I am a doctor in a small, remote hospital with a predominantly Aboriginal patient load. My colleagues and I know we are facing an unprecedented disaster when Covid-19 takes hold in our area, as it seems it must inevitably do.

Our patients are already among the sickest in the world. They suffer from diabetes, heart disease, obesity and hypertension more severely and at a younger age than any other group anywhere. The rates of kidney and respiratory disease are sky-high. We see sepsis on a daily basis. We see people dying of preventable disease in their 30s, 40s and 50s. I have been a doctor for over 30 years. I have worked all over the world. These patients are the most ill I have ever looked after.

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When Covid-19 hits, we are expecting very high death rates among our vulnerable Aboriginal patients, and there are a lot of them. In the 2009 swine flu pandemic, Indigenous Australians made up 11% of all cases and had a six-fold higher death rate than non-Indigenous Australians. We already know that for Covid-19 older age and pre-existing illnesses are strongly associated with an increased death rate, but that is going to be far from the whole story. Widespread house-sharing in overcrowded houses means infection will spread like wildfire, and a significant minority of our patients are already reluctant consumers of healthcare, who only turn up to the hospital when they are very ill. As soon as they start to feel better, they often leave before treatment is completed, only to come back when they get ill again a short time later. Trying to keep some of our Covid-19-infected, ill patients in isolation in hospital or in reliable self-quarantine in the community is simply not going to be possible. And while the judicial power may exist to detain people who pose a risk to public health, neither the resources, nor the political will exist to do so.

The lack of staff would eventually mean the hospital would have to close entirely and the population left to fend for itself

Our hospital is very remote, linked to our referral hospitals only by the lifeline of our aeromedical provider. We will not be able to transport our Covid-19-infected patients to the referral hospital. There will be too many of them. Besides, the logistics of infection control for the aircraft make it almost impossible to transfer on any meaningful scale. That means we will need to ventilate them and then keep them, which we have neither the staff, nor the facilities, to do. Critically ill patients with Covid-19 who require assisted ventilation mostly suffer from a condition called Acute Respiratory Distress Syndrome (ARDS), for which the median ventilation period is 9.5 days.

No one knows how bad it could really get, but in Northern Italy around 10% of all Covid-19-positives are needing intensive care. If only 20% of our catchment gets infected over a three-month period, and if 10% of those infected need ventilation (an improbably low percentage, given the ill-health of our population), then we would still need to ventilate six new people every day. At best – which means with a full complement of staff working flat out – we think we can probably ventilate three or four people at any one time.



But it gets much worse. The hospital has just one negative pressure infection control room. Elsewhere in the hospital it will be almost impossible to segregate infected patients. The hospital is going to become a giant petri dish for infection, just as the Diamond Princess did. And then there is the issue of the personal protective equipment (PPE). The PPE we are being asked to use does not cover our necks or hair. Goggles are too small. There are no boots. There are not enough of the higher level N95 face masks. There are not enough theatre scrubs for all staff to wear. There are not enough clean facilities for us to don and doff the PPE and to ensure disinfection. Our PPE stocks for the hospital are currently sufficient for just five weeks of normal use, a fraction of what will be needed. We all know, doctors and nurses, that if we work, we will get infected. We also know that, as for our patients, there will be no ventilators for us if we require them and there will be no evacuation.

The medical and nursing pool of staff in this hospital is tiny and our remoteness means that no other help can easily be brought in. And who would want to come anyway? We can just about meet current demand most of the time, though both medical and nursing rosters are always stretched. When the epidemic hits, many staff will be quarantined early, many will get ill, some of whom will die, and many, for very understandable reasons, will simply choose not to come to work at all.

At a time of unprecedented demand, therefore, the human resources required to meet it, which would be inadequate at full strength, could be cut to a half, a third or even less. Our emergency department and wards would then be full of people we can’t treat effectively or evacuate and before long we would be turning patients away at the door to go home and die. The apocalyptic, but credible, scenario is that the lack of staff would eventually mean the hospital would have to close entirely and the population left to fend for itself.

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This is far beyond just a medical problem. This is a full-scale civil defence emergency. Western Australia and the Northern Territory have now released their pandemic plans, and yet we on the frontline are seeing no overall strategic thinking, little understanding of the need to physically segregate Covid-19-positive patients, and little understanding of the implications of our remoteness and the need to isolate vulnerable Aboriginal communities to keep the disease out.

After a late start, the Chinese have got their act together and have done a phenomenal job in all aspects of the epidemic, from contact-tracing and screening, to running huge numbers of patients on assisted ventilation and ECMO. Survival rates in China have been surprisingly good and new cases are now falling rapidly. It’s the ruthless top-down command and control, which unfortunately makes the Chinese regime so unpalatable, combined with the massive resources at its disposal, which allows it to deliver huge infrastructure projects with unbelievable speed and efficiency.

Meanwhile, here in this remote corner of Australia, we dig trenches and fill sandbags in the “phoney war”, that time of eerie silence when everything looks and feels as it always has, but the prescient know that mayhem looms just around the corner.

• The author is a hospital doctor in a remote Australian community