Craniofacial Surgeons in Different Settings Facing the COVID-19 Pandemic

To the Editor: As the COVID-19 pandemic continues to spread and impact life globally, with a profound impact on healthcare system at all levels including surgical practices with suspension of nonemergent consultations and procedures and a potential high risk of infection during manipulation of oral and nasal mucosal surfaces. Critical recommendations could assist craniofacial surgeons in decision making during this ongoing COVID-19 outbreak.^1,2 However, the overall impact on government, healthcare system, workforce, and citizens vary among countries.^3,4 The authors explore their recent interaction as craniofacial surgery fellow and supervisor in Taiwan to illustrate how this unprecedented global health crisis can drive future change.

The first author finished a long-term international craniofacial surgery fellowship in Taiwan (Chang Gung Craniofacial Center) under the supervision of the 2nd author and returned to Brazil just a few weeks before the beginning of the COVID-19 outbreak in China. Curiously, the fellow's reflection on this pandemic era revealed that the fellowship period was not only a scientifically productive year^5,6 but was also marked by sociocultural differences. The regular wearing of masks in public places (a practice that the fellow had previously only seen on TV shows set in Asian countries) became a reality in the fellow's daily life. The fellow was fascinated by this year-round mask-wearing habit, which is widespread in Taiwanese society, but the full importance of this attitude of social responsibility was only understood by the fellow when COVID-19 reached Brazil. Unlike in-time surgical learning at the individual level, this was a case of delayed learning from Taiwan that was only fully realized due to the “potentially lethal nightmare” of the pandemic. It is hoped that this delay will not be repeated at the government and society levels.

Historically, Brazil has faced neglected tropical diseases.⁷ Despite the government's investment in well-known sanitation and hygiene policies (eg, vector-control efforts against dengue), these are not thoroughly implemented across the entire population, and preventable infection-related causes of disability and premature death remain an important issue to be solved.⁷ As with many other countries, the Brazilian government is now struggling with how to effectively convey to more than 210 million citizens the necessity of nonpharmaceutical interventions (eg, personal hygiene and other social-distancing measures) to mitigate human-to-human dissemination. The week-by-week data showed that many community members did not adhere to this public health policy,³ reflecting in some way the historical dilemma of neglected infections⁷ and signaling that much work is still needed at government and society levels to avoid an imminent health system collapse.

Taiwan has been widely recognized for its achievements in dealing with this pandemic, accomplishments which are particularly striking given Taiwan's proximity to China. Taiwan adopted lessons learned from the SARS epidemic in 2003 (eg, the critical-point for instituting mask-wearing in public) to proactively and quickly implement policies (ie, a flexible command structure, a comprehensive epidemic prevention strategy, integrated medical big data, and practical information disclosure) that resulted in effective curbing of coronavirus spread.⁴ Other countries, including Brazil, must learn from Taiwan's model⁴ as new outbreaks of unknown diseases are an ongoing risk.^8,9 It is of paramount importance to think beyond the ongoing pandemic and to act now not only to overcome the current challenge but also to develop the necessary knowledge and actions that will enable timely action against future pandemics.

The actual political, economic, and sociocultural impact of COVID-19 remains uncertain, but it is historically justifiable⁸ to take advantage of this devastating global moment to set up action plans at many levels of society, from managerial macro-allocative decisions to primary school education. For example, children who are suffering from this stressful, life-limiting situation may be better prepared to learn at school about hygiene measures (ie, hand-washing and mask-wearing)¹⁰ and the potential impact of their activities and engagement in facing the unexpected emergence of new infectious outbreaks. This may in turn promote a “domino effect” as this knowledge is brought back to the parents and can spread through society at large, possibly persisting into future generations; the potential impact on the healthcare provision would also be satisfactory. The evidence is clear^8,9 and a successful example exists⁴; we must act now.