Public Health is a long-term urgency

Dr. Carlos Alberto Díaz. Profesor titular de la Universidad Isalud.

The reform of the health system is one of the many urgencies that require the long term, which cannot be subjected to the tyrannies of the circumstantial majorities, but in generating agreements on the collective direction of the new social contract.

The current global Covid-19 pandemic has sparked significant interest in the impact of communicable diseases, particularly epidemic diseases, on humanity.

Health is not only a value, but also a productive ecosystem with social value, a foundational driver of the society of the future, with the breadth that the term encompasses and this, with the current system will not work, forces a different clinical governance, professional, technical, based on data. Including social determinants, chronicity, and the freedom of people to express themselves in shared decisions. To have a social ecosystem of the future it is necessary to think about health, universal coverage, formal employment, equity, infrastructure, habitat, environment, reduce inequality, improve the income of the poorest not only in magnitude, but fundamentally in formality.

The health needs of the population even before the pandemic had changed due to the prevalence of chronic diseases. At this time, as an aggravating factor, these requirements were postponed and postponed (without certain dates) that is, after the cases decrease, the system must have a proactive behavior on the unmet demand, on chronic pathologies, the silent epidemic of this new century in constant growth.

The care model due to the characteristic of our fragmented health system is episodic, based on the care of acute patients, it costs a lot to adopt proactive modalities, disease management, progressive care, continuity and longitudinally of care, which are not  incentivized in the public sector, because their structures are financed on the basis of historical budgets, therefore, the increase in demand directly affects the financing, they have no programs or population assigned. A passive model of care for the disease if acute complications are generated.

In the social security sector, provider contracts do not involve aspects of prevention, health promotion, chronic disease control or disease management, or   case management programs, the interests are not aligned to generate a comprehensive benefit model and the networks do not have management, they are a succession of contracts with isolated providers and without objectives or management commitments.

Private health insurance has developed a marketing oriented to the consumerism of booklets or lists of specialists and providers, with a scheme of free choice and access to specialties, a model characterized by the inefficient choice of “partners”, not taking them through a health plan, which, for middle-class people, would be a very interesting and attractive approach. In addition, they have failed in the planning of their beds and their structures, which did not have, nor will have characteristics of areas of clinical management, but of services receiving the demand generated by the internal clients, which are the doctors of primer. It is an inefficient expansive spending model. It tends to generate health as a luxury good. Encouraged by the characteristics of its establishments and the areas of attention of consultations, administrative offices and conspicuous figures of the sport that constitute in its image.

The health system faces major challenges, such as increasing life expectancy, population ageing, chronic diseases, the rising cost of treatment, personalized medicine, or various economic, political and social pressures

The second wave is another disease:

Towards the beginning of 2021, he changed his health minister in the middle of the pandemic, without understanding what was happening or explaining something that was wrong, but that had to be contained and transparent. That was a setback for the health system because of the lack of effective response. Leaving as an alternative a governance team fundamentally oriented to solve a single problem: vaccines and vaccination campaigns. It seems to be a ministry with less capacity for influence for the generation of articulated policies.

This second wave is a more serious and deadly disease, the new strains of Covid and especially the Manaus strain are more contagious and have the capacity to generate reinfections. We are seeing it today, breaking a record of 41,070 cases in one day, with 78% occupancy in intensive care units. A study of blood donors in the city of Manaus has found that 1 in 6 of those infected with the coronavirus were reinfected with the P.1 variant. The results were higher than the researchers anticipated and those found in reinfections studies conducted elsewhere.

Lot transmissibility of this strain is higher, the viral load in the more severe as well, and more antibodies are needed to face the disease.

The combined association of obesity, diabetes and/or cardiovascular disease with severe covid-19 Manaus outcomes may be stronger in adults than in older people. Obesity alone and combined with Diabetes M and/or CVD had more impact on the risk of COVID-19 severity than dm and/or CVD in both age groups.

The study also supports an independent relationship of obesity with severe outcomes, including a dose-response association between degrees of obesity and death in adults. Obesity has more weight in younger people. So, I warn that we need to look closer at young patients with BMI between 27-29.

I have some certainties, that things will not be the same again, that neither, deserved to be called normality. Because what we experienced was not normal.

We saw and will see some habits change: the pandemic was the most phenomenal planetary hand washing campaign. It was the most formidable race to decipher the viral genome. By the development of vaccines, which shortened the times from ten years to months, greater personal hygiene, management of air quality in hospitals, avoid crowds and poorly ventilated enclosed places. With an exponential deployment of digitalization in the health system. It must awaken a notorious growth of public-private collaboration in that order (salaries, equipment, collection, etc.) but it is not considered in state policies, but in intentions of submission and appropriation. Moderna took 42 days to have a vaccine candidate messenger RNA after China published the complete genetic sequence of SARS-CoV-2. In comparison, it takes an average of 10 years to develop a conventional vaccine. This makes messenger RNA ideal for developing rapid immunization against future rapidly expanding pandemic viruses.

  This second wave also modified the clinical picture, which is requiring first more attention or hospitalizations of moderate patients (more hospitalizations and no defined inflammatory responses, but tend to appear after the second week), later lung inflammation, more   complications, more shock, more acute renal failure,  which extends the period of active observation and respiratory distress with a tendency to frustrating chronicity and that does not respond as it did in the first stage.

Public hospitals and sanatoriums this year are again under stress due to Covid, with no remaining non-Covid beds to respond to that retained demand, which progressively aggravates the situation, which will extend in the most optimistic context until the end of August (which vaccinates 70% of susceptible adults), but more realistic would be until the end of September.

The SARS Cov 2 pandemic: A syndemic perspective.

Since the end of the previous year, the term pandemic has been symbolized as syndemia, to clearly indicate that the problem is not only health, or medical, but social, economic, political and cultural. Covid-19 affected the obese the most (overweight-obesity-Covid pandemic). It had worse results in marginal individuals, people with housing problems, employment, etc. It generated a crisis of demand and productivity.

Therefore, public policy decision-making must necessarily be made based on data, not surveys. Information and evidence on patterns of infection, mortality, lethality, transmissibility, effectiveness of vaccines, but also consider factors such as employment, education, income distribution, fiscal accounts, economic assistance and production.

As for the sindemia of the political increased the crisis of the political parties and the representativeness, the political continued in other lanes, increase taxes, apply inflation to make cosmetic adjustments, more populism, not agree with the debtors because it would be kneeling in front of capitalism, vote laws to reform the justice system and have impunity.

Simplism in democracy occurs intentionally so that the political arenas concur for the own benefit of allies and friends, executives and parliamentarians, our political systems are not being able to manage the growing complexity of the world and are powerless before those who offer a simplification, sometimes falsifying reality and are nothing more than a passing illusion that never reaches reality.

They are politicized descriptions that overestimate the possibilities for collective action through central interventions, as if people were responding uniformly. Some have too much confidence in the state’s ability to intervene from the outside and others rely too much on individual behaviors and the ability to self-correct the system or the MARKET, which we know their hands to universal systems do not reach.

The liberal agenda of solving all problems through austerity is as inadequate and dangerous as the belief that they can be solved through participation or by moralizing them.

That austerity after the crisis of the financial system and the mortgages of  2008 led us to divest in health, and part of what we had to do in a hurry was for that reason. Today politics is operating in environments of high complexity that has not found the democratic theory that contains it, we must rediscover the world.

One cannot look with setentist convictions at the problems of the twenty-first century that demand vision, competence, leadership, and the ability to manage social complexity, interdependencies, negative externalities, under conditions of ignorance and quality of the unthinkable ruling class. In addition, the complexity of the pandemic has been pushed out of the objective, to perpetuate itself, not to transform, even if the conditions of the social quality of life worsen employment, education, security, access to health.  It must go through a transition from representativeness to transformative legitimacy.

The people seem by their passivity to be resigned to poverty, ignorance and marginality, they think that it can be worse if they do not vote for these rulers, that without these representatives their lives would be more necessary, “at least we eat”.

We are living through a crisis that conditioned us with urgent decisions, without data or experiences, in a scenario where Argentina’s disadvantages were aggravated without reservation to face the situation.

This Covid crisis requires  practical people, who detach themselves from the ego and conveniences, who organize, decide, lead, are visible, do not contradict, take care of words and descriptions, balance sacrifices, I am convinced that behind many decisions that were made wrong there was more ignorance than lack of resolution, and in others ideological bias, overacting positions, being good with someone who distrusts and who holds true representativeness, hearing what he wanted from the “experts” in the pandemic who were theorists who read  the same as us, who did not deal with patients, who were not scientists, were nourished by the same sources, only that they mentioned it as truths revealed by the oracle and without touching a patient.

We observe, with little hope, the deep crisis that will remain when the waves of Covid cases go down, and these people immunized, the list of questions are impossible to answer. As society will recognize itself after the coronavirus. Forget? Change? Will it change their behaviors? What will the job be like? Employment? Education? the health system? Who will they choose in the midterm lessons? Democracy. Representativeness. Candidate elections. Where and that will represent the parties, the coalitions, the movements. Is virtuality in health here to stay? Which patients will be hospitalized? What will the investment in technology be like? How, when and in how long will we forget about the pandemic heroes, the health workers? and the consequences that will be burned to them by the exercise of their profession.

The skeptical conviction that after a small movement on some things, the status quo will prevail is palpable. Some will move forward a bit. Society, all the marginalized, will be in a worse position.  The aid will be interested and appropriated, from the various blocs, and sovereignty and independence will be lost.

We always put the chest, the same, the toilets on the ground. Fights are alien.

We do not live from the applause of the members of the health team, because we are mobilized by the vocation, minus the five thousand or six thousand, who never arrive, but we are affected by the lack of real recognition, rest, mention, respect for citizens, this is reflected in a constant worsening of working conditions, nothing changed. Nothing changed for politicians in terms of the importance of health, the human factor that cares for the sick, working conditions, rest and remuneration,

Covid-19 left the hard learning of the interrelationship that exists between health, formal employment, income distribution, economic growth, and social welfare, with health outcomes. The normal functioning of the economy makes the progress of a society, requires that its inhabitants, its citizens have education, and equal access to health, its promotion and care.

Health is a public good, which improves social equity, at the same time efficiency in the economy, these things will be the true multipliers of well-being in society, in that way health is a productive investment, and build citizenship within the framework of the valuation of efforts.

“The urgency of the long term” is not an empty or gimmicky slogan, but the call to think about unavoidable measures that will impact on the desired future.

The reform of the health system is one of the many urgencies that require the long term, which cannot be subjected to the tyrannies of the circumstantial majorities, not in generating agreements on the collective course.

Conclusion:

We have a sad virtue of not learning from mistakes and making amends, and insisting on giving fights for lost causes, which lead us to failure. We are in a worse situation than other countries, with a poverty rate that worsened the possibility of complying with confinements. These are times of positive alliances between all social and sectoral forces, increasing the speed of implementation of decisions. Confront the current inequity of the planet, with the unequal allocation of resources. Abandon the tendency to isolate Argentina.

When Covid is controlled or disappears, there will still be the historic challenges of health systems, of an aging and more demanding society, new incremental cost technologies, cancer treatment, the possibility of treating diseases that had no therapy, and orphan diseases.

Publicado por saludbydiaz

Especialista en Medicina Interna-nefrología-terapia intensiva-salud pública. Director de la Carrera Economía y gestión de la salud de ISALUD

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