The courage of Emilio Balmaceda in his column of April 27 in this digital medium, has a burning question for health workers: all these disruptions prevented a health crisis?
In the best of cases, they replaced one for another, since today we are witnessing a severe health emergency, caused not by COVID, but by the effects of the focus on COVID on the pre-existing health situation. It is enough to look at the excess deaths –the percentage of deaths greater than expected for the period– in Chile compared to Sweden, where a more liberal management of the pandemic was chosen in terms of civil rights, resting on individual responsibility. It is fair to say that we are not the Swedes of South America, we are more like the English. Like his Prime Minister Boris Johnson, good for partying and lying, although the country always has the ability to improve and go further.
The dimensions of this crisis are various. Let’s list three:
- Disruption of health institutions from the modest rural post to the central level of the Ministry of Health, generating a reduction of 60% or more in health activities in all their spectrum, delay in benefits, suppression of some, work overload in officials, limitation of admission to relatives to accompany their patients, slowdown in the functioning of primary care.
- Increase in two very important causes of pathology: malnutrition and sedentary lifestyle.
- The disturbance of the affective and intellectual state (mental health) generated by confinement. The experience of concentration camps in the world and in Chile indicates that confinements are harmful.
It is not surprising then that, to give a very simple example, tuberculosis mortality in the world has increased in 2021, after a decade of sustained decline. Tuberculosis expresses not only a matter of contagion, but of the effects of a severe disruption in collective life, as happened with our Yagan brothers who were decimated in Dawson or La Candelaria at the beginning of the 20th century.
When mortality is reviewed by large groups of causes in the country from 2016 to 2022 (base available on the DEIS site), the increase in mortality for large groups of causes during 2021 is verified and it is possible to explore some specific ones by territory.
We do not want to stop at what happened, but rather outline the difficulties of the present.
Although we are stigmatized as hospital-centric, reductionist or biomedical, the focus should be on serving those with relevant pathology with the greatest diagnostic and treatment/rehabilitation power. This implies recognizing the emergency of unresolved pathology in a pandemic, the aforementioned complications of the confinement, in addition to the pending issues prior to March 2020. The surgical waiting list is just one of those dimensions. But what it is about is understanding that we need an organized plan to address health difficulties, by prioritizing and ordering in an emergency, that considers making Chile’s large hospitals and their associated specialty clinics fully operational, moving from there to primary care (causing the consultants of the Emergency Unit to be visited by the Cesfam teams within 24 hours of their discharge, for example). Feed back to primary care with health information from patients who are consulting hospitals, for which they are territorially responsible. Establish a bidirectional relationship between primary care and hospitals, with specialists going to the clinics (currently occurring in some specialties) and PHC doctors going through different hospital services, depending on the programs that have been prioritized.
Recover the operation with the number of beds at least existing prior to the pandemic and its eventual complexity. At the same time, we must incorporate the non-COVID approach, skills, techniques and knowledge obtained during these two years of pandemic in molecular biology, imaging, critical beds, for example. Another great lesson we learned from the pandemic was that home hospitalization can be equivalent to almost a quarter of a hospital, in number of beds in use. In Valparaíso it meant “adding” approximately 90 beds. All the more so in the current crisis it can be promoted as a large intersectoral national program, in which caregivers can be trained and paid.
It will be necessary to rethink hospital architecture. Are the big 120,000 square meter “shoe boxes” still good for us? Perhaps we need to move to a “guerrilla cell” design, independent interconnected structures with compartmentalized functions, in order to deal with a pandemic without shutting down all other health care.
We must analyze the comparative experience of how the pandemic was faced in other places, in relation to the economic and social cost, as well as the health results. Not to point fingers but to learn and prepare to face the next pandemic. Uruguay stands out in its management and results, being a close country to which we can turn for advice.
The exercise of a structured plan will be the best tool to resolve the debate on the organization and financing of health care. Just as the approach to health problems after the 1939 Chillán earthquake planted the possibility for the SNS, a few steps in real action will be worth more than 100 statements. Incidentally, we could reduce the conceptual burden, at least in health matters, of a Convention overwhelmed by tensions.
Of course we must promote school sex education and the prevention of drug and alcohol use. We have to sit down with the education sector at the central and local levels. Increase the hours of physical education or rightly entertaining dancing at recess (or whatever it takes to end sedentary lifestyle). Require calories and proteins of good quality and in appropriate quantity, for the different feeding programs. Establish a dialogue with urban planners to have “15-minute cities” or the closest thing to that, to favor walking to public services and commerce. Implement initiatives described in the Children’s City by Francesco Tonucci, so that children can walk to their schools without fear and reoccupy public spaces.
We would like to give thanks to the writer of this write-up for this remarkable content
Health: statements or tasks?