Some realities and a dream

A friend sent this picture to me. I have not been able to find the source of this. This graph  highlights the multiplicity of issues that we are currently facing and will be facing as we go through this season.

Most of what is written here is out of “listening to stories from the ground” than from data.

Most of the rural health care institutions are trying to get ready and be prepared for the first wave, the anticipated wave of COVID19. They are getting systems and processes in place for triage, isolation, quarantine, care for the moderately and critically ill who might reach institutions tomorrow. But as institutions prepare and wait, they have already started seeing waves of other epidemics around.

The most visible is the epidemic of hunger, starvation, homelessness because of the sudden lockdowns. Many in developing nations are facing an uncertain future due to this.

In addition, we have started hearing of the emerging epidemic of stigma of the illness leading to unacceptable behavior toward patients and even health care workers who are taking care of patients.

The other epidemic of urgent non COVID19 has already started surfacing. Many who have not been able to access care due to various reasons have started coming into institutions in late stage of illnesses resulting frequently in loss of lives. There are many patients who are on chronic illness treatment but are not able to access their ongoing treatment. There are stories of many patients on Anti-retroviral treatment, Anti TB treatment, who have not been able procure drugs due to health care institutions not being functional or lack of transport. There would be many with Diabetes, HT, cancer etc. in similar situation. Immunization clinics have started sharing data of dropping immunization rates. ANC clinics have started reporting major drop in numbers of checkups and immunizations. The potential future outcomes of these, one cannot imagine now.

There is already the psychological trauma that is evident among health care workers, families and communities, due to a multiplicity of factors.

But we do not even know if the above graph would be true or whether we should be ready for a future that might be much different from what we are anticipating today. 

Would COVID19 spikes continue in decremental but multiple spikes over the next many months, or would we see an ongoing endemic of COVID19 in some of our nations and locations? Would there be another similar epidemic soon before health care systems can recover? Questions for which there are no immediate answers.

What we are learning thus far is, health care systems across the globe and especially in resource challenged contexts have failed to provide ethical and accessible care to all the challenges the community is facing. Overwhelmed by the pandemic, systems are failing in being available for the community and their larger health care needs.

Considering three scenarios for tomorrow, questions for us to consider, as we face an uncertain tomorrow: 

Scenario A – Graph A, (the best scenario) or modified graph A with multiple decremental COVID19 peaks over next 6 months ((second best scenario) where COVID19 19 gets over but we need to address the multiple epidemics around. What would a health care system that takes care of each of these other epidemics look like? What can we do today to be ready for such a context tomorrow?

Scenario B – COVID19 becomes an endemic and we need to live with the regular disease burdens and COVID19 alongside. How do we re-engineer our systems to live in such a context?

Scenario C – COVID19 gets over, another epidemic and pandemic strikes tomorrow. What are the lessons we should learn today from COVID19 that can teach us for another similar or different epidemic tomorrow?

The pandemic of COVID19 has brought multiple issues to the forefront that need innovative thinking for health care systems for the here and now, and for the tomorrow.

There is an urgent  need to re-envision Health care systems that focus on the four pillars of Bio Ethics that we hold on to namely, Autonomy, Beneficence, Non-maleficence and Justice at the same time, that are compassionate and take care of the most vulnerable in our midst.

What are some core principles that we need to hold on as we dream of a tomorrow? A tomorrow where we would have learnt from the failures of today, and set in systems that are different?

We will have a health care system that listens to the community. We will not have a top down hierarchical system which tells communities what to do, but one which listens, empowers, and supports the community. Support to protect themselves and find relevant ways of preventing spread of future epidemics. Communities that have found ways to be resilient to epidemics and illness and are able to care compassionately.

We will have a system of care that is holistic and provides continuum of care. We will strengthen the home care, primary care, family practice systems. The system will protect the elderly and the challenged and those with other co-morbidities and vulnerabilities due to immuno-suppression. 

A heath care system, policies or interventions that will not impoverish people, families and communities.

We will have a system that has a well-oiled and run referral system, that is accessible. The referral from primary, to secondary and tertiary will be planned in such a way that those who need these will have no difficulty in accessing these.

We will have a transparent system. A system that is run based on open transparent data and disease surveillance. Using these data to plan and envision, health of communities along side treating of diseases.

We will have health care professionals who have adequate knowledge, right skills, and attitudes. They will practice ethical medicine and will not allow finance or other factors to affect their practice of medicine.

We will have national and health care leaders who are visionaries and will look at the health of the nation and communities and work towards setting up systems to facilitate a healthy nation and communities.

I might have been dreaming when I wrote the second part of this article, but it is a dream I want to dream…