Ethical ending of lockdowns: a patient's perspective

Tuesday, 9 June 2020

As the world turns towards ending the lockdowns, thoughts and considerations around how the restrictions can safely be lifted abound. In line with our vision of a world where patients’ perspectives are heard and healthcare is designed, organised, and practised with the patient at the centre, IAPO CEO, Kawaldip Sehmi calls for this to be put into consideration as society transitions into the new normal.

 

Introduction

Any new disease that is emerging faster than our understanding is never under control, said Dr Margaret Chan the Director General of the World Health Organization at the 66th World Health Assembly in 2013. Amazingly she was referring to the SARS-MERS virus. She added that looking at the overall global situation, my greatest concern right now is the novel coronavirus. We understand too little about this virus when viewed against the magnitude of its potential threat. These are alarm bells and we must respond. The novel coronavirus is not a problem that any single affected country can keep to itself or manage all by itself. The novel coronavirus is a threat to the entire world.

Now many leaders are telling us that they have full control over the COVID-19 pandemic and are now thinking of ending their lockdowns and circuit breakers.

Getting off a tiger

Health was always a political choice, but it was never such an extreme choice as it has become now in deciding when to end the COVID-19 lockdowns. It is like getting off a tiger.

Ending lockdowns in an ethical and scientifically effective manner, while balancing the needs of the economy and society, is not only important for the nation but it is also important for the many immunocompromised patients with chronic conditions now shielding in self isolation.  

Before the COVID-19 pandemic, our relatively stable health and economic environments did not require our political leaders to make any career finishing stark choice between health or the economy. No leader had been asked to abandon the safety of Egypt and undertake such an exodus across the desert of a pandemic’s ecosystem. Leaders are now wandering through a landscape of high mortality, political paralysis, economic failure, and social upheaval.

WHO six stage pathway to ending lockdowns

The World Health Organization has given us a scientific and technical route map to ending the lockdowns:

  • First, transmissions must be controlled. This centres on the R0 or reproduction number. The virus reproduction rate must be suppressed to under 1 and keep falling.
  • Second, the state must have a sufficient safe and quality health system capacity in place to detect, test, isolate and treat every case and trace every contact.
  • Third, the outbreak risks must be minimised in special settings like health facilities and nursing homes. These house some of the most vulnerable immunocompromised groups.
  • Fourth, preventive measures are in place in workplaces, schools, and other places where it is essential for people to go. These are what is termed as super-spreader venues. Long and regular exposure, with little social distancing opportunity.
  • Fifth, importation risks can be managed. Your borders and ports of entry, and the International Health Regulation (20005) obligations, have evidence based and proportionate measures in place. Bilateral agreement with regions (air bridges) are managed properly.
  • Sixth, that communities are fully educated, engaged, and empowered to adjust to the “new norm”. Wearing masks, using sanitisation gels, keeping a safe distance, proactively getting tested when symptoms first appear and self-isolating themselves must be institutionalised.

 

Shielded Patients-prolonging their isolation safely and equitably

For patient advocates, until the countries have a viable and effective vaccine/s and have attained the herd immunity, we must continue shielding our most vulnerable patients behind evidence-based and effective programmes that safeguard their mental health and wellbeing.  

In meeting the six WHO conditions, the State will have to ensure additional measures to shield these patients before giving the go ahead for the commencement of normal economic and social activity. Most vulnerable patients are immunocompromised and have chronic co-morbidities and polypharmacy needs. They will need to be assured that the State will provide the enhanced evidence-based healthcare services on a case by case basis, after a proper risk assessment, to keep these patients safe in their homes-this will have to be almost personalised healthcare!

There is sharp balance to be struck with the wider COVID-19 health and wellbeing costs. Prolonged shielding can have mental health problems. Employers will need to prolong furlough or continue patients working from home.  Working from home was a novelty and exciting for a time, but nothing beats the face to face water fountain moments for strategy and planning.

The fear now is that the already stressed economies will not be able to support this economic burden of shielding the patients as we end the lockdowns. There may be a push-back to any delays in ending the lockdown. The biggest worry, judging from the communication being delivered in daily briefings around the world, is that the politicians will blindly follow the letter of the law and not its spirit.

Who is controlling the infodemic?

We are being reassured that the transmission is being controlled because we have certain number of test kits, ventilators, beds, and hospital capacity in place. None of the politicians have given us the evidence to reassure us that these measures are being implemented effectively.

Unlike South Korea and Taiwan, many leaders cannot reassure their populations that they have quality testing regimes with the requisite sensitivity and specificity standards to detect, test, isolate and treat every case. The IT and communication technology rich Asian Tigers have highly effective track and trace mobile apps that have been functioning since 2015 due to the MERS Virus outbreaks.

Many official scientific briefings have turned into political briefings as the politicians supress the public health epidemiologists and try to bamboozle us over the testing for new asymptomatic and recovered infections. Confusion reigns over the antigen tests to test newly infected patients and the antibody tests needed to certify that the patient has recovered and is fit and non-contagious and can return to work and mix with vulnerable patients. Brazil has gone even further; they have removed all COVID-19 statistical information from their websites!

Perhaps the loudest silence patients are hearing is that leaders are unable to tell us how effective their sentinel systems are in detecting new hotspots early enough and how robust and effective their contact tracing infrastructure is. There is no global standard as everyone is relying on a variety of smart phone and Bluetooth technology meshed up with a mixture of geo-positioning and proximity location linked to central health records and databases. Many of these are still experimental systems, some countries having a history of bad IT implementation.

A crisis of global leadership

COVID-19 has pressed the re-set button on our global political, social, economic, and public health and we may require a new kind of leadership to find new global health solutions. The use of the defence that health is a sovereign matter to thwart any global scrutiny can no longer be justified. We need new and skilled global political leadership that can navigate us in the global sea between the rampant uncontrolled COVID-19 mortality and lockdown triggered economic collapse in finding some Ithaca of normality.

We relied on the expectation that cometh the hour, cometh the man/woman. This pandemic has revealed that no man/ woman cometh and there are major fault lines in our national and global political lives.

We need a global strategy to improve global leadership and governance. We need to promote internationalism even more now. We all know that ending lockdowns ethically and effectively will require global cooperation and synchronisation.

Yester year political leaders had to really earn their salaries by constantly making stark choices between security threats and avoiding economic collapse. You were always laying your political career on the line while making a tough trade-off between health and the economy, for the greater good of all. These old school leaders practised a different type of politics. Their skilled leadership involved much more national engagement with their own society and even more complex and skilled foreign policy and political skill to engage with the global community. They could get their citizens and the global community behind them. It was not just tweaking of a few social media algorithms or tweeting a few sharp tweets to get global political legitimacy and national consensus behind them.

International Health Regulations (2005) or a new Framework on Global Health

Synchronising the ending of the lockdowns is now an urgent global need. We just cannot meet WHO’s fifth condition to end importation risks in isolation.

The International Health Regulations (2005) was the backstop that we all relied on to prevent the COVID-19 pandemic. It is an international agreement that is legally binding on 194 countries (States Parties), including all WHO Member States.

The IHR’s main aim is to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.

By the mere fact that all international trade and traffic has been damaged, and an outbreak in Wuhan Province of China has been allowed to escalate into a pandemic with a huge global mortality and morbidity impact is ipso facto pointing at a failure of the IHR 2005.

We had hoped the IHR had clearly:

  • Defined the rights and obligations of countries to report public health events to WHO
  • Established several procedures that WHO must follow in its work to uphold global public health security
  • Built upon on a multisectoral approach, with all relevant sectors of Member State national authorities contributing to detection, assessment, and response to potential public health events of international concern.
  • Have strengthened capacity at all levels in the use of basic epidemiological principles of surveillance, early detection, and response.

A new group of advocates have emerged who now want to take a fresh look at global health. The UN High Level Meeting on the Political Declaration on Universal Health Coverage demands that we look at how the sustainable development agenda can achieve global health with justice within robust, transparent, and effective global governance. The advocates want WHO Member States to look at adopting a new a legally binding global health treaty, the framework convention on global health, that is grounded in the right to health.

They hope that the new framework convention on global health will bring new clarity and precision to norms and standards surrounding the right to health and prompt the Member States to fulfil their obligations and duties under international law to the achieving the full realization of the right to health.

The advocates feel that precise human rights standards would strengthen civil society’s ability to hold governments accountable, while the treaty would require governments and the international community to build civil society’s capacity to do so.

The treaty would ensure adequate financing and an enabling legal and policy environment for civil society to carry out its many functions, such as engaging policy-makers, analysing how policies are being implemented, and intervening when laws, policies and practices are failing to protect and promote human rights.

The new framework convention on global health will help us strengthen the IHR 2005 and give it some backbone in our domestic and international courts. In the future we will no longer have a simple outbreak turn into a pandemic and then have a knee jerk panicked response from our Member States in unethical instituting and ending lockdowns that breach our right to health.