Dilemmas and Differences in Healthcare Approaches during COVID-19 Pandemic - A Comparative Overview of the Art and Science of Healthcare Systems

We are all affected by COVID-19, though the extent of impact clearly varies between countries. Seeing the differences through media platforms, qualitatively and quantitatively, in how countries prepare for, manage and address the spread of COVID-19, you may question the lack of consensus in the approaches - masks vs. no masks, active surveillance vs. passive surveillance, mandatory measures vs. honor system, etc. Your confusion, and subsequent frustration, are understandable. However, please don't be too quick to judge. It's easy and tempting for the general public to pretend they can act and think like a health official through the School of Google and YouTube, and that they can do a better job under the circumstances. What you may not realize is that the delivery of healthcare, especially in controlling crisis such as COVID-19, is an exercise of both art and science. There's the medical science part of the exercise, and there's also the cultural, political, economical, legal and systemic components that cannot be ignored. Hopefully, this comparative overview can provide you with better perspectives for you to understand why your country approaches COVID-19 differently than others.

This is a simplified overview of how and why the COVID-19 healthcare approaches are different between countries. It is purely based on my observations and opinions as a professional with both public health and legal background, and it should not be relied upon as legal or medical advice and for its accuracy and currency. It is not intended to support one approach over another - it is to be read as a reference tool only.

East vs. West

Based on data collected thus far on confirmed cases reported and collected by government officials, the Eastern countries have been controlling the transmission of COVID-19 better than the Western counterparts. These data could be skewed due to reporting methods and testing capacity, but from face value, that is the observation. This result should not be surprising, given that the East has experience in handling SARS and MERS in the past, but we should also look deeper into the cultural and political contrast between East and West, which I believe has played a tremendous role in the healthcare approaches.

The East generally is more right-wing, with a stronger sense of community and obedience to the authority culturally. This allows the government to implement actions faster and more aggressively, as there would be faster public adoption and adaption. The downside is the potential for government abuse of power and lack of government accountability. The West on the other hand is more left-wing, with a stronger sense of individualism and liberty culturally. There is greater accountability in government, but at the cost of slower adoption and adaption of government actions, particularly if honor system is relied upon. With such cultural difference, the measures taken between East and West have been different accordingly. In the East, China can immediately order a complete lock-down of cities as quarantine measures, Taiwan can control supplies of personal protective equipment (PPEs), impose temperature testing policies and order state owned manufacturers to create more sanitizers, Singapore can deploy police officers to track down contacts and issue severe fines and penalties for non-compliance, and the general public in these countries would be self-motivated to wear masks universally to protect themselves and others from COVID-19. These actions may be seen as draconian and unnecessary in the West, but what we see in the West instead is a lack of compliance regarding social distancing and quarantines, lack of supplies of PPEs for healthcare professionals, stigmatization of mask-wearers, and a laundry list of issues that have forced the governments in the West to impose stricter measures as last resort.

Capitalism vs. Non-Capitalism

President Donald Trump's recent statement that "We can’t have the cure be worse than the problem" has been controversial in reference to the social distancing measure and its impact to the economy. Essentially, President Trump values economy more than the well-being of the vulnerable population, or more directly, in the words of the Texas Lieutenant Governor Dan Patrick, that old people (i.e. those most at risk) should volunteer to die to save the economy. That is a fairly morbid and uninspiring position; however, this shouldn't be that controversial in United States where capitalism runs deep, even in healthcare delivery. Countries such as United States which adopt a heavily privatized healthcare system with corporate interests superseding social interests may often fail to deliver timely and needed care to those in need the most - the ones who are less fortunate and most vulnerable. Consequently, it should also not be surprising that the capitalistic healthcare system in United States is ill-equipped and ill-prepared for a pandemic - it is expensive for general public to seek medical care, lacks communication and cooperation between entities, lacks capacity and does not promote optimal use of resources.

On the flip side, a heavily socialistic system may not be the ultimate solution either. While such system should be more coordinated, it is also costly to the government with generally slow response time, greater bureaucracy, long wait-list for patients and inadequate competition within the workforce. United Kingdom and Italy, with a publicly funded single-payer model, clearly have resources and capacity problems. Likewise, Canada, which is a publicly funded single-insurer model where hospitals are funded, but not owned, by government, also faces similar problems though to lesser extent and arguably has a better and more coordinated response plan in comparison thus far. Neither extreme seems to be preferred.

Mixed models that incorporate universal coverage, private and public care, corporate and community interests, such as the systems used in Singapore, Taiwan and Korea may seem to be the ideal models to control COVID-19. Much of their successes are due to careful planning by their governments to ensure there are sufficient market competitions in the workforce and institutions, options for patients to choose from, and governmental control measures in place over the players in their healthcare systems. Consequently, such systems are accessible, well-supplied, responsive, and coordinated - all keys to control the transmission of COVID-19.

Individual Rights vs. Communal Benefits

As mentioned above, the measures taken in the Eastern countries may seem draconian to Western countries culturally. In fact, these measures may even be seen as unconstitutional and illegal in the West, as individual rights are compromised, if not sacrificed, for communal benefits.

A prime example is the drastic lock-down measures imposed in China where liberty is severely restricted. Other countries in Asia also took aggressive and invasive measures, including mandatory quarantines with enforceable penalties and fines for breaches and active surveillance with GPS trackers installed on quarantined subjects' phones, which would not only restrict liberty but also compromise privacy rights. Western countries hesitate to do the same, where liberty and privacy rights are so fundamentally protected in their legal systems that statutory exceptions are possible, but limited and discouraged. This barrier reduces Western governments' abilities to enforce and implement their measures effectively and urgently. For example, Canada's privacy principles strongly emphasize on data minimization, in that only minimal personal information, including location data and identity of a confirmed case, that is relevant or necessary to accomplish specific purposes should be collected, used and disclosed. While public sector may disclose such personal information in public interest and process the personal information for internal purposes, private sector may not do so without consent unless exemption applies such as legal requirement or authorization. There are also concerns regarding stigmatization. Therefore, active surveillance may be difficult in Western countries as disclosure may be limited. Similarly, because of the liberty rights, mandatory social distancing and quarantines are difficult to impose in Canada initially. Canada merely recommended the public to be self-compliant without any enforcement measures until recent changes as compliance has been clearly poor.

Centralized vs. Decentralized

The extent of centralization of the healthcare system would affect its approaches towards COVID-19. Theoretically, the more centralized the system, the more efficient the surveillance, implementation of measures and delivery of care would be in a pandemic. Healthcare decisions would be made at the leadership level and all regions, healthcare facilities and professionals would implement the same approach consistently to their respective general public. Surveillance information would be shared seamlessly between parties, resources will be strategically and properly allocated, and patients would be triaged accordingly. However, that is under the assumption that a centralized system is not bureaucratic, has greater leadership on top and has sufficient buy-in from the relevant parties and general public.

A decentralized system, on the other hand, may not be as ideal during a pandemic. While it may generally serve the particular interests of the respective regions and communities better, such system may have inherent gaps in communication, data sharing and delivery model that would not be ideal in controlling a pandemic, which may require a more unified approach. Surveillance would become more difficult as cases travel, certain regions may not comply with the approaches, resources may be unevenly distributed, and worst of all, the general public might be confused with mixed directives. That is not to say a decentralized system never works - it would if all parties cooperate and communicate with each other when necessary to do so. For example, in British Columbia, different health authorities manage healthcare deliveries of their own respective regions, but when necessary, they will cooperate and communicate under the direction of Ministry of Health. However, a decentralized system can be severely fragmented which would be disastrous. The current situation in United States is a great example of a decentralized and fragmented healthcare system.

In my opinion, one size doesn't fit all in the current COVID-19 situation. While I personally believe the mixed models would work best, they may not be practical in certain countries given the mix of factors that has to be accounted for. Unfortunately, we live in a digital society where judgments are made quickly and misinformation are readily accessible. Regardless of the situation in your country, please keep in mind that your healthcare professionals are doing everything they can, including risking their lives, to protect you and your family, friends, colleagues and community. Yes, social distancing is not fun and it is causing economic downturn, and it would be frustrating to see certain countries faring better than yours. I hope this article can enlighten you, even just a little bit, on why your country may fare worse than others, why it does not implement the same measures as other successful countries, why your health officials seem to be doing not enough, and so on. Stay informed, but educated. Be curious, but also be understanding and patient.