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President’s Bulletin: Accepting Change and Developing the New Norm

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I was reminded by one of my international colleagues that 25th April was World Malaria Day. This has passed unnoticed in many quarters due to our collective focus on the current coronavirus pandemic. In 2018 there were 228 million cases of malaria across 89 countries, with estimated deaths of 405,000. 94% of these were people in the WHO African region, affecting some of the world’s poorest communities. Malaria is both treatable and preventable: it has a vaccine programme. It is, however, not high on the agenda of many developed economies’ health care priorities.

By comparison, on 27th April there were 3,029,709 cases of COVID-19 world-wide and 209,242 deaths. There is no treatment yet other than supportive care and no vaccine. Whilst the impact of COVID-19 on the WHO African region has not yet played out, the highest impact of the pandemic to date has been in countries noted for their affluence. Almost inevitably, therefore, COVID -19 is the focus of health care across the globe, at least for the present.

The public health approach to the pandemic has varied between countries with divergent views on the timing of social distancing measures and the use of testing.

Country Deaths per 1 million population Testing per 1 million population
Spain 503 28,779
Italy 446 29,600
UK 305   9,867
USA 170 16,854
Germany  71 24,738

Country comparisons: deaths from and testing for COVID-19 per million population as of 27.4.20

What is clear, however, is that many of the basic infection control measures (handwashing, social distancing etc.) rely on the availability of clean water, on decent housing which avoids overcrowding, and on a programme of public health education and persuasion which relies on effective digital communication. Not all of this is accessible to the poorest communities, whether they be those living below the bread line in urban and rural communities in the UK and Europe, or under the impoverished conditions endured by the Navajo Nation and immigrant communities in the USA.

With additional irony, chloroquine, the potential, but tenuous, treatment link between malaria and COVID-19, highlights further perversities and inequalities in its effect on scientific research, as reported in Nature News on 24th April 2020:

So far, there is very little data backing the idea that hydroxychloroquine works against coronavirus infection, yet the fervour surrounding it has created drug shortages and affected enrolment in clinical trials for other potential treatments.”

The health and socio-economic impact of a disease and its political consequences, therefore, should give us cause for reflection as we struggle as a profession to readjust to the new norms of our working lives.

The inequalities of provision and strategy within our health care systems are not new; they have for the most part been ignored or hidden under the pretext of politically driven service reforms or targets, which sometimes helpfully promote one health care goal but only by disregarding others. This “disregard”, (perhaps more correctly, the negative consequence of one strategy impacting on another), is often what goes unnoticed or unrecognised.

The uncomfortable reality of the COVID-19 pandemic is that it highlights the existing inequalities of health care produced by a system within which there is unlimited demand but limited service supply— be that for PPE, testing, or skilled human resource. There is, therefore, a continuous tension when determining the priorities for health service provision. This is not new.

What is new, is the very uncomfortable reality that we need to be prepared to accept joint accountability, both governments and professionals together, for the very difficult decisions ahead that will be needed for the restoration of a new service normality. However much both professional and public sections of the community demand, cajole and plead for the restoration of the old normal, this will not be possible. The environment is so changed that the framework of future operation will be different. It will carry different levels of risk of unintended harm and a need for more realistic expectations of what healthcare outcomes can and should look like in the years to come.

It is not a question of just turning the tap back on. To continue with the same metaphor, it’s going to need a completely different approach to water supply, water conservation and water quality. Most importantly it’s going to need some honesty about the existing inequalities in the system and how we prevent, or minimise embedding, the same inequalities in future care. These inequalities, particularly of resource, exist not just between communities and healthcare sectors (social and primary care; secondary and tertiary acute services and chronic disease provision) but within specialty care and within and between medical and surgical sub-specialties themselves. We may even need to consider the previously unthinkable: placing this new order under the governance of a non-political body with a co-ordinated mandate across the UK: principles of care which then inform devolved, locally responsive systems in the four nations: a co-ordinated but federated response.

The first steps, however, are to start thinking realistically about what provisions for acute and chronic disease provision looks like for our own specialty in primary and secondary care settings, in a world where COVID-19 will be present in our communities for the foreseeable future.

The BSG has already started this process for our specialty and will continue to issue further professional guidance. As we start to provide advice on resuming a more normal practice, we have an opportunity to consider the principles of service provision for the future.

Some of the options available are unpalatable: not least persuading some colleagues that switching things back to just the way they were will not serve the long term greater good of the services we wish to protect. The principle has to be that of “the greatest good to the greatest number,” and the road to establishing that new balance will be challenging.

There is an opportunity now to accept our joint responsibility to shape the future collaboratively, realising that some of the choices we will face will be between the least damaging of the available alternatives. Nevertheless, we should recognise that in the continuing phases of COVID-19 pandemic we will find the best opportunity we have had for a generation to address inequalities and transform healthcare in our nation.

With good wishes for everyone’s ongoing safety and wellbeing.

Cathryn Edwards


 Further reading

President’s Bullet Point Bulletin (28th April), which outlines what the BSG is doing and is planning to do to support our members, the wider GI community and our patients.