A Post-COVID-19 Medical Manifesto: How to Reconstruct a Post-Pandemic World
- Posted by Editor JPR
- Posted in Editorials & Commentary
James A. Bourgeois1,✉, Ana Hategan2, Jonathan Artz3
1 James A. Bourgeois, O.D., M.D., Clinical Professor (Affiliated), College of Medicine, Texas A&M University Health Science Center; Chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division, Temple, Texas, USA; ✉ [email protected]
2 Ana Hategan, M.D., Associate Clinical Professor, Department of Psychiatry & Behavioural Neurosciences, Division of Geriatric Psychiatry, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
3 Jonathan Artz, M.S. (M.D. to be awarded 16 May 2020), Baylor Scott & White Health, Central Texas Division, College of Medicine, Texas A&M University Health Science Center, Temple, Texas, USA
The current worldwide pandemic of COVID-19 illness is the macro-level medical urgency of our generation, as were the 1918 Spanish influenza pandemic and the HIV and AIDS epidemic beginning in 1981 in previous times. While recent pandemics and outbreaks of H1N1 (1918 pandemic), H2N2 (1957-1958 pandemic), H3N2 (1968 pandemic), SARS (2002-2004), H1N1pdm09 virus (2009 H1N1 pandemic), Zika (first recognized in 2013, and still unfolding), and Ebola (2014-2016) were associated with large degrees of morbidity, contagious spread, and mortality, none approached the worldwide magnitude of the current pandemic. Depending on venue of practice, psychiatrists will have variable but significant roles in case finding, treatment of psychiatric co-morbidity, and providing supports to patients, survivors, and fellow medical personnel. Once the world manages this pandemic and emerges to a place of greater safety, we will be tasked with deciding how to reconstitute and reestablish societal, social, and clinical routines. Systems of care and societal structures are intimately commingled; therefore, physicians managing clinical illness are appropriately empowered to call for social changes that may well impact the incidence, interpersonal spread, and macro level aspects of illness management. We elaborate several areas that may be illustrative of changes in systems that may help to mitigate and minimize the effects if the next, similar contagious disease pandemics.
Keywords: COVID-19, pandemic, health policy, health disparities, global health, public health policies, pandemic preparedness, post-pandemic rebuilding
The current COVID pandemic is a tragedy of global significance. Even as we all struggle with managing the clinical aspects of this highly contagious and oft-fatal illness, concerns over prior disease surveillance, disease detection and management, control of populations, development of testing and vaccines, and distribution of medical resources are controversial. We will leave the “how did this happen?” and “what do we do now?” to other authors; rather, the topic of this paper is proposed changes to follow recovery from the COVID-19 pandemic to (we presume) at least help to mitigate the risk of virus spread and/or clinical impact on patients.
We present several examples of proposed structural and/or functional changes for medical and government leaders to contemplate in the aftermath of the pandemic. Some of these proposed changes are somewhat technical, others are more philosophical, and many may require significant structural societal changes and redistribution of resources. Most (probably all) require surmounting of bureaucratic inertia and resistance. We do not minimize the realities in implementation of these items, but want to initiate the discussion in an integrated fashion.
Once we recover from the COVID-19 pandemic, the challenge is not to “return to normal.” To show that we have learned well from this collective experience, we need to move on to a “new normal” which will need to be “better than the old normal.” The following sections illustrate areas of improvement, which may be both practical and aspirational.
- Universal access to health care in every nation
The most direct conclusion of a major epidemic is the need of some model of universal health care coverage in every nation. While the exact model can be (and will clearly be) a source of robust debate, and there will understandably (and acceptably) likely be many “differences in the details”, all nations should endeavor to provide some level of basic coverage for all citizens and permanent residents. To be the most pragmatic and achievable, it may be best to focus on basic outpatient and preventive physician (and by inference, nurse practitioner and physician assistant) services as well as emergency services and hospitalization coverage. In addition, coverage for prescription medications is important.
While the exact model for delivery of universal coverage will inevitably depend on national political, financial, and cultural practices, models to consider include direct care provision by government clinicians, single-payer systems, or hybrids of privately employed physicians and other clinicians supplemented by government-provided care for those residents not able to secure insurance privately. Whether jurisdictions wish to go beyond basic levels of service would depend on local resources and priorities. The World Health Organization could develop a model for basic services to stand as a minimum international standard and include them as part of a more comprehensive revision of their 2005 International Health Regulations (1). It would be critical that testing, surveillance, and management of communicable diseases be universally covered.
- Discouragement of smoking/drug abuse/other behaviors that increase medical risk in epidemics/pandemics
This area has been increasingly recognized as a crucial area in population health, but is much accentuated by COVID-19. Given the respiratory nature of the illness, and the practice of smoking as the major preventable risk factor for respiratory disease, the connection cannot be ignored (2). Aggressive campaigns to discourage smoking, including confiscatory rates of taxation on all tobacco products, avoidance of governmental policies supporting or enabling tobacco consumption, aggressive promotion of substance use treatment programs all must be considered. A disturbing trend has been the recent growth of legislation permitting the use of marijuana (which when smoked, is a serious carcinogen, in addition to its central nervous system risks) with little concern (or frank denial of its health risks) which must be reconsidered (3). Similarly, confiscatory levels of taxation on alcohol products to discourage alcohol consumption would be recommended.
- Fully funded and empowered epidemic crisis response teams with international responsibilities
Prior outbreaks have resulted in heightened international concern about epidemic preparedness and calls to address shortcomings in global crisis response, which seem to be promptly forgotten once anxiety dies down (4). However, the scope of the COVID-19 pandemic is unparalleled and the time has come for clearly organized international epidemic response teams. While the exact structure and composition would require much collaborative negotiation, international teams of academic experts at public health and communicable diseases could be assembled under the aegis of appropriate international governance. These teams would have access to all macro-level health data in the involved first nation and would be empowered to share this information openly worldwide as needed. Teams would interface with local health delivery systems to coordinate clinical activity and would have top-level access to government leaders to coordinate policies on containment and measures to control movement of populations at risk as well as distribution of medical resources.
- Minimize large group social and cultural activities
This would prove difficult to implement. One must first acknowledge that large group experiences have been culturally sanctioned and encouraged for millennia. As such, some accommodation would likely be considered; e.g., greater physical spacing between spectators, provision of hygiene methodology at venues, rather than outright prohibition of large gatherings. As a phase-in, perhaps limits on gathering sizes could be considered. It may be that the public is more wary of large events hereafter, so decreased demand for large attendance at sports events, concerts, and other large-group activities may be noted. More real-time broadcasting of such events, where patrons can gather to experience these events more distantly, may become more popular. Personalized ventilation generally used in hospital wards or aircraft cabins to reduce the risk of airborne cross-infection are perhaps applicable in spaces where people are in fixed positions (5).
- Hospitals to be reconfigured with greater ICU capacity, more surge capacity, and all single rooms
The struggles in many cities worldwide to accommodate increased patient flow (especially increased intensive care unit (ICU) beds with ventilation) recently experienced, illustrates the inadequately small margin in bed capacity in many venues. Recent studies have projected that to better accommodate future, similar pandemics, a greater percentage of hospital beds need to be ICU beds (6). Patients currently admitted to general hospitals for relatively minor illnesses need to be transitioned to outpatient care and/or brief observation units. Hospitals must commit the operational capital to increase on-hand access to ventilators and other life sustaining equipment. Other wards in hospital typically accommodating medically stable patients (e.g., psychiatric units, physical medicine & rehabilitation units) need to be built with physical flexibility to be quickly converted to general medical units (e.g., proper technical specifications, hospital beds, wall oxygen) during surges of patient flow. Finally, in a long-overdue development, all hospital beds need to be repurposed as single rooms to minimize risks to patient roommates. Hospitals need to be able to repurpose non-clinical areas and other facilities as wards to house relatively medically stable patients.
- Environmental interventions to decrease air pollution hence reduce risk of respiratory diseases
Recent research demonstrated that those living in countries with higher levels of long-term air pollution, like the United States, are more likely to die from COVID-19; an increase of only 1 gram per cubic meter in fine particulate matter in the air was associated with a 15% increase in the COVID-19 death rate (7). These findings underscore the importance of continued enforcement of existing air pollution regulations to protect human health both during and after the COVID-19 pandemic. However, a serendipitous discovery of the coronavirus pandemic was certain cities experiencing less than usual air pollution due to less economic activity and less vehicular traffic (8). This should motivate governments to continue to pursue aggressive means to decrease atmospheric pollution to improve respiratory status for infected patients. This is particularly important in management of a virus which has a proclivity for pulmonary infection and resultant functional compromise. The medical community can use this opportunity to join other groups advocating for minimization of air pollution for medical as well as environmental improvement.
- Preemptive placement of personal protective equipment and ventilators strategically in a master plan (national or international)
The recent experience of inadequate supply of ventilators speaks to the need for a comprehensive plan to model the anticipated number of ventilators in a given area to manage the more medically complex patients. Collaboration is needed among hospitals/medical centers in a given area with ongoing communication with other suppliers of ventilators to coordinate distribution and movement of ventilators at time of need. Improved interoperability of electronic medical records platforms, hospital inventory software, and other components of the health IT ecosystem would facilitate the required open communication among medical centers for optimum distribution of additional care resources and flow of admitted patients. This can be rehearsed by comprehensive disaster management plan modeling during times of normal operation to simulate the need for this kind of flexibility.
- Reduce emphasis in medicine on unnecessary elective procedures
A notable abrupt policy change seen early in the management of the pandemic was the prompt suspense of elective surgery to preserve surge capacity for pandemic victims. This leads to an important discussion of the role for elective surgical procedures (e.g., joint replacement, bariatric surgery, cosmetic procedures) that can easily be put off during emergency conditions. Health care systems can become unduly dependent financially on procedures such as these, which may represent a “cash cow” in more robust times but which are not important priorities during a pandemic. Rethinking reliance on elective procedures could lead to a reconceptualization of these procedures, with greater emphasis on non-surgical treatment of these conditions.
- New emphasis on comprehensive, well supported primary care systems
Perhaps among the most important take-home messages of the pandemic is the reorientation of medical care systems towards primary care over medical/surgical procedures. This can take several directions. Production of more primary care physicians (along with primary care physician assistants and nurse practitioners) organized into highly functioning teams, decentralized to the neighborhood level, and themselves highly integrated with access to frequently needed specialties in primacy care practice. Notably, primary care needs ready access to psychiatry, endocrinology, obstetrics/gynecology, cardiology, pulmonology, on an easy access basis with liberal communication to and fro.
- Single national licensing of professionals with automatic international reciprocity in crises
State or provincial control of the medical (and other health professions) licensing is a historical anachronism in a modern, interconnected world. This has long been the case, but the need to mobilize large numbers of professionals and move them across state lines accentuates the need to nationalize the licensing process. Obviously, the process of vetting of professionals needs to be appropriately rigorous and thorough, but a single national licensing authority would do more for easy movement of physicians (and other groups) in response to a pandemic. Taking this one step further, there should be an international provision allowing instant reciprocity for physicians licensed in one nation to temporarily work in another during a pandemic.
- Emphasis on virtual health care as a universal approach to medical care
The pandemic led to an administrative decision by the U.S. government to allow, facilitate, and promote proper payment for telemedicine service. While it took a pandemic to move this forward, and telemedicine has particularly great utility during a pandemic, there are many advantages for telemedicine under normal circumstances. Keeping ill patients seeking care from having to travel may decrease the risk of traffic accidents. Minimizing travel has a positive impact on the environment and the carbon footprint. Potentially compromised patients can avoid community exposure to infectious disease. Modern imaging and sound systems are a major improvement in visual and auditory quality. Finally, for academic and supervisory purposes, telemedicine sessions can be recorded for later review and archiving.
- Retrofit inactive cruise ships and deploy as hospital ships
Cruise ships are a problematic environment in the face of infectious disease pandemics with forced crowding, and they use excess energy resources (9). Given the recent experience of COVID-19 on these ships, consumer demand for this form of travel may decrease substantially in the future. These ships could be put to better, more humanitarian use. Especially given the marginal supply of hospital beds in many communities, retrofit of cruise ships as hospital ships (similar to the Unites States Navy ships Comfort and Mercy) in order to add to surge hospital bed capacity should be prioritized.
- Testing for anti-COVID-19 antibodies and acquired immunity
There is an imminent need to better understand the novel SARS-CoV-2 virus and to develop ways to treat and control its spread. Moreover, there is an urgent need to develop effective vaccines and post-exposure prophylaxis to prevent future outbreaks. Institutional settings, including psychiatric hospitals, retirement homes, and long-term care facilities, may be at particularly high risk for COVID-19 outbreak and need to ensure that they have contingency plans to protect, detect, and contain the outbreak if it occurs (10).
There have been preliminary suggestions regarding granting “immunity passports” to key workers, including in health care, to speed up return to work after COVID-19 while mitigating risk of spread to others. To date, the length of time someone may have immunity after they have had COVID-19 is still largely unknown. For example, past studies showed those with SARS, which is also caused by a coronavirus, did not have immunity beyond 1-2 years (11). However, those who have recovered from COVID-19 and test positive for SARS-CoV-2 antibodies are expected to have at least some immunity to the virus. Although setting up a COVID-19 immunity registry can facilitate return to work, close monitoring should be maintained to determine whether these individuals are in fact protected over time.
- Striving for health equity through redistribution of resources according to needs
Organizational leaders must achieve a balance between health rationing and what is acceptable as redistribution of resources. A recent federal report on who requires hospital care for COVID-19 in the United States has found that African Americans disproportionately need hospital care (12). Evidence suggests that race and class, and health and disease, in general, are closely linked (13). Decades of surveillance and research in the global North have documented health disparities in morbidity and mortality, particularly among racial/ethnic minority groups and those of lower socioeconomic status (13). The United States is a country of the global North without a universal health care system. Restricted access to health care is probably a major reason for health disparities along class lines (13); lack of regular access to health care can compromise overall health, with higher susceptibility for getting sick from the coronavirus and to experience its worst effects.
Meaningful efforts to mitigate poverty and social inequality to provide safe and healthy lives for all of the planet’s peoples require a global concerted planning. A clear breakdown of COVID-19 cases by race and ethnicity allows for health care to be matched to the greatest need. Developing policy based on understanding the evolving epidemiology of COVID-19 and guiding planning and prioritization of health care resources is crucial.
- Addressing clinician wellness during and post-COVID-19 pandemic
Navigating the emotions of a pandemic can be difficult. A recent American Psychiatric Association survey conducted online, March 18-19, 2020, provides a glimpse into the psychological well-being of Americans during the COVID-19 pandemic; 36% believe coronavirus is having a serious impact on their mental health (14). In addition to this, frontline healthcare professionals have to work under extremely stressful and often risky conditions to care for COVID-19 patients. A supportive work culture is crucial to maintaining clinician resilience and well-being during the acute COVID-19 pandemic crisis, and beyond. Addressing clinician wellness during the COVID-19 pandemic is necessary to enable the frontline clinicians to provide high quality care (15).
A recent poll shows high levels of concern related to COVID-19 amongst psychiatrists from mixed practice settings, with 76% endorsing worry about becoming ill themselves and 95% worrying that their patients will become ill (16). Leaders should aim to monitor clinicians’ physical and psychological well-being and proactively address concerns related to the safety of clinicians and their families throughout the pandemic (15). For this to be operational, leaders must take common sense initiatives to provide basic provisions during work hours; e.g., access to necessary personal protective equipment, call rooms to enable adequate sleep for clinicians working long or multiple hospital shifts, toiletries, easy access to water and healthy snacks, chargers for phones and other digital devices, and breaks to take their own medications if need so (15). Reduction of non-critical work activities and eliminating non-essential administrative tasks may help to mitigate stress and promote psychological well-being. Developing evidence-based interventions for wellness, tailored to various workplace settings can include wellness committees and employee assistance programs, if available.
Lessons learned from the SARS outbreak showed that identifying and supporting clinicians who are at the highest risk for persistent psychological consequences of a pandemic, may be possible by identifying those whose perceived risk has not returned to normal within a few months after the event (17). Support programs and programs directed toward healthy lifestyles, diet, exercise, and smoking cessation may be important to deal with ongoing residual effects after the pandemic (17). Regarding post-pandemic planning, the likelihood of prolonged subjective distress in a considerable percentage of clinicians should be factored into surge capacity modeling during and especially after the pandemic, particularly because chronic stress and burnout is known to be associated with reduced healthcare productivity. Meeting the current wellness needs of clinicians may determine how well we manage this coronavirus crisis and future public health outbreaks.
Conflict of Interest and Source of Funding:
The authors report no conflicts of interest concerning the subject matter of this article.
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