Going ‘Virtual’ In Global Health – Practices Are Changing Fast – But At An Uneven Pace    
Nurses preparing a diagnostic test for COVID-19 at a “drive-through” testing center at University of Washington Northwest Hospital & Medical Center

As the COVID-19 crisis seeps into financial markets, corporate board rooms, and global health systems, there may be one silver lining in an otherwise dark cloud.

The 21st century era of digital health, virtual meetings and teleworking is upon us.

Countries as far-flung as the Republic of Korea, Israel and even some forward-looking US health care providers are rushing to adopt tele-health, mobile health and AI solutions to protect their front-line health workers from COVID-19 infection.

Meanwhile in Geneva’s global health policy hub, institutions large and small, including Gavi, The Vaccine Alliance; The Global Fund; The International Committee of the Red Cross; and Medicines for Malaria Venture (MMV), are rapidly shifting into the virtual world of teleworking and video conferencing to keep operations going smoothly.

For others, however, change is at a slower pace, and more painfully reached.

Although the World Health Organization has long been outspoken about the benefits of telemedicine, in the case of virtual meetings and teleworking the Organization has been slower to adopt new practices, its critics say.

It’s also starting from a very low baseline. In 2018, WHO’s carbon footprint, mostly due to travel, was the second highest in the UN system, exceeded only by the World Meteorological Organization.  Its staff teleworking policies, limited to 4 days a month and subject to a paper chain of bureaucratic approvals, are among the most restrictive in the UN system.

But as COVID-19 cases explode across Europe, including in Switzerland, where the first infection of a staff member in a UN-affiliate, The World Trade Organization, was announced on Tuesday, the events on the ground are driving ever more rapid change.

After MMV reported to staff about a “probable COVID-19 case” over the weekend, all staff immediately shifted to teleworking on Monday.

In an internal message to staff on Tuesday, WHO said that to protect its headquarters operations, all external meetings would be cancelled, visitor access restricted, and a transition to virtual meetings accelerated. But the agency has so far held back on any dramatic expansion of  teleworking – saying only that current policies would now be relaxed for staff with confirmed “pre-existing medical conditions”.

Despite such hiccups, some global health influencers have dared to say that a faster shift to virtual channels could be a faint silver lining in the COVID-19 clouds.

“This *could* be the moment when we collectively finally crack videoconferencing on a mass scale, for good,” Wellcome Trust’s Director of Strategy, Ed Whiting, tweeted after the World Bank announced it would shift its annual Spring Meetings to virtual channels.

Can health policy institutions and the systems that they guide and manage use this crisis to make some leapfrog improvements in the use of digital technologies to better protect health workers and patients, slow infection transmission, and also make operations more efficient?

Here’s a rundown of scenes from a fast-changing landscape in hospitals, health clinics and head offices.

A nurse deposits a COVID-19 swab taken from a patient at a “drive-through” COVID-19 testing center at the University of Washington Northwest Hospital & Medical Center

Boosting PPE With Virtual Technologies  

Equipping health workers in countries worldwide with personal protective equipment (PPE) to protect them from the highly infectious virus has been a key priority for WHO since the new coronavirus first became a threat at ground zero, in Wuhan, China. Hundreds of thousands of PPE kits were distributed across China and rushed by WHO to countries around the world – although working in cramped, crowded conditions, health workers still often became exposed.

With just a few weeks of experience behind them, some countries, from Korea to Israel and forward-looking hospitals in the United States are experimenting with creative ways to test, triage and treat coronavirus patients while reducing those exposure risks.

Korea has received acclaim for its “drive-in” testing centers where patients can be tested with a nose swab in their cars – making the vehicle a kind of “isolation chamber” and protecting health workers as well as others waiting for similar tests.

The testing model is proving to be contagious in the United States, which invented the drive-in burger bar, after all.

The first American drive-in testing clinic was piloted at the University of Washington’s Northwest Hospital and Medical Center, a state where a large cluster of cases has emerged. Colorado, another outbreak area, soon followed suit. It opened a drive-through testing center on Wednesday. And Connecticut is now experimenting with the same approach too, reports the Science journal, The Verge.

It remains to be seen how fast the trends will be picked up by other US states, where test shortages and rigid protocols have triggered horror stories about the hurdles some people had to face, just to get tested, while also spending time emergency rooms or health clinics where others could easily be infected.

In Israel, meanwhile, people who suspect that they have the virus don’t go leave their home at all. They call a special emergency number, and a mobile unit visits to administer a swab. That has helped give Israel one of the highest testing rates in the world (401 tests/million), outside of Korea (3,692 tests/million), and Italy (826 tests/million), and Guangdong, China (2,820). It has also kept the number of infections down to about one-eighth of those in Switzerland, a country that has roughly the same number of people spread over twice the land area and is limiting its testing to severely ill patients or those with pre-existing conditions.

Health care staff interact with patients via a robot at Sheba Medical Centre.

At Sheba Medical Centre, in the city of Ramat Gan, doctors and nurses are performing basic checks on hospitalized COVID-19 patients via a robot, to reduce the threat of contagion.  One of the first patients to be hospitalized there after returning from a trip to Italy described it as a “Back to the Future” experience.

The robot can monitor lung function with a stethoscope, said Dr. Galia Barkai, head of Sheba’s Telemed Services. Added Eyal Leshem, director of Sheba’s Travel Medicine and Tropical Diseases unit, and a former scientist at the US Centres for Disease Control: “The robot moves has the capability to reduce the most fearful thing about this disease in health care facilities, which is nosocomial transmission,” Leshem said in an interview with Health Policy Watch.

Patients who are not sick enough to be hospitalized, are given a tiny handheld medical device called a Tyto to take home. It allows a medical professional to remotely check the patient’s lung function, throat, heart rate, temperature, and other vital signs, notes al Leshem, head of the hospital’s Travel and Tropical Medicine Centre.

Checking a child’s temperature at home with a remote Tyto monitor.

“We can monitor vital signs, such as temperature, and then talk with them on a secure telemedicine application,” Leshem said. “We can also save a lot of the unnecessary travel as well as contact with health care workers, which is also a source of a lot of nosocomial infections.”

On the other side of the ocean, meanwhile, the crisis may also be providing a boost to virtual delivery of more routine health care services – to keep uninfected patients away from crowded hospitals or clinics where they could catch COVID-19.

In a landmark measure approved last week by the US Congress, Medicare, the universal federal health insurance system for older Americans, will be allowed to reimburse clients living in COVID-19 outbreak areas for telehealth consultations with their regular care providers.

The decision, part of a US$8.3 billion emergency funding bill, was hailed by telehealth advocates as an important breakthrough in a country where growth in telehealth services has been constrained by Medicare rules that, until now, strictly limited telehealth service reimbursements to people in remote rural areas.

“During these types of outbreaks, you really don’t want to go where people are sick,” Rusty Hofmann, medical director of digital health care integration at Stanford University School of Medicine, told the The Verge. Although, he warned that the new provisions should be expanded further so such reimbursement is not only limited to a patient’s pre-existing health care providers.

The US administration is also said to be looking at ways to develop home-based COVID-19 testing solutions. “When we think of telemedicine and home testing, it reduces the risks, and makes it easier,” particularly for older Americans, who are among those most at risk, said Seema Verma, head of the US Medicare programme, at a televised meeting Tuesday between US President Donald Trump and major health insurance providers.

Virtual Meetings – Reducing the Footprint of COVID-19 & Carbon Emissions  

When the World Bank announced on March 4 that it would put its annual Spring Meetings, which draw tens of thousands of people to Washington DC every year, on a virtual footing, Whiting in a Tweet filled with emojis of airplanes and trees, said “Bring it. Interested how tech steps up.”

On it came. Just two days later, Friday 6 March, the Secretariat of the United Nations Framework Convention on Climate Change (UNFCC) cancelled its planned March-April rounds of negotiations in Bonn. In Geneva, parallel sessions and side events around the annual UN Human Rights Council meeting, which would normally draw hundreds of people to the city, were also cancelled. And Swiss authorities announced that they would also forbid any mass gatherings of more than 1000 people throughout the country.

Despite the ominous signs, in a WHO press briefing on the same Friday, WHO Director General Dr Tedros Adhanom Ghebreyesus refused to speculate about whether the world’s signature global health event, The World Health Assembly might have to shift to a virtual footing if it convenes at the scheduled dates in late May.

He said that virtual meetings should be encouraged to reduce costs and climate emissions, but decisions “should be made not because of COVID now, but when there is no COVID as well.”

Against the mounting tide of Swiss COVID-19 cases, which on Thursday stood at 868 cases and four deaths, a new order by Swiss authorities limiting meetings to under 100 participants seems likely to dramatically change the shape of how the WHO does business in the coming months.

In the internal memo sent out to WHO staff Tuesday evening, a rapid scale-up of virtual meetings was promised to offset the cancellation of all meetings at Headquarters with external experts and partners.

“To support these changes in our ways of working, steps have been taken to increase our bandwidth to accommodate the expected increase in virtual meetings,” said the note to all WHO Headquarters staff.  “In order for the Organization to fully implement virtual solutions, additional support in setting up virtual meetings and relevant training will be provided.”

Some WHO insiders, who have been pressing for years for such changes, see it as none too soon.

With 13.7 tons of CO2-equivalent emissions (tCO2-eq) per capita, WHO’s carbon footprint is the second largest across some 50 UN agencies and affiliates, exceeded only by the WMO footprint (16.4 tCO2-eq) per capita, according to the 2019 report of the UN Greening the Blue initiative.

Some 90% of WHO’s carbon emissions  or 12.64 (tCO2-eq) was attributable to air travel in 2018 – a more than 50% increase over emissions from the year before, of just 8 (tCO2-eq), WHO’s own emissions inventory available on the Greening The Blue website.

There are strong arguments that periodic face-to-face meetings are critical to build trust and facilitate collaboration between professionals from vastly different countries and institutional cultures. But critics say WHO has lagged for years on investments in stronger videoconference facilities that would save costs and carbon – and this will jump start the process.

“It’s true that you can’t have hallway discussions, that is correct,” said one WHO scientist, who asked to remain anonymous. “But how much do hallway discussions contribute in comparison to the damage that you are doing to the climate?

“In the 1960s, when telephones were first installed in homes, they were put high up on the wall. You could only talk standing up, and that meant passing on a short message. Today,  we have a completely different attitude towards the phone. So, I think it is for the most part it’s an attitude problem.”

Teleworking   

Teleworking is another area in which attitudes are now changing rapidly.

Staff at The Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi-the Vaccine Alliance, the two giant public-private partnerships founded two decades ago by the Bill and Melinda Gates Foundation, have been teleworking one or two days a week for some years already.

As the COVID-19 outbreak began to amplify, The Global Fund administration asked its IT consultants to build a scenario in which all staff would be teleworking. Today, after weeks of trial runs at team level, an organization-wide drill of teleworking procedures will be conducted, said Melanie Brooks, Editorial Team Manager.

“Technology is increasingly playing a part in our ability to work effectively in the building. We are providing regular guidance to staff for teleworking, including Q&As, tips for effective working from home, and training on our remote-working teleconferencing system,” said Brooks.

To ensure our organizational readiness to be able to react to the developing COVID-19 coronavirus situation, this Thursday morning, 12 March, we are undertaking an organization-wide trial of our home-working capabilities. All staff, consultants and interns are required to work normally, but from home, before coming back to the office for the afternoon, from 13.00. Following the successful testing of our offsite working… last week, this Thursday’s exercise will enable us to more fully assess both our system and individual capacity to work effectively from home.”

Gavi, The Vaccine Alliance, which shares The Global Fund campus, right down the street from WHO, has a less formalized teleworking policy, said spokeswoman Frederique Tissandier. But the overall result is almost the same. Already for the past several weeks, employees have been instructed to back up, and take home their laptop computers…. Just in case.

“The approach is to be mindful of our colleagues and the campus. If someone suspects that they are ill, he is free to stay home, to go home, to work from home and quarantine himself automatically and there will be no questions asked,” she said.

Regular teleworking options have been “standard policy,” at MMV for some time, added Dr David Reddy, MMV’s CEO, whose offices are located in a busy hotel complex near Geneva Airport. On Monday, following a report of a “probable case” among a staff member, MMV shifted to a mandatory teleworking protocol for everyone.

“As part of our COVID-19 preparedness plans that we put into place two weeks ago, we then determined two probable scenarios that would lead to flex in that policy,” he said. “First, in a bid to reduce possible transmission, those employees who wished to do so, could work from home full-time for the immediate future.  Second, as the situation evolved with a probable case among our team over the weekend, we implemented mandatory working from home as of Monday.”

Back at WHO, however, teleworking remains limited to 4 days a month. In order to have a request approved, a staff member has to print out a hard copy form, fill it out and have it signed by a supervisor, then scan it, and then send it to half a dozen other emails – in advance of the planned teleworking days.

WHO’s Staff Association has long complained that WHO’s practice is out of line with broader UN policies on Flexible Working Arrangements, which allows teleworking for up to two days a week, in line with two  UN General Assembly member state resolutions supporting a more  “flexible workforce.”

When Dr. Tedros took the helm of the organization in 2017, WHO’s Staff Association attempted to gain his support for a more flexible policy, arguing among others things, it would “help business continuity in case of a pandemic or natural disaster and enable the workforce to work from outside the premises,” according a message shared by multiple WHO staff, who requested confidentiality.  

A 2019 WHO Staff Association message to the WHO Executive Board publicly called for the standard UN policies to replace the existing WHO provisions. But it was never adopted.

On Tuesday, WHO announced more flexibility for with “pre-existing medical conditions” to request broader teleworking privileges for a time-limited period, through the Staff Health and Wellness Services.

“Medical evidence, which will remain fully confidential, will need to be subsequently provided in support of these measures. The recommended duration of teleworking will be determined on the basis of the evolving epidemiological situation and risk in the community,” stated the message. The announcement hinted that more changes might be on the horizon, but didn’t say what:  “Additional general guidance on teleworking arrangements will be issued in the next update.”

Current policies, staff complain, are contradictory with WHO’s Global Influenza’s Programme Guidelines on pandemic and epidemic influenza measures that company’s can take. Those guidelines recommend the adoption of telecommuting and staggered hours saying that it was associated with a median 23% percent reduction in infection incidence – although the recommendation is framed as “conditional” due to the dearth of controlled bio-medical studies

Now that theory has become reality, staff are worried that the current policy makes it almost impossible for them to use teleworking measures to work from home preemptively, in case they feel just a bit ill, or have returned recently from travel. And that forces them to face a hard choice – take a sick day or go to work and risk infecting others. Older staff, who may be healthy but still at risk, due to their age, are also exposed.

Said one senior staff member, who asked not to be named: “We still have a teleworking policy that requires a physical signature. So  if I do decide I have a cold or want to stay home, I still have to go to the office, print out the form, fill out the form, get it signed, and send it to 7 people, and spread the virus in the meanwhile. Or I stay home, and then I waste a vacation day, or I waste public health resources going to a doctor, saying I need a sick certificate.

“I know there are efforts ongoing in WHO to make us technically fit for teleworking. My guess is that they will start an up-to-date and public health appropriate teleworking policy, when either the Swiss government requires it, or when we have proof of WHO inter-office transmission – and then the baby will have already fallen out of the bath.”

Updated 12 March 2020

Image Credits: University of Washington Northwest Hospital & Medical Center, TytoCare , https://www.greeningtheblue.org/.