Marlon Morris: Does T&T have ‘pandemic response success criteria’ beyond flattening the curve?

Letters to the Editor Friday 17 April 2020 Health, Wellness 2 Comments

“[…] From the onset, the pandemic response success criteria—how we determine success in our handling of the crisis—must be identified with clear timelines and key performance indicators.

“Is the success criteria primarily medical and public health-related or social and economic as well? It appears that the key or only goal here was ‘not to overwhelm the healthcare system’…”

The following guest column, which attempts to look at Trinidad and Tobago’s response to the Covid-19 pandemic as a management challenge, was submitted by Marlon Morris, a program and performance management professional and former ‘Strike Squad’ football star:

Photo: A hospital braces for Covid-19 cases.

While I would never pretend to be a healthcare expert, because that I am not, I would like to make some observations and insights concerning the Covid-19 pandemic, albeit through the lens of a program management and performance management professional.

This commentary briefly addresses four subject areas, namely, the importance of communicating accurate data and problem definition, determining the success criteria of the response, stakeholder analysis and segmentation, and a discussion around three Covid-19 response options.

(Importance of Communicating Accurate Data and Problem Definition)

From a program and performance management perspective, reviewing the ‘lessons learned’ from similar pandemics and related response strategies is an invaluable asset, if available. While there didn’t appear to be a formal written ‘lessons learned’ documentation from the initial countries such as China and South Korea, there were however useful lessons and nuggets that the rest of the world should have and can still use to enhance their pandemic response plan.

For example, the initial response from the Head of the WHO (World Health Organization) was that the pandemic had a mortality rate of between 3-4%. This however, needed to be further clarified as this metric was based on reported cases only, and not estimated or actual number of infections.

This number appeared to be statistically questionable after reviewing the findings from countries such as South Korea that performed some level of significant testing—their mortality rate was less than one percent.

Photo: Medical Journal – The Lancelot Infectious Disease Study Results

Also, a recent study by the Medical Journal – The Lancelot Infectious Disease Study, estimated that only about 0.66% of those infected with the virus will die, and when undetected infections aren’t considered the death rate was 1.38%.

The study found however that the number varied by age with a death rate of 7.8% of those 80 or older. Deaths below the age of nine were extremely rare (a fatality rate of 0.00161%). For age groups younger than forty, the death rate was never higher than 0.016%.

There might be outlying cases that get a lot of media attention but the study’s analysis clearly shows that hospitalisation is much more likely for those aged 50 and over.

(Success criteria)

From the onset, the pandemic response success criteria—how we determine success in our handling of the crisis—must be identified with clear timelines and key performance indicators.

Is the success criteria primarily medical and public health-related or social and economic as well? It appears that the key or only goal here was ‘not to overwhelm the healthcare system’.

Photo: Health Minister Terrence Deyalsingh (left) and National Security Minister Stuart Young discuss the novel coronavirus.

Practitioners in the program and performance management space try to establish goals and related KPIs for all stakeholders. Other success criteria questions such as but not necessarily limited to the following, should also be addressed:

What percent of the at-risk/vulnerable groups have received, acknowledged and the communication and been given an action plan within X number of days of the Pandemic emerging
Reducing the mortality rate to a predetermined figure (say less than 1.5%, for example) among at risk groups and 0.002 percent among the low/medium segment. It appears that we were striving for a 0% KPI (key performance indicator)
An increase in the unemployment rate of no more than 5% within month one and 2% by month 2 (suggested metrics only). Having such a metric is important so that we do not lose site of the economic health of the country
Ensuring a certain ‘personal health quotient’ by encouraging ‘smart’ social distance outdoor exercises.

(Customer Segmentation)

Proper stakeholder analysis and particularly customer segmentation should be quickly identified in this pandemic.

In this segmentation, one must consider predictors and factors such as age, lifestyle, and pre-existing health conditions, so as to direct resources and prioritise the needs of vulnerable groups with higher risk of severe illness.

Photo: A Covid-19 patient is evacuated from the Mulhouse civil hospital, France on 23 March 2020. The Grand Est region is now the epicenter of the outbreak in France, which has buried the third most virus victims in Europe, after Italy and Spain.
(AP Photo/Jean-Francois Badias)

The initial approach by public health care agencies should have been guided by a proper stakeholder segmentation and implementation plan that would minimise the mortality rate, particularly among the vulnerable and high-risk groups such as nursing and senior citizens homes.

Italy, for example, has the oldest population in Europe (median age of 47 years) with a low lifestyle quotient (high percent of smokers), and a high ‘social-contact’ culture.

With early warning analytics and program management guidance the authorities would have developed a tailored action plan that would contain, but not necessarily be limited to: a communication plan, an enhanced smoking cessation initiative, quick social-distancing practices especially for high risk groups, state/municipal funding and resourcing for ventilators, testing kits, stay-home and/or ‘away-from’ the general public and focused resourcing for nursing and retirement homes.

Such an approach, other things being equal, would have reduced their mortality rate.

Moreover, it would be less costly to temporarily place such individuals, who were living in cramped or multigenerational homes, in a tourist resort or hotels paid for by the state, rather than locking down the entire society. There cannot be a one size fits all for the entire population.

Yes, we may be having to ‘manage’ or temporarily close the borders and implement ‘wise’ social distancing practices, and temporarily close ‘high-contact’ events and some businesses. However, we must strike that balance between lives and livelihood, and question if the so call ‘lock-down’ approach applied by many countries is the most effective response.

Photo: Ministry of Health CMO Dr Roshan Parasram.

There appears to be three broad options open to policymakers.

(Option 1 – Significant Lockdown and Containment)

This option is being advocated by most states in the USA, and countries such as the UK and Denmark and entails the total shutdown of the ‘non-essential services’, small gatherings of no more than two, five or ten persons and mass quarantine to flatten the ‘spread-curve’.

Countries such as Trinidad and Tobago, with a population of 1.4 million and a relatively low infection rate, went a step further and prevented anyone from exercising outdoors—even by themselves.

(Option 2 – Herd Immunity)

Herd Immunity is a form of indirect protection from infectious disease that occurs when a large percentage of a population has become immune to an infection, whether through previous infections or vaccination. In a population in which a large proportion of individuals possess immunity and are unlikely to transmit the disease, chains of infection are more likely to be disrupted, which either stops or slows the spread of disease.

The greater the proportion of immune individuals in a community, the smaller the probability that non-immune individuals will ‘encounter’ an infectious individual.

The Netherlands and Norway’s approach to the Covid-19 pandemic is probably the closest example to this approach. While businesses remain open however, they are still taking precautions like washing your hands, practicing pragmatic social distancing and other preventative measures.

Photo: Some countries have sought to remain open for business despite the deadly threat of Covid-19.

(Option 3 – ‘Middle Ground?’)

This approach is being advocated (in varying degrees) by persons such as David L Katz of the Yale-Griffin Prevention Research Center, Nobel Prize-winning biophysicist, Michael Levitt, and countries such as Sweden.

As a medical professional, Katz doesn’t ignore the public health concerns but is deeply concerned about the social, economic and public health consequences of this near total meltdown of normal life—schools and businesses closed, gatherings banned—the ripple effects will be long lasting and calamitous, possibly graver than the direct toll of the virus itself.

Michael Levitt, who apparently accurately predicted the swift decline in Covid-19 spread in China, is arguing an overreaction to the disease can do more damage than the disease itself. They are both calling for a more measured response to the pandemic.

Sweden appears to be a perfect example. The country advocates self-responsibility and keeping businesses open but encourages work from home for those who can or for sick, elderly or an identifiable at-risk person, along with washing your hands, and avoiding non-essential travel.