It's all over. It's the way of life, as my grandmother would say. Health problems can end in different ways: a very specific treatment (the magic bullet), changes in the environment (sewerage and sanitary control of water), adaptation and coexistence with the disease (now there are people with tuberculosis, but we don’t need sanatoriums) and, for sure, we would still find others. The same thing will happen with the COVID-19 pandemic. Perhaps we will mitigate the impact of the pandemic with vaccines, perhaps we will have better diagnostic tools, and perhaps we will be better organized to follow up on cases or a combination of all of the above. It’s likely that, in the end, we will carry on living a long time with a highly contagious disease that, in some cases, has very serious consequences. What is certain is that this tension caused by the successive waves of the pandemic will end.
It’s well known that in crises (especially in health crises) many innovations accelerate. I can think of some questions to assess what we’ve learned and what we could do "the next day."
a) Did we overlook any signs announcing the pandemic?
b) What is the real impact of the pandemic?
c) What are the most relevant innovations that occurred and which ones will withstand the passage of time?
There is always someone who realizes that before the catastrophe there were already signs announcing it (and that, unfortunately, we overlooked it). In Spain, it may be necessary to analyze carefully what happened, for example, from February 14 (cancellation of the Mobile World Congress) to March 14, when the state of alarm took place. I don’t know if the signs were obvious, or detectable, but it’s clear that, as a society, we need to strengthen public health. Richard Horton, the editor of The Lancet, says bluntly that time was wasted during February.
The impact of the pandemic will have many facets, with an obvious economic impact, which will generate more inequalities. But, as a July article in The Economist points out, the pandemic also highlights the urgency of reviewing how to care for the elderly. Outsourcing of care and internment in centres are social decisions that have consequences. More than half of the deaths from COVID-19 in the Western world have occurred in elderly people housed in residential centres. In many cases, protecting the elderly has meant strict isolation, an insurmountable obstacle for family and environmental relations and, also, dying in absolute loneliness. We must urgently find sustainable alternatives. The "social super-apples" of Barcelona City Council, with many points in common with the Buurtzorg model developed in the Netherlands, can be alternatives for social innovation.
From an article in The Economist (November 19), I would endeavour to discuss some elements that have been obvious during the pandemic and that will possibly mark the future. Like any choice, it’s subjective, partial and transitory.
Fear. Some patients already perceive health care spaces as unsafe and prefer to solve their problems in another way. Patients demand practical information directly related to what affects them: how they can safely go to the consultation or get tested. 19% of patients visited in outpatient clinics tell us that the face-to-face visit could have been done differently.
Fatigue. Little attention has been paid to fatigue, especially professionals’ fatigue. Primary care has carried a heavy load during the second wave, with little support, a lot of work (and the uncomfortable feeling of work that is pending), little collaboration between health care reosurces and insufficient recognition from all points of view. This can be a powerful transformative stimulus that would have to go from the bottom up. The engine of change must be the professionals of the first line of care, not those of my generation (the opinion does not mean driving the wheel), or health care structures (inflexible and with limited deliberative capabilities, among other things).
Self-organization. Spinney suggests that the 1918 flu made politicians see the need to ensure affordable and accessible health care, free of charge for the whole population. An example of this change was the creation of the British National Health Service (1948), which was extraordinarily transformative. National health systems are powerful, hierarchical and bureaucratized organizations. In the case of the NHS, it's benn seen that it has been inflexible in dealing with the pandemic. In addition, the response of many national health services has been slow, volatile, and contradictory therefore, too often, internal struggles have emerged between opposing tendencies. In crises, the benefits of sound technical management are obvious. In this context, the ability of professionals to self-organize into teams in the first line of care has been a feature.
Remote care. No doubt. PubMed identifies 230 references related to “virtual visits” during the year 2020. Practically the same number as in the period 1997-2019 (277 references). Remote does not only mean "visits". Remote means rethinking everything that can be done remotely and asynchronously. The pandemic will accelerate the transformation of access to professionals. A unanimous criticism of the patients treated in our hospital is the difficulty of telephone access. The introduction of small changes has had an immediate positive effect.
Focus on needs. Right now no one would dare say that patient-centred care should not be organized, although everyone knows that health care is focused on organizations and, in part, professionals. Who should we focus on but the patients? Perhaps the pandemic will help us go further and change the relationship and service delivery model more profoundly. Focusing on people's needs implies listening and making sensible decisions about people's values and the value that these decisions bring. Focusing on needs means thinking about people (individuals), groups with common needs, and people we need to care for but who don’t yet express their needs, even though they have them. There are no experts (specialists) to solve complex needs. Complex needs can only be met by multidisciplinary teams that are well connected and willing to cooperate.
Acceleration. The cited article refers to the phenomenon of acceleration. Self-organized teams, with good knowledge of local needs, have been quicker to implement changes on their own than following the directions of care structures. We will see how all this ends and how the changes will be evaluated, but it’s clear that the system’s bureaucracy needs to be eliminated. We need to think more about prototypes - simple, easy and quick to apply solutions. We need to maintain them if they work and change them if they contribute nothing. We finally have the results of the classic pilot studies, and we realize now that they are not scalable.
This photo shows a sculpture in homage to William Shakespeare (1564-1616). It’s located in Leicester Sq, London. Apparently it has no interest, but sometimes the details make the difference. Shakespeare's arm rests on a pedestal and, below, you can read:
Perhaps Gabriel García Márquez (1927-2014) thought of this sentence by Shakespeare for the title of his book “Cuando era feliz e indocumentado” (1973) with reports from the Venezuelan press in 1958.
It’s hard to know what the future will be like, but ignorance is resolved collectively with careful observation, systematic study, tireless work, serene reflection and, above all, elegant debate.
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