health systems

This week, the Legislature is convening to make critical spending decisions for the future of our state. Most of these decisions will dictate how we address our local COVID-19 outbreak.

I offer here the perspective of someone who has worked for over 15 years in some of the most severely resource-constrained settings in the world. They’re based on my professional experiences working on another global pandemic — HIV/AIDS.

I began my career at a unique historical moment in which global funds to address HIV/AIDS went from almost non-existent to spectacularly abundant. This happened in 2003 and coincided with President Bush’s State of the Union speech in which he simultaneously announced intentions to go to war with Iraq and a $15-billion-dollar relief package to address HIV/AIDS.

The decade to follow was a remarkable time for research and action, as well as for critical reflection about our responses.

I present three considerations from my work on HIV/AIDS that may provide lessons for moving forward with our responses to COVID-19.

The first consideration is “Know your epidemic, know your response.”

This slogan was led by UNAIDS, the United Nations agency responsible for strategic direction in the global response against HIV/AIDS. The slogan recognized that there is no single HIV epidemic, but instead many diverse ones that reflect the unique social, demographic, economic, and health system characteristics of the places where they occur.

As such, no singular prevention or treatment solution exists. This lesson equally applies to our current COVID-19 outbreak.

“Know your epidemic, know your response” is a reminder that successfully combatting a disease requires nuanced insights into the people infected and affected, including broader community expectations around behavior. Most human health conditions, including those caused by infectious organisms, are rooted in people’s behaviors. People’s behaviors are constrained by social structures.

Social structures broadly describe how we organize our society and the institutions that govern our actions. Our economic and political systems are examples.

Public policies also reflect these, including how we fund health services, who has access to those services, and which services we deem most important. Social structures also manifest in how we define groups — race, sex, occupation — and how we treat those groups, including the options that are available to them to protect their health. Not everyone is treated equally, nor have the same options available to them.

Waiting For A Vaccine

This brings me to the second consideration, biomedicalization.

At varying moments over the past four decades of addressing the HIV pandemic, there were intense debates about who should be “at the table” to address the problem. At times, the epidemic was viewed as “a medical problem best addressed by purely technical, biomedical solutions whose management should be left to biomedical professionals and scientists.” This is biomedicalization. Such a response searches for singular solutions — such as a wonder drug or vaccine — to solve a complex problem that cannot be parsed out from the complicated ways people behave and interact, and the inequalities between people.

This is no different from now. All of us, including myself, are hoping for a silver bullet solution like a vaccine. There are no guarantees one will be developed. In the meantime, we must address the ongoing pandemic. Diagnostic tests and case-tracing are critical tools to effectively address outbreaks across the globe, but they are insufficient. A purely biomedical response to the disease will fail, because it doesn’t consider the people and communities in which disease transmission happens. It ignores the behaviors, and social structures, that facilitate or prevent viral transmission.

This brings me to my final consideration — vertical approaches.

When we biomedicalize a response to a given health condition, like COVID-19, our actions and funding tend to concentrate exclusively on that condition and a set of limited technical solutions to resolve it. This is a vertical approach. While vertical approaches make sense, especially when resources are scarce, they often do not work as intended.

The problem is that most deadly diseases, including COVID-19, are efficient at reaching the vulnerable members in our society. The much higher rates of infection, hospitalization, and death among underserved and marginalized racial/ethnic minorities in the US exemplifies this point. Vertical approaches are incapable of addressing the complex factors that place certain groups at higher risk than others.

The other issue with vertical approaches is the challenge associated with implementing them within health systems and public health networks. Neither function well vertically. When we throw all our money and effort into addressing a singular disease, we risk creating duplicate systems that compete with each other.

After President Bush’s State of the Union speech in 2003, large sums of money went to vertical, heavily biomedical approaches. In general, this new windfall could not be used to build capacity within already fragile health systems.

The result was a fracturing of the existing health system. For example, staff who once treated critical medical issues like malaria or worked in delivery care took better paying jobs working on HIV/AIDS.

Bolster Resources

Governmental agencies limped along with sparse budgets, while newly created HIV/AIDS units flourished. But, these new units could not be sustained without external infusions of money. Because of this, they often lacked independence to make decisions pertinent to their communities and funds frequently flowed in inexplicable ways driven by external donors unfamiliar with the local context. In other words, “Know your epidemic, know your response” was ignored.

We can learn from the considerations above. For example, to properly know our epidemic, we need to identify and target the unique social vulnerabilities that place certain groups in our state — for example Filipinos and Pacific Islanders — at higher risk than others. To do so means avoiding an exclusively biomedical response, part of which requires a diversity of perspectives, including from social scientists and community leaders, to guide the response.

Finally, there are risks to vertical approaches that seek to bolster resources for a singular health condition while failing to support the broader system in which these approaches are implemented. To successfully combat this disease, we should limit our dependence on unsustainable external funds that create siloed, vertical programs, with a limited number of technical fixes, rather than reinforce the whole system.

“It feels a little like practicing medicine in a war and I am not ready for this …”

This was a statement from a very close friend, who is a family doctor in Canada. She was describing her anxiety around a treatment decision that required balancing concerns about bringing an older patient into her clinic for diagnosis and treatment of a chronic condition versus delaying standard care in order to reduce that patient’s risk of acquiring a COVID-19 infection.

Many of our doctors here are currently making similarly challenging treatment and management decisions. Almost no one is trained for this, emotionally or clinically.

As recently highlighted in an editorial in the Lancet, which is the world’s premier medical journal, health care workers are currently our most precious resource. They are at the frontlines of the pandemic and one of the groups most at risk of infection.

The risks taken by our health care workers are well-recognized, as is the unconscionable situation in which so many providers lack personal protective equipment, despite weeks of forewarning that a global pandemic was nearly inevitable.

Equally concerning is that health care workers can be a source of infection themselves, especially when they lack the equipment and support that would protect patients and other providers, and in a context in which it is still unclear how much transmission of COVID-19 occurs by asymptomatic individuals. There is no doubt that insufficient and maldistributed PPEs across the United States, and here in Hawaii, is an acute crisis that cannot be ignored.

However, our providers need other forms of support too, including childcare and eldercare. With schools closed, like everyone else, our health care providers are balancing personal and professional roles and responsibilities.

Our heath care workforce is much larger than just doctors and nurses. It includes staff from a wide variety of disciplines (e.g., pharmacists, information technology specialists, laboratory technicians, interpreters, social workers, etc.) all of whom are critical to the proper functioning of our health system.

One group that is particularly vital, but frequently overlooked and under-celebrated, is custodial staff. In a context in which environmental cleaning and disinfection is paramount, both in and out of health care settings, assuring the health and wellbeing of our custodial staff should be among our highest priorities.

However, all health care staff at the moment need support, as the best way through this crisis is the full and coordinated mobilization of those who are trained to care for sick patients and their families.

While health care workers are our most valuable resource, our health system is currently our most valuable infrastructure. A health system is more than just hospitals. While definitions of health systems vary considerably by professional organization, generally speaking they encompass those that govern and guide health care decisions (policymakers and departments of health), entities that finance services (insurers, Medicaid and Medicare), as well as the places where services are delivered (hospitals, private practices, federally qualified health centers, etc.)

As the number of cases in Hawaii increases, all elements of the health system will be placed under incredible strain and if our local outbreak goes unmitigated, the system will collapse under the pressure.

Extreme Measures

It is crucial to consider what health system collapse looks like to better understand why such extreme measures have been taken to slow the spread of the virus. A collapsed health system entails much more than people with the virus, and resulting disease, not getting life-saving health care. That is, it entails more than being unable to get into an ICU or onto a ventilator when a sick patient needs one.

These are terrible consequences in-and-of-themselves and have been cited repeatedly as explanations for the high case-fatality rates in places like Wuhan, China, as well as in Italy and Spain. In these places, the health system could not keep up with demand.

A collapsed health system is much worse. It means that when car accidents happen, or heart attacks, patients are directly competing for care with those needing treatment for COVID-19 infection. Similarly, it means women who need cesareans to deliver or children with asthma attacks are also competing for care, as health personnel, equipment and materials are redirected towards managing the outbreak.

It means that health staff exhaust and burn out, compromising the quality of care their patients receive. It means that providers are forced to make decisions about who can or cannot receive life-saving care, decisions that may haunt them for years.

As supplies for infection control dwindle, it means that care is provided under unsafe conditions for both patients and providers. The latter also means increased demands on a fragile health system as patients experience complications, such as secondary infections, and providers become sick and are removed from the workforce.

For all of us, it is imperative that we support all classes of health care workers and like many in the community already have, creatively seek solutions to the acute needs facing our health care staff (like insufficient PPEs).

Broader solutions for childcare and eldercare are also needed to assure frontline staff are able to focus fully on their jobs, knowing their loved ones are safe. As for the health care system, full mobilization of all resources under clear and undivided leadership is essential.

This last point is the most challenging, as the United States’ health care system is notoriously fragmented; nonetheless, it is probably the most essential for staving off some of the worst consequences of the outbreak.

Tearing of the uterus is a serious complication in pregnancy that can lead to bleeding, shock and even death. Uterine rupture is very rare in the United States but is more common in low-income nations. A study from University of Hawaiʻi at Mānoa public health researchers that examined data from two countries in West Africa shows that women whose labor slows down or stops altogether, resulting in the need to be transferred to a higher-level hospital, are at increased risk of uterine rupture.

Researchers led by Rebecca Delafield, a PhD student with the Office of Public Health Studies in the Myron B. Thompson School of Social Work, looked at data from the medical records of nearly 85,000 women who gave birth over the course of one year in Senegal and Mali. The researchers found that 569 of the women had suffered a uterine rupture while giving birth.

“The fact that uterine rupture is so rare in high-income nations demonstrates that it is largely preventable,” said Delafield. “We wanted to find out what increases the risk of suffering a uterine rupture for women. A better understanding of the factors involved could point to ways to prevent this outcome and possibly save lives.”

Obstructed labor strong predictor of uterine rupture

The data showed that the likelihood of a woman experiencing a uterine rupture increased with the number of times she had given birth. Women in the sample who had given birth five or more times were nearly eight times more likely to suffer a uterine rupture compared with women who had given birth once.

But the strongest single factor that influenced a woman’s risk of uterine rupture was “obstructed labor,” meaning that her labor had slowed down or stopped.

“We were not surprised to see obstructed labor was a strong predictor of uterine rupture,” Delafield said. “But what this study also shows is that, in addition to obstetric factors, health system factors increase the likelihood of uterine rupture in this population.”

The women in the study who had obstructed labor and were transferred to a higher-level hospital were 46 times more likely to experience a uterine rupture compared with women who did not have obstructed labor and did not need to be referred to the higher-level hospitals.

Findings support health-system improvements

Said Delafield, “Our findings suggest that women would benefit from improvements in the health systems in these settings. By improving the quality of care at the smaller, local hospitals or by transferring patients with obstructed labor more quickly, women might receive the care they need in time to prevent uterine rupture.”

The study was published November 1 in the journal BMC Pregnancy and Childbirth. Delafield’s co-authors include Catherine Pirkle, an assistant professor with the UH Office of Public Health Studies, and Alexandre Dumont, a researcher at the Research Institute for Development in Marseille, France.

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