The strongest health care against corona is the one where prevention is central

Analysis

Tuesday, April 28, 2020 - 11:49

Sofie Merckx & Tim Joye

PTB.be

Prevention must be a crucial aspect of our healthcare response to the corona pandemic. Both to prevent the spread of the virus and to deal with the social consequences of the corona crisis. The fact that many countries fall short in this respect has a lot to do with the organisation of their health care. This brings the importance of strong public health care back to the fore.

"What a bunch of jack of all trades you all are." The reaction of an 88-year-old patient when she got one of our employees or volunteers of Medicine for the People (MPLP) on the line in mid-March. At the outbreak of the corona epidemic in our country, the eleven MPLP health centres together decided to do something extra for the elderly patients. They would be the most vulnerable in this crisis. 3,367 patients were selected on the basis of data from their medical records with the aim of calling them all proactively. It was not easy to get this organized, just in the period when all health centers had to completely reorganize themselves for the sudden corona wave. But it was worth it, because in addition to a lot of gratitude, we received a lot of information about the needs of this vulnerable group.

Many were anxious and sometimes slightly panicked, others were not yet fully aware of the danger and the recommended precautions. Many seniors living alone were unable to come up with solutions around practical problems. Everything was mapped and followed up by a group of callers. Medical questions were passed on to the doctors to answer, social questions went to the volunteer coordinator to find a solution. Since then, for example, a few dozen patients have been getting help from volunteers in the neighbourhood for several weeks now to do their shopping.

A patient wrote a thank-you note to our team after such a phone call: "Your concern for loneliness in single elderly people has really touched me. Above all, a good healthcare is crucial now more than ever. " It is during this corona crisis that it becomes clear to many people how important your way of working is if you want to be ready in case of large-scale health threats. Projects such as calling the elderly show how crucial such proactive prevention initiatives are in combating an epidemic. On the one hand, you can reach people who are still insufficiently informed, allowing you to increase the follow-up of recommendations. On the other hand, you also track down extra needs that can then be taken up, because health - even in corona times - is more than just being virus-free. Think of mental well-being, or self-reliance. Yet it happens far too little in our country.

Government's preventive approach falls short

Through those telephone calls to elderly patients, it soon became clear to us that there was reason for concern about the situation in the residential care centres. Echoes from everywhere sounded similar: There was insufficient protective material, guidelines were unclear, and management lacked a plan of action. Tuesday, April 7, a team of MPLP went to test a first care home in Zelzate, Wednesday 85 other rest homes finally got the long-awaited test kits from the government. But what happened? Two days later, due to a lack of trained personnel and incorrect manuals, it turned out that some of the people were being tested in the wrong way. Painful.

Professor of infectious diseases Erika Vlieghe, a member of the corona expert group, stated on the public radio the following morning that experts had already argued two months ago in favour of mobile test teams in residential care centres. They weren't listened to. Now that the government suddenly has to make adjustments, they even have to call on the army and the NGO Doctors without borders to get the work done. Whoever would have said that three months ago would have been declared crazy.

Between the start of the lockdown for care homes on March 11th and the first reports of anxiety in early April, almost three weeks passed during which the government failed to limit the spread of the virus among our most vulnerable population. Almost all the attention went to getting the hospitals ready. We were able to cope with the peak of the epidemic in our hospitals, but lost the battle to protect our elderly. The hard lesson today is that treatment was given too much priority over prevention.

Of course there are the lockdown measures. The biggest preventive intervention our government has ever carried out. But even there, most countries in the West actually fall short. You can only suppress the epidemic if you also proactively search for the virus in society. Already in February the WHO wrote: "Fundamental is an extremely proactive vigilance to detect cases as quickly as possible, a very rapid diagnosis and an immediate isolation of patients, as well as a rigorous search for close contacts." (1) In Wuhan, at the height of the epidemic, 1,800 epidemiological teams were working to locate thousands of people every day in this way, one of the key factors that enabled the Chinese government to contain the epidemic. But the experience was not applied here, in our country.

The media refer to the lack of test material, but that in itself is not necessary to trace and monitor contacts in advance. The government is now reluctantly preparing to get started within a few weeks. Although we hear from the ministers involved that they are mainly looking at developing one or more apps, and less at training enough staff. However, although an app can certainly provide a certain support, experts warn that it can never replace people's work. (2)

However, we have the expertise. For tuberculosis, another dangerous disease that is highly contagious, the dispensoria of the FARES (Association for respiratory diseases) have existed for more than 100 years. For each new case, a prophylaxis team gets to work in order to contact all of the patient's close contacts. All contacts are then followed up and tested if necessary. Exactly the same principle as the WHO recommendation for corona.

System error in the organisation of our healthcare

What is stopping the Ministers of Health and of Well-being from working with more people on the ground? More than 3000 care providers registered on the medical reserve list, but many testify that they were still not called upon in the weeks after their registration. Hundreds of medical students also want to help, but have been waiting for weeks for concrete news. "We're eagerly standing by to assist," they wrote in the magazine Le Vif. (3) They do, however, fit the profile needed: mobile test teams in the retirement home or tracking teams for contacts of infected persons.

It is a political choice that all these helping hands have so far been insufficiently involved. Because of a misjudgment? It shouldn't be an excuse, with such a wealth of top virologists in our country. The reality is that our health care system is not able to provide a solid framework for such preventive work quickly. The care landscape in our country remains highly fragmented. For prevention and epidemic control on a large scale, you just need a strongly connected basic structure of district-based care networks. In addition, prevention, welfare and health insurance have all become separate competences, distributed among ministers at different levels. A translation of the lack of an integral vision of health that is now avenging itself.

Three pillars are essential for a strong preventive approach and a firm grip on emerging epidemics. First of all, the primary health care must be at the centre of the healthcare landscape. Today in Belgium they receive only 5% of the total public health budget. In order to stop the epidemic, however, the lion's share of the work is done there. In a country without a first line care like the US, anyone with symptoms currently goes directly to the emergency department, causing a lot of loss in quality of care: follow-up of the symptoms, explaining the illness, organisation of support, an eye for mental well-being … At the first line, cure and care are integrated.

The financing system is a second pillar. A global approach is more difficult if you are paid for your work per each intervention. It is thanks to the flat-rate model of the community health centres that we were able to quickly make room in our health centers for preventive projects such as calling the elderly. Funding is patient-related and not performance-related. This broader autonomy comes in handy when circumstances suddenly change. When it suddenly became clear that it was best for care providers to avoid direct contact with coughing patients as much as possible, flat-rate clinics could easily switch to telephone consultations, even if these were not (yet) remunerated.

Finally, it is important that there is a structure that connects all health professionals. The current care landscape is fragmented. This makes cooperation enormously difficult. Residential care centres do not know who to turn to in case of problems. Teams of tracers have no point of contact to start. In a public health care system such as in Sweden, for example, everything is built according to a central structure so that it is clear to everyone who is responsible for which part of the population. Each district has its own first line care centre, where all disciplines work together under one roof and everyone from the district can go to the same address with all their health questions.

Corona as a tipping point for a new care model?

"The politics of the past four decades must be reversed. The government must be given a greater role in the economy. It should no longer see public services and public utilities as expenses but as investments." A quote from the Financial Times early this month. (4) This is absolutely true for healthcare systems worldwide. The above principles are only possible if a government takes the organisation centrally into its hands. In 1978, the WHO launched this universal model of 'Health For All' in Alma Ata. (5) But it was immediately pushed aside when, shortly afterwards, neoliberal doctrine began to dominate policy everywhere. (6, 7) Today, the coronacrisis in the US shows the complete bankruptcy of that liberal model.

In the past, major epidemics have been moments in history where major changes occurred in the way we looked at health around the world. Cholera provided public sewerage, after the Spanish flu the first public health care systems came into being. Today could be another tipping moment like that. In recent weeks there has been regular discussion about a premium for care after this crisis. But the discussion about the healthcare sector is about more than just more resources. No country spends more on health care than the US, and yet the system does not give a good result.

In the short term, the government should set up socio-epidemiological teams. These teams can assist residential care centres and institutions in containing the epidemic and can start tracing and monitoring close contacts with each new infection. They are best integrated into the existing first line care zones, so that the connection with that first line is maximum. Three teams per zone, each with four people, that means about 1250 employees for the whole country. These persons can be searched for from the medical reserve list, students, existing preventive first line organizations and local volunteers.

After the crisis, we can learn from the experience, and see to what extent we can retain some of these teams for further prevention work in the future. A large group of academics warned earlier that the budget for prevention in our country is far too low. (8)

It is clear that a discussion is needed about the entire organisation of our health care system. Growing needs for care require more resources, and these should go to the primary health care as a matter of priority. Make prevention and health insurance one central competence again, and rebuild the care landscape with the existing actors according to a public vision such as the Nordic model in Sweden. The roll-out of more community health centres is essential. This is the only way we will be better armed to prevent the spread of the virus from the outset.

Sofie Merckx is doctor at Medicine for the People and PTB deputy, and Tim Joye is a general practitioner at Geneeskunde voor het Volk and health specialist at the PTB-PVDA.

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