AS the Editor-in-Chief of the MJA, I am in the very privileged position of being among the first to critically evaluate early and emerging data. I’m also able to talk to experts around the world through my medical, research and academic links.
Early on in what is now a pandemic, I remember seeing the first outbreak data from China and proposed R0 values, and initial models of exponential spread. Evidence from past outbreaks provides many lessons including the importance of the public health measures going very hard and very early, well before all the facts are in. I therefore watched with increasing alarm as despite the early warnings from the World Health Organization (WHO) there were limited initial steps taken by many governments. I remember when I first saw the alarming Imperial College modelling for the UK and US, and the impact of mitigation versus suppression strategies in terms of hospital deaths from COVID.
- This article was first published as a preprint at the MJA’s website. Read the original here
Last week the MJA published a new model of ICU bed availability, mortality and COVID admissions, validated against Italian data by Meares and Jones. The model is grim; it proposes that a hypothetical hospital in Sydney may face a steady state of 20 new positive COVID-19 admissions each and every day, one requires ICU admission for 10 days, and a 20% increase each day. By day 15 when ICU beds run out, the mortality more than doubles and stays that high, as has happened in Italy. Those who do outbreak modelling know how complex the models can be and how many unknown assumptions need to be inputed especially early in a new infectious outbreak; some use super computers to do their calculations and can take months or years to build. However, the predictive validity of complex models in an outbreak may also fail to hold up elsewhere because human behaviour is complex and changes. For this reason, sometimes simple models are more robust, at least early on when it matters.
Many have spoken out about the public health measures needed to suppress COVID and recently bold action has been taken in Australia and elsewhere; those medical leaders who have stepped up and the political leaders who have heeded the advice early enough are the initial heroes of this pandemic.
The next wave of heroes will soon emerge, namely the frontline clinicians in each hospital who will look after the COVID surge. As I write this piece the medical profession largely continues to undertake business as usual although major preparations are underway to increase ICU bed and ventilator capacity, and personal protective equipment (PPE) is being donned to protect staff. Based on the ICU bed modelling today it won’t be enough.
Those who will face the COVID frontline and manage the sickest patients will need our greatest support, every single one of them. We will need to ensure we don’t waste current stocks of PPE and more is obtained, a clear Government priority we must support by cancelling routine surgery and procedures. I hope there will be directives to order manufacturers to make what we need and fast; we would retool factories in wartime and not rely alone on private companies to step up as many have, and while some dislike the wartime analogies they resonate with me.
We will need to work together to support our medical teams. For two-doctor or health professional families with dependents, both must not be placed at high risk of exposure and severe disease, not a straightforward rostering task, particularly outside of major hospitals and in rural Australia.
We need a statewide and preferably a country-wide plan; the states closing borders is counterproductive to our response, in my view. Training of all staff needs to ramp up and this must be more than simple videos on-line. Mental health support needs to be put in place as post-traumatic stress disorder will be a serious risk, and now. We need to also protect staff financially and professionally. It is as yet unclear what the indemnity implications are for doctors called up to work outside their scope of their usual practice and this must be resolved immediately. I am a gastroenterologist; I am fully prepared to step up to either work on COVID wards or fill the gaps in the non-COVID wards, if required. But what happens if I make a mistake? And if I die will insurance cover my family?
The Australian health Practitioners Regulation Agency is working to determine the role of medical students in this hour of need. Only those near graduation could play a direct clinical role under close supervision if they volunteered but we had better start upskilling them now if this is going to prove of any use; it takes time to transition from a medical student to a fully functioning safe and competent intern. Calling doctors out of retirement is happening in the UK and this may be needed but I hope not, as this strategy places the most vulnerable in the wrong place. We will also need our health system leadership to understand at a time like this the structure should, in my view, be a military-like command-and-control one, led by senior frontline clinicians; bureaucrats must step out of the way.
The MJA has stepped up to do its part in this crisis including ultra-rapid review of COVID papers and pre-print publication so the newest data and viewpoints are released as soon as possible. In addition, all COVID articles are fully free access for anyone to read. Our medical and structural editors are working from home and the MJA will continue to publish as usual in these extraordinary times. The new rapid publication risks errors, but being too slow with information sharing is a much bigger risk. We will work to refine the preprints prior to publishing online early and in print, and correct and update along the way.
Models matter even if they are imperfect representations of the real world. The same could be said for climate change models and health, but that is a topic for another day. While the results reported by Meares and Jones may represent a worst-case scenario and may not come to pass, we must better prepare, now. Over the coming months it’s going to take courage, brains and a concerted unified effort by the medical profession to manage COVID. Let’s not leave anyone behind.
Distinguised Laureate Professor Nick Talley AC is Editor-in-Chief of the Medical Journal of Australia. He is a neurogastroenterologist, past president of the Royal Australasian College of Physicians. He is currently Pro Vice-Chancellor, Global Research, at the University of Newcastle.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.