Amid a delta outbreak, a pandemic still roaring around the world, and a push towards reopening borders, we should consider the realities at the sharp end of the NZ health system, writes former Intensive Care doctor Alex Kazemi.
Buried somewhere in the landslide of articles about the current pandemic is a National Geographic piece on a previous one. The article, from March 2020, looked at death rates associated with different public health measures across cities in the US during the 1918 influenza pandemic. What caught my eye was a neat grid of line graphs showing the death rates over time superimposed on bars illustrating the timing and duration of the interventions. The conclusion was stark. Cities that closed down earlier, and for longer, had half the deaths of those that didn’t, and ones that reopened too early suffered large second waves. It felt at the time that we had learned these lessons before, that it would be rational to use them while waiting for the vaccines to come, and that a pandemic that had come crashing into our world would one day exit it with the noise of a door slamming shut.
Eighteen months and many deaths later it rages on. A combination of a patchwork political landscape and an organism whose sharpest essence is to replicate and evolve at speeds we can barely fathom, has meant that the pandemic hasn’t played out as many of us might have, perhaps naively, predicted. For a considerable amount of that time Aotearoa has been in the calm eye of the cyclone, watching it spin around us, but it’s not surprising that we are brushing up against the eyewall again. What happens now we’ll have to wait and see, but at least the swift lockdown has given us the best chance of coming through this particular outbreak, if we play our respective parts.
The calculus of what we do from that point is more difficult. The Skegg report on reopening borders considered the multiple complexities, and rightly recommended a more cautious approach, though there are still hurdles to even broach those recommendations. There is talk of roadmaps but usually when you draw a roadmap the roads are already built. No navigation system could plot a route from here to there when the terrain is shifting as fast as it does under our feet now. The elimination strategy has saved many lives, and thrown a lifeline to the healthcare system, but we are not in control of what happens beyond our borders. When people say the virus will become inevitably endemic it’s not clear that they always understand the range of scenarios endemicity can cover, or how bad it could be for already strained healthcare systems. Far from the assumption that the virus will eventually settle into a milder form, there are many other scenarios of evolution that could be much more problematic if we let the virus run free, as detailed in a recent Science article by Kai Kupferschmidt. When even the experts in viral evolution say they are uncertain as to the trajectory it will take, it is prudent to sit up and listen.
There is hope that vaccination will act to uncouple infections from hospitalisation and death. That is a major step in itself, particularly if we are to keep our health services above water. How much that limits the impact of the virus will depend partly on the coverage of vaccination. Rather than accepting the homogeneity of a target of, say 80%, it’s better to ask who are the 20% that would be left behind? The virus has no agency, other than to replicate, but its transmission characteristics means that, if it is allowed to, it is guaranteed to find its way into pockets of the unvaccinated, something that is well demonstrated in the US. Many months after the production of the vaccines, their distribution is still not equitable, both globally and here in Aotearoa, where appropriate calls to prioritise Māori and Pasifika communities haven’t been given sufficient weight. Our societies have been built over chasms of inequity so why would you expect the virus not to rip those open further if we do little to address them now?
With all this in mind the question of healthcare capacity in Aotearoa, how it affects our ability to deal with outbreaks and to re-open our borders, has come up recurrently. We should preface this by drawing some lines in the discussion. Politicising the issue is not just tedious. To an exhausted healthcare workforce it can be demoralising and it can be dangerous. There is work to be done but pointing fingers does none of that work. Anyone who works in healthcare long enough sees governments come and go but problems remain. Partly this is due to system complexity, and long term underinvestment over decades. A history of fragmentation and imposed rigid hierarchies mean that information flow, up and down, can be difficult, with information from those who deliver the care becoming mired in quicksand, making the realities of that care invisible. Increasingly, too, healthcare systems have struggled to keep up with large scale changes in our world that alter how disease is delivered to our doorsteps.
Intensive Care is one area that has come to the foreground of public consciousness, as in a large enough outbreak a proportion of patients will require ICU admission. Issues with standing ICU capacity currently are prominent in the media, but the discussion of the problem has been hampered by misinterpretation of numbers, which mean different things to different people, and misunderstandings of how the care is delivered.
ICU is highly labour intensive. Amid the glowing machines, the human element of the care is often ignored in its representation. And both the physical and emotional burden of caring for patients falls heaviest on the ICU nurses. While often rewarding, the work can also be exhausting, particularly so during the pandemic. Despite their training and specialised nature, these nurses are frequently overlooked in discussions of ICU capacity. A paper published this year in the US showed that articles in both the media and academic journals ignored the impact of nursing shortages on ICU provision for the pandemic, in favour of discussing ventilators and PPE. That we chronically undervalue, and underpay, such care work speaks much of where we have arrived as a society. Better pay elsewhere, combined with spiralling property prices and living costs, means that sustaining a sufficient workforce for the beds we already have is difficult. The specialisation means that we are constantly lagging in replacing lost nurses if we cannot retain them.
Reporting on ICU bed numbers is difficult too if we are not clear what we mean. Counting physical bed spaces if those bed spaces are not staffed by an ICU nurse is essentially meaningless as they cannot safely be used. The correct measure of bed availability then is staffed beds. Even worse is counting bed spaces that do not exist in normal operation. This has happened in several countries through either error or political spin. When the NHS Nightingale hospital opened in London in the first UK wave, it was possible for their government to say ICU had not yet reached capacity in the capital, despite the number of beds being well in excess of 100% of normal operations. This glossed over the fact that, due to government inactions, these beds needed to be stood up at short notice with a model of care that had to be rapidly and radically altered. ICU capacity here could, and would, be increased to cope with outbreaks but those additional beds do not exist in the conventional sense nor is it easy to make them sustainably and safely operational for anything other than short timeframes. Studies demonstrate worse outcomes when ICUs run over capacity. In its very nature, ICU is not made to upscale vastly at speed, hence the desire to avoid that being required in the first place.
The problem goes broader than just ICU. This winter, as winters before, hospitals are overfull, Emergency Departments overstretched and Public Health Units overworked, incessantly focusing on the pandemic both during and in-between community outbreaks. If you listen closely enough you can hear the whole system shudder and in reality the wider system needs to be re-addressed. That has started with the health reforms but these issues of surge capacity will need addressing before those reforms are due to be implemented.
Threats to the health system other than Covid may also appear after any border reopening. This includes the combination of holes in population immunity with re-emergence of viruses that have disappeared from view in the last couple of years but which may return in seasonal or non-seasonal epidemics in the future. This was seen recently with RSV and is likely to be seen with influenza, and potentially, through worrying and inequitable gaps in vaccinations, measles. With the possibility of sporadic future introductions of Covid outbreaks from beyond these shores, especially if it evolves, these all threaten to overload our hospitals and Public Health Units in future years at their current capacity limits.
So there is hard work to be done. And to be done before we rush headlong into whatever version of the new normal some people are envisaging. This is usually the work of years, not months, so doing it at a shorter timescale is challenging. The work will need to engage those who deliver the care and who are best placed to come up with solutions. Caution in any phased reopening of borders for Aotearoa is wise but even that route is a very uncertain one and subject to all the shifting sands of probability that the pandemic brings. Healthcare capacity needs to be increased urgently but not as a shortcut to a premature reopening that will bring surges we couldn’t possibly absorb, even with that increase.
I don’t know how the pandemic will end. I doubt anybody really does. There is a set of possible futures and we won’t know which one we have entered until after we have stepped through the door to it. But not knowing exactly where the road ends doesn’t mean we shouldn’t start down it; we just have to be mindful to steer around the trees in our way rather than heading straight at them. Besides we have little choice but to keep moving. It’s likely that the pandemic will burn through our world for a while yet. But it will end one day. And when it’s become just spitting embers there will still be work to do. Our job is to make sure we get through it collectively as best we can without getting burned, or burning all the people that might look after us. And, if we were to look hard at ourselves in the looking glass, we ought to do better in our efforts to pull others out of the fire too, both here and elsewhere.
Alex Kazemi is a doctor and writer, currently studying Public Health at the University of Auckland. He has worked as an intensive care specialist and was formerly Clinical Head of Intensive Care at Middlemore Hospital, Auckland. He is also an avid day-dreamer.