COVID-19 is not a health crisis, it is a health systems crisis

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by Raywat Deonandan

This article was published in The Toronto Star on April 7, 2020. It is based on an earlier blog post.

Most models of the COVID-19 pandemic show it continuing for another year or two, with North America stifled beneath the current wave of cases until June at the earliest. With such harrowing realities, it’s easy to mischaracterize this crisis as solely a medical one.

But this is not a health crisis, in which salvation lies in the arrival of a vaccine or cure. Rather, COVID-19 is a health systems crisis, in which we manufacture our own salvation through proper management of existing tools and resources. Two health systems strengthening initiatives would be particularly helpful in the near and medium term.

First, all public health experts are unified in the opinion that mass testing with rigorous contact tracing is needed if we are ever going to control the epidemic. When viewed through a clinical lens, testing is about diagnosing a disease so a proper treatment can be assigned. But from a public health lens, the role of testing is to identify possible carriers who must be quarantined before they can spread the disease further. Testing must serve both functions.

Of all beset nations, Iceland has chosen the most scientific approach to testing. In addition to clinically testing those who present with symptoms, as is done in Canada, Iceland engages in small-scale random testing of the national population, giving their public health planners a more accurate sense of the disease’s true prevalence.

We need to take the Icelandic approach, but at a larger scale. Testing should be deployed as part of a national, or preferably global, surveillance system, with both active and passive components. The active half involves the random screening of people, regardless of whether or not they are symptomatic. The passive component expands upon the present system of clinics registering patients as they present themselves for care, and will likely continue to identify more serious symptomatic cases.

A properly resourced and empowered surveillance system could identify, locate, contact trace, and quarantine incident cases in almost real time. Not only would this obviate the need for total population lockdown, it would also provide the accurate incident data needed for predictive modelling, which would in turn allow our decision makers to more easily and efficiently navigate our economy past this morass.

Second, a rich clinical epidemiology database needs to be created and made freely accessible to all researchers immediately. Such a database would be fed by hospital discharge records and emergency room reports. It would include information about every known COVID-19 case, specifically patient demographic information, medical history, test results, comorbidities, treatments and prognosis.

With such data, scientists could statistically nail down specific clinical and behavioural factors, which would then help in refining therapies to reduce death rates. These data would also help planners to identify genuinely vulnerable populations and likely transmission routes.

The backbone of both of these systems additions is information technology. And the barriers to enacting them are bureaucracy, funding, and leadership. The battle against COVID-19 should not be fought by doctors and nurses alone. Rather, data analysts, computer programmers, records keepers, and, frankly, middle managers all have powerful roles to play, as well.

There is a path out of this mire, and it is paved with the drudgery work of administration and data analysis. But those are two resources of which we are not in short supply.


Raywat Deonandan is an epidemiologist, associate professor and assistant director Interdisciplinary School of Health Sciences, University of Ottawa

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