Prevention must be a central aspect of our health response to the coronavirus pandemic, both to stem the spread of the virus and to deal with the social consequences of the crisis. If many countries are not up to the job, it’s mainly due to their organisation of health care, confirming the importance of a strong public health care system.
“You really are the men and women who do everything eh, you people!” That was the reaction of an 88-year-old patient when she received a phone call from one of our Medicine for the People (MPLP) volunteer workers or staff in mid-March. At the outset of the coronavirus epidemic in our country, the 11 MPLP medical centres together decided to pay special attention to elderly patients, who would definitely be the most vulnerable in this crisis. So 3367 patients were elected on the basis of their medical records, with the goal that all of them would get called up proactively, in anticipation of potential problems. Setting up this work took a lot of energy, particularly given a period when all medical centres had to completely reorganise in the face of the sudden surge of the coronavirus. But it was well worth the effort because, in addition to getting a lot of gratitude, we gathered a great deal of information about the needs of this vulnerable group.
Many people were anxious, and sometimes slightly panicked; others were not yet fully aware of the danger and the precautions being recommended. Many elderly people living alone faced practical problems they could not solve. All of this was mapped and tracked by a team ringing around on the telephone. People’s health-related queries were then passed on to the doctors, while social issues went to the volunteer workers’ coordinator to look for solutions. Since then, for several weeks now, a few dozen patients have received help from neighbourhood volunteers, for example, to do their shopping.
One patient wrote a small thank-you letter to our team after one of these phone calls: “Your interest in the solitude of elderly people living by themselves really touched me. Good health care is more essential than ever today.” This coronavirus crisis has made many people aware of the importance of work methods in being prepared to meet large-scale health threats. Projects such as calling on the elderly show how crucial these proactive prevention initiatives are in fighting an epidemic. On the one hand, you find people who are still insufficiently informed, which allows you to increase follow-up on recommended precautions. On the other hand, you also detect additional needs, which can then be taken care of, since health is not limited to the absence of viruses, even in the middle of a coronavirus crisis. There is also mental well-being, physical autonomy… Unfortunately, such initiatives are all too rare in our country.
The authorities’ preventive approach isn’t enough
After telephoning elderly patients, we quickly realised that we had to worry about the situation in nursing homes. Everywhere the feedback was the same: there was not enough protective equipment, directives were not clear, and management did not have an action plan. On Tuesday April 7, an MPLP team set off to screen its first nursing home in Zelzate (East Flanders). On Wednesday, 85 other nursing homes finally received the long-awaited screening kits from the authorities. But what happened? Two days later, due to a lack of trained staff and faulty instruction manuals, it turned out that some people had been tested the wrong way. A painful mistake.
Virologist Erika Vlieghe, a member of the coronavirus expert group, said the morning after on Flanders public broadcaster FTV’s Radio 1 that the experts had already urged the creation of mobile screening teams for visiting nursing homes two months previously. They hadn’t been listened to. Now that the authorities have had to rectify the situation in a hurry, they are even calling in the army and Doctors Without Borders to do the job. If someone had said three months ago that this would happen, they would have been taken for a fool. Between the start of the lock-down of nursing homes on March 11 and the first reports of concern at the start of April, almost three weeks passed. Three weeks during which the authorities failed to limit the spread of the virus among our most vulnerable population. Almost all attention has gone into preparing the hospitals. The hard lesson to be learned now is that in combatting the epidemic cure has been prioritised over prevention.
There are, of course, lock-down measures in place. This is the largest preventive intervention our authorities have ever carried out. But even on this front, most western countries are not up to the task. We cannot stem the epidemic unless we also go to search proactively for the virus. Already in February, the World Health Organization (WHO) wrote: “Fundamental to these measures is extremely proactive surveillance to immediately detect cases, very rapid diagnosis and immediate case isolation, rigorous tracking and quarantine of close contacts […].” In Wuhan, at the height of the epidemic, 1,800 epidemiological teams totaling 9000 people worked to locate thousands of people every day. This is one of the keys that has enabled the Chinese government to contain the epidemic. But this experience is not applied here in our country.
Media reports point to the lack of screening equipment, but this is not necessary to track and follow up on contacts. The government announced late and timidly that monitoring would start in a few weeks. We’re already hearing that the ministers concerned are mainly seeking to develop one or more apps, and not so much to train enough staff. However, although an app can certainly help, experts warn that it can never replace human labour, according to Wouter Arrazola de Oñate in the April 8 De Standaard.
Anyway, we have the necessary expertise. For tuberculosis, another dangerous and highly contagious disease, Respiratory Trust Fund (FARES) teams have existed for 100 years. With each new case, a prevention team tries to get in touch with all the close contacts of the patient. All these contacts are then followed up and tested as necessary. This is exactly the same principle that WHO recommends for coronavirus.
Faulty system in the organisation of our health care
What is stopping [Belgian health minister] Maggie De Block, [labour, economy and consumer affairs minister] Wouter Beke, [Wallonia government health minister] Christie Morreale and [Brussels government environment minister] Alain Maron from working with more people in the field? Hundreds of health professionals have signed up on the volunteer list, but many testify that they have still not been called. Hundreds of medical students also want to help, but have been waiting for weeks for concrete news. “We are ready to help—now”, they write in an open letter published on the Vif.3 website. They perfectly fit the profile required for setting up mobile screening teams in nursing homes or for following up the contacts of infected people.
The fact that all these volunteers have so far not been used enough is a political choice. Could it be the result of an error in political judgment? Hard to believe with so many renowned virologists and epidemiologists in our country?
The reality is that our health care system is not geared to providing a rapid response in such work of prevention. Health care in our country is particularly fragmented. For prevention, and therefore to fight large-scale epidemics, we need a network of neighborhood-based primary care zones that are also well connected with each other. In addition to this, the remedial and preventive aspects of health provision belong to fragmented jurisdictions divided among our nine health ministers at the different levels of power. This reflects the painful absence of a global vision of health, which we are paying for dearly today.
Three essential pillars of a strong preventive orientation and firm response to emerging epidemics
Above all, the front line must be at the core of the health care system. Today, in Belgium, it receives only 5% of the total budget of the National Institute for Health and Disability Insurance (INAMI). Yet it’s at this level that most of the work is being done to stem the epidemic. In a country without a front line, such as the United States, everyone with symptoms currently goes straight to the emergency department, but at the cost of a loss of care quality because good treatment requires the ability to follow up on symptoms, be informed about the illness, organise supervision, pay attention to mental well-being, etc… The front line works by integrating the remedial and preventive aspects while taking overall care of the patient. The system works in this way for tuberculosis at FARES, where contact-tracing is carried out as part of the treatment that also monitors diagnosis and treatment.
The system of funding is the second pillar. Applying a comprehensive approach is harder if you are paid by service provided. It is thanks to the flat-fee system operating in health centres that we were able to quickly free up resources for projects of prevention in our MPLP centres, such as the proactive ringarounds to the elderly. This system allows care-givers to be more independent, because they are not financially dependent on the number of services provided. In situations like this, it has made it possible to quickly reorganise work, for example by switching to phone consultation without worrying about the remuneration for this service.
Finally, it is important that a structure exists to connect all health professionals. Currently, our health care provision is fragmented. This makes cooperation extremely difficult. Nursing homes do not know where to turn to in the event of a problem. Contact tracing teams have no-one to start out from. In a public health system like Sweden’s, for example, everything is built from a central structure, so that everyone knows exactly who is responsible for which part of the population. Each neighborhood has its own front-line health centre, where all service-providers work together under the one roof and where all residents of the neighborhood can go to ask all their health-related questions.
Coronavirus, starting point for a new model of health care?
Radical reforms–reversing the prevailing policy direction of the last four decades–will need to be put on the table. Governments will have to accept a more active role in the economy. They must see public services as investments rather than liabilities, and look for ways to make labour markets less insecure. Redistribution will again be on the agenda; the privileges of the elderly and wealthy in question. Policies until recently considered eccentric, such as basic income and wealth taxes, will have to be in the mix.
This quote was taken from an editorial in the Financial Times earlier this month. It applies to health care systems around the world. The principles above can only be applied if a public authority takes care of the organisation of health care centrally. In 1978, the WHO launched this universal model of «Health for All» at Alma-Ata. It was, however, immediately discarded when neoliberal doctrine began to dominate politics everywhere soon after. Today, the catastrophic management of the coronavirus crisis in the United States shows the complete bankruptcy of this model.
In the past, big epidemics have been moments in history when major changes have taken place around the world in the way we view health. Cholera gave rise to the establishment of public sewer systems and the Spanish flu to the first systems of public health care. Today’s epidemic could be another tipping point of this kind. In recent weeks, there has been regular talk of offering a bonus to health care workers after this crisis. But the discussion in this area is not just about increasing resources. No country spends more on health care than the United States and yet that country’s system has not worked well.
In the short term, the government must set up social-epidemiological teams. These teams can help nursing homes and institutions contain the epidemic and begin tracing and tracking close contacts for each new infection. It is better to integrate these teams into existing front line areas, so that the relation with this front line is optimal. The government has just announced its intention to recruit 2000 people for this task. That’s a start, but it might be too little, too late [in English in original]. In Wuhan, a total of 9000 people were mobilised for a population of 11 million. But here we are talking about a plan with 2000 people, and the Belgian Federal Public Health Service is already warning that they will not be able to get to work “for a month at least” (Het Laaste Nieuws, April 22). However, given the scale and duration of the challenge, swift and ambitious action needs to be taken now. We will have to hire staff, but we can already start looking for these people on the medical reserve list, among students, in medical centres and in the many structures for prevention and health promotion in our territory, and among local volunteers.
After the crisis, we will be able to learn from this experience, and see to what extent we can keep some of these teams for future preventive work. A large group of academics has warned in the past that the budget for prevention in our country is far too low (as reported by Wouter Arrazola de Oñate and André Emmanuel in De Standaard on October 7 last).
This crisis opens up the debate on the organisation of our entire health care system. Growing health care needs require more resources, which should be allocated as a priority to the front line. Let’s reintegrate prevention and health insurance into a single central administration, and rethink with the existing professionals the organisation of our health care within the framework of a global public vision, along the lines of the Nordic model in Sweden. Increasing the number of medical centres will be a key factor in this plan. That is the only way to better arm ourselves against future epidemics.
Note: The references listed in the original article have been incorporated into the translated text as links.
Sofie Merckx, doctor with Medicine for the People (MPLP) and federal MP for the Workers Party of Belgium (PTB); Tim Joye, doctor with MPLP and PTB health specialist