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EESTI ELU reedel, 16. oktoobril 2020 — Friday, October 16, 2020
Nr. 41
Auditor general: Was the coronavirus crisis too mild to inspire lessons? Janar Holm, Auditor General website Now that the new head of the Health Board Üllar Lanno has taken office, we can hope that the new captain can, in addition to addressing the COVID-19 crisis, catch the fair wind and create a robust system and preparedness for solving new healthcare emer gencies in the future. The task of proving the pandemic is real no longer falls on him. This spring’s coronavirus crisis constituted an accident we saw coming. The necessary warnings, many of which were pointed out by the board itself, were there but went unheeded. Different scenarios had been described but were ignored. Legislation was passed, while deadlines therein were allowed to come and go. Despite assurances from in stitutions that we were ready to contain a viral outbreak, Esto nia entered the crisis with preparedness that existed only on paper. Weaknesses in the healthcare system in terms of crisis readiness had been point ed out by the Government Office’s healthcare organization expert group, the National Audit Office (most recently in 2018), the Ministry of Internal Affairs and the Health Board itself. A Health Board risk analysis from seven years ago con sidered an epidemic infection situation likely and its conse quences severe. The same conclusion was drawn in the board’s 2018 risk analysis. Therefore, an extensive infec tious disease of epidemic poten tial was not unimaginable. The only thing that could have been unexpected was that it would start in early 2020. The Health Board’s analysis was accurate also in predicting that the agency would be given tasks they could not possibly hope to accomplish if a nation wide crisis broke out. A medium-sized agency most people usually do not remember exists was suddenly in charge of it all. The Health Board’s crisis regulation management struc ture and work allocation were approved in 2018. This created round the clock response capac ity. At the same time, the board pointed out in its reply to the National Audit Office that it would not be able to man the structure in the case of a protracted crisis. The Health Board’s summer of 2018 crisis analysis high lighted other alarming gaps in capacity. The document re vealed that hospitals only had enough personal protective gear stockpiles for initial reaction. There were virtually no health care stockpiles, including per sonal protective gear. Existing supplies had largely expired and their renewal was overlooked. Laboratories lacked equip
ment, reference laboratories did not exist. There was no over view of ambulance and hospital capacity, especially as concerned treating dangerous infectious diseases. Allow me to empha size that all of these assess ments came from the Health Board. The journey from having the necessary information to taking action proved too long for the state. Perhaps the prob lem was that early warning came too early. It is sometimes said that generals tend to prepare for the last war. In this case, it seems that while the “war” itself was of the future, preparations were few and far between. Repeated trainings were organized and sported strikingly realistic scenarios, but it is becoming increasingly clear that lessons were not learned. For example, an international medical exercise in Saaremaa in April of 2019 tasked the Health Board with coordinating ambu lance teams. The evaluation report points out that despite repeated reminders, the Health Board did not draw up goals in the planning phase and was not aware of its role and responsi bility during the exercise. Another interagency co operation exercise took place in September of 2019. The report reads that the Health Board’s regulatory and supportive role was missed. A recommendation was made following the exer cise for the board to have a clear picture of what type of emergency management centers are to be created and where, as well as how agencies involved in providing solutions would communicate on different levels. Also, in terms of the informa tion different management levels are in charge of and need and how it will be ensured. The problem of lack of clarity in terms of coordination and responsibility in solving health care emergencies went beyond the Health Board. We drew the attention of director general of the Health Board and the health and labor minister to the necessity of creating a crisis management structure that would clearly determine, among other aspects, division of responsibility be tween the board and the Ministry of Social Affairs in our 2018 crisis preparedness audit. While the director general approved the crisis management structure and work organization in April of 2018, it did not cover any aspects of co operation with the ministry. Our report also pointed out that the Ministry of Social Affairs’ crisis work organization directive was outdated and made it impossible to determine the ministry’s tasks in a crisis or how it would perform them, including as concerned persons responsible and exchange of information in an emergency. This lack of clarity as con cerned the roles of the board
and the ministry was visible during the crisis months in spring. Some of the aforementioned gaps in capacity and problems required money to solve, while some were purely organizational and only needed a decision or coordinated management that, nevertheless, did not follow. The Emergency Act required plans to be drawn up by July 1, 2019, while the deadline was allowed to come and go. The Health Board started work on plans in 2019 and by the time the crisis started, all they had was an informal work in progress version. That is why we did not have a functional crisis communication plan for emergencies and a resource plan for activities. Let us move on to the ques tion of stockpiles the very real fear over possible depletion of which took on cinematic proportions. Talk of Estonia lacking healthcare stockpiles to adequately react to crises has been around for years. A Govern ment Office expert group made a proposal for healthcare service providers to have supplies to last 72 hours and the state for at least two months back in 2017. The 2017 Emergency Act prescribes the creation of national operating stockpiles that would include state-owned or contract-ensured resources for solving emergencies. According to the law, the government should have approved a corresponding order by July 1, 2018. The stockpiles do not only concern medica emergencies but are necessary for weathering different crises. No such order was approved in time. The government cannot issue the order before ministers present proposals for comp liance in their administrative areas. Unfortunately, the social affairs minister had failed to sum up the needs of their domain and present proposals to the government. The Ministry of Internal Affairs had to remind the social ministry of its obligation on June 16, 2018, having read the Health Board’s risk analysis and its conclusion that Estonia basi cally lacked medical stockpiles. The reminder was of no use. There is still no government order for the creation of national stockpiles two years after the Emergency Act deadline. That said, the government has been addressing the problem of stockpiles intensively over the past months and is drawing up operational principles and app lications for a stockpiles center. We can hope for a good systemic solution. What to do? One solution would be to include broadbased national defense as a package in state budget talks and make concrete political decisions annually. We have been able to do that in our
Illustration: Gerda Märtens
Kids Corner: Virmalised (The Northern Lights) by Gerda Märtens Vincent Teetsov
absolutely necessary?
The aurora borealis. The northern lights; and all that lives and scurries around below it. It’s a cozy and excit ing setting for a picture book, with visual elements of the mid-century gouache illustra tion style that has been popu lar with children’s illustrators in 2020. In Gerda Märtens’ rendering of this style, she brushes the paint to create warm and glowing scenery for Jon, a polar bear, to share with us. Jon has left his home near the shore, because the driving rain has moved in. It pours “nagu oavarrest” (“like a bean stalk”)! His town was once a place that would bring a smile to his face, and a glimmer to his camera lens. It drew visiting bears from out-of-town. But the sun that shined brilliantly over his home in the morning has been swallowed up by a sinister sky of grey, for an undeter mined amount of time. Rain inundates his town and the snow is washed away. What is most precious to him is gone. The townsfolk dance and party inside at first, until the water floods the streets. Jon becomes physically unwell. For his safety, and to retrieve the beauty he knew before, he decides he must leave. He packs his bag, takes his camera, and travels to the Arctic circle. Two mysteries accompany him on his way: what will it be like in this new place? And what’s in that box that his vanaisa (grandpa) gave him, with specific instructions to only open it if it was
Märtens tastefully depicts the feelings of loss and disruption with this tension of the story arc, but restores hope and light by the very end. It’s a serious and sincere picture book, but one that is always eloquent and natural in its delivery.
preparation for military crises. Preparing for civilian and mili tary crises is equally important, not least because one can turn into the other should unfortu nate circumstances coincide.
This is Märtens’ debut as an author, after illustrating many other children’s books and creating editorial illustrations for publications like Täheke. She has chosen to address the theme of climate change and the challenges faced by animals in the process, which isn’t always easy to articulate while keeping focused on a com pelling narrative. Jon is be lievable. He has dreams. He has dimension. We want to stick by his side as he figures out his next steps. Virmalised is a picture book ideally suited for kids who have started reading more Estonian by themselves and are building their vocabulary and compre hension. It’s in the reading stage just before taking on an “early reader” book. Fundamentally, I think it’s positive for kids to read stories that relate obliquely to what they hear their families talk about. When family members discuss something like climate change, it must seem like a vague and troubling subject. A story like this could start to make some sense of it, but it doesn’t go out of it’s way to frighten. It’s brisk and enter taining on its own, but then it teaches us something valuable about being strong when over whelming changes happen. The texture of the brushwork and coloured pencil is what stood out first for me, and when you savour the words alongside that, it’s a strong book that you’ll come back to for repeat readings. You can find Virmali sed on rahvaraamat.ee.
