COVID-19, palliative care and public health

1. Introduction The lack of integration between public health approaches and clinical care is a challenge for the majority of health systems globally. This became strikingly evident in the context of coronavirus disease 2019 (COVID-19), in which most cancer treatment centres struggled to meet their concurrent responsibilities to protect patients and staff, to prevent community spread, to deliver cancer care and to ensure access to acute care and to palliative and end-of-life care. Although the organisational structure, preparation and agility of some centres to respond to the challenges of the pandemic has been impressive [1], the absence of an integrated framework for coordination and decision-making across public health and clinical medicine often limited the flexibility and capacity to respond to the COVID-19 pandemic [2]. Paradoxically, the collapse of boundaries between the domains of public health and clinical medicine in this ‘war on two fronts’ [3] has created a unique opportunity for intersectoral collaboration and planning. Building upon this momentum holds the possibility of greater success from efforts to narrow the gap between these two domains, as well as between palliative care and both mainstream medicine and public health. The challenges of integration are not unique to oncology, but the organisation of cancer care and its linkages to palliative care and to global health may allow it to be a demonstration model for how the problem of integration can be addressed. 2. The silos of clinical medicine and public health Societal factors and the effectiveness of public health measures importantly frame the nature and prevalence of disease, although the compartmentalisation of medical practice and public health has often obscured this connection. Integrated care within oncology and palliative care would include a balance of attention to the disease, the person and the social context [4], just as the widened scope of public health now embraces the physical, biological and social sciences to achieve ‘health for all’ [5]. Despite the common aims, however, palliative care has often been relegated to the margins of mainstream medicine and public health [6]. The severe symptom burden, social isolation and solitary deaths of those with severe COVID-19 infections have been a dramatic reminder of its importance and that of human connection in the context of advanced disease. Before the pandemic, the large majority of those in need of palliative care in low- and middle-income countries (LMICs) and the poor or marginalised in high-income countries were denied access [7]. This inequity in access to palliative care has been highlighted with cancer because of the growing prevalence of this disease in LMICs and of deaths related to it [8]. It has been amplified by the pandemic, as individuals in impoverished and population-dense settings with weak health systems and vulnerable groups, such as the homeless, migrants, the elderly and psychiatrically ill, are more likely to become infected, to have less access to food, medical care and means of communication and to die as a result of COVID-19 infection [9e12]. These vulnerable groups are also most likely to be affected by the economic consequences of the pandemic on their physical and mental health and risk of suicide [13]. Such inequities deserve attention, not only by government and financial institutions but also by decision makers in health care.