AS was probably inevitable from the outset (in retrospect), the novel coronavirus (COVID-19) first identified in China in late 2019 is now spreading across the world.
COVID-19 is virulent and highly contagious and ideally suited for rapid dissemination through our interconnected global community. Until now travel restrictions, screening and quarantine have been very effective in preventing person to person transmission within Australia and have bought us a good deal of preparation time. There now seem to be too many clusters of patients who have little connection to known sources of infection for anyone to continue to assert that it can be contained indefinitely.
Even though we do not know how severe a pandemic we will experience, it now seems timely to consider how as a community and as health workers we might need to act in the event that our worst fears about COVID-19 are realised.
Continuing meticulous personal hygiene, and the quarantine and isolation of infected patients and those who have been exposed can be very effective at slowing dissemination in the community. While such measures may not decrease the total numbers of patients who are eventually infected, their most important benefit is that they can spread an epidemic over a longer period so that fewer people are infected at any one time. This decreases the average daily demand on healthcare services, making more resources available to each patient, and buying a little time for the development of a vaccine and trial of antiviral medications (themselves a product of the search for effective treatments for AIDS).
As I have discussed elsewhere (here and here), the complexities and codependencies of modern manufacturing supply chains and just-in-time global delivery systems may well be as significant a source of disruption to communities as the illness itself. We are all highly reliant on continuous production and distribution for the necessities of our daily lives and our communities will suffer greatly if we allow commerce to be stifled for long periods by the fear, or even the reality, of disease. This is nowhere truer than in the supply of the vast array of goods necessary for continuity of treatment in high technology health systems.
If the pandemic spreads across the world, there will come a point at which it becomes clear that the balance between the benefits of containment and the care of those who are affected by COVID-19 has shifted.
Governments will face the challenge of identifying when overall community interests will be best served by restoration of communication and trade in support of the effective functioning of communities and their struggling health care systems, even though it may risk increasing the spread of disease.
For most of us (as members of the global community), and pending the development of a vaccine, the almost inevitable appearance of community transmission in Australia will mean that we will become individually responsible for undertaking the personal protection that can slow the spread, but will not eliminate our risk of catching COVID-19.
Clearly, in Australia the hugely complex planning of the community and health system response to the threat of COVID-19 is well underway. Those of us who are health workers must consider a particular set of concerns and questions, the answers to which will guide how, as individuals and as a group, we fulfil our professional duty to provide care to the sick.
- How should our community be prepared for the potential personal consequences of a severe pandemic and how may we reach consensus in prospectively deciding appropriate responses?
- Based on the data currently available, what assumptions are being made about how an epidemic of COVID-19 would play out in Australia? (for a model see Australian pandemic planning assumptions)
- How should we balance our responsibilities to our family and to our community?
- What risks should we be aware of as we fulfil our duty as health workers?
- What role changes would be necessary across the various components of health care delivery in the event that demand was overwhelming? For example, how might GPs and other community agencies be supported to take up the care of patients sick and dying at home in the community if hospitals were full?
- What are the ethical bases for decision making by managers and clinicians forced to make decisions about the allocation of resources in the event that the needs of those people requiring treatment for COVID-19 are greater than the resources available? If there are more sick people than we can treat actively, who should decide which patients we treat, and on what basis? As a 70-year old I expect that my priority would be lower than that of a child or a 40-year old parent.
- Remembering that, during an epidemic, patients will continue to present with the full gamut of other new and existing serious health conditions, how should we allocate resources between such patients and those with COVID-19? How can we promote justice, equity and the interests of the community as a whole, and avoid discrimination, self-interested behaviour, bias and corruption when distributing insufficient resources? (Consider the allocation of hearts for transplantation when the demand is greater than the supply.) Would the law protect clinicians and others who are forced to make choices based on the allocation of limited resources between patients, and in the care of individual patients?
- How would we continue to provide care for those who might not gain access to active treatment for COVID-19 and other conditions? What plans should be put in place for the provision of palliative care to all those dying from COVID-19, how would it be made available nationwide, and who would deliver it?
Clearly these are questions that many have identified already and are best considered prospectively.
Additionally, and as has been advocated for many years, we should all engage in Advance Care Planning (ACP). Talk with your family about what quality of life means for you and for them, what outcomes you would find unacceptable, and if there are any treatments that you would not want. And record your wishes, preferences, choices and directions for care in the event that you lose the capacity to make your decisions for yourself using the documents that have been designed for use in your state or territory (see ACP Australia).
I believe that with careful explanation, our community will understand and accept the decisions and the policies necessary to sustain the complex systems that support the availability of health care. We will all need to know and will be able to accept the consequences if, in this looming emergency, it becomes impossible to sustain the level of healthcare that we have enjoyed over recent decades.
Difficult concepts are best addressed by our active engagement in a public discussion founded on access to accurate information – the good news and the bad – and with guidance from the relevant experts.
It is particularly important for those in the community who would have to implement resource allocation decisions manifest as treatment unavailability to understand their role before the event.
Our leaders need to know that we will support them as they exercise their responsibility to make and implement difficult but necessary decisions in the face of significant uncertainty and in the broad interests of the community as a whole.
We clinicians know from our work with individual patients and their families, and from the evidence in plain view throughout this past summer of disasters, that our community can cope with disaster and calamity so long as we are kept well informed, feel respected for our ability to cope, have our distress acknowledged, and recognise that we are all in the same boat and can rely on one another. These attitudes encourage participation and sacrifice.
It may be that COVID-19 will turn out to be less of a calamity than seems possible from some reports in the media and has been suggested by the World Health Organization (and here). If so, we will be prepared for the next threat with well-considered pandemic management strategies, will have reconsidered the ramifications of our dependency on one another, and contemplated our sense of our locus of control in the face of the chance events of the natural world. That would not be such a bad outcome.
Understandably, COVID-19 is generating concern across our community. I hope that this article will encourage discussion about the wide array of difficult issues that we are facing so that they can be addressed constructively.
Dr Will Cairns is loitering on the brink of retirement from his role as a palliative medicine specialist based in Townsville.
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.