Posts Tagged ‘covid’

Most disasters or crisis-related emergencies involve a migration problem: the bigger the emergency, the bigger the number of displaced populations. Lately, Europe has been shielded from big emergencies involving huge population movements. The last such event originated in its territory dates to the Balkan Wars; that changed with the Ukrainian crisis, bringing in almost 4 million displaced persons. Those in-born crises do not take into account the on-going crisis and constant inflow of people originating in the East and South of the continent. Thousands if not millions of Middle East and Sub-Saharan individuals are ready to jump over the Mediterranean as soon as the autocrats governing the countries east of Europe or Northern Africa decide that their role as gate keepers is not worthwhile for them.

Focusing on the healthcare sector, Europe has been able to deal with the recent flow of Ukrainians mainly because those arriving had a relatively high standard of care in their country. But what would happen if the gate keepers opened the door for those trapped in Turkey or the southern shores of the Mediterranean?

So far the response, in a most peculiar if not plainly hypocritical way, has been to ignore their health needs and process their cases as expeditiously as possible, so as to make their return to their point of origin the main objective of the European policy. Ignoring the fact that they have migrated because their existence in their countries is unbearable and without any future does not make for good policy. Ignoring the fact that Europe is in the midst of a demographic crisis and a good flow of immigration and new blood could help to alleviate the crisis does not make for good policy. Ignoring the fact that all the available research suggests that migrants pay more in taxes than what they receive from the state does not make for good policy. It seems then, that the only policy guiding our policymakers is the appeasement of the far-right groups and their focus on immigration as the root of all evil.

But suppose we in Europe change gear and decide to incorporate the flow of immigration into our societies? One of the aspects that would have to be considered is their healthcare needs. Primary care, as the entrance to the healthcare system, would be where the pressure would most be felt. And primary care has been overcome by the Covid-19 pandemic, even more than hospitals and ICUs. My question is: have policymakers realized the importance of strengthening primary care? Even without the change in immigration policy, primary care needs a boost. Europe cannot attempt to survive without a strategy to absorb millions of newcomers and without a strategy to make a healthcare provision fitted for the future: an older population together with a younger migrant population.  

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Those words by Olof Scholtz (German Chancellor) struck me as a very simple motto and, at the same time, something that we all need to practice. Expect in the coming year a few occasions where practicing “never to be hysterical” will be helpful. For instance, when facing the surge of the Omicron variant of Covid-19, or the EU relations with Russia or China, not to mention the on-going renewal of the Iran nuclear deal.

Let us focus on the Covid-19 surge. Most countries in the EU have fallen back to restrictions that were established in previous surges. The difference is that now most people are vaccinated, so the EU Digital COVID Certificate can be used as an extra tool in avoiding the spread of the virus.

Have we learned anything from the previous surges? Unfortunately, the answer is NO. Two variants have spread recently and caused respective surges: Delta and Omicron. The first originated in India and the second in South Africa. According to most researchers, variants originate in populations with low vaccination levels, e.g. South Asia and sub-Saharan Africa. Has COVAX fulfilled expectations for supplying the quantity and quality necessary to those regions? Again, the answer is NO. On 29th November 2021, the WHO stated that “the majority of the donations to-date have been ad hoc, provided with little notice and short shelf lives.” Images from the BBC show how Nigeria, with as little as 5% of the population vaccinated, had to destroy one million vaccines due to their short expiration dates.

Will 2022 bring about a change to that situation, with the USA and EU countries for once making good their commitment with COVAX in quantity and quality? Will South Asia and sub-Saharan Africa attain a level of vaccinated population so as to prevent new variants? If so, most likely, we could put Covid-19 in our rearview mirror, still present but not affecting our lives so much.

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We all saw it on TV, and many of us still remember: The Director General of the WHO declaring the SARS-CoV-2 a pandemic on 11TH March 2020. The observation, that carried no legal or official importance, triggered into action most governments and civil society.

Notwithstanding, it was on the 31st of December 2019, that the WHO country offices in China picked up a media statement on cases of “viral pneumonia”. From there on, the WHO had been tirelessly gathering information and giving advice to governments and civil society on how to overcome what was coming.

The single most important tool the WHO has to fight a health emergency is the Public Health Emergency of International Concern (PHEIC). The PHEIC is triggered by the International Health Regulations (IHR) of the WHO. On 22-23 January 2020, the WHO Director General convened an IHR Emergency Committee, which on 30th January 2020 declared the coronavirus outbreak a PHEIC. This was the moment when governments should have been taking actions to fight the outbreak.  At that time, 99% of reported cases were in China, while there were only 176 in the rest of the world.

It took the entire month of February and a good part of March for European Governments to take measures to stop the spreading of the virus. The call by the WHO on 3th March 2020, for industry and governments to increase manufacturing of personal protective equipment (PPE) by 40% was mainly ignored. The result was that most governments had to rely on China for PPE, creating a fight among them for the scarce supply.

It is all very nice to look for the scapegoat when things do not go as we expect. The exercise gets into full gear when we can point at somebody outside our jurisdiction. How many times have we blamed the UN for not stopping a war, or the EU for countless evils? Now it is the turn of the WHO. But we forget that National Governments are the masters of those international bodies. National Governments do not like transferring any of their power to an international body. The UN cannot act if the five powers do not agree on the issue. The EU has no jurisdiction over health problems because National Governments are keen on keeping those issues under their wing. And the WHO can trigger the PHEIC but has no power to make governments abide by its recommendations, or even to collect data once the PHEIC is declared. So it cannot follow up on the emergency and can only guess what is going on.

If only we could learn from the Covid-19 pandemic and realize that some problems are better solved with international collaboration, maybe something positive will have come from this ordeal.

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I have tried very hard not to write about the Covid-19 pandemic. Today I am giving up. I was going through some old documents about resilient societies and the Hyogo Framework for Action 2005-2015 came to the fore. Page 11 of the framework says, “Integrate disaster risk reduction planning into the health sector; promote the goal of ‘hospitals safe from disaster’ … and implement mitigation measures to reinforce existing health facilities, particularly those providing primary health care.” Faced with the actual international response to the pandemic, my only possible reaction is an unmitigated cry of desperation.

It is obvious that only those countries in Asia that suffered the previous avian flu pandemic were ready for the new SARS‑CoV‑2 pandemic. As for Europe, nothing was prepared and nothing was done. Not even the most basic Individual Protection Equipment was available. The recommendations of the Hyogo Framework were ignored and the Sendai Framework, which covers 2015-2030, has been no more than another document to be shelved in the library.

I am not too convinced that, once this pandemic passes, the healthcare sector is going to focus on preparing for the next one. That will require thinking about the future and not being caught in the day-to-day business of caring for the immediate. For many years, due perhaps to budget restrictions or to lack of political willingness, healthcare has been losing ground in most countries. According to Eurostat “… 16 of the EU Member States reported a lower ratio of healthcare expenditure to GDP in 2017 than in 2012 …. In the Member States where the ratio was higher in 2017 than it had been in 2012, the increase was 0.6 percentage points or less, …”

It was with those resources that Europe’s healthcare had to face the pandemic. No wonder, according to Eurostat,  there have been 700, 000 additional deaths in the EU and EFTA countries between March 2020 and the end of February 2021, against the average number of deaths in the previous three years, of which 25%  were in the period from mid-March to end of May 2020.

But now the point is: will Europe learn and adequately resource healthcare for the future or will it keep driving with dipped headlights?

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El año pasado empecé mi felicitación de Año Nuevo con “2020 tiene un sonido mágico, suena bien”. Y continué con un post que hablaba de sociedades resilientes. Probablemente todos hubiéramos deseado un “sonido” más agradable, pero a pesar de todo la sociedad ha demostrado ser resiliente. Trabajemos hacia un futuro mejor, hacia un nuevo Felices Veinte, lo mismo que nuestros abuelos fueron capaces de sacar lo mejor después de una devastadora guerra hace cien años.

Las sociedades han demostrado ser resilientes. La historia habla de “Guerras Mundiales”, pero el número de países afectados por ellas no tiene comparación con el de afectados por el Covid-19 que sí que ha afectado a todos los países del mundo. Sin embargo, el número de muertos causado por el Covid-19 es muy inferior, felizmente, al causado por cualquiera de las dos guerras mundiales.

Oímos hablar de la “Nueva Normalidad”. No sé quién ha inventado tan estúpida expresión y su concepto. Creo que debemos aprender de las sociedades de posguerra: reinventarse. Los “Felices Veinte” de después de la Primera Guerra Mundial o los “Trente Glorieuses”, como lo llaman en Francia, después de la Segunda Guerra Mundial no tienen nada que ver con “Nueva Normalidad”. Supusieron una completa revolución en la sociedad, tanto desde el punto de vista sociológico como económico.

Es este tipo de revolución el que estoy esperando ahora. Un movimiento violento hacia un mundo mejor; más humanizado y al mismo tiempo mejor sostenido por la tecnología. Con la tecnología trabajando para la persona, al igual que en los “Trente Glorieuses” una revolución invisible (J. Fourastié, la Révolution invisible) transformó Europa, combinando un aumento de la productividad con mejores sueldos y, sobre todo, un nivel de beneficios sociales sin precedente en la historia de la humanidad.

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Last year I started my New Year’s greetings with “2020 has a nice ring to it, a magic kind of sound.” And I continued with a post talking about resilient societies. Probably all of us would have liked a “nicer ring”, but society has proved to be resilient. Let us work towards a brighter future and work towards a New Happy Twenties, the same way that our grandparents were able to make the best after a devastating war 100 hundred years ago.

Societies have proved to be resilient. History talks about “World Wars”, but the number of countries affected hardly compares to those affected by Covid-19. Covid-19 truly affects the whole world. Happily, its effect on society has nothing to do with the number of casualties caused by either of the two world wars.

We now hear about the “new normality”. I don’t know who invented such a stupid word or imagined the concept behind it. I think we should learn from what society did after the two world wars: reinvent themselves. Be it the Happy Twenties -after WWI- or the Trente Glorieuses as the French called it -after WWII- it had nothing to do with “new normality”. There was a complete overhaul of how society behaved, sociologically and economically.

It is this kind of overhaul that I am looking forward to this time. A push for a better world; more humane and at the same time more technologically based. With technology working for the person, the same way that during the “Trente Glorieuses” an invisible revolution (J. Fourastié, la Révolution invisible) transformed Europe, combining high productivity, higher wages and, above all, a level of social benefits unprecedented in the history of humankind.

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Due to the current situation, Primary Care has been brought to the limits of its endurance. This cannot come as a surprise. Most systems are tailored to the current needs that the system has to attend to, not to emergency situations. The job of Primary Care is to attend the day-to-day business of the population, acting as the front door to the health system, and to monitor the evolution of chronic patients.

Covid-19 has added a new dimension to this job description: doing the triage of the population in view of identifying those infected with the virus. It would not be a big problem if that were a normal procedure: anamnesis, decision, and derivation to the appropriate health resource or, as is the case of the flu, a recurrent winter event that can be pre-programmed. But this is not the case. To start with, SARs-CoV-2 is a very infectious virus that occurs throughout the entire year. The fact that it is highly infectious has changed the way the healthcare professional has to confront his/her prospective patient. The professional has to be equipped with Personal Protective Equipment (PPE), the premises have to be disinfected regularly, incoming people have to be pre-checked to avoid unnecessary contagion of personnel and contamination of the premises. All of these procedures necessarily slow the flow of patients precisely when the flow increases due to the pandemic. The result is a bottleneck in the system, and in an attempt to solve it, monitoring of chronic patients is sent to the back of the Primary Care priorities. The system assumes that a chronic patient will not evolve so quickly as to need urgent intervention: just take your medication and hope for the best.

But there is a solution. There are plenty of simple ICT applications to monitor vital signs and other signs like glucose. Unfortunately, we must admit that the biggest barrier to its introduction has come from healthcare professionals. While it is assumed that if the patient needs a medication, the healthcare professional will administer/prescribe it, it is still exceedingly rare that the same professional will prescribe an app. There is no explanation for this dichotomy. How can you explain that a professional will not recommend/prescribe something that is good for the patient and for himself/herself? It saves work for the professional and empowers the patient, allowing the latter more control of the management of his/her condition. There is for sure a long way to go, but the first step in the journey is to convince health professionals of the usefulness of ICT apps, probably using the same procedure that pharmaceutical companies use to introduce their products.

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The current Covid-19 pandemic has made possible the explosion of telemedicine. Those more reticent to its use, healthcare professionals, have discovered that it is an efficient working tool.

At the same time, individuals have discovered that they have to take their health in their own hands. There has been a lot of talk in recent years about empowering the patient/individual. But only when the pandemic has hit us have we discovered that there are a lot of health apps that can help us to keep fit or control our ailments. The Quarterly Digital Health Trends Report has some amazing figures. Comparing pre-covid and post-covid Google searches, terms like healthy-eating or healthy-living have increased by 385% or 850% respectively.

It is easy to see how those two trends are related. Professionals feel that they have to be more efficient in the way they provide their services; teleconferencing is a very efficient way to deal with some consultations that do not require an in-presence meeting of patient and medic. At the same time, we individuals have come to the conclusion that we should not take advantage of the medical services by drowning them  with requests that could be solved if only we were aware of the implications of our behavior: basically eating, drinking and exercising.

Eating, drinking, and exercising, probably together with complying with medication medical orders, are the realm of apps. There has been a 22% year on year increase of downloads in health and fitness apps (The State of Health & Fitness Apps, SensorTower, 2020). The more we use these kinds of apps, the less the pressure on medics. I know there is a long way to go till health and social services realize that prescribing apps saves money to the system. We will have to go through a long period in which we will have to pay for those apps that will help us to keep fit and healthy. But what is sure is that the money will be well spent.

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“… two-thirds of people aged 16 and over report to be in good health in 2016” (OECD/EU (2018), Health at a Glance: Europe 2018: State of Health in the EU Cycle, OECD Publishing, Paris.) Which means that one-third of Europeans think their health is less than optimal.

Taking care of roughly 170 million citizens is not easy. Our health systems are stressed to the limit even without the Covid-19 pandemic. But we have to deal with 170 million people with health problems, 340 million whom we don’t want to get sick, and all of the 510 million exposed to sar-cov-2.

To attend that demand there are approximately 1.7 million licensed physicians and 3.1 million practising nursing professionals. In relative terms, that means 333 physicians and 607 nurses per 100.000 persons (figures for 2018, Eurostat).

It has become quite clear that those numbers have not been able to cope with the pandemic; hence the second wave we are currently going through. I do not know, and what is more, nobody knows, who is to blame and where the fault lies. Only one thing is sure: healthcare professionals are overworked, non-urgent interventions are postponed, and the second wave is here.

We cannot “produce” healthcare professionals. “Importing” them should be ruled out. Depleting other countries of their professionals should be banned. Basically, this is saying: we take your professionals and you keep your pandemic. Furthermore, we will block your country so that no spill over will infect our sancta sanctorum.

Infrastructures are not easy to build and, in the best of scenarios, are just remedial actions for an already sick population.

If healthcare professionals cannot be produced and infrastructures come too late in the process to avoid illnesses, what is left? I can only identify ICT as the solution. Health and fitness Apps should be the solution to make a real difference. They are intended to prevent the user from becoming ill and help him to be fit. The time from inception to the market is relatively short.  And their price is in a range that most people can afford if, as is mostly the case, the healthcare system does not cover them.

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Remedial care, meaning actions taken after an ailment has been detected, has been the traditional focus of healthcare. Probably that is the reason why, when politicians decide to invest in healthcare, they put the emphasis on hospitals and fancy machinery. Let us not be cynical and think that it is because a picture taken in front of a multimillion-euro hospital looks better than one taken in front of a non-descript primary care building. Most probably, policy makers are the slaves of some defunct theory (to paraphrase Keynes).

They, or probably all of us, do not follow the advice – Keynes again- that “When my information changes, I alter my conclusions.” We see it on the current so-called second Covid-19 wave. There is a lot of talk about building more wards dedicated to Covid-19 – remedial – and little emphasis on reinforcing primary care – prevention – where the pressure for tests and tracing is mounting.

Contrary to reacting to a situation, preventing it is a lot more efficient and effective. Unfortunately, the Covid-19 pandemic has demonstrated how few preventive measures have been taken by all of us. We cannot say the problem lies solely with policy makers; it has been all of us who have decided not to take the most basic measures to fight the spread of the virus. We are all to blame.

Apart from the tracing app, there has been very little development of ICT based instruments to fight Covid-19. The fact is that we, as a society, tend to focus on the immediate, and not to look at the big picture: too many tactics and very little strategy. Confronting the problem as a Covid-19 problem will not solve the imbalance in favor of remedial care against prevention care.  We need to divert our investments, human and material, to primary care, where healthcare becomes much more than treating illnesses, where healthcare is preventing people from becoming ill. Thinking that way, I can see lots of ICT applications that could help primary care do its job: simple, user-friendly applications to be used by normal people, designed to help practitioners do their job and the population to remain fit and healthy.

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