How to prepare our health systems for the spread of COVID-19

Back in 2009 I was directing the UK Department of Health’s preparations for the 2012 Olympic & Paralympic Games. We were busy planning our responses to various disaster scenarios when the Swine Flu (H1N1) pandemic hit. Suddenly our disaster planning seemed very real.

Over the following six months I saw first-hand how the Department of Health co-ordinated the UK’s response to a pandemic that infected an estimated 1 Billion people (16% of the world’s population) and killed an estimated 364,000 people.

As we now teeter on the brink of a pandemic that could infect millions of people across the globe, I want to share some key learnings and strategies for how health systems should be preparing for a likely COVID-19 pandemic and how they can work with other government agencies to manage an effective response.

CORONAVIRUS CONCERNS

According to the World Health Organisation (WHO) the world is now in “unchartered territory” with the COVID-19 outbreak. When we compare (a) the percentage of infected people killed by COVID-19 and (b) the average number of people infected by each sick person (see graph below, from the New York Times) we see that COVID-19 is likely to be far more contagious and deadlier than seasonal flu.

How the New Coronavirus (COVID-19) compares with other infectious diseases

COVID-19 could be as bad as the 1918 Spanish Flu, which killed more people than the entire First World War. At the time of writing, the WHO are reporting outbreaks in 74 countries with over 90,000 confirmed cases. So clearly international governments and health systems need to rapidly accelerate pandemic preparations.

THE PURPOSE OF PREPARATION

The aim of health system pandemic preparations is to:

  1. Minimise the spread of the pandemic
  2.  Minimise the impact of the pandemic on public health (reducing severity, death & hospitalisations)
  3. Manage the surge in demand on healthcare services in the most appropriate settings
  4. Increase the public’s confidence and capability to respond to the pandemic
  5. Engage communities to maintain their safety and wellbeing
  6. Maintain societal stability and reduce the impact on public services
  7. The diagram below summarises the key components of the health response to COVID-19 needed over the coming months.

Key components of a health system response to a pandemic

BEFORE A PANDEMIC

During these early stages of COVID-19, it is vital that we improve our scientific understanding of the virus to be able to model the likely progression and strengthen the counter measures available, including accelerating the development of anti-virals and a vaccine (recognising a vaccine could take 6-12 months and hence be useless for the first wave of the pandemic).

Transparent communication with the public is essential to build trust, minimise hysteria and to ensure the public accepts any more stringent measures needed e.g. mandatory quarantining, selective closure of schools and lockdowns of aged care homes in outbreak hotspots.

Governments need to carefully balance their efforts to contain the pandemic with the wider societal impacts and the longer-term economic impacts. For example, the Australian government has a very different social contract with its citizens than an authoritarian state such as China, where COVID-19 originated. Whilst the draconian restrictions imposed in China proved effective, western democracies would struggle to emulate these measures.

Whilst restricting air travel can slow the onset of a pandemic (and buy time to prepare our health systems), modelling has shown these measures to be surprisingly ineffective in the past. Modelling from the UK Department of Health showed that restricting air travel by 99.9% simply delays a pandemic by 2 months without reducing the overall number of cases.

There is also less evidence than you might imagine that restricting large public gatherings reduces transmission, and these events are an important indicator of ‘normality’ that can help maintain public morale. The decision to cancel the Tokyo Olympics in July is therefore particularly tricky.

DURING A PANDEMIC

Some scientists already believe we are in a pandemic, but the WHO has yet to formally declare a pandemic, acknowledging that some efforts to contain the virus spread have succeeded, and also recognising the additional global panic that will inevitably come when the WHO make this announcement.

Global health systems are already stretched as they cope with growing, ageing populations with more long-term health conditions. Even without COVID-19, our health systems need to be rebalanced. People need to be better equipped to self-manage their own healthcare. People with long-term conditions need to be managed closer to their homes. The demand for hospital services needs to be reserved for the sickest patients. These fundamental principles of healthcare reform will be especially relevant as health systems respond to the inevitable surge in demand from COVID-19 patients.

The diagram below outlines a range of strategies that health systems can deploy to prepare for COVID-19, recognising that very different approaches are needed depending on the needs of different patient groups:

    Key components of a health system response to a pandemic

    THE LONG SHADOW

    Because COVID-19 is a novel coronavirus that currently has no vaccine, it is exceptionally challenging for governments to contain the escalation. Governments will be vigorous in their responses, but some may decide that the societal and economic cost of extreme containment measures is too high and choose to put in place more moderate measures. Global cases are therefore likely to continue to escalate for many months, potentially in multiple waves.

    However, one way or another, the tide will eventually turn. Either containment methods will succeed, and a vaccine will be developed or COVID-19 will run out of people to infect. Once COVID-19 has run its course, governments and health systems need to gradually restore normality. Health and other affected public services such as social services, transport, education, police, utilities and justice will need to gradually remove pandemic controls and restore services.

    COVID-19 will cast a long shadow. Having already wreaked havoc in China (the “world’s factory”) global supply chains will be severely tested. It looks increasingly likely that this pandemic will be the catalyst for a global recession that will cause businesses to fail and unemployment to increase. Governments will respond with stimulus packages and will need to choose wisely how and where they provide targeted financial assistance. Significant increases in population stress will need to be met with commensurate increases in mental health support.

    One positive to emerge will be the improvements in air quality emerging from travel restrictions – ironically COVID-19 will help reduce global warming in the short term and could encourage longer term switching behaviours away from air travel towards remote technologies (the share price of US video conference company Zoom has already doubled this year).

    NOW IS THE TIME

    Whilst new global disease outbreaks are inevitably alarming, it is important to put COVID-19 in perspective. From current evidence, the vast majority of infected people will make a full recovery and for most people life will go on.

    COVID-19 is a stress-test for global health systems that already need to be rebalanced. We must apply the fundamental principles of health system reform, such as proactive health promotion, community engagement, empowering self-management, increasing the use of remote healthcare and reserving hospitals for the sickest patients.

    Health systems that develop a robust response to COVID-19 will dramatically reduce the impact of COVID-19 whilst laying down the foundations for more sustainable future health systems.

    On both these fronts, the time to act is now.

    Jay Rebbeck is the Managing Director of Rebbeck, an international healthcare consultancy.

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