As the world works its way from emergency response to recovery post-pandemic, one thing is sure – we will never fully recover. “You can get the monkey off your back, but the circus never leaves town” is a quote attributed to George Carlin (with reference to addiction and recovery). It reminds us that even when the cases of COVID-19 become manageable, we will never really be rid of the virus. How we learn to cope with the new normal and with subsequent waves of infection is essential to our recovery. How quickly we adapt to new ways of caring for our patients and our healthcare community will also determine our ability to future-proof our recovery. Adaptability, agility and resilience are key.
New York City, USA
New York City has been among the cities hardest hit by COVID-19. The crisis exposed the healthcare divide within the country – hospitals, particularly non-profit ones that serve the poorer communities, struggle to procure personal protective equipment, which has become increasingly expensive. Photo: studiokiet / iStock
ONE FOOT ON THE ACCELERATOR, ONE FOOT ON THE BRAKE
Almost overnight, outpatient care was transformed. Wherever possible and suitable, face-to-face encounters have been replaced with care that is administered remotely. Video consultations, remote monitoring of vital signs, e-prescribed medications, remote diagnosis and evaluation, as well as centralised digital triage are among the tools being deployed. Known broadly as telehealth, these services were slow to take off before the pandemic. The coronavirus catalyst was not something anyone expected or planned for, but it has accelerated care transformation. Coordination among primary, secondary, tertiary and community care services has also been strengthened in order to deliver care more effectively within the community. With this in place, Singapore was able to get special care up and running in record time for foreign workers in their dormitories and community care facilities (CCF) to contain the COVID-19 outbreak.
While we keep our foot on the accelerator in order to future-proof a speedy recovery, it would be wise to know when to take it off the accelerator and start applying the brakes. Living with the ‘circus in town’ demands that we remain cautious, adaptable and agile. Instead of operating from a mindset of fear, we should adopt a mindset of possibilities. Changing outdated policies, simplifying workflows, and ensuring flexibility in task-assignment are some good places to start.
As we enter mid-October, autumn (in the northern hemisphere) brings with it additional challenges. The flu season begins, and its full impact will be felt in winter, as the severity of the flu strains in wide circulation further stresses healthcare services.
With people spending more time indoors due to the cold weather, healthcare systems will have to contend with the spread of both the flu and the novel coronavirus. To complicate things further, travel bans are slowly being lifted and movement restrictions becoming less stringent. The resilience of the healthcare sector will be tested again as we try to resuscitate our economy.
Caloocan city, Philippines
On 16 March, the government of the Philippines imposed an enhanced community quarantine (ECQ) in Luzon, which is effectively a total lockdown. Residents had to rely on food aids distributed by the barangays. Photo: Aaron Favila / AP Photo
From a logistical perspective, our recovery needs a fine balance between being crisis-ready and business-as-usual. The ability to shift gears in a timely manner while steering in the right direction needs adaptability and flexibility. For example, demand surges of Intensive Care Unit (ICU) beds and isolation facilities need to be managed in tandem with sudden drops in demand for elective surgeries, outpatient services and preventive or community health programmes. Similarly, while the world waits eagerly for bio-research and the pharmaceutical industry to deliver vaccines to combat the virus, we must also prepare ourselves to deal with complex access and distribution problems. Navigating these start-stop-shift cycles over and over again will test our collective resilience and our ability to recover sustainably.
Kuala Lumpur, Malaysia
Malaysia began to impose mandatory COVID-19 screening on 1.7 million foreign workers on 1 December, regardless of sectors, in view of the high number of cases involving Selangor's Top Glove cluster. In neighbouring Singapore, 95% of all 58,000 cases of COVID-19 have been contracted by foreign workers. Photo: Abdul Razak Abdul Latif / Dreamstime
COOPERATION, NOT COMPETITION
Crises pertaining to wars, civil unrest and natural catastrophes are usually more contained. A global pandemic, however, spares no one and no part of the world. Until we are all safe, no one is safe. By virtue of its highly transmissible nature, individuals as well as nations need to cooperate to tame the spread of the virus.
In Singapore, private and public entities were quick to realise the importance of establishing and enforcing a Business Continuity Plan (BCP). Various ministries, including those of health, the environment, manpower, communication, finance, defence, home affairs, foreign affairs and transport, immediately pulled together with businesses and the community to make plans to endure the crisis and to emerge stronger from it.
It did not take us long to come to the conclusion that the notion of business-as-usual – a state we had targeted to return to – would be anything but usual. How we used to work, rest and play has been disrupted irreversibly.
In any society, healthcare spending relies on the allocation of finite resources. What happens in other sectors often has an immediate and direct impact on healthcare. Cross-sector coordination and resource optimisation are therefore extremely important during a time of severe economic contraction. It does not help when the economic downturn is caused by a pandemic that threatens to cripple the healthcare system itself. In the foreseeable future, we will be under enormous pressure to contain healthcare cost while having to improve overall healthcare efficiency and affordability.
Within the healthcare sector, the distribution of limited resources to competing functions also requires skilful decision-making. In the current climate of labour shortage (especially in the nursing profession), irregular and unreliable supplies (including protective gear, basic equipment and drugs) and frequent service interruptions due to movement restrictions, cost control becomes even more challenging.
The need to enable more appropriate allocation of finite resources has accelerated the adoption of real-time data collection and the deployment of advanced analytics, predictive modelling, artificial intelligence and natural language processing in the healthcare sector. This has in turn fuelled the introduction of innovative models and processes of patient care. Many of these healthcare solutions are based on timely information sharing and effective collaboration among healthcare providers, supported by new data technology and innovative healthcare policies. Cooperation rather than competition will create and add value to the new normal in healthcare.
The device can be used by clinicians to remotely track, analyse and monitor the rehabilitation progress of knee replacement patients during the entire continuum of care. Image source: Kinexcs
AN INNOVATION THAT CONNECTS PATIENTS WITH PHYSICIANS REMOTELY
The need for physical distancing due to the COVID-19 pandemic has accelerated the adoption of telemedicine all over the world. As non-essential access to care facilities was suspended and fearful patients refrained from visiting hospitals, telemedicine quickly became the solution to the new limitations in healthcare delivery.
For Kinexcs, a medical technology startup currently incubated by NUS Enterprise in Singapore, this was nothing less than an opportune time to introduce an ingenious product to the orthopaedic industry. Since its inception in 2015, Kinexcs has been working on building a wearable medical device, named KIMIATM, which can be used by clinicians to remotely track, analyse and monitor the rehabilitation progress of knee replacement patients during the entire continuum of care (pre-operative, intra-operative and post-operative). According to Dr Pillay Premkumar, a Neurosurgeon at Mount Elizabeth Hospital in Singapore, who is also a medical advisor to Kinexcs, KIMIA™ combines advanced sensory technology with intuitive software platforms to give feedback to physiotherapists on whether recovering patients comply with the prescribed exercises correctly. This in turn allows the therapists to deliver evidence-based personalised prescriptions.
“Orthopaedic patients’ visits to rehabilitation centres were often very cumbersome due to their restricted mobility, especially for the elderly. That motivated us to build something that would help patients comply with their routines from the comfort of their homes, and even better, with improved quality of care even when consultation is done remotely,” says Mr Abhishek Agrawal, cofounder and CEO of Kinexcs. When physiotherapy and rehabilitation centres were forced to close during the Singapore ‘Circuit Breaker’, KIMIATM proved to be an even more timely solution in enabling the continuity of quality care without face-to-face consultation.
Found to collect highly accurate clinical data around the clock, KIMIATM has recently been named the winner of Singapore’s James Dyson Award in September 2020, and made it to the Top 20 international shortlist. KIMIATM is currently undergoing clinical trials in three public hospitals in Singapore. Meanwhile, Kinexcs is looking at adapting the device for use on other parts of the body, such as the spine, hips, ankles and shoulders.
Care home outbreaks
Long-term care homes emerged as COVID-19 hotspots, putting the residents and healthcare staff at high risk. Photo: Haydn Golden / Unsplash
CARING FOR THE CARERS – HEALTHCARE PROFESSIONALS AND THEIR WELL-BEING
To prepare our healthcare system for similar challenges in future, we need to first keep our healthcare workers (HCWs) healthy – physically, mentally and emotionally. Technology- and science-enabled healthcare transformation have already received a lot of attention and funding during the pandemic. However, much less attention was given to the well-being of our HCWs. The average human lifespan is growing, but that is not the case for ‘healthspan’ due to the overall increase in and early onset of chronic diseases.
The resulting burden to the healthcare system, coupled with the complications brought about by COVID-19 (not forgetting the seasonal flu and dengue too) can have adverse effects on the wellbeing of HWCs in our hospitals, nursing homes, rehabilitation centres and clinics.
As someone who leads the well-being, resilience and burnout prevention efforts in a group of public hospitals, as well as being a member of the COVID ICU Ethics Committee, I have seen first-hand how burnout rate and mental health problems among HCWs were exacerbated by pressure from work and from home. Worldwide experiences with SARS, H1N1, MERS and Ebola have given us some in-depth understanding of the effects of epidemics on HCWs, but COVID-19 is making those lessons more profound.
There are many factors that affect the psychological well-being of HCWs during an epidemic outbreak. The primary ones are: inadequate social support, stressful work environments, insufficient training, prolonged usage of personal protective equipment (PPE), infection risks and heavy workloads. Added to these factors in the case of COVID-19 were a shortage of protective gear, fear of infecting loved ones, feelings of isolation, the stigmatisation of HCWs as well as harassment from the public while enforcing infection control protocols.
Besides workplace challenges, HCWs may face circumstantial difficulties at home too. Financial strain arising from the economic downturn, challenges of overseeing their children’s home-based learning and infection risks faced by their elderly parents are some examples of domestic stressors that make the lives of exhausted HCWs even more excruciating.
Maintaining a safe environment that allows HCWs to openly share concerns with their leadership and ask questions is vital to their wellbeing. Just as important is acknowledging and addressing their concerns, even if the solutions are not immediately implementable. Managing an unrehearsed crisis requires regular, timely, honest, up-to-date, sincere and empathetic communication. It is also good to empower staff to redesign the way they work and subsequently execute their creative solutions responsibly, so as to promote ownership and accountability.
Well-being vigilance should be extended to non-clinicians as well.
Essential workers supporting the work of HCWs include cleaners, porters, environmental workers, food service workers, security personnel, maintenance personnel, IT staff, social workers, delivery workers and persons giving religious comfort. Making sure that care and communication reach the less visible lines of command is just as vital.
Should the crisis be drawn-out, whenever possible, HCWs should be given the opportunity to recuperate – for example, by rotating them between high- and low-stress functions. It may sound glib when supervisors encourage their staff to take care of themselves – to eat well, sleep well, exercise, manage stress – but these are fundamental to well-being. Helpseeking behaviour may sometimes be wrongly perceived as revealing personal weakness or incompetence. Efforts must therefore be made to dispel such misconceptions. Simply put, always share the truth, project optimism, give hope, and offer some breathing room.
HEALTHCARE EDUCATION – MORE THAN JUST MEDICINE
Sustaining medical education and training for healthcare professionals while having to adhere to strict infection control measures is another big challenge. Hospitals have suspended non-essential access to their facilities in order to minimise contact, preserve scarce supplies, and focus on their core care-delivery mission. On the other hand, clinical rotation and residency programmes are essential to develop skills and contextual understanding for medical students. Restricted clinical exposure is creating a bottleneck in the medical education pipeline. This could result in fewer qualified doctors and other medical professionals joining the already stretched healthcare workforce.
To strike a good balance, access restrictions should not be categorical for clinical exposure in medical education. Healthcare providers, medical schools, accreditation bodies, professionalisation councils, licensing boards, the government and leaders in the healthcare sector will have to be willing to boldly break bureaucratic barriers and adapt qualifying regulations to help replenish and sustain an adequate healthcare workforce.
As an educator, I marvelled at how medical students adapted during the height of the crisis. All their teachings were solely online, including attending interviews and preparing for examinations. Didactic sessions were supplemented by simulation technologies such as augmented reality. When agility and flexibility were called for, some students volunteered to do translation work to help care for migrant workers, while others volunteered to administer serology tests in worker dormitories and to fill medical posts. Upon reflection, the key learnings from this crisis are not so much the clinical ones, but the softer skills of communication, leadership, collaboration and teamwork. ‘Leading self’, the most important of all leadership qualities, and sustaining resilience are perhaps the most valuable lessons learnt.
Healthcare workers are facing immense uncertainty, vulnerability and grief due to the COVID-19 pandemic. High levels of staff burnout leading to staff turnover may collapse a healthcare system. Photo: Azamat Imanaliev / iStock
In spite of all the initiatives to reinforce healthcare education, a shortfall in qualified manpower may still arise. It would be a good idea to recall retired HCWs or those who have temporarily left the workforce by offering attractive packages for locum tenens and part-time positions. In the long run, providing lifelong learning opportunities, fair remuneration and deserved recognition will be necessary to retain HCWs and recruit new entrants to healthcare professions.
The race for safe and effective vaccines against COVID-19 is ongoing but the finish line is still not in sight. Our sustained recovery depends on how we manage the circus that is staying in town. The most common definition of circus is “a company of performers who put on diverse entertainment shows that may include acrobats, trained animals, trapeze performers, musicians, dancers, hoopers, tightrope walkers, jugglers, magicians, unicyclists, clowns, as well as other object manipulation and stunt-oriented artists”. Other meanings of circus include a central arena where sports and games were held, and an open circular area where several roads join. All three definitions connote activity, movements and changes. During a trying time like this, our ability to cope and thrive lies in how agile, adaptable and resilient we are while we try to juggle important things in life and move on safely in a different normal.
PREVENTIVE DIGITAL HEALTHCARE SOLUTIONS FOR NON-COMMUNICABLE DISEASES
As early as March 2020, the WHO issued an Information Note to warn that people with preexisting non-communicable diseases (NCDs) appeared to be more vulnerable to becoming severely ill with COVID-19. These NCDs include cardiovascular disease, chronic respiratory disease, diabetes and cancer. For instance, among the death cases in Italy, 68% had suffered from hypertension, and 31% from type 2 diabetes.
Nearly 75% of the 163 Ministries of Health that responded to a WHO survey in May 2020 reported that NCD services had been heavily disrupted. In response to this, the WHO provided a forwardlooking strategy that aims to “build back better tomorrow”, which recommends developing systematic approaches to digital healthcare solutions for NCDs.
Singapore, famous for its effective healthcare systems, includes chronic disease management and prevention as a key area of focus in its National Artificial Intelligence (AI) Strategy, and encourages private sectors’ innovation in digital healthcare solutions.
Some Singapore-based start-ups, such as Mesh Bio, are developing solutions for greater healthcare impact in chronic disease management. Founded in 2018, Mesh Bio, which is located at NUS Enterprise’s incubator – BLOCK71 Singapore, provides the advanced predictive analytics clinical software solution “DARA” (Disease-Associated Risk Assessment) for personalised risk assessment and health management. Mesh Bio helps primary care providers, health screening centres and hospitals save time by automating health screening report generation. Its patient-centric reporting allows patients easy interpretation and understanding of their laboratory reports, and actionable lifestyle recommendations can be customised by doctors to direct patients towards suitable healthcare and wellness services. Mesh Bio’s risk assessment algorithm can be customised to comply with local clinical practice guidelines. This enables early detection of dysfunctions, easing the complexity of healthcare delivery – a challenge faced by patients, healthcare providers and payors.
Ever since the COVID-19 outbreak, people have begun to pay even more attention to personal health. In addition to spending more time on exercise and adopting healthier diet options to build greater immunity, people are also more aware of their underlying medical conditions. The pandemic has made more Singaporeans realise the importance of health and become more aware of the importance of the prevention and early detection of NCDs, particulary so when Singapore has the second-highest proportion of diabetes patients among developed nations. According to 2019 data, the prevalence of diabetes in Singapore was 14.2%, against a world average of 8.8%.
There has also been a change in healthcare delivery and patient experience in healthcare providers, with an increase in the uptake of digital solutions to enhance workflow efficiency and cope with increased patient volume and staffing pressure. Mesh Bio has seen an uptake of their solutions since then by healthcare providers in Singapore, as they directly address the care delivery challenges.
Mesh Bio is the first Asian start-up to join Startup Creasphere, the Digital Health Innovation Programme, established by Plug and Play, Roche, and Sanofi CHC. Andrew Wu, Co-Founder and CEO of Mesh Bio, shared his vision for the company:
“We want to enable healthcare transformation, a solution to the traditionally illness-focused system, transitioning it to a patient-focused one. We want to enable the ecosystem of healthcare stakeholders to help patients live healthier lives and improve patient outcomes. COVID-19 has accelerated the adoption of technology in healthcare, and reinforces the importance of early intervention of chronic diseases. Our solutions aim to help healthcare providers to make better, faster clinical decisions, and empower patients to be their own health manager.”
DR MALEENA SUPPIAH CAVERT
Dr Maleena Suppiah Cavert is Deputy Director of Clinical Education at the National University Health Systems. In this position, she has coached many healthcare professionals in the areas of empathy and compassion, communications, mindfulness and stress reduction. She also partners with counterparts at the Ministry of Health to focus on physician well-being and developing resilience-building strategies. Dr Maleena is a qualified Mindfulness-Based Stress Reduction (MBSR) trainer who runs Train-the-Trainer initiatives and actively mentors colleagues who experience excessive stress and burnout. Also a lecturer at the National University of Singapore, Dr Maleena’s international career spans France, Italy, Austria and the United Kingdom.