Why are some health systems doing better than others?

Most people will have seen this graph, or a variant of it over the last few days showing the spread of Covid-10 Coronavirus:

It’s clear from this graph and lots of others in the media that some countries are doing much better than others at controlling the spread of the disease. Some of these numbers need a pinch of salt – countries with poor public health systems, and weak leadership probably don’t know how many cases they have.

Yes, America, that’s you we’re talking about.

The question is – why?

Firstly we can look at countries like Japan and South Korea. They have been doing much better than anyone else at controlling the spread of the disease. Although they aren’t on the graph we could add Singapore and Taiwan to the list of successful nations too.

Some of this is cultural – those countries have a much more collectivist culture and place a very high premium on cleanliness. Japan is the cleanest country I have ever visited.

But there are some specific issues around South East Asia

South Korea has spent the last 60 years terrified that it’s increasingly crazy neighbour to the North is going to launch a bacteriological or chemical warfare attack. They are the most prepared country in the world, and have the biggest stockpiles of bacteriological and chemical kit anywhere.

Seoul underground stations have respiratory kit the same way the London underground have defibrillators. In fact the closer a country is to Kim Jong-un the better they have coped with Covid-19.

Respirator cupboard, Seoul underground station

With the obvious exception of China.

In China the response of the autocratic government was to cover up the outbreak, hide the data, persecute the scientists. Their disaster was of their own making. It is rather ominous that we have had no data on Covid-19 from North Korea, and that Russia continues to claim it is almost disease free, despite sharing land borders with lots of badly effected countries.

Outside of South East Asia Europe is being badly hit, and North America isn’t far behind. The Middle East however seems to have faired much better. This might reflect patterns of air travel, but it is odd that it has skipped this part of the world. . The exception to this rule is Iran, where the attitude of it’s own autocratic regime seems to have mirrored China.

But I think there is a historic health policy perspective we have missed.

There have been 2 previous respiratory outbreaks: SARS (Severe acute respiratory syndrome) in 2003 and MERS (Middle East respiratory syndrome) in 2012.

All major healthcare systems around the world prepared plans and contingencies after SARS, and should have refreshed them after MERS, and again after the last Ebola outbreak.

It looks to me that countries that experienced SARS or MERS directly have kept their plans up to date, maintained their stockpiles of kit, and have kept staff trained, while countries that had few if any cases assumed that would be the case again.

Western European countries have let their plans and contingencies lapse, while Japan, Korea, and lots of Middle East states kept their plans current. In the US Trump actively dismantled the White House infectious disease unit because of this obsession with trashing the legacy of Obama, his better looking, more successful, more popular predecessor.

The NHS definitely used to have plans for a severe outbreak of a respiratory illness, with stockpiles of kit, and plans for additional, dedicated capacity. These plans included using rural stately home hotels as recovery centres, and remote community hospitals as isolation centres for patients who were infectious but didn’t need Critical Care.

I know because some of these were on my patch, and I took part in table top planning exercises to practice how we would deal with an outbreak.

People who follow me on Twitter and Facebook will have spotted that I am shocked at the slowness of the UK’s response. We should have been standing up our extra capacity weeks ago, instead we have the Secretary of State for Health asking on live TV if anyone knows how to make a respirator, and gin distillers been asked if they can make hand sanitiser.

It is clear that whatever plans the NHS/Department of Health once had have been abandoned, lost, forgotten about. My guess is that the stockpiles of kit long ago got used as part of someone’s cost reduction/efficiency scheme during a period of financial crisis. The staff who knew what the plans were have retired, or run gin distilleries.

This is a terrible failure of organisational memory. Too many badly thought out re-organisations, too many Secretaries of State surrounding themselves with yes men, too many individuals NHS organisations who can’t see beyond their front door.

It would be wrong to single out any one Secretary of State for blame, but it is clear that the massively expensive structural re-organisation of the NHS under Andrew Lansley did huge and lasting damage to it’s management and leadership.

What will happen next will depend on whether the virus is seasonal (ie it will die down on it’s on in a few months), and whether effective treatments can be found. The UK is late switching from mitigation to suppression, but it is not too late for this plan to work for areas outside London.

The US has been lucky that so far it’s outbreaks have been in place like Seattle, which are affluent, have great healthcare facilities and a high rate of health insurance.

If it gets into the poorer, chronically ill communities, with poor healthcare facilities and low levels of health cover things could get worse very quickly.

Trump’s decision to spend most of his first term in office trashing the Affordable Care Act, and rolling back healthcare coverage from poor Americans always looked like a dumb move, no matter how many cheers to get at rallies.

Now it looks crazy.

Stay safe.

Do it clean. Lyrics make as much sense as HMG daily briefings


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