Mariusz Gujski, Dean of the Faculty of Health Sciences of the Medical University of Warsaw and Dr. Paweł Żuk, President of the CMD Management Board: What’s Next With the Epidemic?

<br>Mariusz Gujski, Dean of the Faculty of Health Sciences of the Medical University of Warsaw and Dr. Paweł Żuk, President of the CMD Management Board: What’s Next With the Epidemic?
The COVID-19 mortality rate is low compared to the SARS or MERS pandemic. Why was the world closed this time?

dr. hab. Mariusz Gujski Dean of the Faculty of Health Sciences, WUM: It should be noted that the mortality rate is different in each age group. It is most dependent on age and comorbidities (e.g. in the 80+ group it reaches a dozen or so percent, in the 30-40 group 0.4%, in the group under 30 years of age we talk about per mille), but mortality is also influenced by the efficiency and standard of the system health care in a given population. Poland does not do well in this category, hence a great deal of concern that the system does not collapse. On the other hand, COVID-19 cannot be viewed only through the prism of mortality, but the severe course of the disease and the possibility of complications must be taken into account. It is easy to paralyze the health care system, which is already ineffective at this point.

Despite the insignificant percentage of deaths of young people, we are dealing with the tragedies of many families in which young people suffer from COVID-19 very hard or the disease ends in death. One of the problems with COVID-19 is the unpredictability of the disease.

In a situation where the risk of dying from COVID-19 is greatest in the elderly and the sick, wouldn’t it be best to focus on protecting and isolating people in this age group?

MG: I am close to the Swedish model. Improving the isolation of senior citizens in spring of 2020 would have been a good solution. Considering the economy as an element on which the health of the population depends, I believe that the price we are paying for excluding some industries from economic activity is too high.

On the other hand, there are children who are not particularly at risk and who remain locked in their homes at a crucial moment in their development. Why are young people not allowed to live normally?

MG: The answer is the Polish family model. Pre-school and early school-age children often live in households with their grandparents. This isolation results from care for seniors, while at the same time children lose out in terms of proper psychological and social development.

The current lockdown policy is having dramatic public health implications. How would you comment on the fact that people quit testing out of fear of the virus, do not use specialist advice, and at the same time their mental health deteriorates?

MG: The pandemic, apart from the fact that it forces changes in our functioning, also has a significant impact on people who suffer from other diseases, both sudden and chronic diseases. In 2020, we observed a significant deterioration in the condition of patients presenting with a heart attack and stroke. Patients were delayed in reaching their doctor, especially in the first phase of the pandemic. This was caused by the delay of patients, fearing the risk of contracting the SARS-CoV-2 coronavirus, but also paralysis of the health care system. Over the past year, we have faced a complete collapse of the system at least twice. For the same reasons, the standard of treatment of chronically ill patients also deteriorated. Undoubtedly, large groups of patients do not receive the help they would have received in 2019.

Quarantine also affects our overall condition and the body’s immunity – the lack of contact with fresh air, sun, and lack of exercise make the body less able to cope with any infection. Why is our immune system sacrificed and our health in the long term?

MG: When it comes to the health aspects, isolation has two consequences. Our mental health is certainly suffering because people are not used to forced loneliness. There are different responses to isolation and loneliness forced by pandemic – for example, depression or anxiety. Many sections of society have also suffered from loss of source of income, experiencing layoffs or being forced to shut down due to a pandemic. In such situations, we deal with very strong stress factors that affect our mental condition. Another problem is the limitations in the field of physical activity, i.e. closing the gym, which is not understandable to me. Unfortunately, in this way, what we have been building for many years – the habits of Poles to everyday physical activity, is ruining.

In times of pandemic, resilience issues are particularly raised. How can we strengthen it and how should coronavirus survivors look after themselves?

dr. Paweł Żuk, Chairman of the Board CMD: When it comes to immunity, our recommendations rely on balance. A balanced diet, physical activity and mental well-being build our immunity and each disorder of these aspects affects us. There are also new things appearing all the time, important for the general condition, which were not previously emphasized and were noticed during the epidemic. It is vitamin D3 supplementation and the issue of physical and mental well-being, i.e. the ability to cope with stress and depressive behaviors, which is quite difficult in an epidemic. For those who have had COVID-19, it is a complex process and we are constantly learning to care for these patients. This is a group of patients who have an extended recovery period and it is based on patients having disorders in several different zones. It is mainly limited exercise tolerance and issues of psychosomatic disorders, i.e. problems with concentration and depressed mood. These people are often breathlessness, but this has no bearing on their heart function, which is good news. The solution for these patients is constant and regular physical activity, which has a positive effect on both the physical and mental zones.

There are many negative effects of a pandemic. If we could go back, what decisions do you think we should change?

MG: Most of the first decisions at the beginning of March regarding the closure of the country were justified by the fact that we knew little about the virus. Today we know him much better and we can behave more rationally. However, I do not understand many, in my opinion, arbitrary decisions regarding the closure of individual industries. At the same time, I would like to emphasize that the health care system in Poland has been underfunded for many years and is on the verge of efficiency. Given this, these extreme decisions can be understood in some way.

We all hope vaccinations will bring the world back to normal soon. However, we hear about coronavirus mutations all the time. Will the vaccine protect us from them?

MG: On the one hand, the mutations of the virus do not surprise us. Viruses generally mutate in such a way that they are more infectious but less severe for the patient, or they become less infectious but the course of the disease is more severe. I think the pandemic will end when the virus starts mutating in a less dangerous side to humans, as it has always been in history. When it comes to the vaccine, based on the current knowledge on this subject, we have a very good chance that it will, in a significant part, protect us against new mutations of the SARS-CoV-2 coronavirus.

Why is outpatient treatment most important to the efficient functioning of the healthcare system?

PŻ: The importance of outpatient care results from the basic assumptions that solving health problems should take place at the lowest possible level of health care. In the outpatient clinic, the patient should obtain information on how to maintain their health condition and be able to undergo preventive examinations, which significantly reduce the costs of the system functioning. If diseases are detected at an early stage, we avoid very high systemic costs that are generated at a later stage, for example in oncology, cardiovascular and metabolic diseases. Importantly, a chronically ill patient should be constantly monitored and have support in disease management. When an emergency occurs, it is alleviated in the hospital, but without adequate support, which only outpatient care can provide, it is certain that the patient will be returned to the hospital. Another aspect is the number of services provided, i.e. contacts with medical professionals. According to data from 2018, primary care in Poland recorded 168 million visits throughout the year, 108 million in outpatient care, and 8.5 million in hospitals. This is a clear difference in the number of services, which shows how often we use primary and outpatient care and how often we are referred to hospital.

Recent events have been a test for the health care system. What conclusions can we draw and what reforms are necessary to improve the Polish system and prepare it for the possible emergence of further crises in a pandemic?

PŻ: The pandemic has shown us that implementing health services within a well-prepared plan is the best solution in a difficult situation. If we have a well-prepared patient record, or so-called stratification, the management of patient groups is much easier. During the course of an epidemic, infectivity issues become most important, but it must not be forgotten that other diseases continue to function. The Polish system lacks health indicators at the outpatient and hospital levels. From the level of coordinated care, it is very important to measure the effects of work, which in Polish medicine is not mentally permitted by employees. We focus on single cases and heroic stories, forgetting about neglected systems. We have to learn to deal with the situation in a systemic way, that is, checking the results and setting work goals. The excess mortality in Poland, which we have observed since the last year, is related to the lack of continuity of care in chronic diseases. Most health care facilities have been closed in Poland and many services are carried out remotely, which in some way saved the functioning of the system in the first period of the pandemic. When we did not know the disease, we were surrounded by widespread fear and the health service was exposed to infections, these services were necessary. However, at this point, we can see that the lack of care in recent months has increased the excess mortality of chronically ill patients, who are the main victims of the epidemic at this point.

The digital transformation of the Polish healthcare system is accelerating and is promising. What are the assumptions of this process and how do you assess its impact on the entire area of ​​healthcare?

PŻ: In the digital transformation of the Polish health care system, the most important are changes in the flow of information about the patient related to critical health parameters, such as diseases or medications. If all this information was in one place, we would eliminate a huge amount of errors, significantly speed up the information gathering process and improve the quality of healthcare. In the long run, this will force a change of the subject, as the work with the patient will become visible, which will ensure transparency in the system. However, digitization is associated with certain limitations – medical documentation, i.e. an individual patient’s account, is difficult to implement, because many people must first notice the need to use it. Here it is very important not to stop the transformation process. We must promote such solutions and, secondly, keep the patient in possession of such an account. On the other hand, Poland is definitely accelerating towards digitization, which is optimistic. It is worth mentioning the e-prescription, the implementation of which is a great success. In a short time, we have achieved almost 100% electronic prescription, which, for example, our neighbors have been struggling with for several years. Telemedicine services have also grown in importance. Previously, patients often feared a situation in which they would not provide all the necessary information about their health. The pandemic has reversed this thinking and telemedicine is appreciated. These solutions should also be incorporated into the overall system and thus support the care of chronically ill patients. Telemedicine also plays an important role in consultations between medical units, which allows to shorten the flow of information about the patient, and an ideal solution would be to combine the telemedicine platform with access to critical patient data.

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