What lessons should Public health services learn from the Covid-19 pandemic?
This essay was submitted to the Cotrell Essay prize for Medicine. (2021)
Though the Covid-19 pandemic revealed far-reaching fragilities within public health services, the best of it has also been ushered out. As we now know all too well, Covid-19 has resulted in tremendous loss of human life, increased unemployment, and significant impacts on public health services.1 Population growth, global warming, and interconnectedness will continue to amplify conditions for the spread of infectious disease and it is unlikely that Covid-19 will be the last pandemic.2 Hence, it is paramount that in contrast to the world’s lacklustre response in 2011 when the WHO gave an explicit warning that “the world is ill‐prepared to respond to a severe influenza pandemic” - lessons learnt from Covid-19 are taken seriously and used effectively for systemic change within public health services.3,4
Investments required from public health systems
Coming out of the pandemic, clear weaknesses that have proven detrimental to the community when severely stressed by Covid-19 have been identified. These flaws require increased focus and economic support to build stronger health systems of tomorrow.
Health of the population
Inherent vulnerabilities of health systems include aging populations and prevalent chronic illnesses. Covid-19 mortality is much higher in patients with underlying uncontrolled medical conditions, such as diabetes.5 Figure 1 shows that in the USA, over 86% of Covid-19 deaths involved at least one comorbidity.6 This vulnerability holds true for other forms of infectious diseases and Covid-19 exposed how fragile these population groups truly are. Bolder approaches by healthcare systems in the prevention of chronic conditions, such as through enhanced screening are needed for eventual healthier populations and lower mortality rates in future pandemics. Current delays in usual preventative measures such as vaccinations will lead to cumulative consequences in the near future.7 Healthcare systems must address this urgently, bridging this gap whilst simultaneously making advancements in preventative medicine.
Prior to the Covid-19 pandemic, the NHS was already stretched extremely thin, with healthcare professionals working long and strenuous hours.8 This was exacerbated during Covid-19, where healthcare workers had to manage a multitude of patients while being restricted by supply shortages. NHS staff not only had to deal with dozens of patient deaths, leading to quadrupling mental health problems; by February 2021, more than 900 NHS staff had lost their lives to Covid-19.9,10 Concrete steps need to be taken to prevent devastating impacts on the workforce in future crises with wider action on supporting staff well-being.11
Funding pressures on social care need to be addressed. Between mid-March to June 2020, upwards of 19,000 care home residents died from the Covid-19 across England and Wales (40% of total Covid deaths at the time), largely due to the serious funding shortages which forced rapid discharge from hospitals to care homes, despite high risks of infection for this sector.11,12 To address these funding pressures tactfully, leadership teams must reassess ongoing investments, redistributing funds to areas that require them most.
Within the NHS, Covid-19 has prompted many to rethink healthcare delivery. Hospitals should have a flexible structure and layout, with the capacity to expand bed counts and isolate air filtration systems in the event of a pandemic.13 To shorten the lengthening waiting list for appointments during Covid-19, the NHS also reconfigured its care pathways, setting up Covid-19 free elective cancer hubs across London.14 To further implement solutions to enhance patient care and efficiently allocate NHS resources, a specific plan is needed to put these changes into motion.
As seen in figure 2, a public health system’s preparedness for a pandemic ultimately affects its response to shock and a pandemic’s overall impact. Exceptional “recovery and learning” (stage 4) in the aftermath of a pandemic, puts a health system in a significantly better position for stage 1, when the next crisis hits. After South Korea’s weak response to the MERS epidemic in 2015, 48 reforms were introduced by its government to enhance public health emergency preparedness, placing the country in a better position to tackle Covid-19, leading to remarkably lower incidences of Covid-19 cases and deaths.15
Conversely, the UK’s initial pandemic response strategy was unclear (stage 1), resulting in the delayed purchase of essential equipment, mixed communication to the public and slow implementation of social distancing procedures (stage 2), ultimately leading to more than 4.45 million Covid-19 cases and overwhelming pressure on the NHS, despite subsequent lockdowns (stage 3).16 Upon assessing their individual pandemic responses, health systems should create a detailed management plan for future pandemics. The creation of a concrete governing body that deals with crisis management would be immeasurably helpful in formulating and enforcing measures, similar to the emergency operations centre established in South Korea.15
Collaboration across and within Public health systems
At the beginning of the pandemic, there was a lack of communication between governments, research teams and hospital workers with regards to rapidly evolving guidelines. Fortunately, this improved over the course of the pandemic. A simplified protocol for nutritional therapy in critically ill covid-19 patients, formulated by clinical dieticians, was issued to replace an original lengthy guide, enabling doctors to treat patients with this therapy whilst on a tight hospital schedule.17 Adaptations to the communication of information from research teams to hospital practitioners should continue to progress beyond the pandemic, enabling clinical research to be adapted by hospitals more widely.6
Proper governance is the glue that brings all the components of public health response together. Governments must begin to use science to influence public health policy, instead of individual political agendas. Covid-19 has proven that vulnerable countries who had leaders that listened to science were considerably more successful in containing the virus.18 Due to Taiwan’s geographical proximity to China, it was expected to be at a high risk for Covid-19 importation. Despite this, Taiwan had next to no average daily cases for a year since April 2020, because of its incredibly effective government crisis management response.19
In today’s interconnected world, where infectious diseases can spread across the world in the span of a day, global collaboration across governments is cardinal. The unfortunate truth is that countries are not equal, with vastly different healthcare systems, populations and socio-economic statuses. International benchmarking is hence essential.20 For instance, India has a high proportion of its population living in slums, making it difficult for the nation to go into a stringent lockdown. At the time of writing, the country is reporting the highest daily Covid-19 cases in the world, with the Indian variant spreading rapidly to other countries.21,22,23 A chain is only as strong as its weakest link and poor management of disease in one country will affect the rest of the world . Countries hence need to collaborate and aid each other in crisis response.18,24 Improved governance and global collaboration to support healthcare systems is a crucial lesson that must be learnt, as scientific breakthroughs and dedication from healthcare workers is futile without it.
Technology in healthcare has progressed immensely throughout Covid-19, complementing public health measures and contributing to reduced human and economic impact of Covid-19; displayed in figure 3. Technology was harnessed to collate real time Covid-19 public health data - from laboratories, hospitals, and symptom tracker apps.25 Subsequently, increasingly specific strategies can be used to identify and combat potential pandemics.
Implementation of Technology
Online medical appointments in primary and secondary care, have been used to reduce avoidable patient contact and prevent transmission in NHS settings. This has helped to mitigate the situation of unmonitored chronic patients and to triage patients online. It can continue to play a large role in reducing hospital admissions and allowing health systems to redistribute crucial finances.26
Technology has been indispensable in the dissemination of information to the public. To prevent the spread of false information, Google prioritises WHO and trusted sources at the top of search results, while posts on social media with Covid-19 related content automatically contain a link to official government resources.27 Online chat bots have also been made available to provide concise information from credible sources, reducing burden on non-emergency health advice call centres.28 As the future of public health becomes increasingly digital, rapid evaluation will allow for flaws in current systems to be fixed and for innovations to be fully implemented.
Overcoming Racial Inequalities
Covid-19 shone a light on racial inequalities in the healthcare system, among both healthcare professionals and patients alike. In October 2020, the UK government’s Covid-19 risk algorithm pinpointed a BAME background as a top risk factor for serious illness and death.29 Black patients admitted to hospital with Covid-19 tended to have fewer pre-existing health conditions, yet with eventual worse health outcomes.30 This was largely due to social disparities of citizens from BAME backgrounds, who were less likely to receive preventative health services.31 BAME healthcare workers were similarly disproportionately affected, accounting for 63% of healthcare workers who died from Covid-19, despite making up only 21% of staff.32 Covid-19 revealed a stark problem that has existed in the healthcare system for years, but has encouraged healthcare providers to strengthen their interpersonal skills with patients from all backgrounds.18 The NHS and government must develop a more ambitious plan in reducing health inequalities and there is hope that Covid-19 can be the spark for paradigm shift.
Though Covid-19 has been destructive in many areas of the world, there is hope that it can truly be the catalyst for much needed transformation within global health. Healthcare systems are meant to guarantee health protection, but the truth is that they are often under-financed, under staffed and politicised. Optimistically, global collaboration seen between public health systems, scientists, governments and pharmaceutical companies in the development, production and distribution of vaccines can be applied to bettering public health systems too. Positive shifts already made by Covid-19 in public health systems must be expanded upon for long term change.
All references accessed 20/5/21
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Figure 1: Franki R. Comorbidities the rule in New York’s COVID-19 deaths. Hospitalist. 2020; https://www.the-hospitalist.org/hospitalist/article/220457/coronavirus-updates/comorbidities-rule-new-yorks-covid-1 9-deaths
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Figure 3: Budd, J., Miller, B. S., Manning, E. M., Lampos, V., Zhuang, M., Edelstein, M., Rees, G., Emery, V. C., Stevens, M. M., Keegan, N., Short, M. J., Pillay, D., Manley, E., Cox, I. J., Heymann, D., Johnson, A. M., & McKendry, R. A. (2020b). Digital technologies in the public-health response to COVID-19. Nature Medicine, 26(8), 1183–1192. https://doi.org/10.1038/s41591-020-1011-4