Victor Luca, 18-Aug-20.
Despite the priveleged position we find ourselves in during this COVID-19 pandemic, we didn't get it all right.
On 17-Jun-20 I wrote a column in The Whakatāne Beacon entitled “Plague of infectious diseases” and pointed out that pandemics are nothing new. They have been with us since at least the Antonine Plague of AD165 - AD180 during which about five million people died. It is named the Antonine Plague after Marcus Aurelius Antoninus, the stoic philosopher and emperor of Rome who probably died of what was probably a plague of small pox.
Around the time of Marcus Aurelius there were only an estimated 200 million people on the planet. I gave an entire list of pandemics and the dates during which they occurred and emphasized that they have been coming with increasing frequency. Pandemics of infectious diseases are strongly dependent on population increase, our incursion into animal habitats, domestication of animals and factory farming and more recently climate change. Warnings of pandemics have been coming thick and fast from the scientific community for decades.
For instance, refer to the paper by De Jong et al. published in the prestigious science journal Nature entitled “A Pandemic Warning” dated 1997. I could cite literally hundreds of scientific articles along similar lines.
The US Homeland Security Council published a “National Strategy for Pandemic Influenza” in 2005. This is a sort of a manual about what to do to prevent and deal with a pandemic. The World Health Organization, the US Centers for Disease Control Prevention (CDC) and other similar international agencies have of course also been onto it for decades.
More recently, famous folk have been warning us about pandemics. For instance, Barak Obama warned us in 2014 and Bill Gates warned us in 2015. In another of my columns entitled “The Fragility of Human Existence” I pointed out that pandemics have been for decades firmly on the list of global existential threats that have been studied at prestigious institutions such as the Centre for the Study of Existential Risk based at Cambridge University.
While this has been going on, another more insidious sickness has been taking hold in our community. I am talking about the ideologically-driven rationalization, consolidation and privatization of our health system by the neoliberal (market-oriented economics) crowd. These folk believe that excesses in the medical system beyond easily foreseeable daily needs equates to waste. So we should not have excess beds, we should not stockpile PPE and we should spend as little public money as possible on new health technologies. We should ration out the consumption of medical supplies, pharmaceuticals and access to diagnostics and therapeutics and we should definitely not stockpile. In short, we should keep the health system on life support and make individuals pay for whatever they use. If a person doesn’t have the money to pay for private health insurance then they are consigned to the dreaded waiting list.
I was shocked to find on my return to Whakatāne in 2019 that our hospital did not possess an Echo Doppler Ultrasound Scanner. Nowadays, this is a basic bit of kit that looks like a laptop with a few sensors hanging off it. Among other things, it is an excellent tool for monitoring the function of the heart in a non-invasive procedure that lasts barely 15 minutes.
Despite ischemic heart disease being the major non-communicable killer disease in our society, our hospital in Whakatāne did not have one of these basic machines that is worth between $2K and $20K depending on sophistication and costing little or nothing to operate. Instead, the nearest ultrasound scanner to Whakatāne of this type was located in Tauranga hospital and was transported and used here one day per week. What a pathetic situation!
Nor do we have one of the most important diagnostic tools to have been developed in the past several decades. I am talking about a Magnetic Resonance Imaging (MRI) instrument. An MRI unit costs between one and two million dollars.
Unsurprisingly, getting an MRI scan in New Zealand is not easy. There is, as I said, a waiting list.
The development of MRI for medical applications occurred in the 70s. Paul Lauterbur and Peter Mansfield were awarded the Nobel Prize in 2003 for their development of MRI. Like so much of our modern technology, fundamental developments occurred in publicly-funded research institutions like Universities. That is, the tax payer forked out for the development. Like so often happens with scientific breakthroughs, private companies then come on board and drive further technological development and ultimately commercialization.
In New Zealand, almost all MRI imaging services are provided by private companies. However, the vast majority of the diagnostic cost is borne by the district health boards. A small fraction is paid by ACC, private individuals, health insurance companies and others. That is, most of the cost is carried by you the tax payer.
When it comes to pathology services we are in a similar situation. About nine years ago, some Whakatāne Hospital's pathology laboratory services were the subject of consolidation resulting in the discontinuation of microbiology analyses in the lab. Instead, samples were transported to Tauranga Pathlab and analysed there. This consolidation of services in Tauranga was facilitated and approved by Bay of Plenty District Health Board. Most microbiology specimens are now transported to Tauranga where a private lab does the work formerly done, arguably better, at the Whakatāne hospital lab.
Forermed YJ-580 Full-Digital Laptop Ultrasound Scanner. $1,500 from Alibaba.
Specimens from EBoP communities are now used to bump up numbers for Pathlab in Tauranga, and this justified their purchase of hi-tech equipment, which is fine for Tauranga and Pathlab but not so great for Whakatāne and nearby towns which need prompt results nearer the point of care (POC) in order to give appropriate treatment swiftly. For this system to work well, samples have to be analyzed as early as possible after collection from the patient. The guidelines used by the Ministry of Health state that some specimens should be processed within 15 minutes and most not more than two hours after sampling. I am talking about samples of excreta, pus swabs and the like. Biological specimens degrade with time so ‘time is of the essence’. A sample that arrives at the laboratory late, may be compromised and test results may be misleading. The result could be delayed and/or incorrect diagnosis and treatment and extended hospital stays could result. EBoP specimens typically reach Tauranga 4 - 24 hours late. It is certainly not unheard of either that during transport samples do not make it to their destination. Think about how many times you have not received a package on time or not at all that was sent to you by courier or mail.
As a major regional center, with a high level of deprivation, surely we deserve to have these capabilities here so that a prompt diagnostic service and treatment can be provided to the patient at the POC.
Now we have to deal with a deadly pandemic, and were COVID-19 to really have infiltrated our community at the start of the breakout, I am certain that we would have struggled to deal with it considering that everything is stripped down to the bare bones.
Ask yourself how many spare beds you would find in Whakatāne hospital right now and what would happen were there to be a sudden influx of COVID-19 patients tomorrow?
We dodged a bullet during the first outbreak and I hope we will again. If we don’t, I can’t help but wonder how a health system, itself on life support, would deal with having to save lives?
Isn’t it funny that when it comes to a Pandemic, the lender of last resort and the creator of money (I mean the Government) is able to step in and come to the rescue with the biggest balance sheet in the land. Why not spend a few bucks in prevention (proactively) rather than have to react hastily to a public health catastrophe or climate change for that matter and risk disaster?
I have trawled through the list of 120 of our politicians and found relatively few with any sort of scientific/technical background and expertise. I was looking for folk who might be suitably qualified to really appreciate that we face a range of global existential threats that require us to get our act together before it’s too late. Very few had specific expertise in science and technology. I am not saying that none of our politicians are smart, but if you haven’t been in the science game, it must be hard to fully understand the evidence and discriminate poor advice from good advice. Using similar arguments, I am unlikely to be made the coach of the All Blacks because I have never really played the game.
Consider Chris Hipkins who was the minister of education. As far as I know he had never taught in a classroom, and yet, he was minister of education. Now, just like that, he is the COVID-19 response minister having no training in medical science or any related discipline. Politics is the only profession I know of that does not require any specific qualification, or any qualification at all for that matter. I hope you get my point.
So I have to ask where the evidence is that these neoliberal-inspired rationalizations of the medical system, including pathology services, lead to improved health outcomes?
I hope I am wrong, but I get the impression that this pandemic is just a shot across the bows. I also hope that it alerts us as to how slack we have been in our preparations and what our medical system is worth when you know what hits the fan. The old adage that “a stitch in time saves nine” certainly seems applicable.
Siemens MRI scanner (left) and image of a diseased heart (right).