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  • Nonadherence to medication is a vast and rapidly growing killer epidemic
  • The epidemic is under reported, under-treated and costs healthcare systems billions
  • No healthcare stakeholder has assumed responsibility for reducing the burden of nonadherence and so it has become an orphan issue
  • Psychological techniques used by policy makers have been shown to change peoples’ behaviours, improve healthcare and reduce costs
  • The proliferation of smartphones embedded with behavioural techniques designed to coax people to adhere to medications holds promise
  • But recent research suggests that thousands of apps devised to reduce nonadherence use behavioural techniques sub-optimally
  • There is an opportunity to significantly improve nonadherence to medication by optimally utilising behavioural techniques and digital technology
  • The challenge needs to be embraced by all healthcare stakeholders
 
Nonadherence to prescribed medication: an orphan killer epidemic
 
Nonadherence to prescribed medication for patients with chronic long-term conditions (LTCs) is an out-of-control epidemic, which is undetected and undertreated. It kills hundreds of thousands, erodes the life chances of millions, costs billions and is one of the biggest obstacles to effective healthcare in the 21st century. According to the World Health Organization (WHO), “increasing the effectiveness of adherence interventions may have far greater impact on the health of the population than any improvement in specific medical treatments”.
 
There are a number of reasons why people with LTCs stop taking their medication, which include: (i) fear of potential side-effects, (ii) lack of understanding because taking a medication every day to reduce the risk of something bad happening can be confusing, (iii) failure to see immediate improvement, (iv) too many medications that often cannot be taken at the same time, (v) patients who are depressed are less likely to take their medications as prescribed, (vi) concerns about becoming dependent on a medicine and (vii) high drug costs, particularly in the US.
 
No healthcare stakeholder - patients, doctors, carers, regulators, pharmacists, pharmaceutical companies and healthcare providers – has made nonadherence a priority, so it has become an orphan issue. We suggest that all health stakeholders have a role to play in nonadherence and would benefit  by employing psychological techniques designed to encourage people to change their behaviour. 
 
In this Commentary

Because nonadherence to medication has a significant prevalence in people living with LTCs, we begin this Commentary by describing the vast and rapid growth of LTCs and their associated eyewatering costs. The management of LTCs rests with primary care doctors, but the average doctor-patient consultation is just a few minutes and more importantly, the majority of patients do not remember most of the information provided in such consultations. Not only do primary care doctors have little time to prescribe and explain medication regimes, there is little incentive for them to address nonadherence. We raise the question of whether doctors might be part of the problem by  citing a seminal paper published in The Lancet in 1974, which suggests that doctors have a propensity to medicalise healthcare and over-prescribe medicines. This can transform reasonably healthy people into habitual patients. We then describe a trend gaining momentum both in the US and the UK, whereby community-based pharmacists are becoming a healthcare destination and are well positioned to play a significant role in denting the nonadherence epidemic.  We draw passing reference to pharmaceutical companies’ interest in reducing nonadherence. We conclude by describing a number of research studies, which examine the confluence of mobile telephony and advances in behavioural science, which facilitate the increased use of apps embedded with behavioural techniques to address nonadherence to prescribed medication. Despite the large and growing use of such apps, studies suggest that the use of behavioural techniques in mobile applications to address nonadherence is sub-optimal. Thus, there remains an  opportunity for using advances in behavioural theory and practice to promote sustained and significant lifestyle behaviour changes designed  to reduce the nonadherence to prescribed medication epidemic.
 
Impact of LTCs in the US and UK
 
LTCs, e.g. diabetes, chronic obstructive pulmonary disease (COPD), arthritis and hypertension, are diseases for which there is currently no cure and they are managed with drugs and other treatments. Each year in the US, LTCs affect about 133m people and this is projected to rise to 157m by 2025. According to a 2012  study published in the Annals of Internal Medicine, people who take prescription medicines for LTCs typically only take about half of the prescribed doses. The study’s findings were updated to estimate costs in US dollars to reflect inflation for 2016 prices and published in the March 2018 edition of theAnnals of Pharmacotherapy. The authors estimated that the, “annual cost of drug-related morbidity and mortality resulting from nonoptimized medication therapy was US$528.4bn, equivalent to 16% of total US healthcare expenditures in 2016”.  This compared to 8% and 13% in 1995 and 2008, respectively. Although this estimate accounts for overall price inflation, it does not include non-medical or indirect costs, such as lost productivity or caregiver expenses, which have been estimated to be more than the direct medical costs for many LTCs. Also, the authors estimated that nonadherence results in about 275,689 deaths each year. 

In the UK nonadherence to prescribed medication among people with LTCs has a similar impact. According to a 2014 UK House of Common’s Health Committee report, “Effectively managing LTCs is widely recognised to be one of the greatest challenges facing the 21st-century”.  Seventy percent of total expenditure on healthcare in England is associated with the treatment of the 30% of the population with one LTC or more, and the number of people in England with one or more such condition - currently 15m - is projected to increase to around 18m by 2025. Care for LTCs presently accounts for 55% of primary care doctors’ appointments, 68% of outpatient and A&E appointments and 77% of inpatient bed days. The cost to NHS England of people with LTCs not taking their prescribed medicines appropriately and thereby not getting the full benefits to their health is estimated at more than £500m (US$635) a year, with a further cost of £300m (US$381) on wasted medication.

 
Nonadherence is not a doctor’s problem

Despite the fact that a medical consultation is a complex and multidimensional process, which is pivotal to the health of patients, the average time spent for each consultation is short and there is little or no time for doctors to educate or motivate patients. A 2017 paper published in the British Medical Journal (BMJ) reviewed 28.6m doctor-patient consultations across 67 countries and found that, in 18 countries, which represented about 50% of the global population, on average a doctor-patient consultation is five minutes or less. On average, British patients spend just over nine minutes with their primary care doctor  during an appointment and in the US, it is  17 minutes. More significantly, a 2016 study published in Health Expectations, suggested that patients only remember about a fifth of the information discussed in a standard doctor-patient consultation.

 

In addition to time constraints there is little incentive for doctors to address nonadherence. In the US, fee-for-service medicine incentivizes services, not improved outcomes. Although this is changing as insurers pay for value rather than activity, pay-for-quality programmes tend to be too small to motivate busy doctors. Similarly, the UK’s public healthcare system, which is free at the point of care for all citizens, lacks incentives for health professionals to be overly concerned about nonadherence to medication. Primary care doctors view their primary responsibility as making an accurate diagnosis followed by an appropriate prescription and generally tend to be unaware of the magnitude of nonadherence to medication.
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The medicalization of health

Compounding the problem of nonadherence is the medicalization of healthcare, which can transform healthy people into patients. This was graphically described by Ivan Illich, in a seminal paper entitled “Medical Nemesis” published in 1974 in The LancetThe same year, Illich published a book with the same title, which opens with the sentence, “The medical establishment has become a major threat to health”. Illich continued, “The disabling impact of professional control over medicine has reached the proportions of an epidemic”, which Illich referred to as an iatrogenic  epidemic:  derived from the Greek word “iatrogenesis” (ιατρογένεση), which means “originating from a physician or treatment”.
 
Healthy people transformed into patients

In a similar vein, a paper entitled “Let’s not turn elderly people into patients” and published in the May 2009 edition of the  British Medical Journal, suggested that annual health checks, which primary care doctors are incentivized to carry out, can transform reasonably healthy older people into habitual patients. The author, Michael Oliver, Professor Emeritus of Cardiology at the University of Edinburgh, suggested  that doctors view people over 70 to be at risk of one or other LTC and insist on medical checks. These  can lead to reasonably healthy individuals being told that they have high cholesterol levels or hypertension etc. and prescribed regular medications, instead of being encouraged, in the first instance, to exercise more and adopt healthier diets and lifestyles. Thus, a number of elderly people who considered themselves healthy on the way to the doctors, return home as patients. “What kind of medicine is this?” asks Oliver rhetorically, and answers, “It is politics taking preference over professionalism, obsession with government targets superseding common sense, paternalism replacing personal advice. It seems that many Western governments regard all people aged over 75 as patients”. And such perceptions can lead to over testing, over diagnoses and over treatment.
 
Pharmacists becoming significant healthcare destinations

Over the past decade pharmacists and pharmacies have been increasingly viewed as underutilised assets well positioned to improve nonadherence. In both the US and UK retail community pharmacies are accessible on a walk-in basis, without the need for an appointment. Pharmacists are the last checkpoint before a patient takes their medication and are therefore available to provide personalized advice about health and medicine to millions of people.
 
In the US there are approximately 314,300 pharmacists, and some 67,000 pharmacies; half of which (33,000) are conveniently located within drug stores, grocery stores, department stores, primary care clinics, universities, nursing homes, hospitals and prisons. In 2019, over 4.4bn retail prescriptions were filled throughout the US. Similarly, in England, there are some 42,990 registered pharmacists; 32,000 of whom work in 11,700 community pharmacies. Every day in England, approximately 1.6m people visit a pharmacy and for 89% of them a community pharmacy is within a 20-minute walk from where they live. Each year community pharmacies in England dispense over 1bn prescriptions.
 
The fact that pharmacists are rapidly evolving from a focus on product preparation and dispensing to becoming significant healthcare destinations is welcomed by both the UK’s Royal Pharmaceutical Society (RPS), the Royal College of General Practitioners (RCGP) and NHS England. Three 2016 reports demonstrate this: two published by the RPS and one published jointly by the RCGP and NHS England.  In September 2016, a RPS report entitled, Community Pharmacy Forward Viewset out a vision to expand and improve pharmacy services by: (i) facilitating personalised care for people with LTCs, (ii) acting as a trusted, convenient first-port-of-call for healthcare advice and treatment, and (iii) providing a hub for neighbourhood health and wellbeing. The report was complemented by another, published in November 2016, entitled Frontline pharmacists: Making a difference for people with long term conditionswhich argued that the expertise and clinical knowledge of pharmacists must be fully utilised to support people with LTCs and help them to achieve the desired outcomes from their medicines, thereby making more efficient use of NHS England’s resources. Such views were echoed in the General Practice Forward View, a report published in April 2016 by the RCGP and NHS England. The report suggested that pharmacists were, “one of the most underutilised professional resources in the [healthcare] system” and suggested that there was a need to, “bring their considerable skills into play more fully” and promote the need for pharmacists to be part of the broader health practice team.

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Pharmaceutical companies

Pharmaceutical companies have an incentive to reduce nonadherence with innovative solutions. When patients fail to take their prescribed medications, not only does their health deteriorate and health providers lose money, but doctors often change medications. This translates in a potential loss to the pharmaceutical company. Some experts estimate nonadherence in the US costs the pharmaceutical industry US$30bn a year in lost revenues, which others suggest is the tip of the iceberg.
Apps using behavioural techniques to reduce nonadherence

Over the past two decade, reducing nonadherence to medication has sought solutions in smartphone apps embedded with psychological techniques to encourage users to change their behaviour. Recent studies suggest that 90% of total time on mobile phones is being spent on apps and individuals may spend an average of 30 hours per month on apps. Such preoccupation raises the possibility that apps could be utilized by healthcare providers and their patients to reduce nonadherence.
 
Behavioural science’s  signature policy is set out in the 2008 book  Nudge, which looks at how people make decisions and applies this to healthcare. Nudges are a particular type of behaviour change intervention, which steer people in certain directions while maintaining their freedom of choice. The key insight is that changing the way choices are presented to people can have a significant impact. We end this Commentary by briefly describing some studies that have examined apps embedded with ‘nudge’ techniques to address the nonadherence to medication challenge. But first, we describe the rise in the influence of behavioural techniques in health policy.
 

The rise in the influence of behavioural techniques on health policy

In the early 2000s, both the US and UK governments began to explore how psychological and behavioural techniques could be used to improve public policy and healthcare, while maintaining a significant element of personal choice. In 2003, policy makers in the US were influenced by a paper entitled ‘Libertarian Paternalism’, published in the American Economic Review. Its authors, Richard Thaler, a University of Chicago economist and Cass Sunstein, a Harvard University  Law School professor, suggested that it is both possible and legitimate for private and public institutions to influence people to make decisions about health and wellbeing without coercing them. In February 2004, the UK’s Prime Minister’s Strategy Unit, published a report entitled ‘Personal Responsibility and Changing Behaviour: the state of knowledge and its implications for public policy’, which described behavioural theories of change  and explored ways the government might employ psychological techniques to influence personal behaviour in order to improve public policy. In 2008, Thaler and Sunstein published a book entitled Nudge’, which described how behavioural techniques and mental processes could be used to ‘nudge’ people and groups, rather than ordering them, to do things expected to improve public policy and reduce costs. In 2009, the US government recruited Sunstein to head the Office of Information and Regulatory Affairs (OIRA) and streamline regulations. In 2010, UK Prime Minister David Cameron established the Behavioural Insights Team (BIT) (referred to as the ‘Nudge Unit’) in 10 Downing Street, which was headed by David Halpern, the first author of the 2004 Strategy Unit Report referred to above. This was the first formal and systematic application of behavioural insights to public policy. In 2014,  President Obama set up a similar unit - the Social and Behavioral Sciences Team - in the White House. Over the past decade, similar units have been set up by governments throughout the world, the word “nudge” and ‘Nudge Units’ have become common place in social and public policy, and the application of behavioural techniques, have become a significant aspect of public sector management. Nudge techniques  have been employed to reduce the burden of nonadherence to medication.
 
Apps to nudge people to adhere to medication

Over the past decade, there has been a plethora of apps launched to tackle nonadherence to medication. A December 2015 study published by the UK’s Health Foundation entitled Behavioural Insights in Healthcare, suggested that “nudge-type” interventions could, “improve rates of medication adherence, particularly for chronic conditions”. In September 2018, Public Health England published a similar report entitled, Improving People’s Health: Applying behavioural and social sciences to improve population health and wellbeing in England. These and other studies reflect the prominence gained in recent years of the potential benefits behavioural and social sciences can make to improving peoples’ health.
 
Limited use of ‘nudge’ techniques

A research paper entitled, “Behavior Change Techniques in Apps for Medication Adherence” published in the May 2016 edition of the American Journal of Preventative Medicine drew attention to the vast and growing number of apps promoting medication adherence available in the two largest app repositories: the Apple App Store and the Google Play Store. The authors identified and coded 166 medication adherence apps according to 96 established behaviour change techniques and found that the apps only used a limited number of these, and “do not appear to have benefitted  from advances in the theory and practice of health behaviour change”. The most commonly included behaviour change techniques were “action planning” and “prompt/cues,” which were included in 96% of apps, followed by “self-monitoring” (37%) and “feedback on behaviour” (36%). The authors of the study concluded that the apps did not appear to have benefitted from “advances in the theory and practice of health behavioural change”.
 
Four research studies conclude that apps are using behavioural techniques sub-optimally

Four research papers published between 2017 and 2020 in the Journal of Medical Internet Research assessed thousands of apps embedded with behavioural techniques to address medication adherence in different regions of the world and all reached similar conclusions to the 2016 paper in the American Journal of Preventative Medicine mentioned above: that apps designed to enhance medication adherence use ‘nudge’ techniques sub-optimally.
 
In the April 2017 edition of the Journal of Medical Internet Research, a paper entitled “Assessing the Medication Adherence App Marketplace from the Health Professional and Consumer Vantage Points”, identified  824 adherence apps and evaluated 645 of them. Researchers found that the quality of the apps “varied considerably”.  A 2018 review paper published in the same journal,  provided one of the first comprehensive assessments of medication adherence apps in terms of their evidence base, medical professional involvement in their development and the strategies they used to facilitate behaviour change and improve adherence. Researchers identified 5,881 apps, tested 1,486 according to predetermined criteria and concluded that there was, “a concerning lack of healthcare professional involvement in app development and evidence base of effectiveness”.  
 
A paper entitled, “Using Health and Well-Being Apps for Behavior Change” published in the July 2019 edition of the Journal of Medical Internet Research, provides a systematic review of a large sample of healthcare apps marketed in Australia. The initial search identified 212,352 apps, from which 5,018 were identified using a priori key search terms.  Of these, 344 were classified as behaviour change apps and were reviewed and rated. Conclusions suggested that only a limited number of the apps were found to be using behavioural change techniques expected to promote and sustain lifestyle behavioural change and improved health. 
 
And finally, a research paper entitled, “Quality, Functionality, and Features of Chinese Mobile Apps for Diabetes Self-Management: Systematic Search and Evaluation of Mobile Apps” published in the April 2020 edition of the Journal of Medical Internet Research evaluated apps that are available to millions of people in China living with diabetes and designed to help them self-manage essential medications they are required to take regularly throughout their lives. Among 2,072 apps identified, 199 were selected based on the authors’ criteria and 67 apps were analysed.  Conclusions were similar to those in the previous studies mentioned in this section and suggested that the, “general quality” of the apps was “sub-optimal”.
 
Takeaways
 
Nonadherence to medication is a vast and rapidly growing killer epidemic, which is under reported, under-treated and cost healthcare systems billions. This is partly because no healthcare stakeholder has assumed responsibility for denting the burden of the epidemic. Thus, nonadherence is an orphan issue. More recently, the confluence of mobile telephony and behavioural techniques has held out a promise to reduce nonadherence. However, research has suggested that while there is a proliferation of mobile apps embedded with behavioural techniques specifically designed to lower the burden of nonadherence to medication, the overwhelming majority of these are not using tried and tested behavioural techniques optimally. This suggests that there is an opportunity to significantly improve nonadherence to medication by optimally utilising behavioural techniques and digital technology.

 
#LongTermConditions #nonadherence #nonadherencetomedication #behaviouraltechniques #Nudge
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Dr Srinivas (Sri) Gada has been a Consultant Paediatrician with expertise in Childhood Neurodevelopmental Disorders and Paediatric Neurodisability for 14 years.
Dr Sri Gada worked as Consultant Community Paediatrician with an interest in Neurodisability at Oxford University Hospitals NHSFT, for nearly 14 years (2005-2019). He practiced in the NHS (National Health Service), for nearly 25 years. He has been a Hon Senior Clinical Lecturer at University of Oxford since 2007. He has also served in NHS in other roles such as Consultant Appraiser, Clinical Governance Lead, Educational Supervisor and Clinical Supervisor for over 12 years.


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  • The CoVID-19 pandemic created an unprecedented global shock and killed hundreds of thousands
  • Nations responded by closing their borders, implementing stringent lockdowns and saying the  world is at war with a common invisible adversary
  • Responses to the outbreak diverged in the different regions of the world
  • Asian countries responded rapidly and effectively
  • The US and UK responded slowly and ineffectively
  • Observers suggested that the divergent responses to CoVID-19 signal a shift in power and influence from West to East
  • National responses alone are insufficient to effectively deal with the coronavirus
  • Only by embracing effective international cooperation will governments protect their citizens and safely exit the CoVID-19 crisis
 
National leaders have described the coronavirus CoVID-19 pandemic as “the enemy”. In attempts to protect their citizens, nations turned inwards and closed their borders, implemented stringent lockdown restrictions and suggested that the world is at war with a common adversary it cannot see. The speed and effectiveness of national responses to the new coronavirus crisis differed, but not even the wealthiest, most advanced nations were able to protect their citizens. The global coronavirus crisis made millions seriously ill, killed hundreds of thousands, destroyed industries, bankrupted thousands of companies, caused economies to nose-dive and threw societies into turmoil. Only by avoiding nationalist policies and embracing effective international cooperation will governments protect their citizens and safely exit the CoVID-19 crisis.
 
Viruses are notoriously difficult to treat and cure

CoVID-19 has rapidly spread throughout the world with a scale and a severity not witnessed since the devastating Spanish Flu in 1918. So-called because Spain was neutral during WW1 and was one of the few countries where journalists were free to report on the outbreak. In an era before antibiotics and vaccines, the Spanish Flu claimed the lives of nearly 0.68m Americans, 0.25m Britons and between 50 to 100m people worldwide. Adjusting for population growth, that is equivalent to between 200 and 425m today.
 
At the time of writing - June 2020 - neither an adequate therapy nor a vaccine has been developed and CoVID-19 remains prevalent in populations throughout the world. Even with today’s scientific advances, infectious diseases are notoriously challenging to either treat or cure: an Ebola vaccine was more than two decades in the making; despite the first cases of the human immunodeficiency virus (HIV) presenting in 1983, we still do not have a therapeutic preventative vaccine for the disease; nor do we have a vaccine for severe acute respiratory syndrome (SARS), a killer coronavirus, which also originated in China and was unknown before its outbreak in 2002.
 
Recovery will neither be straightforward nor quick

Notwithstanding, governments have lifted lockdown restrictions in order to get their economies working again. V, U, W and L are letters of the alphabet used to describe the shape of a recovery following the economic crisis caused by CoVID-19. Stringent lockdowns forced economies into unprecedented cold storage, and no one knows what shape a recovery will take since professional forecasters have never encountered anything like the sheer magnitude of the current economic crisis.
 
The Bank of England’s Monetary Policy Report published in May 2020, warned that the coronavirus has caused the worst economic crisis in 300 years. So, emerging from this is unlikely to be either straightforward or quick. National responses to the coronavirus outbreak were mixed. Although it is too soon to know the longer-term effects of the virus, China, Singapore and South Korea are among the countries that responded early and effectively, while the US and UK, together with other Western European countries, responded late and less effectively. As of June 1, China, with a population of 1.4bn, had 83,017 confirmed cases and 4,634 deaths; South Korea with a population of 52m, had 11,537 cases and 270 deaths,  and Singapore with a population of 5.7m, had 34,884 confirmed cases and 23 deaths.
 
In this Commentary

This Commentary describes the divergent national responses to the CoVID-19 pandemic; in particular that of China, Singapore, South Korea, the US and UK. China’s more effective response might have been because Beijing benefitted from the lessons it learned after the SARS epidemic in 2002. Governments also differed in their approaches to lifting restrictions. China’s approach was slower than that of the US and more determined to make some of the unexpected benefits thrown up by the crisis permanent. Some observers perceive such variances as a difference between liberal and illiberal nations. Others view the divergences as a shift in power and influence from West to East. We suggest that the divergent responses and outcomes are a product of the capacity and legal authority of different states and reveal different mindsets and competing views about solutions. We also contend that the devastation created by the pandemic will only be resolved with effective international cooperation. However, it is difficult to see this happening in the near term as the pandemic has become a theatre for a wider political disagreement between the US and China, in which other nation states are being forced to take sides.
 
Asian nations won the battle against CoVID-19

China, Singapore and South Korea leveraged the collectivists mindset of their citizens, their centralised authority and digital infrastructures to quickly implement the gold standard “test-trace-and-isolate” strategy to reduce and control the virus. The reason for such prompt actions and the subsequent relatively low number of cases and deaths in these Asian countries is described by  Byung-Chul Han, a South Korean-born German Professor of Philosophy at the Universität der Künste in Berlin. In an article published on May 22, in the Spanish newspaper El Pais, Han suggests that Asian nations won the battle against the CoVID-19 outbreak because their citizens, “have a collectivists mindset, which comes from their cultural tradition of Confucianism. Asians are less rebellious and more obedient than people in the West. They trust the state more. Daily life is much more organised, and Asians are strongly committed to digital surveillance. The epidemics in Asia are fought not only by virologists and epidemiologists but also by computer scientists and big data specialists”.
 
Confucian mindset rather than authoritarianism

Given Iran’s response to CoVID-19 has been less effective, it seems reasonable to suggest that the Confucian mindset, rather than authoritarianism, appears to provide at least a short-term advantage. In early March, at the Shia Muslim Masumeh shrine in the holy city of Qom, pilgrims licked and kissed its gates. Qom experienced Iran’s first outbreak of the coronavirus and became the country's worst-hit city. Shortly afterwards the government closed all major Shia shrines across the Islamic republic and reopened them again in late May. As of June 1, Iran with a population of 81m, had confirmed 154,000 cases of CoVID-19 and 7,878 deaths.  

 

Smaller democracies appear to cope well

Small democracies such as New Zealand and Greece seem to raise some doubt about Han’s thesis because they too have effectively responded to the outbreak. As of June 1, New Zealand, with a population of 5m, had confirmed 1,154 cases and 22 deaths and Greece, with a population of 11m, had a total of 2,917 cases and 175 deaths.
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Notwithstanding, New Zealand’s lockdown only occurred after significant pressure was applied by civil society that suggested the government needed to change track. Both New Zealand and Greece have concentrations of political power, access for vested interest, a lack of public participation in politics and weak media. Further, Greece had no choice but to act swiftly and robustly to the coronavirus outbreak because the country has been in an almost constant state of austerity management since 2008, which has significantly reduced its resources to tackle an outbreak of this magnitude. In both countries the effect of stringent nation-wide lockdowns could further weaken already fragile civil societies, media and parliamentary systems by concentrating power in political leaders, curtailing civil liberties, adjourning parliaments and restricting the normal operations of the media.
 
The Swedish exception

By contrast to all other developed countries, Sweden exercised a radical laissez faire no-lockdown approach to the CoVID-19 outbreak. The architect of this was the Swedish State Epidemiologist Anders Tegnell, who argued that, “nothing [to do with lockdowns] has any scientific basis”, particularly decisions to close schools because there is no evidence that children are a major cause of coronavirus transmission. In Sweden, primary and secondary schools, day care centres, restaurants, bars, cafés, cinemas, theatres, shops and places of work all remained open as normal, with Swedish health authorities relying on voluntary social distancing and people choosing to work from home. Schools for over-16s and universities were closed, and gatherings of more than 50 people were banned. As of June 1, as the death toll has fallen substantially in other European countries, 4,403 people had died from CoVID-19 in Sweden, a country with a population of 10m. Its neighbours, Denmark, Finland and Norway - each with populations of about 5m - have recorded death tolls of 574, 320 and 236, respectively.
 
Not only does Sweden’s no-lockdown approach enjoy significant support among its citizens, it also has the backing of Jonathan Sumption, an historian and a former Justice of the Supreme Court of the UK. Writing in The Times of London Sumption suggests that, “The lesson of CoVID-19 is brutally simply. . . . . . Free people make mistakes and willingly take risks. If we hold politicians responsible for everything that goes wrong, they will take away our liberty so that nothing can go wrong. They will do this not for our protection against risk, but for their own protection against criticism”.
 
At the beginning of June, Tegnell conceded that Sweden should have imposed more restrictions to avoid having such a high death toll. 
 
The US and UK mindset

Compared to the responses described above, the US and UK were slow to implement testing, late to acquire essential equipment, gave confusing public health messages and delayed introducing stringent lockdowns and social distancing. For example, in mid-March, when borders were being closed and mass quarantines enforced across Europe, the US government was failing to establish a clear and focused response to the outbreak. By the time the US President declared a national emergency, several states had introduced lockdowns, universities had shifted to online learning and churches had begun to close. At the same time, schools in England largely remained open and the UK government was pursuing a strategy of exposing its population to the coronavirus in the expectation that citizens would develop a “herd immunity”. As of May 31, the US with a population of 328m, had confirmed 1.83m cases and 106,000 deaths, and the UK with a population of 67m, had 276,000 cases and 39,045 deaths.
 
Signs of danger ignored

Neither the US nor the UK government appeared to have been influenced by well publicised signals of pending dangers, which included: (i) CoVID-19 being a highly contagious ‘novel’ coronavirus without either a therapy or a cure, (ii) around January 23, after the discovery of the outbreak and before the lockdown of Wuhan, the city in China where the virus originated, some 5m people left the city and were potential super spreaders, (iii) by February 4, the coronavirus had spread to 24 countries, (iv) also on February 4, China had opened the first of two mega hospitals in Wuhan, both built from scratch in a couple of weeks specifically to cater for patients affected by the fast-spreading coronavirus. Together, the two hospitals had a 2,600-bed capacity and were staffed with over 3,000 health professionals.
 
Mixed messages

Inside the US messages about CoVID-19 were mixed. Main media outlets reported the acceleration of the virus internationally and state governors independently started to take emergency actions. Notwithstanding, on February 26, at a White House briefing, President Trump urged Americans to take the same precautions for coronavirus as they would for normal flu, and US Health and Human Services Secretary Alex Azar advised that the coronavirus only posed a low risk to the American public. On February 25, the Centers for Disease Control and Prevention (CDC) confirmed that there were 60 CoVID-19 cases in the US and warned Americans that “it's a question of when, not if” the virus, which had killed thousands, would spread within the US.
 
Convinced of a rapid V-shaped recovery

In late February, in tune with White House messaging, many US business leaders from sectors not seriously affected by CoVID-19, were convinced that the coronavirus outbreak would be a relatively short-lived regional issue, concentrated in China with some limited transmission through supply chains to other parts of Asia, Europe and the US. They believed the outbreak would only have a temporary impact on global GDP and trade and weigh modestly on US business activities in Q1 2020. Although it might be difficult to contemplate now, in late February some US business leaders were suggesting that their companies and the American economy would bounce back in Q2 2020 after a modest V-shaped dip.
 
Such optimism might have been influenced by the SARS outbreak, which also originated from China, spread to 37 countries, infected more than 8,000 people and killed about 800. The impact SARS was to reduce China’s GDP growth by about 1% and it only had a limited effect on world GDP and trade. Although the SARS epidemic did not register much with US business leaders, it prompted Beijing to overhaul its healthcare system and prepare China for another potential virus epidemic. After SARS China invested in systems for disease surveillance and reporting, as well as epidemic prevention and control. Centres for disease control were built across the country and public insurance programmes were expanded to provide affordable care for the rural population. Arguably, this strengthened China’s preparedness for its response to CoVID-19.
 
By contrast, the US and UK did not appear to perceive a threat of a pandemic as serious. In May 2018, President Trump disbanded the US Global Health Security and Biodefense unit responsible for pandemic preparedness, which was established in 2015 by Barack Obama’s National Security Advisor. The UK did something similar. According to Professor Sir Ian Boyd, the UK’s Chief Scientific Adviser between 2012 and 2019, the nation’s biological security strategy, which Boyd partly wrote and published in 2018 to address the threat of a pandemic, was not properly implemented because of a lack of resources.
 
Commercial impact

As a consequence, on March 11, when the World Health Organization (WHO) declared the coronavirus CoVID-19 as a pandemic the US and UK were unprepared. The WHO pointed to Europe as the “epicentre” of the outbreak and, by the end of March, the outbreak had a significant effect on most industries in the developed world. Transportation, manufacturing and wholesale trade sectors were substantially affected by disrupted supply chains and travel restrictions. In many countries retail and hospitality sectors experienced sharp falls in demand and were closed. However, sectors differed in their ability to respond flexibly to supply disruptions and falls in demand. For example, business as usual continued for many professional services if their employees were able to work from home.
 
Impact on healthcare

The impact on healthcare was mixed. Demands on hospitals increased significantly as they shifted their resources and efforts to treating CoVID-19 patients. Policy responses were aimed at managing the increased capacity demands on hospitals by ‘flattening the curve’ of infection. The impact of the coronavirus outbreak on the MedTech sector was bifurcated. The vast and increased demand for critical care devices and personal protective equipment (PPE) significantly advantaged some manufacturers, while others, particularly orthopaedics, were disadvantaged as hospitals dedicated capacity to treating infected coronavirus patients and deferred non urgent surgeries. Sector forecasts suggested a reduction in medical device use in the Q1 and Q2, and a moderate recovery in the second half of 2020. But this hinged on successful efforts to halt the virus' spread. The global economic slowdown and the shift in healthcare resources toward fighting CoVID-19 dented MedTech sales and triggered a hit to their stock valuations.

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CoVID-19 weakens the ‘Western brand

Some commentators perceive the CoVID-19 crisis as a test of the competing claims of liberal and illiberal states to better manage significant social and economic shocks. According to Stephen Walt, Professor of international affairs at Harvard University's John F. Kennedy School of Government, the slow and diffident responses to the outbreak from US, UK and some other European governments could potentially weaken the dominance of the Western brand, and “accelerate the shift of power and influence from west to east”.
China building on the response to SARS

Despite China’s endeavours to be ready for a pandemic after the SARS outbreak, CoVID-19 exposed cracks in China’s preparedness, which Beijing swiftly sought to fix. This included enhancing the nation’s healthcare system’s cost management by further centralizing procurement, purchasing drugs in bulk and implementing a two-invoice policy to eliminate layers of bureaucracy in the nation’s distribution channels. Beijing also encouraged product innovation from local and foreign companies by fast-tracking approvals for medicines and medical devices. And, like many other countries, China increased its digitalization strategies by accelerating the integration of big data, artificial intelligence, telemedicine, online pharma retail and more. The coronavirus impact in China and elsewhere in the world prompted a massive shift in patients and doctors using Internet-based options for diagnosis and treatment. This shift to digital necessitated by the coronavirus outbreak is well positioned to become the ‘new normal’, which could help healthcare providers, hospitals, health systems and clinicians optimise their use of resources.
 
G7’s response to CoVID-19

Between March and April, G7 nations (Canada, France, Germany, Italy, Japan, the UK and the US) injected US$2.5tn of new money into financial markets through quantitative easing and liquidity programmes to help nations recover from the economic crisis caused by CoVID-19. Notwithstanding, only about US$1 in US$10 lent by British banks went to non-financial service companies. Most of the new credit supported financial trading. A similar pattern occurred in other G7 countries. As these nations navigate their way out of the crisis, there is little evidence of any industrial strategy being linked the CoVID-19 shock. For economies to recover, they will need financial markets to do something similar to what they did following WWII when banks worked closely with governments and used the increased liquidity for committed long-term financing that created jobs, enhanced productivity and stimulated innovation.

Interestingly, on May 30, President Trump said he will postpone the G7 meeting planned for August at the White House. He called the current group’s format , “very outdated”, suggested that it does not properly represent "what's going on in the world" and said its membership should include Russia, Australia, South Korea and India.
 
The pandemic is not over

Compared with G7 nations, China has opted for a more strategic approach to its recovery from the pandemic. Beijing has put the prevention and control of the CoVID-19 crisis as the keystone of a national strategy. Significantly, Premier Li Keqiang, did not use his annual report to China’s National Legislature on May 29 to claim victory over CoVID-19. Instead he stressed that, “The pandemic is not over” and outlined Beijing’s plans for continued vigilance against the coronavirus, which, Li said, “is a core thread in determining everything from macro-level strategy to micro-level policy for the foreseeable future in China”. Beijing committed a ¥1tn (US$138bn) rise in its fiscal deficit and ¥1tn of special governments bonds to its CoVID-19 recovery strategy, which is dedicated to: (i) securing jobs, (ii) maintaining and increasing people’s livelihoods, (iii) developing businesses, (iv) securing food and energy, (v) developing and maintaining stable industrial and supply chains, and (vi) reducing government red tape.
 
CoVID-19 strengthens the US$

Beijing’s coronavirus recovery strategy does not guarantee that China will evolve stronger than the US from the crisis. Indeed, the US may surface in better shape than analysts suggest. This is because of the strength of the US$, which remains the world’s reserve currency and is perceived as a relatively safe asset in times of crisis. The CoVID-19 crisis reinforced the US$’s strength and therefore it seems reasonable to suggest that the coronavirus outbreak may not do as much damage to the US economy as some observers suggest. Walt’s prediction, mentioned above, that CoVID-19 will accelerate the shift of power and influence from West to East will depend on whether: (i) the US successfully restarts its economy and avoids a resurgence of the coronavirus, and (ii) the US maintains its ‘America first’ approach to the pandemic or changes to its natural global leadership position, which it assumed after WWII.
 
US suspends payment to the WHO

On March 26, after a virtual G20 summit, there were encouraging signs when a joint statement said that, “Combatting this pandemic calls for a transparent, robust, coordinated, large-scale and science-based global response in the spirit of solidarity. We are strongly committed to presenting a united front against this common threat”. Despite this pledge to cooperate, little cooperation followed, and the pandemic became a theatre for a wider disagreement between the US and China. On April 20, President Trump suspended US payments to the WHO in protest at what he regards as the body’s China-centric approach, reflected, by what he suggests is the WHO’s failure to challenge China sufficiently over the origins of the CoVID-19 outbreak. On May 29, Trump said, “We will be today terminating our relationship with the World Health Organization and redirecting those funds to other worldwide and deserving urgent global public health needs”. In the near-term, before the US presidential election in November, it does not look that the US will change its ‘America first’ strategy.
 
Takeaways

CoVID-19 has created an unprecedented global crisis. Governments throughout the world responded to the crisis by closing their boarders, implementing stringent lockdown restrictions and used wartime rhetoric to rally their citizens. While this temporarily lowered the rate of infection it is not a permanent solution. Two significant takeaways from the coronavirus crisis are: (i) not even the riches and most technologically advanced nations with state-of-the-art healthcare systems were able to protect their populations and (ii) only by turning outwards and embracing effective international cooperation will nations protect their citizens and safely exit the CoVID-19 crisis.

#coronavirus #coVID-19 #pandemic #coVID-19outbreak #lockdown
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Rod Gillingham

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North Raleigh Pediatric Group

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