“All happy families are alike; each unhappy family is unhappy in its own”
This opening sentence of Leo Tolstoy’s Anna Karenina, in my view, holds the key to understanding the COVID Puzzle.
At the moment we are witnessing huge confusion by politicians and policymakers as to what is the best course of action. Many of those are diametrically opposite of what others are doing or what good common sense dictates.
So what does this have to do with Anna Karenina?
The key insight is that the COVID 19 crisis is not a medical crisis but a capacity crisis. There is a huge difference in outcomes if you can get access to a hospital, a doctor, a ventilator and money to pay for the treatment.
Like in Tolstoy’s conceptualisation, all nations who have things in control are doing the same things. All out of control nations are failing for different reasons!
Let try and understand this using the 4A model – a model I created during my three decades as a Healthcare leader.
Essentially caring for a patient successfully brings into play 4 capacities which I call the 4A’s.
1. Access :
The first capacity is that of access to infrastructure and supplies. In the COVID-19 situation these are hospital & ICU beds, quarantine lodgings, ventilators, Personal Protective Equipment (PPE), test kits and as we discover them vaccines, treatments and the like. While these are key just focussing on getting (capturing/hoarding) these does not solve the problem. And some of these cannot be built overnight e.g. ICUs, ventilators. So the policymaker needs to determine
“What is the number of patients I can reasonably handle given my access to infrastructure & supplies”
2. Adoption :
The second capacity is that of healthcare practitioners – the human resources. Do we have enough trained infection control personnel, nurses, intensivists, support staff to manage and isolate patients? Again this capacity is limited and cannot be built overnight. On the contrary this can be severely depleted if Healthcare workers start getting infected. The second question thus is:
“Given my Healthcare manpower, What is the number of patients I can reasonably handle?”
3. Awareness:
The third – and possibly in this case the most important variable as it determines demand – is patient flow. Are patients educated to do the right thing? Does the referral and triage chain work effectively to send patient to the right place? Are we making sure the flow of patients is not overwhelming to the earlier two capacities?. The third question therefore is:
“How do I manage demand in a way that I don’t overwhelm my Infrastructure and Healthcare manpower capacities?’
This is the place where most countries who have low numbers have directed their initial efforts – with good results. The have “flattened the demand curve” and provided relief to the first two capacities. But they must remember that unless we have a cure, the moment we let things open up – like many states in the US are planning to do shortly – we will again see a rise of patient numbers and overwhelm the first two A’s.
4. Affordability:
The last but not the least capacity if the ability to pay. In a pandemic this is quite complicated. It’s not about being able to build capacity and pay for the hospitalisation but also the ability to survive during shut downs of the economy! Also inability to pay cannot be a reason for not treating as untreated people can (re)infect others. So the fourth question for policymakers is:
“Do I have the resources to save lives and maintain livelihoods during the period of the pandemic?’
This is a difficult question since no one knows how long this will last! We don’t know if we will have a treatment/vaccine in reasonable time to permanently control the demand?
These are not easy questions. But they are important perspectives of the problem for healthcare policymakers to understand to focus on the right part of the problem.
Controlling the number of patients thru social distancing and lock downs is effective but only buys time so that we can manage the other more difficult to build capacities. And opening up too early can be a disaster if we don’t have ways of segregating and managing the infected separately from the uninfected; the vulnerable separated from the robustly healthy.
© Alok Mishra, April 22, 2020, All Rights Reserved
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