Geneva, Saturday 18 April 2020
Let’s start with the lighter stuff before I tackle COVID-19 statistics, lifting lockdown and overloading health services.
Boris the sourdough starter went through a particularly troublesome transition from adolescence to adulthood; I was on the verge e-ordering a cattle prod! But he’s come up trumps and my wife made her first no-yeast whole grain sourdough loaf for our scrambled egg brunch this morning. Truly delicious! Hopefully we can find some white flour in the next days. It’s in short supply.
I’ve edged forward in the putting competition by winning 2 and 1 today; that’s 15 games to 8. I think the golfing goddess was distracted by the prospect of a trip to a nearby garden centre to pick up some sweet peas for potting up on the balcony.
I have noted in this Diary how the lockdown has coincided with an almost spooky spell of fine, dry weather that has lasted five weeks now. Today, we crossed the River Rhône just where it comes out of Geneva’s massive Lac Leman. There was no flow. This is unheard of at this time of year when the lake normally fills with alpine snow-melt. At the end of a hot summer, maybe.
So, COVID-19 statistics, lifting lockdown and overloading health services. I take this on with some hesitation; it is a subject too close to my heart. There are now two very clear schools of thought. One school believes that the number of cases of COVID-19 – with associated mortality – can and should be reduced by some variety of imposed lockdown until the pandemic shows signs of abating. Whether or not this happens and whether or not there is a resurgence of cases after lifting lockdown measures, time has been bought to prepare the health-care services and to protect them from overload as much as possible. We will all just have to shoulder the burden of the economic impact of the lockdown.
The other school of thought believes that the lockdown will not change the number of cases in the long term; it will simply delay their presentation. In other words the epidemic bell-shaped graph will have a lower peak but will simply spread over a longer period of time. The thinking is that whichever way we go, the pandemic will only pass when a sufficient proportion of the population is immune; by having had the disease or by vaccination. This school of thought points to the massive impact on the economy brought about by the lockdown that, ultimately, will outweigh the direct toll of COVID-19. The missing consideration here is that the time bought by lockdown measures serves to prevent overload of the health-care services.
Seeing as I am neither epidemiologist nor economist, I am not qualified to comment on the merits of the two arguments. I accept them both as valid. We won’t know what the right road is until we’ve gone down it. I do know that lifting lockdown before there are zero cases simply means moving policies from the first school of thought to the second.
However, there is one part of this story I am qualified to comment on: the overloading of health-care services. In my work as surgeon with the International Committee of the Red Cross, I have been involved in dozens of situations where there simply weren’t enough people or resources to address the needs of those who reached and needed a hospital. Try this. In this pandemic, policy-makers and commentators need to know what overloading health-care services actually means. It is not just about overworked heroes or scandalous lack of protective equipment or ventilators. To work – or attempt to work – in a barely functioning system at precisely the time when that system is required to function even better than normal can be devastating.
If ever rational thinking about the capacity of health care is required by policymakers, it is now. A health-care service is an integrated system comprising infrastructure, people, their professional skills and, most importantly, their ethics. Overloading such a system easily finds its weakest links. The worst thing to experience is not the lack of equipment; it is to be rendered useless by one’s own and one’s colleagues physical and mental exhaustion; this precisely when you are needed most. Then the whole thing is worse if you have fears for your own safety. Believe me, it can come to the point that you simply don’t care. In brief, health care is not guaranteed when health-care services are overloaded.
Protecting health-care services in this pandemic means not only injecting resources but also, more importantly, buying time. Time allows systems to be tried, tested and to become resilient. This resilience permits the system to function effectively under overload; the physical and mental well-being of health-care workers can be preserved. Indeed, in my experience, if the system functions in an overload crisis, working within it can be a totally uplifting experience.
The term “triage” is often applied to a situation where health-care services are overloaded. It is commonly understood to mean sorting patients by priority so allowing the system “to do the best for the most” or, in other words, to use the available resources in a way that can maximise the outcome for the patients as a group. This is not the whole story. What effective triage really does is protect and maintain the integrity of a heath-care system and the people working in it. Triage becomes easier and more effective if the health-care system concerned has the opportunity to practice it on multiple occasions. In this pandemic, health-care services need to be given the opportunity to try, test and improve their practice of triage. Spreading the burden of this pandemic on health-care services over time could avoid one massive and debilitating overload that could lead to a health-care service with no functioning personnel.
So here I nail my colours to the mast. Applauding our health-care workers is not enough. We have to protect them and buy them time, otherwise we may find ourselves without any effective health-care services.