Value Addition

COVID 19 : Segmented Isolation

Solving Anna Karenina’s COVID-19 Puzzle Part 3 :The Wisdom of Bodhisattva

To cover all the earth with sheets of leather—
Where could such amounts of skin be found?
But with the leather soles of just my shoes
It is as though I cover all the earth! . . .
SHANTIDEVA (685-763)
Bodhicaryavatara: The Way of the Bodhisattva

A long time ago, there lived a king who loved his land and his people very much. His favorite thing to do was to wander all over his kingdom, meeting his subjects and finding out what they needed. It made him happy to help. His only problem was that his blistered feet would ache and bleed from walking everywhere barefoot. It was painful.

One day on the road the kind king met a little girl. The girl asked the king how he was feeling, and the king replied, “Oh, I am very happy. All day long I wander my kingdom granting my subjects’ wishes. The only problem is my feet really hurt! What to do?” The king thought for a moment. Then his eyes lit up and he continued, “I hereby decree that the land shall be covered with leather so my feet will be protected.”

Can you imagine that? So much work, and no flowers would be able to grow! Luckily, the little girl was very wise and kind. She made the king a pair of slippers so he could cover his feet instead. From that day on, he was able to help everyone without hurting his feet.¹

*Story & picture from : Shantideva: How to Wake Up a Hero, Dominique Townsend, 20 July 2015, Simon and Schuster*

What Does This Have to do with COVID-19?

If we look across the World most nations have adopted the strategy of a “General lock-down” to manage the COVID crisis. Essentially putting a stop to almost all human activity – with rather drastic impact on the economic wellbeing of people, specially the small businesses and low income class who have neither the savings to survive nor the real estate to “social distance” themselves. They, in many cases, ended up both poor and infected.

Have we missed the opportunity for sensible segmentation? Or as in the tale of the barefoot King from Shantideva have we tried to cover the earth with leather instead of just making shoes for those who need them most?

We all know by now that COVID-19 is out there and is potentially going to be with us for a long time. It’s also clear that the magnitude of the task in testing all citizens or vaccinating them is extremely daunting and not a practical solution.

In my view the way forward is to focus on that where we are most vulnerable and where can have an impact yet releasing human energy towards repairing the economy as quickly as we can.

The COVID 19 crisis is not a medical problem any longer. It’s a delicate balance between health and economics and needs each of the 5 stakeholders to understand and play their role in a coordinated way to bring the economy back to health before it goes into shock! It can’t be left to Government alone!

So What Do We Do Now?

Step 1 : Segregate the vulnerable from the robust :

As a first step we need to rethink the lock down and quarantine strategy and segment and segregate people into three groups:

Group 1 Patients with COVID-19

Action : Hospitalise

Group 2 : Vulnerable People (Above 65, obese, heart conditions, diabetes etc)

Action : Quarantine/Lock down and look after using group 3 with hospital like infection control protocols in place. Prioritise them for vaccination as soon as we have a viable product.

Group 3 : Healthy/Asymptomatic

Action : Allow them to go back to work but manage rigorously their interface with group 2. This may help build herd immunity and we could potentially utilise their services to take care of Group 1 & 2 and relieve the burden of Healthcare Practitioners.

Step 2 : Setup multi-stakeholder team with constant communication and transparent access to metrics

Provider

Constantly monitor infrastructure/supplies vs hospital/ICU occupancyRaise alarm bells to Policymaker if saturation is near

Physician

Redirect Healthcare workers to caring for sick patientsEnable GPs to test/prescribe quarantine measures to PatientsInvolve community ( People) in creating capacity for quarantine of vulnerable people

People/Patient

Shift responsibility back to People with demographics/health-profile based guidelinesInvolve People (Community) in creating quarantine capacity away from hospitals and vulnerable population

Policymaker

Constantly monitor infrastructure/supplies vs hospital/ICU occupancy and tighten/open up based on capacity to care Fund care regardless of economic status to avoid re-infection ( Payer)

Payer

Ensure cost of testing, vaccination & care is born by the State ( Policymaker) to avoid affordability-based infections/deaths

Step 3 : Setup metrics for tracking demand vs supply at various capacity bottlenecks : Infrastructure, Supplies, Doctors, Nurses, Finances

The key metrics to be tracked are:

Hospitalization Capacity (H) : Number of additional patients I can take everyday given my resources : Beds, Ventilators, Doctors, Nurses, Money (see discussion on 4A’s)

Patient Flow (P) : Number of sick patients coming in for hospitalisation every day

The moment P starts getting within 80% of H there is a need to set up emergency talks to increase capacity and/or impose stricter lock downs..

In summary recognizing that we still don’t have a vaccine or an effective treatment and the fact that a large proportion of people are immune or have few symptoms a logical solution would be to segregate and protect the vulnerable while allowing the rest of the economy to go back to normal. We will still need to practice hygiene, safe distancing etc but in a practical and not a paranoid way. And mostly when dealing with the vulnerable segment.

We need to wear shoes. Not to cover the earth with leather!

Anna Karenina and The COVID-19 Puzzle Part 2 : The Dance of the Stakeholders

“Healthcare is a 5 stakeholder game often with little shared perspective or incentive”

The COVID 19 crisis is not a simple medical problem. It is a complex crisis of logistics, healthcare capacities and stakeholder alignment.

The Capacities represented by the 4A’s are : Access to infrastructure & treatments, Adoption of treatments by the medical community, Awareness among patients and Affordability of the care by patients. (See Anna Karenina and The COVID-19 Puzzle)

What makes it very interesting is that these 4A’s have to do with 5 very powerful stakeholders – Patients, Physicians, Providers, Payers and Policymakers – who are responsible for creating these capacities. And they, more often than not, don’t have their objectives and incentives aligned!

Let’s look at the roles of these stakeholders in the context of the 4A’s discussed earlier.

Providers :

Key Concern: Will I make money for my shareholders?

These are the stakeholders who provide access to infrastructure and supplies for patient care. In the COVID-19 situation these are healthcare institutions as well as pharmaceutical & Medtech companies providing hospital & ICU beds, quarantine lodgings, ventilators, Personal Protective Equipment (PPE), test kits and (as and when we discover them) vaccines, treatments and the like.

This set of stakeholders has one characteristic – they are businesses. And generally they don’t focus on public health other than as a social responsibility activity. They do not build capacity for extremely unlikely events like the COVID-19 crisis nor do they invest R&D dollars to create capacity for the next pandemic. That then becomes the responsibility of another key stakeholder : The Politician

Politicians (Policymaker) :

Key Concern: Will people vote for me during the next election?

Unlike physicians who looks after patients, the politicians’ customers are all people (read voters). The Policymakers are important in healthcare as they set the rules of the game – who can provide healthcare? how many doctors can be educated? can we import manpower from other countries? Which drugs and medical devices can be allowed into the country? How much should the patient pay for treatment? And many other such decisions.

In a pandemic, this becomes the most important stakeholder as people can become patients in days! If that happens all planning falls apart and all healthcare capacity becomes inadequate. We have seen this in the COVID-19 crisis.

Unfortunately usually this is the least educated stakeholder when it comes to medical science. And their primary focus is on looking good & maximizing votes and less on patient health. Therein lies one of the biggest sources of friction and expensive delay.

Some countries are fortunate. These are Countries where the funding and management of healthcare is largely public and quick alignment is possible between policymakers and physicians and quick shared decision making saves vital time. China, South Korea, Singapore, New Zealand, Japan acted relatively fast and implemented measures to redirect capacity faster than others where things are left to private enterprise

Physicians :

Key Concern : How do I treat my patients successfully?

Healthcare practitioners are the key human resources for healthcare. Infection control personnel, nurses, intensivists, support staff are the key defense at the frontline to manage and isolate patients. Again this resource is limited and cannot be built overnight. On the contrary this can be severely depleted in a pandemic if Healthcare workers start getting infected.

Unfortunately in its drive towards productivity and high value surgical procedures, most hospitals today are not built to manage infectious patients. The surgeons are largely those focused on cancer, cardiac, general and orthopedic surgery and physicians are specialized to manage NCDs (Non-Communicable Diseases). In fact most of us were so confident that the era of communicable disease is over that perhaps the physician with the least power or clout in healthcare institutions was the Infectious Disease specialist. I doubt that many high caliber aspiring medical students put communicable disease or public health as their first choice. A serious leadership issue in a pandemic!

Patients :

Key Concern : How do I get better soon without going bankrupt?

The third – and the real “consumer” of healthcare – is the Patient. A lot of healthcare depends on the patients’ behaviour:

Do they adopt the right preventive measures? Do they accept the sick role? Do they seek help from a doctor? Do they follow advice? Does the GP refer them to the correct Specialist?

Each one of these represents a variable that determines the flow of patients to the healthcare system and determines whether or not the system can cope with the demand. In the COVID-19 pandemic this is the most important stakeholder. If they listen and behave according to guidelines – hand washing, social distancing, reporting sick early, quarantining in a disciplined way – the patient flow is low and the healthcare capacity is not overwhelmed. “Flattening the curve” is essentially the attempt to space out sickness so that the healthcare system can cope and provide time by which treatments can be found.

This is once again a stakeholder where the Policymakers can have a big impact. If they take timely actions and send the right messages the patient flow can be managed. If not the pandemic becomes a pandemonium!

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.

Payers :

Key Concern : How do I fund the healthcare costs?

The fifth stakeholder – and often the most important one – is the payer.

This is a difficult role since no one knows how long the pandemic will last! And its is doubly complicated as the pandemic adversely affects the economy further reducing the ability to pay.

It is quite clear that the COVID-19 pandemic is a complex problem of capacities, multiple stakeholders with often conflicting objectives, lack of clear/effective treatment or prevention measures and a race against time.

This is a not a time for passing the buck or assigning blame. This is time for joint efforts and concerted Global leadership to prevent mankind and economies from collapse.

Anna Karenina and The COVID-19 Puzzle

“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?’

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.