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Are COVID 19 Pandemic Policies Good for Public Health

The answer posed by the title of this article may seem obvious: that pandemic policies are formulated as a crucial part of public health. However, a more in-depth exploration show that the situation is complex and one may not simply assume that all pandemic policies equate with good public health. To do so would imply that these policies override all other aspects of public health. Current debates among Western societies on this topic are highlighted, and discussed with respect to current pandemic policies in Hong Kong, where differences in culture and health and social systems exist.

 

 

The answer posed by the title of this article may seem obvious: that pandemic policies are formulated as a crucial part of public health. However, a more in-depth exploration show that the situation is complex and one may not simply assume that all pandemic policies equate with good public health. To do so would imply that these policies override all other aspects of public health. Current debates among Western societies on this topic are highlighted, and discussed with respect to current pandemic policies in Hong Kong, where differences in culture and health and social systems exist.
 

Horton [1] put forward the concept of using the term syndemic instead of pandemic to describe COVID 19. There is a need to consider biological and social interactions between conditions and states, interactions that increase a person’s susceptibility to harm or worsen their health outcomes, rather than follow purely biomedical solutions to COVID 19. An integrated approach is advocated and would likely be more successful than simply controlling epidemic diseases or treating individual patients. This theme is further developed by the Lancet Chatham House Commission on improving population health post COVID-19, which highlights that in order to maintain resilience: breaking barriers between clinical, academic, and policy boundaries, involvement of commercial and other non-state actors, public, policy makers, in modifying key behaviours contributing to NCDs are important strategies [2]. Another aspect in the formulation of pandemic policies is the disagreement between scientists on what should be done, which contributes to a breakdown of trust of pandemic policies [3]. Lastly a book has been written attacking pandemic policies as an example of ‘biomedical imperialism’, ending with a plea to put both health and care back into healthcare [4].

 

These comments resonate with the situation in Hong Kong. The government has a panel of scientific and medical advisers, who all have different perspectives based on their area of expertise. The media frequently reports on the opinion of various experts, presumably based on which government policies are made. It can be seen that pandemic policies appear to be dominated by infectious disease and public health experts, who would not have the responsibility of considering the impact of such policies for the whole of society. This is not to negate the important scientific contributions that have been made, such as the monitoring of social movements using the Octopus cards, that enables prediction modelling, as well as the screening of drainage system of housing blocks for COVID-19 pandemic response policy that incorporates risk benefit considerations, that does not accentuate health inequalities, and that are guided by ethical principles. With successive mutations in the virus, policies need to respond in a timely fashion to fulfill such criteria. These principles also apply to policy implementation. Formulation of policies should take into account not only scientific evidence, but with input from the public as well as experts in ethics, and communicated to the public on this basis.

 

While older people are recognized as the most vulnerable group in terms of hospitalization and death, such that pandemic policies place vaccinations of older adults of the highest importance, the adverse health and social consequences of pandemic policies have received little attention. Among Western societies it has been pointed out that COVID-19 has given rise to some of the worst examples of ageism, where the pandemic has been characterized as ‘the boomer remover’, where age becomes a rationing criteria for use of ventilators in Italy, and unwillingness to adopt social distancing measures by younger people to protect their older relatives [5]. Hong Kong cannot be said to be deficient in its intensive care provisions in normal circumstances, such that age alone will not be used as a criteria for rationing. There are other clinical indicators of likely response to intensive care treatment, such as frailty, that may guide management. However, when the system is overwhelmed, some form of rationing is unavoidable. This is not apparent to the public, and yet public dialogue would be welcomed, as there is increasing interest about choice of treatment in hospitals, and even choice of admission to hospitals, for those in the last years or so of their life [http://www.ioa.cuhk.edu.hk/end-of-life-care ].

 

COVID-19 shines a spotlight on how health and social welfare system have been grappling with unmet needs of the aging population for some time already in all sectors: primary care, hospital care, long term care in both community and residential care settings [6]. Fragmentation and lack of communication exist between health and social service providers; policies exist but there are problems with effective implementation and evaluation. Performance targets are constructed for the service providers rather than for care recipients, suggesting that ‘care’ may not be appropriately included in the phrase health care or social care system.

 

It is well established that older people who fall ill and admitted to hospital often require a period of rehabilitation before they can recover premorbid functioning, even though the acute problem has been resolved. Before the pandemic, non-acute hospitals as well as Geriatric Day hospitals fulfill this function. During the pandemic Day Hospitals were shut down. Non-acute hospital beds are often used to make up the short fall in hospitals beds due to increase demand for covid cases. At the height of the pandemic three nonacute hospitals were told to convert to care for covid patients. A large number of sick patients with COVID admitted to hospitals were older adults. At a time when such rehabilitation services are in high demand, paradoxically such services were cut. The consequent pent up demand has not become apparent, but would likely contribute to an epidemic of frailty and disability in the not too distant future [7]. Furthermore, older adults who survive COVID 19 infection have persistent symptoms and functional impairment, particularly those with multi morbidity and frailty, requiring a period of post acute care [8, 9]. Such services must be regarded as essential and not take a second place to acute care. From a broader perspective, older people are more vulnerable to pandemic measures in addition to the infection. Successful pandemic control must be balanced against adverse consequences of pandemic measures [10]. Community support services must also be regarded as essential, and not left to individual non-governmental organizations to decide. Withdrawal of services results in functional and cognitive decline, resulting in carer stress [11].

 

There is a need to go beyond a biomedical vision for solving this syndemic, and to distinguish the difference between biosecurity and public health [12]. There is an urgent need to develop a resilient health and social care system that work in synergy; with fit for purpose policies to support this.

 

Prof. Jean Woo, Co-Director of Institute of Health Equity; Director of Jockey Club Institute of Ageing, The Chinese University of Hong Kong

 

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References

  1. Horton R. “Offline: COVID-19 is not a pandemic”. Lancet 396 (2020): 874.
  2. Rutter HR, Horton R and Marteau MM. “The Lancet-Chatham House Commission on improving population health post COVID-19”. Lancet 396 (2020): 152-153.
  3. Horton R. “Offline: Science and the breakdown of trust”. Lancet 96 (2020): 3945.
  4. Horton R. “Offline: How others see us Comment”. Lancet 398 (2021): 1290.
  5. Morley JE. “Editorial: 2020: The Year of The COVID-19 Pandemic”. J Nutr Health Aging 25 (2021): 1-4.
  6. Woo J. “Designing Fit for Purpose Health and Social Services for Ageing Populations”. Int J Environ Res Public Health 14.5 (2017): 457.
  7. Grund S., et al. “The COVID rehabilitation paradox: why we need to protect and develop geriatric rehabilitation services in the face of the pandemic”. Age Ageing 50 (2021): 605-607.
  8. van Haastregt JCM., et al. “Management of post-acute COVID-19 patients in geriatric rehabilitation: EuGMS guidance”. Eur Geriatr Med 13 (2022): 291-304.
  9. Chen LK, Woo J and Arai H. “What we need for COVID-19 post-acute care”. Eur Geriatr Med 13 (2022): 1-2.
  10. Lim WS., et al. “COVID-19 and older people in Asia: Asian Working Group for Sarcopenia calls to actions”. Geriatr Gerontol Int 20 (2020): 547-558.
  11. Wong BP., et al. “The impact of dementia daycare service cessation due to COVID-19 pandemic”. Int J Geriatr Psychiatry 37.1 (2021).
  12. Horton R. “Offline: Reasons for hope”. Lancet 396 (2020): 1057.
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