthly stipend of $30 USD to help pay for food and travel to medical appointments.
A group of patients in a nearby village who received the exact same medical care from his clinic, minus the monetary and nutritional support, did not achieve nearly the same rates of cure. Twelve months after treatment, 43% still had pulmonary symptoms compared with barely 7% in the group with the financial and nutritional package (Farmer et al, 1991). Farmer found that ‘compliance’ is complex—and that medical care cannot cure hunger, nor can patients meet their daily medication adherence or monthly appointments if they do not have the funds to afford food, childcare, and travel.
COVID-19 is exposing the holes in our health and social care systems, which we have conveniently ignored until now. We have relied on acute and emergency healthcare services to act as downstream nets, catching those who fall through the gaps in our narrowly defined system and—in most cases—forcing this pointy end of healthcare (ambulance services, general practitioners (GPs), community crisis teams, and emergency departments) to fashion improvised ways of insulating vulnerable patients from the most severe of society's inequalities.
This pandemic has revealed to what extent we have been barely holding our heads above the water. Yet, while we grapple with the consequences of healthcare systems already over capacity, we have also seen a new face emerge—an unimaginable ‘can do’ fervour that has gripped entire hierarchies. In the midst of preparing for battle against an invisible foe, frontline staff, managers, and policy makers alike have embraced change and pragmatic action in a refreshing manner. The sentiment has been shared by many: look how much we can do when ‘push comes to shove’.
It is inspiring to see entire rosters ripped up and redrawn, telephone triage redesigned, on-site sleeping quarters built within days, and entire patient flows re-mapped. Among the suffering and the sick, policy makers and budget holders are beginning to see (many for the first time in their lives) that the arbitrary lines drawn between what constitutes one healthcare service, and another, are exactly that: imaginary distinctions.
Ambulance service staff are being met with the real challenge of transport to hospital often being a palpably riskier intervention for the patient than care in the home. Paramedics are having to find new and unconventional ways of providing safe care that creatively use existing local services.
Inventive schemes, both formal and informal, are germinating: increased use of telemedicine, greater acknowledgement of the potential in community paramedicine, alternative referral pathways unencumbered by previously strict criteria… the list continues. One can experience optimism at the renewed collaboration between community physicians and paramedics.
In Canada's Renfrew County, community paramedics have been placed at the helm of the public health response. They are tasked with home-based assessments, collaborative virtual clinics run in partnership with physicians, remote SpO2 and blood pressure monitoring, and the distribution of home-oxygen systems. They are effectively running a county-wide hospital-in-the-home service on a scale never before seen (Helmer, 2020).
Governments have uncomfortably acknowledged that GPs cannot be relied upon to screen patients if they are not provided with the personal protective equipment to do so (Tobin, 2020); assorted mish-mashes of public and private diagnostic labs have been forced to work cohesively for the very first time; surgical colleagues have been performing consults on medical patients at the bed-side with never-before-seen gusto across entire hospitals. Whole communities are waking up to the harsh reality of life on the streets for rough sleepers (Waegemakers et al, 2017).
Homelessness, living in cramped quarters, and reliance on below-minimum-wage gig-based income have shed light on the sociogenic modes of disease transmission most resistant to surface-level change (Farmer et al, 2015; Ly, 2019; Culhane et al, 2020). Only in this pandemic, when the health of those who make decisions has become reliant on the health of the poor who suffer the consequences of bad decisions most, do we now see how important the health of everyone within a community is.
The pandemic may have an immunologic cause, but its impact will have rippling sociological consequences far beyond the time span of the pathogen itself. We can and should expect to see dramatically increased rates of depression (Ko, 2006), suicide (Tsang et al, 2004; Cheung et al, 2008), intimate partner violence, sexual assault (Fisher, 2010; Ariyabandu, 2010), and non-accidental injuries in children (Daughtery and Blome, 2009; Stevenson et al, 2009; Becker-Blease et al, 2010; Seddighi et al, 2019).
Furthermore, it is likely that we will see an increase in chronic disease exacerbations as a result of the fear of transmission from attending healthcare facilities, and due to a spike in unemployment as the economy struggles to equilibrate (Tsang et al, 2004; Ko et al, 2006; Seddighi et al, 2019).
Why did we need a pandemic to occur for us to instigate dramatic change? And where will we find the deep reserves needed to deal with not just the response, but also the recovery phase of this crisis?
Let us see what positive changes can be sustained. Health professionals must maintain our advocacy efforts and continue to apply firm and considerate pressure upon policy-making bodies—our patients and our future health relies on it.