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An ICU doctor on how we can emerge from the storm into a place to mend

Dr Alex Kazemi, an ICU specialist, writes here in his personal capacity on the opportunity Covid-19 provides to rebuild our healthcare system.

The tooth fairy never showed. My daughter had written a note – “You are invited to a tea party on Saturday at 10.30. If you cannot come please leave this note behind” – placed it carefully with the plain brown envelope next to her pillow, and drifted to sleep. By the time of waking both the tooth and the note had gone, replaced by a single coin. Equally carefully, she laid out the cups of juice and biscuits on the Saturday in question, then waited for an hour, face pressed up against the window. It was a little before the lockdown had started but the neighbourhood was still quiet, anxiety filling the air. The front gate never opened and the biscuits lay untouched for the rest of the day. I span platitudes about how perhaps the fairy might be busy elsewhere. Dreams abrade against reality often enough but this does not seem the time to let them vanish. 

Since the start of lockdown it’s been a strange dreamtime in New Zealand. Where I work, in the ICU at Middlemore Hospital, the start was frenetic. We worked rapidly to reconfigure, amid a torrent of unfiltered news, watching a global domino trail. 

Then it was suddenly quiet. A blanket of stillness laid down on the city mornings, the only noise the sound of the Earth turning. I drove to work along an empty highway, past where the sunlight glittered on the undisturbed mirror of the Manukau harbour. But the surge never came. We have, all of us, held our collective breath, worked together to draw the curtains and wait, knowing we live side by side in this land. 

So, as we emerge from the storm of preparation and uncertainty, where are we now but in a quiet place. A place to mend. A time to dream. For many the effects of lockdown have been devastating; there were never any easy choices to make. I acknowledge my own privilege in that. But it is right to dream where you can. Of undisturbed birdsong, of clearer skies, of the sense that we could continue to see that we are all in this together, of the politics of inclusion rather than self-interest. 

And of rebuilding a healthcare system that before all else cares for health, where concerns of performance and efficiency become another tool in our hand rather than the rod for our back. We can use the same imagination that created our universal healthcare, with the same ideal of ensured access for all. Over successive iterations we have moved further away from that ideal. But it wouldn’t be that hard to wind that back. The raw fuel is still there – the people. I see the energy and creativity within our hospital during this crisis. It’s time to harness that, not to hamper it further.   

To do that we need to adjust our focus. The strangest part of this pandemic is that this tiny, non-sentient, replicating machine has fashioned a lens that magnifies the fractures in our society, a window into a prison of old ideas and misconceptions. The problems we face now are just more urgent extensions of problems long present. 

We talk now of numbers. I believe that mathematics is as beautiful in its own way as the sound of the sleeping city. But seeing numbers without context, without recognising the non-linearity of our world, is a fundamental mistake. Failing to place the output of our mathematical models into a framework of how we are and wish to be is at best useless, at worst dangerous. 

This argument that pits health against economic concerns has long been shallow and asymmetrical. There are many things we can do, if we have the political and social will, to mitigate economic impacts alongside preventing deaths. There is very little we can do to avert the catastrophe of rising deaths if the healthcare system becomes overwhelmed. Be clear that would not be bringing inevitable deaths forward. We all die at some point. But that scenario creates deaths in a time frame in which they would not have otherwise occurred. It would create a long-lasting rent in our fabric, crush dreams for those who had no voice to say otherwise. Each excess death is one of us. The trade-off presents a false dichotomy when we have options to save lives and create the conditions for recovery. 

Our sacrifices as a community have given us room. Keep that room to breathe, think, treat those who have lost access. Better this than thinking of healthcare capacity as an ever-expanding buffer, to follow some ill-advised economic shortcut to how we used to be. The idea of a buffer assumes that you can simply move up the gears quickly within healthcare, without the necessary additional investment in time and resource, and still expect the same outcomes.

This has never been true. The fundamental units of intensive care are people – not beds or ventilators. Each bed needs a nurse, each unit needs its team. Look after the people and they will look after you. Driving the machine at maximum for a sustained period of time, in the vague hope that you will get there faster, just wears down the gears and breaks the people inside it. Yes, at heart, our duty is to care for the sick, no matter in what numbers. Yes, in the moment healthcare workers will seek to give extra-ordinary effort for extra-ordinary problems. Those things are a given. But being able to go to these lengths is an answer to a different question to the one that asks: is it right to allow that to happen in the first place when there are better alternatives?

Elsewhere we see that strained capacity causes excess deaths. Our model of care produces excellent outcomes but it is not made to be scaled up massively and still produce the same results. Stretch the resources to their thinnest, well above the dotted line of ICU capacity, and the system will break in unpredictable ways. These ripples flow out through the hospital into the community. In countries with stringent lockdowns there are few or no excess deaths. In countries where healthcare capacity has been overwhelmed or asked to greatly expand, all-cause mortality curves drive up vertiginously from seasonal averages. And a number of these will be healthcare workers too, the same people asked to do their utmost, clapped along to be this buffer to keep the system grinding on. 

If the assumption is that it would be possible to control running at a certain level over capacity in a second wave, then the reality is that there is a thin margin between that happening and the numbers spiralling out of control. 

The fallout is not even either. Covid-19 causes the fires of inequity to rage fiercest where they are already smouldering. Excess mortality disproportionately affects the vulnerable – the elderly, the disabled, the homeless, those with unevenly distributed pre-existing comorbidities. Over and again we see how this disease lands hardest in those communities with most deprivation and chronic ill health and poorest access to healthcare. And this distribution weighs heaviest against certain ethnicities and indigenous peoples. 

We are not powerless in this pandemic. It’s in our power to define what matters and to make that matter. The questions we now ask of ourselves are questions we should have been asking anyway. What kind of society do we wish to become? Do we cast aside the notion that the dollar value of one life must be traded against another, in favour of a more humane view of ourselves and our collective wellbeing?

So, with respect, keep your physical distances. Let the government do its hard work and listen to those who have expertise in the matters at hand. Avoid rushing into a catastrophic future that is peddled by some as the best way back to normal. This lens we have been given by the virus is a grim one, and many have suffered loss, but New Zealand is gifted hope and it is in the vision of the long and better distance of a world rebuilt.  

My daughter’s birthday came and went in lockdown, the tooth fairy never arrived, and I chose not to address matters such as the reliability of magic spirits, because I know they all fade with time. I often think the hardest part of being a parent is contemplating the juxtaposition of the dreamworld that is childhood with the rougher surfaces of our reality, the worse aspects of this world we have made. Still, we should always be allowed to dream. We are fragile beings. Maybe the virus represents the disregard the universe has for our species’ sense of entitlement. But if the human race were to have any birthright, then I think it should be that the air that we breathe, until our last breath, be woven with these dreams for ourselves, our children and our fellow humans. Therein lies the future that we imagine. 

Alex Kazemi is clinical head of intensive care at Middlemore Hospital, Auckland. This piece represents his personal views.



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