Testing times for health systems

Without understanding, humility and strict conformity to the public health interventions that are being drummed into unwilling heads, I am afraid that – the worse is yet to come

By Dr R Neerunjun Gopee

It is now widely acknowledged that practically all countries were unprepared to face the Covid-19 pandemic by the time it swept into them. This applies to even the richest countries with the most advanced health systems in the world, especially in Europe and North America. The comparative table below reveals some interesting details. It shows the statistics pertaining to Covid–19 as at March 31, 2020, 12:34 GMT (Total cases & Deaths, Cases & deaths per million), as well as the latest available GDP figures (World Bank) as % of total government expenditure (2018 for South Korea, 2016 for the other countries).

These countries have been selected for specific reasons. USA has the highest GDP expenditure; China is where the pandemic started; India has a population that roughly equals China’s; Italy is the first European country to be affected by the pandemic, where it caused havoc to the health system from the very beginning; Singapore had prepared itself prior based on its 2003 SARS experience; South Korea swung into action immediately with extensive mass testing; Sweden, to the dismay of other EU countries, is persisting with its more relaxed approach, that is, no lockdown – which in fact is also the case with Singapore, South Korea and Japan. And for obvious reasons Mauritius.

As with all previous epidemics, it is only well after it is all over that the complete statistics will be available for more comprehensive analysis. This means many months to go, and most likely not for a year after the pandemic is considered have been controlled and the Covid-19 has settled into a quiescent phase, like the influenza virus – that too if it does. Nobody can say at the moment.

This same kind of uncertainty has given rise to controversies about various aspects of the pandemic, leading to delays in decision making with consequential straining of health systems’ capacities. A major worry that is emerging now is the impact on health personnel.

To test or not to test? Several issues have affected decision making, such as availability of test kits, type of test to be conducted (for antigen or for antibody), reliability of tests (90% at best), rapidity of test (how long to get the result), whether to do only contact tracing only or combine it with community testing, and of course the resources of the country in terms of capacity for analysis that includes skilled personnel and equipment. The WHO advice to ‘Test, test, test’ was not accepted by all.

An article by Doyin Odubanjo, Executive Secretary, Nigerian Academy of Science in The Conversation of March 30 discusses the issues and challenges which are equally relevant to our own situation. He observes ‘that there are a myriad of factors to consider and that, particularly in Africa, countries have to take them all on board when making their decisions to curtail the spread of the virus.

The factors include the dangers posed by false test results, the fact that testing data is being badly communicated leading to a rise in panic levels and the fact that testing capacity is limited in many countries’. Further, ‘we should not just follow the admonition of the WHO to “test, test, test” without examining it in the context of our local peculiarities. Testing is important but countries should adapt guidelines for testing that work for them’.

I strongly recommend concerned parties to read this article, in particular because it makes very salient points about the test results especially false negative ones, and the manner of communication of positive test results and deaths which may generate unnecessary fear and panic.

According to some online posts,  Italy, Spain and the Netherlands have returned test kits that were sent to them by China as they were defective. This should caution us to apply due diligence when procuring test kits, enuring that they are compliant with approved regulatory standards.

Lockdown or no lockdown? Central to breaking the chain of transmission of the virus, this measure has divided countries in their approach, and thus led to a lag in response with dire consequences in terms of rising numbers and deaths. This was first evident in Italy, which very rapidly became the epicenter of the pandemic in the West; this unenviable position is now occupied by the US. Paradoxically, the country with the highest GDP expenditure now has the highest number of cases, which far exceed China’s, and finds itself like all other countries struggling to contain the spread of the pandemic. It has now extended the lockdown by another two weeks.

Shortage of equipment and human resources, illness and death among medical and nursing staff – Everything is in short supply – testing material, protective gear such as surgical masks and aprons, hospital beds, ICU beds, ventilators. All these are required by the millions; factories and businesses are ramping up production; others are being repurposed to meet the enormous demands.

As regards health staff, 63 doctors have died in Italy, 5 in France, and hundreds more infected and off work across the world. So too is the case with nurses, and the emotional trauma of seeing their colleagues wired up and struggling for their lives is demoralizing doctors and nurses.

An article in Medscape Orthopaedics (March 25), titled ‘Hospitals Muzzle Doctors and Nurses on PPE, Covid-19 Cases’ exposes the fear among health professionals, who are using online platforms ‘to lament short supplies, share concerns, tell stories, and plead for help’.

Predictions about the pandemic – Mathematical modeling can help in forecasting the progression of the pandemic and provide insights about how to efficiently allocate limited resources and assess the consequences of public health measures so as to prevent as many deaths as possible.

But there is no way of forecasting the number of deaths, as one epidemiologist tried to do in the case of the H1N1 pandemic locally, publishing an article in Le Journal de la Reunion which was given wide publicity. He predicted 600 deaths, and implied that the Mauritian authorities were deliberately hiding the figures. The finally tally of 28 deaths gave a big slap to the claim and the publicity, but of course there was never any apology or rectification.

Such are the vicissitudes that are complicating our handling of this unprecedented global human tragedy. Without understanding, humility and strict conformity to the public health interventions that are being drummed into unwilling heads, I am afraid that – the worse is yet to come.

Laymen in the matter must stop bothering the health authorities about case statistics, and instead help themselves and their countrymen by assiduously practising the public health measures and help to spread awareness about them.

* Published in print edition on 1 April 2020