In late March — as the menacing spread of coronavirus shut down Australia amid a rising sense of foreboding over what was to come — Jackson faced a choice: transfer from his job as an intensive care nurse in one of the country’s largest public hospitals, or stay on, knowing he would be on the frontline in the fight against a mysterious disease that had already left thousands dead overseas.
“I was quite proud to do my part,” he says of his decision. “I wanted to be able to say that when COVID-19 happened, I was there, I helped.”
But Jackson — who once worked as an emergency department nurse and is familiar with high-stakes critical care — admits to feeling nervous as he entered the coronavirus ICU for the first time. Two sets of doors marked the entry to a quarantine area with razor-sharp protocols around applying and disposing of protective equipment, even the shoes Jackson wore, were in place.
Despite the tension, the ICU was calm, he says. The medical staff set to work. “It became the new normal,” says Jackson, who wants to be identified by only his first name.
In another hospital, in another part of Australia, Stephen Parnis — a doctor with 28 years in the game, many of them as a specialist in emergency medicine — had answered the same call for help.
Despite decades immersed in the urgency of healthcare crises, plus time as vice president of the Australian Medical Association, Parnis says now the months of March and April were “the most stressful of my career”.
“That feeling is not unique to me,” he says, of the period when Australians were being presented with scenarios suggesting coronavirus could take as many as 150,000 lives .
“Those months were characterised by real fear about what was happening across the world in countries with health systems that were not that dissimilar to ours.”
Algorithms that drew in numbers of potential infections, and spun them together with spread rate and hospital capacity and availability of life-saving equipment like ventilators, spat out figures that made terrifying reading for people like Parnis: “We faced, I think, a real possibility of being overwhelmed .”
Not just that, he says, but heading to work each day knowing “we were at significantly increased risk of our own health being put in danger”.
Where to from here?
With locally acquired cases on the rise again in Victoria COVID-19 has delivered a sharp lesson in vigilance. Restrictions have been tightened once more, while across the country, authorities and individuals are watching closely for a potential second wave .
But thoughts are turning to the future.
As Australia counts the cost of coronavirus — 7,436 infections as of yesterday, 102 deaths , almost 1 million unemployed — and notwithstanding the pain of those who have lost loved ones or livelihoods, many experts believe there is space now to feel grateful, to take stock and to consider where the healthcare system should go from here.
As they reflect on their experiences over the past three months, both Jackson and Parnis agree that Australia’s response to COVID-19 was impressive.
“Fear is a powerful motivator,” Parnis believes. “But this is a marathon. We should all be proud, but not lose sight of what we’ve learned and what we need to do in the months ahead.”
Stephen Duckett — a health economist and health program director at the Grattan Institute — is the lead author of a new report that attempts to do just that .
The think tank’s report, titled Coming out of COVID-19 lockdown: the next steps for Australian healthcare , is released today and frames Australia’s response to coronavirus in four phases so far — containment, reassurance, cautious incrementalism and national action.
We have now entered phase five: transition to a new normal, a period that “has no endpoint unless a vaccine is found”.
“Planning for this transition is as important as the planning of the response during the initial wave of the pandemic,” the report finds, warning that failure to act now not only risks a second wave, but losing beneficial changes to the health system that occurred during the pandemic.
“That would be another tragedy on top of the trauma caused by the pandemic itself,” the report says.
A power shift in healthcare
Duckett believes coronavirus has highlighted a significant power shift in healthcare, ushering in a move from the dominance of medical and hospital staff, to public health — the branch of healthcare that unites government regulation, education and policy with things like hygiene, epidemiology and disease prevention to oversee the health and well-being of all Australians.
“Public health has traditionally sat in the back corners, but it really came to the forefront in a way it never has before. Dramatically so,” he says.
As a result, Duckett’s report has highlighted seven key areas of focus for the future of healthcare in Australia: the rise of telehealth, wider application of out-of-hospital care, changes to the delivery of primary care, interaction between public and private hospitals, supply chains, public health preparedness and system planning and coordination.
“The issue is do we have the right structures? Should public health be more centralised or more disseminated? These are the questions we need to ask,” says Duckett. “There needs to be more money, too, but we’re not talking about building another huge hospital.”
This approach chimes with that of Terry Slevin, CEO of the Public Health Association of Australia, who has argued that governments should consider increasing the percentage of health budgets devoted to public health.
Slevin also supports creation of something like a centre for disease control to help work across jurisdictions to coordinate everything from sourcing personal protective equipment, to protocols for arriving cruise ships.
Thumbs up for telehealth
For Duckett, and also Parnis and Slevin, the most profound change coronavirus has delivered to Australian healthcare is a widespread shift to telehealth — a model that had been discussed for years was implemented across Australia in weeks.
“One of the big successes is how the health system pivoted so rapidly,” says Duckett. “There was an enormous amount of innovation taking place on the ground.”
He says converting outpatient services to a virtual model was key not just to delivering better quality healthcare but in closing off a route “with huge risk for coronavirus spread”.
But beyond those primary consultations, a virtual model also showed its value as a method for monitoring patients with chronic health conditions, and even using technology to guide rehabilitation in the home. The Grattan Institute report recommends that all of these methods deserve to retain a place in Australia’s healthcare strategy going forward.
But thumbs down for state-federal cooperation
But Duckett believes coronavirus has also exposed “the creakiness of the health system” in some instances slowed down by a relationship between the states and the commonwealth “that was not as nimble as it should have been”.
There was also vulnerability in areas like supply — most notably in the lack of protective equipment for frontline staff — and capacity: will we have sufficient ICU beds? Are there enough ventilators?
While Australia did ultimately find up to three times as many ICU beds, Duckett believes achieving that took too long, being announced only after the peak of coronavirus cases had passed.
Not only that, but while the extra beds would have had a huge impact, Duckett says the unpalatable reality is that in the event of the worst case scenario those beds would have bought medical workers just a week before escalating numbers of patients once again stretched the system to breaking point.
The answer this time, and in the future too, was a speedy move to lockdown.
“The number of infections was doubling every two or three days,” he says. “The demand had to be stopped by lockdown or we would have been overwhelmed. Like Italy.”
Difficult ethical questions
Chris Moy is aghast when he considers the harsh way ethical guidelines were allegedly applied in Italy: patients over a certain age were denied access to scarce ventilators , a decision that would have cost many their lives.
Moy — an Adelaide GP and head of the AMA’s Ethics and Medico-Legal Committee — was putting the finishing touches on a new set of ethical guidelines for doctors when COVID-19 hit. He says the experiences of doctors treating the virus in Australia will inform the new document the AMA produces.
“Disasters create new challenges which are not applied in normal situations,” Moy says.
“A doctor’s first priority is of course the patient in front of him or her, but coronavirus showed us they also need to consider their own safety, the safety of the patients they are going to see next and also of their families at home.”
Coronavirus has also raised unexpected ethical dilemmas for Moy to consider. In Australia, the question of “who gets the ventilator?” is likely to be soon replaced with “who gets the vaccine?”: with the entire world waiting for the shot it will take time to reach everyone. So who should get it first?
Another question consuming Moy is the ethics of using medical students to supplement doctor numbers in a crisis: “We need to consider when they can be used and their level of training,” he says. Their wellbeing is also important.
When medical risk becomes personal
Nurse Jackson felt his personal ethical responsibility acutely: with a young son and a partner at home, he was fearful of “bringing something back” at the end of each shift. But emotionally, his background in Accident and Emergency and ICU prepared him well.
“It’s hard seeing people pass away. But the hardest thing was knowing family can’t be with them. Had it been as bad as Italy or the US I think that I would have coped differently,” he says. “Knowing you would go to work and pretty much every patient you looked after would die, that would be hard. But it never got to that stage in Australia.”
Parnis — who had his own scare with coronavirus but ultimately tested negative — agrees: “We’ve seen in recent times confronting stories of health workers around the world becoming ill and some have died. It makes you think not only of your own health and wellbeing but the people you care about.”
But he says while most doctors accept an element of risk exists in their work, ethical questions about when to use medical resources were sharpened during coronavirus.
“Patients I’ve seen who have subsequently become COVID-19 positive are often the patient you’ve least expected,” he says. “It’s someone with a runny nose, someone with nausea and diarrhoea. The time when you think — do they really need a test?”
Slevin, of the Public Health Association of Australia, argues that the ethical fallout from coronavirus goes even further — raising questions about the way our societies are structured and the pressure we are placing on the environment as those societies expand.
“COVID-19 has demonstrated that human and animal health are interdependent , and closely linked to the health of ecosystems,” he says.
Recognising links between destruction of animal habitats and urban expansion are paramount to preventing future pandemics, he believes.
“This won’t be the last pandemic,” he warns. “And we need to deal with what’s around the corner.”
Duckett says COVID-19 delivered both a warning and a chance to learn lessons for how to reform healthcare in Australia: “Despite my criticisms Australia did remarkably well,” he says. “I’m quite proud of how the system worked as a whole, and also how the public responded.”
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