That the Covid-19 pandemic is swamping the US medical system should come as no surprise. Western healthcare is oriented toward chronic disease treatment, and specialized individual care. This is a tremendous advantage when it comes to addressing diseases like cancer and diabetes, but a major liability in ramping up the response to a highly infectious pathogen.
One adage explains the current response, “You play like you practice.” We’ve practiced to take on one opponent, but are now facing another. Our healthcare community works valiantly but, implicit in the analogy, our practice has not set us up to win. Medically speaking, we prepared for the wrong disease.
As a result, we’re engaging in a global effort to make up for lost time. Universal enforced quarantines have brought new infections in China down to zero. Versions of lockdowns and social distancing are effective tactics. But no one could argue that this is a long-term public health strategy, given the economic and societal costs the world has already paid.
The good news is that we know which strategies and practices work. Some of these are already being deployed, like surge hospital bed capacity in New York City’s Javits Center. But these measures on their own will not be enough to beat back a global pandemic before losing hundreds of thousands of lives.
What is needed is a comprehensive approach to pandemic mitigation and control that redirects our doctor-centered health system towards one focused on patient needs in communities. We should immediately:
1) Establish hospital and community based specialized rapid epidemic response and control teams.
2) Move care and testing of most patients from the health facility to the home
3) Minimize contamination risk by standing up mobile facilities able to treat patients outside hospitals en mass
4) Deploy electronic health record and clinical support systems that standardize diagnostic and care protocols while sharing patient care and outcomes data to inform public health response.
Specialized Rapid Response Teams
In medicine, protocols and repetition save lives. Establishing these protocols is not complicated, but does require standardization, rigor and repetition. During the Ebola response in West Africa, specialized medical and ancillary health teams learned to take off and on personalized protection equipment by repeated practice; they trained on treatment protocols in advance of providing care. We need to establish similarly specialized teams, with the ability to deploy rapidly for safe testing and care. These rapid response teams require dedicated training and workforce, leaving non-rapid response teams to focus on what they do best: Taking care of patients who are not ill with Covid-19.
Home-Based Care and Testing
The US healthcare system is focused on delivering care at clinics and hospitals. But in pandemics, this orientation overwhelms the care system. It also allows patients to unknowingly spread infection. Standing up a home-based health care force, able to test and treat patients in place reduces infection spread. In the international setting, lay community health workers serve as in-home health monitors in part due to doctor shortages. In the United States these health workers by proxy are paramedics, firemen, medical students and medical resident staff. Led by cadres of physician retirees, they could dramatically increase the care of shelter in place individuals while safely transfering those requiring emergency care.
Stand up mobile facilities away from main hospitals
City’s need to be able to stand up mobile care facilities equipped and staffed to handle thousands of sick patients. Pandemic by nature produce mass causalities. But anyone who works in the current health care system knows a single bus accident overwhelms the best ER. Now imagine 100 daily bus accidents outside your local hospital. Extreme circumstances require creativity. We need to build response capacity that allows hospitals to work with the military to stand up tent hospitals. Health care providers not affected by the epidemics such as psychiatrists, dermatologist and pediatricians must put back on their once generalist caps to deliver emergency care. And there was be enough sufficient personal protective equipment: All gloved hands on deck.
Link medical and public health systems with quality data exchange relay
Western medical systems lag behind other major industries by at least a decade in technology uptake. This includes electronic data management systems or in healthcare the notorious electronic medical record never actually shown to improve effectiveness of care. Yet errors in clinical decisions in the U.S. system fall between 20-40%. This rate is too high for infectious disease epidemics where a single mistake such as a breakdown in infection protocol has exponential effects. Doctors must have access to technology that makes the right decision around constantly changing diagnostic and treatment protocols clear. This technology must aggregate and share clinical results for public health bodies to calm the public and direct scarce resources.
We do have one of the best medical systems in the world. But it is proving tragic fodder for infectious disease killers like COVID-19. Even when we recover, we will undoubtedly face another super pathogen in our lifetimes. We must deploy a new playbook now, so as to not be out maneuvered again.
