COVID -19: Weak health systems, medical inequities, and inequalities. Whose business?

Covid 19 pandemic caught many people by surprise. Being a novel virus, that was and remains unpredictable, it has continued to baffle both the lay and the medical experts. Enigmatic. Many world bodies including the World Health Organization (WHO) and the Centers for Disease Control (CDC) Atlanta were caught flat foot, sometimes not knowing which directives to give. There was no published data. No evidence based randomized clinical trials that clinicians are so fond of quoting. What was certain is that there was Covid. And Patients were sick. Others dying dying daily at an unprecedented rate. Decisions had to be made. Fast. There was no time for rehearsal or case studies.

It took more than 3 months for the WHO to issue guidance for the use masks by citizens, even though it now seems quite logical and commonsensical that masks prevent the spread of the respiratory aerosolized illness. Initially the guidance was Masks are only meant for health care workers (HCWs), to wear a mask if you cannot keep social distance (ABC news 2020) Governments in Africa long enforced the mandatory mask method months ahead of the WHO. It took another 10 months before the CDC advised on the mandatory mask policy (Washington post 2020), which became fully enforced only after the new government in the USA was sworn in 2021 January.  

Exceptionally, countries like Tanzania completely rubbished the mask narrative, denied existence of COVID-19, instead, telling citizens to continue with business as usual. The result has been a huge death toll, with the Clergy directly encouraging the congregants in Tanzania to implement COVID-19 control measures. Indeed, the Government of Tanzania finally seemed to admit the existence of respiratory illnesses and urged citizens to take precautions (East African 2021). COVID-19 exposed many countries’ health systems.

In the west, HCWs had to choose which patients were to be put on ventilators. Those that had slim chances of survival were not prioritized for intensive care units (ICUs). The triage has been brutal and painful, resulting in psychological distress for many health workers, some indeed committed suicide, not being able to withstand the negative psychological sequalae. Health system failed. There was little resilience. Breakdown of health systems led to many deaths. To date, more than 2.5 million deaths have occurred. Majority of these in the USA. What went wrong? In the UK, Black, Asian and Ethnic minorities (BAME) were disproportionately affected by Covid infections and death. The first 11 doctors dying of Covid came from the BAME community. The Covid related mortality rate of Blacks in England is 3.5 times higher than the White counterparts. Poverty levels, frontline workers, ethnicity and inequalities reflect this higher mortality rate in the UK (Otu et al 2020).

A lot has been said about the need for health systems strengthening (HSS). It has become the catch phrase when engaging ministers of health in various countries. But what just is HSS. Whose business is it to strengthen health systems? According to the WHO (2007) framework for action, HSS is defined by 6 building blocks: service delivery, health work force, information, medical products, vaccines and technologies, financing, and leadership and governance. It is evident that COVID-19 impacted all the building blocks. Service delivery was affected in the early stages of the Covid 19 outbreak. Stigma and fear were rife. Patients who had other illnesses such as Malaria did not access care out of fear of contracting the virus. Many pregnant women cancelled their antenatal care, eventually not being able to make it to hospital for deliveries. (Pallangyo et al 2020).

The health workforce was severely strained. There is a paucity of respiratory medicine specialists. Limited ICU facilities and inaccessible oxygen supplies or equipment. High nasal flow rate, simple devices that can deliver high amounts of oxygen to patients are still lacking in many facilities. Eventually, health workers became the casualties. From USA, Europe, Africa, scores of health workers succumbed to the virus. According to the South Africa Medical Association (SAMA), 300 doctors had lost their lives as of January 2021 (Africa news 2021). 4 months after the first case in Italy, 150 doctors and 40 nurses had died (Nava, Tonelli and Clini 2020)

Information and misinformation did not help matters in the COVID-19 outbreak. There were rumors on the origin of the virus with accusations and counter accusations. China did a lot in preventing free flow of information. There was lack of transparency in China and elsewhere, many people who openly spoke about the virus faced sanctions. There was the talk of detergent and sunshine would prevent the virus. Lack of good guidance and accurate information contributed immensely to the spread and resultant fatalities of COVID -19.

Drugs specifically targeting Covid 19 virus were not widely available. Some were still in experimental stage and had to be made under license. Still, they were quite expensive and out of reach. Other drugs like hydroxychloroquine that were reported to be effective initially, were later disapproved. Convalescent plasma was thought to provide the all-important antibodies to fight the virus. That too became obsolete after randomized clinical trials put the claim to rest (Pathak 2020).

Enter the vaccine stage and it is a big scramble. Rich countries have virtually secured most of the supplies, leading to the WHO call for vaccines for all. Health workers all over the world should be given top priority before any other persons, but that is not the case. Luckily for the developing world, Covax facility has become a lifeline, but the quantities are far from adequate. Prevention through social distancing and masks will continue to play a pivotal role in preventing infections and deaths. The scramble for vaccines has also evoked health nationalism. “My country first” before other countries are considered. As usual, Africa is at the tail end, but thanks to WHO and partners’ leadership on Covax initiative. Mitigation plans have kicked in.

Health financing in the era of COVID-19 has been quite challenging for many families. Initially, there was a reluctance by National Health Insurance companies to cover for the COVID 19 expenses. According to Barasa and Kairu (2020), it costs between 200-500 USD per day in Kenya to treat a COVID 19 patient, depending on the presentation of the illness. In a country where a 36% live on less than 2 dollar per day (WB 2018), that becomes an uphill task.

Finally, leadership and governance played a key role on how different governments managed to deal with the COVID crisis, a classical example being New Zealand, which took early measures and has remained virtually COVID-19 free with business returning to normal after a short period of time. Countries that were in the election campaign mode last year saw huge swings of COVID-19 cases that could be traced to large social gatherings. Leadership not only meant political, but also medical and institutional. No one had the right answers. Schools were opened, then closed and opened again. Life had to return to normal. There were many instances where governments had to choose between lockdown and free movement. A good case study was Sweden. Unlike Tanzania, Sweden continued to provide data on the number of cases and mortality. By end of January 2021, Sweden had registered almost 700 K cases and 13000 deaths (WHO 2021) The country has registered an higher than normal increase in annual excess deaths compared to previous trends. Some authors attribute this to COVID-19. If so, such is the sacrifice they had to pay for free movement throughout the pandemic. Was it worth it? There is no clear-cut answer. 

Health systems strengthening is everybody’s business (WHO 2007) It cannot be left to the government alone. WHO will continue to provide policy, evidence, and guidelines. Other players, including the private sector need to come on board in partnerships that can improve the health systems. It is not always about expensive equipment, brick, and motor kind of solutions. It could mean provision of hand washing stations, public education on disease awareness and prevention, training, and empowering community health workers to reduce the burden of disease at the health facilities, training more midwives for the safe delivery of children, keeping safe and social distancing, provision of accurate data to inform policy and action. So long us you have prevented someone from falling sick, you have contributed in your own small way to strengthen the health system of a village, a town, a county or state, a continent, and the finally whole world. It is my business. It is your business. It is everyone’s business.

Own opinion piece.

REFERENCES:

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Barasa E, Kairu A (2020) What Does it Cost to Treat a COVID-19 Patient in Kenya?Available on line from https://kemri-wellcome.org/zp-content/uploads/2020/07/HERU-Policy-brief-Treatment-costs-for-COVID-19-patients-in-Kenya.pdf  Accessed on 7th March 2021

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