In an unprecedented scenario, SGIM members from around the world are facing the same novel virus. At the time of this writing, COVID-19 has claimed the lives of more than 1.14 million people worldwide, with cases reaching 41.81 million.1 While all countries are facing the same pandemic, the responses and outcomes have varied dramatically from one country to the next. SGIM International members Enrique Casal, MD (Argentina); Moira Kapral, MD, MSc (Canada); Shinji Matsumura, MD, MSHS, PhD (Japan); Patrick Bodenmann, MD, MScPH (Switzerland) share their experiences during the last six months.
What were your countries’ initial policies to curb the spread of COVID-19?
Dr. Casal: At the end of February 2020, the Health Authorities hypothesized that the disease was not going to be a major issue for Argentina, not realizing how contagious the virus was.2 Despite swift action in March, there were few precautions taken at the beginning of the year. When the first cases presented from abroad and afterwards indigenous cases, the country installed an ad hoc Committee of Infectious Disease Experts. Argentina implemented strict quarantine measures and postponed an upsurge of cases, giving the health system’s public sector extra time to organize their response. This early quarantine was not followed consistently by other measures, however, and now, in October 2020, we are in the upslope of the curve, and in the world’s ten most affected countries by new cases.
Dr. Kapral: In March, Canada’s borders were closed, a 14-day quarantine was mandated for returning travelers, large gatherings of more than 250 people were prohibited, and schools and non-essential businesses were closed. The federal government released billions in economic aid, including an emergency benefit of $2000/month for anyone unable to work due to COVID-19 illness, caregiving duties, or unemployment.
Dr. Matsumura: On January 16, the first COVID-19 case was diagnosed in Japan. Soon after that, Japan had to deal with Wuhan’s returnees and an outbreak on the cruise ship, the Diamond Princess. Then, we began facing local outbreaks of COVID-19 in large cities, such as Tokyo, Osaka, and Sapporo. In the beginning, the PCR testing capacity was not enough, so the government focused on detecting clusters of infections and contact tracing. On April 8, Prime Minister Shinzo Abe declared a state of emergency, although the government did not impose a strict lockdown. As most residents in Japan followed the government’s request, the number of COVID-19 cases gradually decreased. On May 25, the governments lifted the nationwide state of emergency order. After societal activities resumed, the number of cases steadily increased. However, the infection has not led to a rapid spread as of October 2020.
Dr. Bodenmann: The virus was confirmed to have spread to Switzerland on February 25, 2020. On March 16, schools and most shops were closed nationwide, and, on March 20, all gatherings of more than five people in public spaces were banned. Additionally, the government gradually imposed restrictions on border crossings, and announced economic support measures. Those measures of partial lockdown were prolonged until April 26, 2020. Since then, Switzerland has eased restrictions gradually. The implementation of the SwissCovid app among more than two million people (a quarter of the general population) has permitted partial contact tracing of the population living in Switzerland. Since the beginning of the pandemic, the Federal Council has focused on the protection of the most vulnerable individuals (i.e., older persons and persons with pre-existing medical conditions). Taking care not only of the biomedical vulnerability but also of socioeconomic vulnerability is critical to decrease inequities.
What factors (social, political, cultural or otherwise) do you attribute to the success or failing of your country’s response to COVID-19?
Dr. Casal: While the capital, Buenos Aires, had a well-planned response, Argentina is a federal country, and the Ministry of Health has limited capabilities to lead action across the entire geography. Imported COVID-19 cases were attributed to commercial air transportation and concentrated on the metropolitan area of Buenos Aires. The severe lockdown initially succeeded and improved the infrastructure of the needed health services. The city of Buenos Aires constructed an appropriate health intervention, but as the pandemic spread, the poorer provinces received a growing number of cases. They have less developed health services and there is a special difficulty in providing tests and contact tracing in these more rural areas. From March to October 2020, the care of people without COVID-19 was severely affected, especially for people with chronic conditions, who often were forced to stop their treatment or follow-up visits. What I and many of my colleagues have observed is that people with acute illnesses suffered considerable delays in access to health care, increasing the number of complications.
Dr. Kapral: Canada’s response has been facilitated by its universal healthcare system, a coordinated public health response with the provinces taking direction from the Chief Public Health Officer, centralized distribution of PPE, early ramp-up of testing, broad public acceptance of masks and physical distancing, provision of basic income and other financial supports, and consistent messaging from politicians across all party lines. But there have been important failures. Most deaths in the first wave occurred in long-term care facilities, and subsequent investigations exposed major gaps in care and infection control measures at some of these sites. COVID-19 has also had a disproportionate effect on people of color, those from low-income areas, and those from underhoused populations.
Dr. Matsumura: Japan has a relatively low mortality of COVID-19 despite its high population density and aging population. One reason may be attributable to the social behaviors of the Japanese people. Japan has already had a habit of universal wearing of surgical masks in winter, and the early stage of the outbreak coincided with the spring pollen allergy season. Hence, the outdoor mask use was close to 100% from the beginning of the pandemic. Japan also has a culture where physical contact (shaking hands, hugging, and kissing) is uncommon.
Dr. Bodenmann: I practice in the canton of Vaud where the current figures of positive tests and quarantines required are increasing for a number of reasons: the density of our population compared to other cantons, the large number of young people, the presence of many educational institutions, and the borders with France. In addition, there has been a gradual abandoning of barrier gestures (measures people can take to reduce the risk of infection). On the other hand, the socio-political stability of the country and the constant interaction and coordination between politics, public health offices, academics and clinicians enabled us to respond effectively. However, there remains a need to focus on patients lacking financial resources or without legal status in Switzerland.
What do you imagine are the long-term changes to societal life in your country? Do you anticipate long-term changes to medical care?
Dr. Casal: Argentina is living a deep and progressive socio-economic decline in the last 30 years; it is highly impoverished with around a 40% of poverty rate, and a high level of unemployment. We have an opportunity to change these conditions and try to find a way towards effective production and wealth. COVID-19 may be helping to conceptualize this potential turning point. Medical care should be a leading part of this change, offering a better destiny of our almost 9% of GNP invested in health with a central role for primary and universal health care. Telemedicine has arrived to stay, but no one knows for certain in what proportion of usual care or how to charge and pay for these encounters. The cell phone may play a central role in telemedicine.
Dr. Kapral: The pandemic has demonstrated the importance of investment in public health, long-term care, healthy urban design, childcare, housing, social programs, and poverty reduction. If the initial measures that have been enacted to address these issues are continued and amplified, this could lead to long-term benefits for our communities and our health. And I expect that the increased availability of telehealth will be a huge benefit to our population, many of whom live in remote or rural areas with limited access to in-person health care.
Dr. Matsumura: People in Japan are changing the way they behave. There will be further expansion of online clinics, online meetings, and remote schooling or working. There is also the impression that people are becoming less directly connected and more socially isolated in the community. Telehealth will expand, and most health care will be more information driven. As physical examinations become more challenging to perform, our consultation process may differ. Primary care practices in Japan, which has had excellent access to medical care, are likely to change. Restrictions of visits in hospitals wards or long-term care facilities may affect the nature of end-of-life care.
Dr. Bodenmann: The socio-economic stability of Switzerland may reduce the economic impact of the health crisis compared with other countries. However, the social crisis is inevitable and we will have to focus our attention on the most vulnerable people in medical terms but also in terms of mental health: this includes seniors, young people and all those left behind and too often invisible and neglected. COVID-19 gives us an opportunity to review our healthcare procedures, our quality processes, and even our missions regarding the most vulnerable and marginalized patients in our healthcare system.
As of October 24, Argentina had 1.05 million confirmed cases and 27,957 deaths.1 Canada had 209,148 confirmed cases and 9,862 deaths.1 Japan had 95,835 confirmed cases and 1,706 deaths.1 Switzerland had 96,731 cases and 1,866 deaths.1 The United States had 8.32 million confirmed cases and 221,564 deaths.1 As these numbers continue to grow, especially so as we face the winter months in the norther hemisphere, it is necessary that our healthcare professionals around the world share their experiences and insights in the fight against COVID-19. Lives are saved when we do.