COVID-19: What's next?

Dear Editor,

The tragic images of the last few weeks are still too fresh, and it is difficult to take stock of the magnitude of pandemic figures. However, the pain of the family and friends of the dead and the bewilderment of many colleagues who have dealt admirably with situations for which it is difficult to be prepared are easy to understand. At the time of writing, although the epidemic is far from under control, glimpses of a new situation in which trends are shifting can be discerned. Specifically, in the next few weeks, we will have to start planning a new future, in which the current fear will gradually be supplanted by the desire to return to a normal life.

Although history tells us that predicting epidemics is not an exact science, experience with SARS in 2003 and MERS in 2012, both coronaviruses, as well as other pandemics of viral aetiology in recent decades ought to have taught us something. Experts around the world had warned of the next pandemic, there was quite robust understanding of its latent determinants and there were well-founded hypotheses on the most likely pathogens, foci and routes of transmission. It is now painfully clear that poor-quality political leadership, with a limited vision that rarely went past horizons marked by election periods, and obvious miscalculations in technical resource management barred us from channelling this knowledge in order to ward off catastrophe.

The impact of the measures that we have adopted in recent weeks, which were essential in our efforts to keep units and hospitals safe, have had an intense and immediate impact on our clinical practice, and have aggravated chronic problems with our healthcare system to an extent that is still difficult to ascertain. The initial anguish felt by professionals, who did not hesitate to put themselves on the front line despite knowing that they were abandoned by a system that failed to protect them, often turned into rage. We should not allow understandable frustration to lead to desolation and paralysis at a time that demands that we clearly comprehend what we have experienced and calmly reflect on our response to new challenges that we will have to face in the immediate future.

In these last few weeks, we have learned the hard way the critical importance of strategic management of ventilators, hospital beds and personal protective equipment. Yet we have also marvelled at the technological developments that have enabled us to sequence the viral genome, start designing vaccines and build entire hospitals in a matter of days. However, if this experience only teaches us how to deal with future pandemics caused by viruses, or other similar pathogens, then the suffering caused by the current pandemic will have been useless and we will have missed another opportunity. Throughout history, other human societies, and whole civilisations, disappeared because they failed to understand the changes in their environments or were incapable of deriving lessons with applications to broader contexts from specific knowledge.

It is abundantly clear that the degradation of ecosystems, a result of the current model of human development, will fuel future catastrophic events, and the fragility of our health systems has been laid bare like never before. The deep impact of their collapse on our social, economic and political structures is obvious and will have serious middle- and long-term consequences. Although no leader can ignore the pressing need for better governance of the public health system any longer, it will be our responsibility, as citizens, to ensure that these subjects are at the top of the political agenda.

In the middle and long term, hopes of resuming a normal life now rest on accelerated development of a vaccine and on some already available drugs, or newly developed compounds, that are effective in treating the most seriously ill patients. However, we cannot fail to appreciate the irony that in this technologically advanced society, with artificial intelligence and gene editing, in which complex networks through which data flow grant us, in theory, unlimited access to information, the most effective response to mitigate the pandemic has consisted of population isolation measures which have been known for centuries. Therefore, just as constructive criticism and demand for political accountability do not exempt us from fulfilling our own obligations, it has now become a matter of urgency to lead the necessary changes with all the means at our disposal. Although it can be foreseen that the need for improving the efficiency of healthcare systems will accelerate the implementation of existing trends and technologies, such as telemedicine and artificial intelligence, we should not have such faith that technology will rescue us that we forget some useful lessons from the past.

It is said that in 1942, Albert Einstein, then a professor at the University of Oxford, was asked why he had given his final year physics students the same exam as the previous year. Today, his answer is more relevant than ever: “the questions are exactly the same; the answers have changed”. When facing endemic problems in our departments and hospitals, now magnified by the pandemic, it is fair to say that, just as in 1942, we knew the questions, but our answers were clearly lacking. In recent decades, obvious delays in effectively incorporating new scientific knowledge, unjustified clinical variability and fascination with technology, which have led us at times to implement procedures and administer treatments of uncertain efficacy and poorly gauged risks, have done damage to medical practice. Well-known inequities in access to services; overdiagnosis and overtreatment, possibly accounting for a substantial proportion of waiting lists; and exponential increases in healthcare costs not accompanied by commensurate benefits for patients and society are but a few of the symptoms of these dysfunctions.

To overcome this crisis, we must engage in honest reflection on the culture of our departments and units. Critically analysing the evidence on which we base our clinical practice is imperative, and searching for innovative solutions in order to deliver now-scarce resources to patients who need it most is an ethical obligation. I have no doubt that the germ of this change already exists in our departments, but properly channelling it begins with fostering an environment of real change, in which our younger colleagues can contribute their vision, and having the intelligence to understand that we cannot do it alone. Current technologies break down many of the traditional barriers to the dissemination of knowledge, but harnessing the success of local experiences for the common good will require greater efforts in terms of communication and management. Our scientific societies and associations could be the natural forum for bringing together these changes, but not with their current structures. They will not be able to assume this transformative role without revising their missions, redefining their objectives and working to become more dynamic, plural and democratic institutions.

There is no doubt that this will be a formidable challenge. As in the case of politicians, we could refrain from taking it up, and the consequences would not be evident for some time. However, sooner rather than later, we would have to justify our inaction. Even crises as tragic as this one come with an opportunity for change that we should not squander.