The COVID-19 Pandemic and the New Normal: Do Key Areas Need New Preparedness?

Introduction

As the traditional time-tested teaching goes, “a well-functioning health system working in harmony is built on having trained and motivated health workers, a well-maintained infrastructure, and a reliable supply of medicines and technologies, backed by adequate funding, strong health plans, and evidence-based policies” [1]. However, with the changing times and interconnectedness of our globalized world, a capacity to identify, control and address global public health threats such as epidemic diseases and newer catastrophes is fast turning into a universal mandate. But Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2, shook the world in a once-in-a-century manner and awakened us to a no-contact medical care paradigm. The health system needs reforms and the direction now has to be new yet sustainable. Structured guideline revisions, new policy formulation with core committee revising the existing and adapting newer policies is the mandate of the hour. Capacity building of staff to be more responsive to surroundings is a prerequisite to effectively deliver the outcomes.

Resilience of old-fashioned health systems collapsed under the tremendous pressure of this contagion and gave way to this new normal of physical distancing, social isolation and universal sanitization. No other time in recent history had seen such a convergence of public health and critical care medicine. Quarantined patients moved into frightening intensive care units at unprecedented rates. The intermediate isolation wards turned automatically into behavioural intensive care units where patients clashed with the personal protective equipment (PPE)-clad faceless health personnel. Sectors like civil police departments became front line workforce without adequate preparation on health aspects of the pandemic.

With the advent of the ‘new normal’, however, we also saw schools shutting down but education continuing online; medicine shops and private clinics close but health care being delivered; malls and movie halls shutting down but online entertainment platforms thriving. Hence a new era is beginning which needs to segue from our old customized traditional pre-pandemic world. It is, as if, the globe broke open a shell and regenerated into a new planet with new understandings and increased empathy. Health systems underwent sea changes in terms of new infrastructure being built due to COVID-19 (COVID-19 ward, COVID-19 screening clinic, COVID-19 vaccination centre, isolation ward, quarantine centre, etc.), in terms of human resources (COVID-19 warriors/survivors) and newer policies and guidelines (testing protocols, travel protocols, report generation systems, etc.). A lot of webinars and research went into these evolving policy decisions.

However, a big jolt to the medical research field was that an avalanche of publications including pre-prints. The jolt was the funnelled results from a spate of reports which showed effectiveness of almost every medicine known to infectious disease experts. Every known conceivable therapy was added to the guidelines on and off based upon updates. There was also a fast-forwarding of research process resulting in many intermediate analyses. The therapy which became time-tested in due course was something which general practitioners were misusing for a long time viz. oral/parenteral steroids. The pandemic also brought a heightened awareness of anticoagulants which could play havoc in a situation where dengue rises alongside the endemic COVID-19 situation in future.

Now post-COVID-19 clinics are emerging to manage long COVID-19 syndromes and possibly post-traumatic stress disorder like syndromes among recovered patients. A pandemic has suddenly been recognized as potential trauma even by experts in mental health field. Doctors and health systems realized not only that prevention sometimes is the only cure, but looking into the affective domain with an insight of mental health is as important as an understanding of physical ailment. Various support programmes were initiated for COVID-19 warriors in terms of resilience in the presence of a novel disease, uncertain management strategies and changing guidelines [2].

Modifications

Some operationally feasible yet small managerial modifications in the blueprint of the system could be incorporated for blended health care behaviour which will aid in tiding over the crisis, if not now, but also in the near future [3]:

1. Integrating mental health in all aspects of healthcare:
   1. Strengthening of community mental health services- Doorstep screening of common mental disorders and providing user-friendly customized modules for domiciliary care and capacity building of staff along with intensive training of supervisors. These clinics can be operational in the offline and online mode, catering to field areas and reducing the burden on the medical colleges.
   2. Opening of post-COVID-19 wards with special emphasis on the affective domain for all patients along with the patient case sheet mentioning COVID-19 history of the patients. The post-COVID-19 clinics should also be able to deal with the problems and symptoms faced by the patients, developed in a structured format, uniform across the nation.
2. Strengthening preventive and promotive health services:
   1. Creating a cadre of preventive health staff with designated job responsibilities at the field and hospital level with community engagement programs.
   2. Health promotion and effective communication using validated strategies such as Attention-Interest-Evaluation-Trial-Adoption model.
   3. Multi-stakeholder engagement at various levels of health care to raise awareness and addressing target groups such as children and adolescents, mothers and the geriatric population.
   4. Creating volunteer groups for promoting health communication between families, peer groups and communities with special help-groups for additional assistance.
3. Adopting information technology in routine healthcare:
   1. Developing online and offline mode of care, inclusive of digitally illiterate patients. The lack of physical examination as apparent during the New Normal healthcare interactions, could be supplanted by integrated multi-consultant online consultations alongside the routine out patient department (OPD) consultations.
   2. Developing user-friendly applications for availing various health services.
   3. Increasing the use of computerised health services across the country, such as OPD card generation, health information management system, electronic health records etc.

The AYUSH component of the health system could also be incorporated in the long term care of the recovered COVID-19 patients who are in need of physical rehabilitation. The broken chain of care for Non-Communicable Diseases (NCDs) could be well-adapted to the Mid-Level Health Provider (MLHP) in Health and Wellness Centres being set-up across the country [4].

To fight global pandemics, health has to expand its horizons and incorporate multi-stakeholder engagements to deal with the imminent crisis and usher changes that are user-friendly, cost-effective, sustainable yet deliver outcomes in line with Sustainable Development Goals 2030. Health system strengthening also needs a change of mindset among all citizens, both public and frontline workers.

References

1. World Health Organization. Helath Systems Strengthening. [Internet] [cited on October 20, 2021]. Available from: https://www.who.int/data/gho/data/themes/topics/health-systems-strengthening
2. Abdulla EK, Velladath SU, Varghese A, Anju M. Depression and anxiety associated with COVID- 19 pandemic among healthcare professionals in India- A systematic review and meta-analysis. Clin Epidemiol Glob Health. 2021;12:100888. [doi:10.1016/j.cegh.2021.100888]
3. Ramani S, Sivakami M, Gilson L. How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India. BMJ Glob Heal. 2019;3[Suppl 3]: e001381. [doi:10.1136/bmjgh-2018-001381]
4. Ved RR, Gupta G, Singh S. India's health and wellness centres: realizing universal health coverage through comprehensive primary health care. WHO South East Asia J Public Health. 2019;8(1):18-20. [doi:10.4103/2224-3151.255344]