Changing strategy to a new normal
Twenty-one months into this pandemic, three key factors are driving countries to change their Covid 19 response strategy. First is a genuine concern with the detrimental impact of Covid fatigue on social, physical, economic, and mental well-being. Second, the arrival and dominance of the more transmissible Delta variant. Third, progress in population vaccination, better access to a wider range of tests and treatments (post-exposure prophylaxis and therapeutic).
Some countries have deliberately changed their response strategy from various forms of suppression and elimination to living with the virus. There are variations and pace of transition, but they all share the following:
- The key re-opening is a high rate of vaccination.
- Ensuring their health system is not overwhelm as they re-open.
- Some form of restrictions remains such as social distancing and wearing of masks and
- Introduction of vaccination passport.
A fundamental flaw amongst countries making the transition is not changing their operating model fast enough once they decide to change their strategy.
A new operating model
In 2020 and the first half of 2021, policy, process, performance reporting, prevention, and protection measures came from an operating model that supported the suppression or elimination strategy. Changing to a "living with the virus" strategy requires a new operating model. The new model may incorporate some elements (with some modifications) of the previous operating model (for example, the importance of PCR tests, being supplemented by rapid antigen tests). However, there will be new elements in the new operating model (for example, home recovery for asymptomatic and mild symptoms cases).
A new operating model supporting the "living with the virus" strategy requires a different mindset to design and implement a blended approach that manages positive cases with none, mild, moderate, and severe symptoms differently. This blended approach must be evident across all response counter-measures – surveillance, screening, prevention, protection, treatments, quarantine, and isolation.
The lack of pace and the stop-start rhythm during transition is a source of confusion and frustration. For those tasked with making the change, to unlearn what has worked in 2020 and early 2021 and relearn new operating models is, first and foremost, a mindset challenge. Patience will be the biggest challenge during a bumpy transition for the average person waiting to get on with the new normal.
High vaccinations, daily cases, hospitalizations, and deaths
Different countries have set different vaccination targets as the threshold to start their transition to a new normal. The numbers are anywhere from 70% (Denmark), 80% (Singapore), and 90% (New Zealand).
Most countries during this pandemic have kept their daily cases and deaths to a comparatively low level through various forms of restrictions and lockdowns. However, as restrictions ease as part of the transition phase of re-opening, rising daily cases and deaths, especially amongst the unvaccinated, are reported. There are breakthrough cases but real- world data, for example, from Singapore, shows that 98% of these breakthrough cases will have no to mild symptoms. Fatalities amongst the vaccinated are rare, and most will have existing underlying immune-compromised health conditions.
During this transition period, governments face the psychological challenge of dealing with ongoing daily cases and deaths. How various countries react to this challenge depends on their historical track record in 2020 and early 2021 with daily cases, hospitalizations and deaths.
Different starting points
In 2020 countries like the UK, Portugal, Denmark, Norway, Germany had a proportionately high number of cases and deaths. On the other hand, countries like Singapore, Australia, and New Zealand had very low cases and deaths. Compared to the latter group of "covid naïve" countries, the former has a more accelerated pace of easing restrictions and a higher level of acceptance on high daily cases and deaths during the transition.
However, a common principle that both groups share is protecting their health system during the transition.
Protecting health systems
Making sure health systems are not overwhelmed as they transition into the new normal requires deliberate planning, investments, and focus execution. A key part of protecting the health system is ensuring hospitals are well resourced to care for those severely ill from Covid 19 infections. However, protecting the health system requires more than just focusing on hospital capacity.
If most cases (especially breakthrough cases) are asymptomatic or have mild symptoms, sending them all to the hospital for observation is inappropriate. More importantly, it is a sure recipe to overwhelm hospital capacity as more cases are detected. An integrated approach that allows positive cases to be cared for appropriately at home, in community care, and in hospitals holds the key to protecting the health system. This approach is part of Singapore's transition plan - from self-care at home, community care facilities, community treatment facilities, dedicated hospital wards, and ICU beds. The implementation is in progress and provides valuable lessons for other countries with similar plans. In this media conference1, government ministers outline transition challenges, including implementing plans to support their health system.
Living through the transition – Singapore in transition
Singapore, an island nation of 5.5 million, is living through this transition. In May 2021, their Prime Minister announced the "government's plan to 'live with the virus' and transition away from a COVID-zero approach. Their case numbers and deaths from Covid 19 at the start of their transition were amongst the world's lowest.
By early October 2021, as daily case numbers increased exponentially, the transition plan appeared to have stalled. The return of previous restrictions caused a level of confusion and frustrations within Singapore and attracted some international publicity on whether Singapore is having second thoughts about re-opening.
For "covid naive" countries like Singapore, a significant hurdle to get over during transition is ensuring their health systems are not overwhelmed as daily numbers continue to rise without resorting back to restrictions of the 2020 and early 2021.
The Singapore Prime Minister on 9th October 2021 directly addressed the nation to reaffirm the re-opening strategy and announced changes to simplify the transition process together with a revised timeframe.
It is one thing to plan for a transition. But living through the transition will test the mindset, will, and resolve of any government and its population.
Lessons
Making this transition in the real world is not a linear and straightforward exercise as countries find out. Important lessons are emerging from countries in transition:
- The supporting operating model (policies, process, tools, performance measures) needs to change when strategy change.
- Changing from an existing to a new operating model always takes longer than expected.
- Successful strategy and operating model changes require a different mindset, talent, skill, knowledge, capacity, and capability.
- Changing course will not be a straight and linear exercise. Pauses and even some U-turns resulting in varying degree of frustration and confusion is part of the transition.
- Experts will be divided with the change in strategy and operating model.
- The unvaccinated population will make up most of the reported daily cases and deaths.
- Breakthrough cases will also be amongst the reported daily cases as the transition progresses. But most will be asymptomatic or have mild symptoms. Fatalities amongst the vaccinated population will be rare and will come mainly from those with existing immune-compromised illnesses.
- Protecting health systems during the transition will require investment: a. in an integrated care model that must include self/home care, community care, hospital wards, and ICU beds, and b. a broader range of antigen and molecular tests as well as treatments.
- In certain high-risk settings, some level of social distancing and wearing of face masks will remain.
- A vaccine passport will become a vital feature of the new normal.
Final word
The accountability for changing the Covid 19 response strategy rests solely with our elected politicians. The responsibility to change and execute an appropriate operating model rests with senior public servants, health professionals, and partners. The successful transition that countries must now make in their Covid 19 response requires clarity of roles and having the right people to do the job at all levels.
The transition journey has begun. As politicians, health professionals, and experts debate what changes are necessary to re-open, the journey ahead will be long, bumpy, and less than perfect. Our own transition experience will be based on our circumstances, our choices, and our expectations. Living through the transition will likely be a confusing mix of emotions from relief, anticipation, excitement, frustrations, disappointment, anger, and acceptance. When we emerge on the other side of this new normal, there will be plenty of stories to tell and lessons to share of how we transition.
CHUAH Jin Chai 蔡 仁材
Wellington, NEW ZEALAND
12th October 2021