‘Health services need to be stress-tested’
The slide of international stock markets when the recent Omicron variant of Covid-19 was discovered was a clear indicator of the interdependent relationship between health and the global economy. The uncertainty faced by banks, insurance companies and investment funds as to what will happen in terms of the pandemic, combined with the stress and shocks faced by established and strong health systems, has made subjecting national health systems to stress tests an absolute necessity. This is what Elias Mosialos highlights in an interview with Kathimerini, borrowing a term that slid into the everyday lexicon during the financial crisis, when banks had to be evaluated to see how they’d respond to a range of hypothetical scenarios. The Greek professor of health policy at the London School of Economics and the School of Medicine at Imperial College London points out that there are three basic steps to bring this cycle of the pandemic to a close. Specifically, a vaccination rate of over 80% globally, widespread availability of antiviral medication, and adequate monitoring of all coronavirus developments.
An 18-year-old Athens Law School freshman who asked for a selfie during our meeting at a central Athens cafe did not make Mosialos uneasy. The academic is very sociable but also very careful with his words. These are precious virtues at a time when many are skeptical about the “overexposure” of doctors in public discourse and how their statements have a social impact. Citizens do have a duty to keep themselves informed, but at the same time they are desperately looking for a glimmer of hope to keep them going in these unprecedented times. “There are fewer unknowns about the virus. We are better prepared,” says Mosialos, who is waiting to see how the virus will react when it is truly up against the ropes with more and more people receiving the vaccine globally.
“The international scientific community had been expecting a pandemic for some 10 to 15 years. There were tell-tale signs. I am referring to the large-scale internal migration of populations in low- or medium-income countries, increases of populations in large cities dominated by a state of regulatory anarchy, as well as widespread coexistence of humans and animals that creates an opportunity for epidemics. The largest migrant flows are internal. We witnessed them in China and India, and it will soon also unfold in countries like Pakistan, Indonesia and Bangladesh, as well as on the African continent,” notes Mosialos, warning that “the idea that the next pandemic will take 100 years to appear must not be allowed to take root. It could happen sooner. It is necessary for the ministries of Health, Civil Protection, Agriculture and Finance to work together and develop a coordinated policy for the issues that will start cropping up, whether due to climate change, internal migration, or antibiotic resistance as a result of their overuse. The next international health crisis will be related to antibiotics. We have been using them excessively and it has left us vulnerable. We need a new generation of antibiotics to enhance our treatment capabilities. This will require collaboration between governments and the private sector to ensure adequate funding.”
When the pandemic comes to an end, whether in 2022 or slight later in 2023, will we forget the ills plaguing humanity? Human nature is at its very core optimistic, but shortsighted, grasping on to the hope that “it won’t happen to me,” Mosialos says. There are three basic steps to protect the world from a new pandemic, according to the Greek academic.
“It is worrying that 80% of new coronavirus variants have been identified in North America and Europe, with only 20% being identified in the rest of the world. This is a clear sign that the national health systems of medium- or low-incomes countries must be supported to protect the planet,” Mosialos states, pointing to the extreme difficulties faced by established and strong health systems like those in Northern Italy, the United Kingdom, and even Germany. “We need to stress-test national health systems around the world to measure their ability to respond to the changing conditions. The World Health Organization needs to take on an institutional role and assume oversight of these system evaluations.” As has been tragically proven, he adds, we did not monitor the coronavirus group of viruses. Monitoring the mutations and developments of this group of viruses and immediately evaluating the dangers as part of a wider framework of an international epidemiological monitoring system is the second thing the international community must do, according to Mosialos. “Studying virus groups, similarly to how we have flu labs all over the world, to track down mutations and develop vaccines,” is vital, he says.
The third way to support national health systems, according to the Greek academic, is allowing for the production of vaccines and drugs in a shorter time frame, from the current nine to 12 months, down to four. “This is what the European Union is moving toward with the creation of the Health Emergency Preparedness and Response Authority (HERA), which will be responsible for developing new vaccines and drugs. Also, the European Center for Disease Prevention and Control (ECDC) must be reinforced and should extend its coverage to all European countries,” he notes.
“Healthcare investments are needed and the sector must not be included in the wider financial adjustment of the eurozone,” states Mosialos, underscoring that “international credit institutions should take healthcare developments into account when making their calculations. Don’t be surprised if in the future banks and insurance companies hire doctors and healthcare specialists.”
“Greek universities, based on their positions in international university rankings, are of quality, especially if we take into account their financial situation and the difficult institutional framework they operate in, defined by its lack of flexibility,” notes Mosialos when discussing Greek higher education. He began his studies at the University of Athens’ School of Medicine before continuing them in the United Kingdom, where he now teaches.
The United Kingdom
“My university founded its Public Health Department in 2017 after an internal decision by the institution. This sort of decision, to start a new department, does not need to be approved by some regulatory authority or the British Ministry of Education. The department is self-funded, with revenues from university fees and the research projects it applies for and completes. We are not dependent on a state budget,” says Mosialos, believing that in Greece, “for example, my department would be evaluated annually for its academic achievements, its research achievements and its financial situation. These evaluations would be the basis for reorienting its decisions. Greek universities would be in a much better state if they had more flexibility, along with the necessary safeguards against instances of nepotism, party politics, and wider non-meritocratic personnel decision-making.”
At the same time, Mosialos is focused on the need to utilize the large number of Greek scientists living and working abroad. Remote teaching offers a unique opportunity. Many Greek academics would like the opportunity to teach at a university in Greece. There could be a way for Greek universities to utilize these people, he says.
“There is a Greece abroad that we often talk about but rarely do anything for it to help us. It seems that in practice we have forgotten about it,” he points out.
Changes and reforms
“I’d like it if Greece had an institution like the surgeon general. It used to, but it was abolished in the 1980s. Along with the surgeon general there would be an organization that collected data, analyzed it, ran through different scenarios, and would inform the government, its institutions and the citizens of scientific developments. The surgeon general would handle communications in a crisis like the one we face today,” Mosialos responds when asked to comment on the many overlapping scientific voices in the media. “Institutional delays contributed to the creation of many sources of information. When an institutional presence is missing in the event of a crisis like the pandemic, it can create confusion,” he stresses.
Mosialos has suggested several reforms to the Greek National Health System, from redefining the role of the relevant minister to restructuring all teaching programs across the entire health sector. Among his recommended policies for improving the Greek healthcare system, as they were laid out when he was recently conferred an honorary doctorate from the Medical School of Athens, is that the “Ministry of Health must be responsible for charting the strategy adopted by the National Health System and must monitor the ministry’s organizations, which will have to be granted greater autonomy to become more efficient. Their administrations must be selected through transparent processes, without considering party politics and only focusing on administrative efficiency and necessary skills.”
Mosialos’ suggestions have also focused on hospital staff, and he tells Kathimerini that the “hiring of doctors must be pursued with their clinical skills and knowledge primarily in mind, not their track record. Selection committees must not be dominated by local members of the system and should be broadened with the participation of esteemed clinical doctors from the wider health system.”
Reforms must also include the education of future doctors. “There must be goals, courses of study, and training across all health sectors at both an undergraduate and postgraduate level. It is necessary to establish high-quality standards when evaluating results, along with the continuous transfer of know-how and skills, both at universities and teaching hospitals,” Mosialos believes.
He also proposes that apart from funding for preventative examinations, there must be more substantial efforts to inform citizens, collect data and record results. “The cervical cancer vaccine is an indicative case. While it is free, the vaccine take-up is very low,” he observes, adding that the creation of a network of multi-specialization doctors, nurses and other healthcare staff might be necessary, with augmented technological and diagnostic abilities. “If this does not happen, doctors and nurses will simply be guiding and admitting people into hospitals,” he says.
“At the same time, in more rural areas of the country, local hospitals need to be connected with their closest teaching hospital to further improve training and the transferal of skills. On a legislative level, if there are two or three hospitals in a region, it is important that they have a unified decision-making framework and complementary functions.”
Finally, an important issue is the immediate digitization of the national health service and the creation of databases for all its activities, so all its decisions can be based on available data. There must also be a consistent strategic framework for pharmaceutical policy with an improvement of the evaluation process for biotech and with incentives for clinical trials and research investments in Greece, says Mosialos.