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During the COVID-19 pandemic, the health system stretched and stretched and stretched. So did the people in it. We must resist the inevitable urge of funders and policy makers to assess that this was the true system capacity all along, writes Jillann Farmer …
THE first article I wrote for InSight+ came from a space of believing we could do better in the coronavirus disease 2019 (COVID-19) response. The start of 2023 seems an appropriate moment to reflect and consider where we are. There is no shortage of excellent pieces analysing our pandemic response, its shortcomings, its missed opportunities, the disappointment that there was not a reset with a change of federal government, and the emerging reality of repeating waves of infection without the “holy grail” of herd immunity emerging. The current Australian wave is lower than the preceding winter and spring waves, but it is a summer wave – we must look northwards, to Canada, the United States and the United Kingdom, to get a sense of what winter might bring, and it is not pretty.
We are at an interesting time in Australian medicine. We are now three years into the COVID-19 pandemic, so we have interns who have just started work who have had three years of training affected by the extraordinary conditions that the pandemic created in health services. We have registrars starting work in their roles who have never worked in a “normal” health system. We have newly qualified consultants who have spent the past three years carrying the enormous burden of pandemic work and trying to study for Fellowship examinations. And we have the grizzled warriors – the senior staff who have stayed the course and provided support, teaching, mentoring and guidance throughout, all the while carrying workloads and burdens that would be unthinkable to most people.
New variants continue to emerge. Immune evasion continues to evolve. The prominence of “ hybrid immunity” language has likely contributed to poor vaccine booster uptake. Somehow, a message of “get infected to prevent getting infected” took hold and language that infection was “necessary” was promulgated even by public health officials. But getting infected does not permanently protect you from subsequent infection, and those subsequent infections can have escalating consequences in terms of COVID-19 complications, so the pain is likely to continue for some time yet. Based on what I see in the US, Canada and the UK, the end is not in sight (here, here and here). Not just because of the nature of the virus and its behaviour (which is, in fact, shaped by human behaviour), but because of the current policy settings that seem certain to skew in favour of transmission if that is the price to be paid for “normalcy”.
Those of us in health care knew (and continue to know) that the “nothing to see” narrative was not true, and that the veneer of normality has been maintained by extraordinary efforts of the people who work in health care across all sectors, including general practice, outpatient care, hospitals, aged care, disability care and mental health. No part of the health care system has escaped the impacts of COVID-19, and many continue to bear them. People who are using the health care system experience it, but those who enjoy the privilege of not needing to engage can remain oblivious and live happily in a world that they believe to be unaffected by COVID-19 – but it is.
The efforts of health care workers are now taken for granted. It’s just expected — this is the “new normal”. The ongoing marginalisation and isolation of vulnerable populations is also just taken for granted, expected, and part of the “new normal”. Is this really the future we choose for ourselves? Community awareness is gone. Public health messaging is absent, and government seems very comfortable to continue with the status quo.
One of my reflections, looking back, is that at the height of transmission, I found that I felt strangely disconnected from the general public. They were being fed a narrative (and believing it) from government that all was well, that this was “expected”, and even “necessary”. Attitudes and acceptance of ongoing morbidity and mortality were being shaped by ensuring a perception of “otherness” in those who succumbed — the constant emphasis in reported deaths of people who were elderly, infirm and had underlying conditions. The normalisation of COVID-19 has been a resounding success. The public are nowhere near adequately informed, with national cabinet decision making opaque, and failure to release modelling and advice upon which decisions are made. Part of me understands that this was inevitable, but another part of me longs for a world where government is a little more honest, and, by at least trying to reduce transmission, shows a little respect for the health professionals who are propping up the system.
It is possible that this lack of respect is one reason for the accelerated pace of the crisis currently facing general practice. General practice was singled out for particular and targeted disrespect by state and federal governments during the past three years, while operating under difficult circumstances perhaps not appreciated by our hospital colleagues. The narrative of “slack GPs refusing to see patients” definitely gained some traction, and this image would be unattractive to potential GP registrars. COVID-19 brought increased costs of operation to practices, and an increased need for self-funded sick leave for doctors, perhaps also accelerating the shift away from bulk billing.
I doubt it is coincidence that there is a rising percentage of junior doctors and medical students, whose attitudes and perceptions were shaped during the pandemic, who are not choosing general practice.
We need a few reset points. We need to reset policies about damping down transmission — France has just announced air quality standards for day care and schools. Schools across the US are starting to do projects to make Corsi–Rosenthal boxes (a cheap, do-it-yourself HEPA filter solution), and Amazon in the US sells a package of filters and duct tape for making these, all you need to add is the fan. World leaders in air quality engineering and the public health benefits are here, in Australia, but their message is not gaining traction. These discussions don’t seem to be happening in mainstream Australia, because it’s over. But it’s not. Perhaps recognising the terrible toll that repeated infections in children have on the children themselves, but also on the entire family, federal and state governments have started to fund improvements to ventilation and filtration in schools, but are still not educating the public about the importance of these measures and the risks of crowded poorly ventilated spaces. This dichotomy is perplexing.
We need a reset in what is considered normal and acceptable. The system stretched and stretched and stretched. So did the people in it. But we all accepted reductions in standards of care and professional behaviour. This is not a criticism; it is simply an inevitable consequence of the shortcuts that had to be taken to spread a workforce across impossible demand. We just need to strongly resist the inevitable urge of funders and policymakers to assess that this was the true system capacity all along.
Amongst the “normal and acceptable” that we must not accept is hospital acquired Covid-19 infection, and occupationally acquired Covid-19 infection. Somehow, hospital acquired infection has become passe, acceptable and just the cost of doing business. This is the price we’re paying for “normal”.
We also need a reset in the perceptions of general practice – the negative rhetoric that emerged during the pandemic has been deeply damaging, and that, combined with the increasing pay and conditions gap between GPs and hospital-employed doctors, creates a definite and valid question of “why would you?”
I hope for better days for our healthcare system, but, in particular, for the junior doctors whose early careers have been shaped in such awful circumstances. Those of us whose careers pre-dated the pandemic, who have more years of experience outside it than in, must hold that space for our junior colleagues, in the hope that we can one day return to, and they can experience, a healthier health care system.
Jillann Farmer is a Brisbane based physician currently working in emergency medicine. She lived in New York during the first wave of COVID-19.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Things are not in fact normal because I refuse to accept mass transmission of Covid-19, Covid-19 infections and deaths as being normal as it is not normal as per 2019, by definition. There is a phrase that describes a state where people can’t visit shops, art galleries, family gatherings etc. It is called social exclusion. That is what, sadly, I have concluded societies now are engaged in (and are in effect now supporting by their own normalist behaviour perpetuating high levels of Covid-19) against those who have to mask to protect themselves and those that have common sense, in very short supply, such as myself that shares this situation.
The comment about the “markedly less dangerous nature of Covid” gets me, because it is untrue. Covid is still dangerous through the long-term effects it causes, which are not reduced by vaccination as much as what people directly see in their faces. My country has in fact managed to change a 1%/2% mortality rate into over 3% by allowing excessive transmission of Covid. There is no evidence the variants now are less dangerous than the original virus and in fact evidence instead that they are more severe for children than what previous versions of the virus were for them. Effective treatments are being made ineffective by increasing new variants, the evolution of which is sped up by mass behaviour as if it is back to before Covid existed and it is not true that vaccination means the disease is not as dangerous as it was when the long-term effects of Covid disease are not yet fully clear, what we do know should be of increasing concern and the disease could well be as dangerous as it ever was in what it may cause there. The best part of the comment is when it is said every dollar and minute spent on Covid is one less on more dangerous issues and it is said we should a range of things including motor vehicle accident deaths (that kill far fewer people than Covid-19) and cardiovascular disease. I like the fact it is agreed we should prevent cardiovascular disease. Given that Covid-19 is in fact a cause of cardiovascular disease, one of many conditions Covid-19 increases the risks of, in order to prevent cardiovascular disease I therefore agree we need to spend more on Covid. To prevent cardiovascular disease, as well as other sources we need to tackle Covid-19.
At first glance, I thought this was a Canadian thread. We mirror everything touched upon here. Our medical professionals are getting the hell out of the business. Med students are avoiding family practice. Emergency rooms are at capacity or overflowing and nurses are worked to the bone without receiving due compensation. Doctors tweet to remind citizens not to treat variants lightly and end being trolled with violence and death threats. Misinformation abounds. And people are still dying of covid. The US is worse , but gone are the daily news updates from both our countries. Shame on our governments.
While I agree that the pandemic is ongoing and evolving in its impacts, I disagree that the current resources allocated to the management of Covid19 are inadequate/inappropriate. Simple cost-effective measures such as ongoing promotion of basic public hygiene/handwashing/masks etc. would seem appropriate, but I tend to agree with Dr. Lange’s comments. The health budget is finite and there are other areas where money could be better allocated.
My personal belief is that our health system is more than reasonably funded/resourced for an appropriate standard of public care in general. I think that most of the problems arise from the mistaken belief (among both the public and the medical professions) that essentially limitless money should be thrown at every issue regardless of cost-benefit analysis, i.e. In my view it is the unreasonable expectations of what the health system should provide that is the problem, and the health system is rightly not funded to meet these.
Regards, Michael (Specialist in the Public Health System)
I agree that we need to fix filtration systems. Although, we have top of the range air filtration systems in all the classrooms and corridors where I teach, and COVID still ran rampant during the early stages of last year. We all had masks on and the teachers were vaccinated too. We also kept windows open and had regular air quality checks. Maybe transmission was slightly less than it would have been, but COVID did hit our school really bad. I understand that there are limitations to all the different approaches we can take to mitigate transmission. Maybe the government’s approach in accepting the new normal is a recognition of this fact.
I’d never again support coercive measures as life is too precious to waste away in hiding. I do feel for groups of elderly and immunocompromised people who have to watch others get along with their life and I understand that there would be resentment there, but the reality is that there are only a limited amount of things which can be done, and the relative effectiveness of these measures are unfortunately limited.
Thank you. Just thank you.
I am so tired of the Emperor’s New Clothes problem. No, we are not providing best practice care anymore. We cannot provide best practice care. People are dying in corridors. Awful things are happening in hospitals. People are living with the shock of realising ambulances cannot come. GPs are leaving in droves because they can no longer bear being scapegoats in a broken system.
We can’t fix the system until we are honest with ourselves. We can no longer afford what we want. We are building a system where the rich have choice and some of the poor have nothing. It breaks my heart.
To those commenting that the death rates are lower than previously: you are correct. And that avoiding public places ,travel hugs etc is no longer of benefit to our mental health, etc l: you are also correct.
What we as physicians respectfully wish for is a federal and state wide response that no longer places the onus on individuals and secondarily on the a worn out medical system.
We have been talking about this being an air borne virus from very early on the pandemic yet no one in government has taken responsibility to upgrade our air filtration systems in public buildings including our hospitals and schools. We have doctors and nurses still working in unfiltered open spaces with COVID positive patients. We are not going to be the public’s scapegoat anymore
What’s missing from this analysis is the addition to the calculation of the markedly less dangerous nature of covid now. this is not when the early reports suggested 2% mortality. less dangerous variants, effective treatments, vaccination means the disease is simply not as dangerous as it was. Priority needs to return to the major dangers to ourselves and our patients.
Every dollar and minute spent on covid is one less on more dangerous issues. Let’s focus on preventing drowning, suicide and motor vehicle accident deaths in our young, and cancer, cardiovascular disease and dementia in our middle and older aged.
I agree and find this article very true to life. I am a nurse and everyone seems to think Covid is over. People are still dying of covid19 and some in the acute phase some in the long covid phase. I myself got covid once at an outdoor wedding. Only time I was’nt wearing a mask. I still have some lung issues 6 months after covid and am fully vaccinated and boosted. I do not want to get it again. Thankful for the scientists that are researching and publihing all aspects of covid19. I want to be informed so I can make the best decisions for myself.
Well said. But there are none so blind as those who will not see that dismantaling General Practice and reassigning those very highly qualified Medical Practitioners and assigning them roles in a team they do not want to be in where they will be expected to think that lesser trained and experienced providers are equal players will strengthen Primary care is a fraud of breathtaking ignorance. Without a doubt the plan is to drive Doctors out of Primary Care and replace them with cheaper labour at great loss to the public.
I feel seen. What a despairingly accurate description of the current state of play. Our workforce is exhausted and we have an entire generation of junior doctors who will not last the distance if circumstances don’t change soon. A patient of mine described watching the health profession “running to stand still” over the past 3 years. We’re still trying (and being expected) to sprint, but fair to say we are now going backwards.
The policy framework is no longer medical but instead economic. Accordingly there are “casualties” as in this article, being an inevitable consequence of utilitarian political decisions to give the economy priority, and so provide benefits such as jobs and the like. Effectively, government has chosen what is perceived as the lesser of two evils, but it should still be doing all it can to mitigate the risks and consequences of its decision.
What’s missing from this analysis is the ever decreasing morbidity and mortality from Covid-19, and the costs of pursuing. Going off SARS at first we thought it might be 10%, initial reports out of China 2%. Initially it was 20-30% in our most vulnerable. Now with vaccination, lower risk variants and good treatments it is completely different as I see in the figures and every day in my work.
I’m much more concerned about the delayed cancer diagnoses, the increased dementia mortality, the undetected, unmanaged cardiovascular risk factors killling Australians.
The health budget is finite: Every minute and dollar spent on prevention in ultra-low risk groups is not spent on our most vulnerable and preventable deaths. Spend money and time on road traffic accident and suicide prevention in young people and dementia and CVD prevention the middle-aged and elderly.
Dr Farmer is “recognising the terrible toll that repeated infections in children have on the children themselves”, but the recent media coverage has recognised the estimated 10 million swimming lessons missed due to Covid precautions, the 141 deaths by drowning over the last year, and a massive rise in school refusal – hardly surprising for children who have been told that attending school is dangerous. HEPA filters sound appealing, but Covid has spread in planes during mask mandates – even the cleanest air generally available does not prevent transmission, especially if you drink or eat.
Looking at the ABS website today (https://www.abs.gov.au/articles/covid-19-mortality-wave) the median age of death in the Omicron wave is 86, with only 175 males and 109 females under the age of 60. 39.4% of those who died had chronic cardiac conditions, 31% dementia, 17.5% cancer – by my back of envelope calculation, at least half of the people who died of Covid would have been eligible for VAD. Infant mortality at 3.2/1000 for 2020 and 3.3 for 2021, is less than the 3.8 of 2011.
The concept of preventing transmission is noble, yet quixotic. No country has achieved it. Like preventing pancreatic cancer, it cannot be done with current technology. For two years our health system banned surgery for painful arthritis as Category 3 non urgent, so now half a million Australians are waiting for ‘elective’ surgery for painful or disabling conditions. And simple arithmetic tells us that if every hospital increases surgical output by 20% (impossible in the overburdened public sector) it’ll take 10 years to clear that backlog. If you are on the waiting list for a hip replacement, how many extra years are you willing to suffer, if your op is cancelled when any team member (surgeon, assistant, anaesthetist, anaesthetic/scrub/scout/recovery nurses) wakes up with a sniffle?
The infectivity of Omicron is so great that the commentators below have failed to appreciate the implication: if you are immunocompromised, you can never share a meal or even a drink with anyone, never hug or kiss, you must attend a 70th birthday with your N95 firmly in place, refuse to ‘toast’, no-one will ever see you smile (except on screen). Or you get fully boosted, then take the chance to live a ‘normal’ life.
The politicians have finally realised there is more to life than avoiding disease, that crossing a border to hug your grandkids is worth a risk of dying. We respect those who took leaky boats from Vietnam, or crossed the Berlin Wall, to get to Australia – sometimes, freedom is worth the risk.
Thank you Dr Farmer, it is reassuring to hear a voice that reflects reality. It feels like we are living in the novel 1984. The pandemic is spoken about in past tense, and science, serious health and health service impacts of the disease are completely ignored. The cost to life, quality of life, the economy and the medical profession increases the longer our politicians remain in denial. We need an urgent shift in approach to managing and reducing the spread of COVID-19.
Terrific article Dr Farmer .
Thank you.
To my surprise I have passed 80 despite stupid mistakes and near misses for which I blame me, not Gov’t. I also have AF for which I take coffee, (I get more hours of AF but it doesn’t affect me anymore. I am also fortunate to live in the post-warfarin era — Thanks Gov’t) I believe Vit’ D helps my immunity, and I am better for exercise. Sometimes I wear a mask, which helps with all resp’ infections, though my phone doesn’t recognise me then. I hope there are prospects for vaccines with better coverage, so I offer appreciation to dedicated scientists, who, even as they work diligently, know they have limited chance of success.
My life is limited as I am a carer, none the less, when I woke this a.m., life was good.
How wonderful it would be if this article could be read by every politician and bureaucrat ….This is EXACTLY where we are at – and leaving the vulnerable and the health workers happily behind ….it is so sad to see that no one really stands up for the vulnerable – what kind of a society have we become ?
And we as the health work force HAVE stretched and stretched – and no end in sight, let alone real appreciation of what GPs have contributed. So I do what everyone does – go into my cocoon called consult room, do the best I can – and now looking forward until I can retire. Never used to even think about it , let alone brining it forward. But I am tired, exhausted, sick of battling the narrative with nearly every patient who thinks it’s all back to normal. the catch up of missed screening still ongoing and overall the mental health of my patients going down ( surprise surprise ).
At least articles like this give a tiny light of hope that someone out there actually speaks up about what is going on – thank you.
Fantastic article. Things are always changing. Why would a global pandemic (ongoing!) be any different? Our lives have changed. Our knowledge has changed. We have lost friends, family members, and colleagues. Enforcing ‘normal’ (when normal means what exactly?) erases our experiences – past, present and future. Why would we NOT stop to re-evaluate things? Why are people comfortable ignoring or denying (and attacking) anyone who resists the “moving on” narrative? Why has the huge amount of death and disability not been formally acknowledged and acted upon by our government?
In New Zealand we have a very similar narrative, which is not pleasant to witness as a person with autoimmune diseases and lung problems. As far as most people know, things are ‘normal’ now, but my life has narrowed considerably. I can’t go to shops, art galleries. museums, restaurants, family gatherings that are inside, shows, concerts, flights etc etc because I am the only one wearing a mask and if I catch Covid I will likely die of it. I (and many others like me) am invisible. My elderly parents believed the hype and started living life as they used to, and caught Covid within a week. In their 80s and fully vaccinated, they survived, but my mother now has serious atrial fibrillation caused by Covid. Many of my healthy friends have had Covid 2 or 3 times and are starting to feel the effects (Long Covid symptoms such as POTS, chronic fatigue). What sort of strange society are we turning into? I can’t see what the future holds but for me it is mostly staying at home, forever!
So reassuring to read this perspective. Thankyou for your writing and work. I was at a 70th birthday party yesterday. About 50 people in a relatively ventilated living room space as well as outdoor seating. To enter the home one had to go through a low ventilated spaces. Most people present were highly educated people. They have joined the masses of Australians “over Covid”. I was the only person who masked whilst indoors. A weird confronting experience amongst friends and family. I will continue to mask in inside crowded spaces as I know it has contributed to me not having yet contracted covid ( …to my knowledge…I understand I may be have been an asymptomatic covid carrier….but really doubt that considering my propensity to lung infections pre covid. ) It’s hard being part of a small minority who follows the science when loved ones and the public have been sucked into the void of “over Covid”. So wish our governments were more like France and Belgium re clean air education and like the communities still masking in many public places.
Bravo! Brilliantly articulated. The new rhetoric around COVID defies belief: I wonder what the conversation- and action – would be like if these COVID deaths were instead drownings or MVA deaths.