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Public Health in the Time of Covid-19: Three Lessons Learned

Public Health in the Time of Covid-19: Three Lessons Learned
 Angèle Malâtre-Lansac
Former Associate Director - Healthcare Policy

The crisis we are going through is total: sanitary, political, economic, social, geopolitical. Faced with Covid-19, each country chooses its own strategy and reacts more or less quickly, more or less clearly, to an unprecedented health danger. Of course, political decisions regarding population containment and border closures will undoubtedly play an important role in the fight against this epidemic, but beyond these measures, some healthcare systems appear to be better prepared than others to face the epidemic.

What are the key measures that are proving particularly effective in the face of Covid-19? Does the French healthcare system, known for being highly efficient, have the equipment and the organisation best able to protect the population and avoid a health catastrophe? Three assets seem to predict an appropriate response to the crisis: knowing how to use health data and carry out mass screening; having a healthcare sector that is not essentially relying on hospitals; and the capacity to control personal protective equipments’ stocks.

Using health data and carrying out mass screening

Faced with such an epidemic, targeted and rapid measures are particularly effective. This has been shown by some countries who have successfully achieved the stratification of their populations in terms of risk levels, while other countries have made no distinction in the measures adopted. Taiwan, for instance, was able to effectively control the spread of the epidemic by cross-checking health databases with customs data from January onwards. By quickly identifying and confining people who had travelled to high-risk areas, as well as those at higher risk from the virus, the Taiwanese authorities have avoided many deaths and protected the most vulnerable citizens. As of March 16th, only 100 people have been infected and only one person has died from Covid-19.

To concentrate efforts, prevent the epidemic from spreading rapidly through the population and protect those most at risk of death – the elderly and frail – health data is an invaluable asset. The French health insurance database enables us to accurately identify those most likely to be severely affected by the virus and hospitalized. These people are known; most of them have a referring physician. Contacting them, targeting them in a personalized manner, screening them regularly, equipping them with masks and monitoring them over time is a priority. France hasn’t yet activated this possibility and is reacting to the crisis as it would have done fifteen or twenty years ago, when big data and artificial intelligence tools were non-existent.

The database of the French health insurance allows us to identify precisely those most likely to be seriously affected by the virus [...] France is reacting to the crisis as it would have done fifteen or twenty years ago, when big data and artificial intelligence tools were non-existent.

The use of data must be accompanied by a policy of systematic screening to enable rapid and appropriate management. If we don't know who is sick, how can we target our efforts? How can we know how many people are infected and monitor the evolution of the epidemic? How can we ensure that those most vulnerable are effectively protected? Having enough tests available and screening the entire population at higher risk of infection or with major health risk is a necessity. Test, test, test: the World Health Organization recommends to massively test the population in order to identify where clusters of sick people are, to follow the evolution of the virus, and to quarantine people who are contaminated to avoid the epidemic spread and contamination. Once again, France, as is the case with Italy, the United States and the United Kingdom, has not opted for systematic screening and tests are virtually unavailable.

The challenge however lies in the ability to respond quickly by concentrating resources on the populations that need it the most, and to avoid hospital overcrowding and non-targeted measures that generate a great loss of energy without being truly effective. By limiting the number of tests and choosing not to carry out large-scale screenings, France is depriving itself of a major lever to control the epidemic. Such a policy is nevertheless possible and other health systems have shown their ability to produce tests in large quantities and to organize innovative circuits for testing the population, as shown by example in Germany, Israel, Korea and Singapore.  

Avoiding hospital overcrowding by relying on primary care and telemedicine

The French healthcare system, which is extremely hospital-oriented, has not made sufficient use of primary care, which finds itself in a particularly difficult situation in the face of the epidemic. While it is known that hospital capacity must be preserved in order to provide care for patients most severely affected by Covid-19, who amount to about 20% of those contaminated, primary care medicine is an essential asset for carrying out an initial selection, enabling continuity of care and preventing hospital overcrowding. French general practitioners have not been clearly nor quickly informed about their role and what to do, nor have they been equipped with personal protective equipment, including masks, to deal with the epidemic. These difficulties reveal a real weakness in our public health system, which focuses essentially on hospitals.

The use of telemedicine, which is a corollary of well-structured ambulatory care, is also an essential asset in limiting hospital overcrowding. Telemedicine platforms have thus exploded in China with the coronavirus, enabling remote monitoring of contaminated patients and continuity of care for confined people. Teleconsultation also allows caregivers to protect themselves and to carry out initial detections by asking about symptoms. In France, barely 2,000 doctors were practicing telemedicine at the end of 2019. Low penetration of telemedicine, despite exemptions introduced at the beginning of March and the rapid mobilisation of teleconsultation platforms, constitutes a major barrier.

Low penetration of telemedicine, despite exemptions introduced at the beginning of March and the rapid mobilization of teleconsultation platforms, constitutes a major barrier.

Finally, the hospital is of course at the heart of the crisis. Having enough acute care beds, as well as ventilators to care for the most severe patients is crucial in the face of the epidemic, as tragically shown by the Italian example – and as the American case will likely reveal in the coming days. France should currently have about 7,000 beds for recovery care and about the same number of beds for intensive care. Beyond the number of beds, hospitals must also demonstrate their ability to quickly create dedicated patient pathways to avoid chain contamination, as well as to train and protect their staff and reorganize their schedules to free up beds while maintaining continuity of care.

Being able to equip caregivers, patients and the general population with masks and hydroalcoholic solutions

Last but certainly not least, basic personal protective equipment is obviously central to effectively combating the spread of the virus. The Covid-19 epidemic will have tragically shown how difficult it is for Europeans to access sufficient protective equipment for preventing the spread of the virus.

Masks, including surgical masks, are in tragically short supply in pharmacies and within health establishments. Many primary care doctors are not equipped despite the amply demonstrated usefulness of masks in preventing contamination - in contrast with public discourses somewhat minimizing their importance. The same situation has been observed for hydro-alcoholic solutions. Yet, masks and hydro-alcoholic solutions are inexpensive and very effective equipment for slowing down the progression of epidemics and protecting the population. Enabling all health care professionals and vulnerable people to be equipped seems to be a basic and priority measure that is largely lacking.

The Covid-19 epidemic will have tragically shown how difficult it is for Europeans to access sufficient protective equipment for preventing the spread of the virus.

The lack of transparency about this equipment, the difficulty of producing it in a short amount of time and our dependence on other countries for these goods reveal real weaknesses in our public healthcare system. This shortcoming, reinforced by the predatory behaviour of some people who have not hesitated to steal stocks from caregivers and hospitals, constitutes a real failure in what should be an essential public health policy to protect front-line staff, caregivers and the most vulnerable people.

It is evidently too early to draw all the public health lessons from this unprecedented crisis, but the wealth of information available in real time on different health systems and on countries' responses to Covid-19 is shedding light on some of the shortcomings of our own healthcare system. This information shows that there are other possible reactions that could inspire us for the future.



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