Covid before cancer. Or maybe not.

The Northern Ireland Health minister was interviewed on the BBC here.  After first saying that he didn’t want anyone in the health service to be put in a position of making ethical decisions to deny essential medical treatment the interviewer told him that the Chief Executive of the Belfast Health Service Trust has said that they are already being made, and are life and death decisions.  Does Swann deny this or say he will investigate?  No.  He immediately and without hesitation attempts to justify something he said he didn’t want to happen, as if it hadn’t been happening.

He says that these decisions have to be made – “the ethical decision is could we turn a Covid patient away?  The answer is no.”  For other patients, “sorry your operation, your scope your diagnosis is going to have to be put off.”

When it is put to him that what he is saying is that a Covid patient won’t be turned away but that the result of this is that a cancer patient may die his answer is “yes, that’s as black and white as it is.”

So how is this ‘black and white’?  There has been no medical assessment provided that this blanket prioritisation is justified, in fact it is presented as if its justification is self-evident, an obvious ethical decision.  Except it’s not obvious and it is without justification, in both senses of that term – it has not been justified and any attempt to justify it would be wrong.

Swann says that we ‘cannot turn a Covid patient away’ but we already know that while over 50,000 people in the UK and over 3,000 in Ireland have died with Covid it is not at all clear how many of these have died of Covid.  So how can this particular disease be prioritised?

More people die of cancer than Covid-19.  There are around 165,000 deaths from cancer in the UK – that’s every year.  In 2018 over 4,000 people died of cancer in Northern Ireland.  In the Irish state over 9,000 die every year.

It cannot be because of the severity of the disease: cancer kills cancer patients because of their condition, while for most sufferers of Covid the disease is so mild they may not even know that they have had it.   If someone with Covid has a serious underlying condition making them vulnerable to death compared to a relatively healthy person with the same disease, what is it that makes the difference between survival and death?  Covid may be the proximate cause of death but Covid may not be the underlying condition without which death would not occur. If this is not considered an important distinction then presumably the health service and whole swathes of the economy will close down during the next flu season. A report from the Health Information Quality and Quality Authority shows that not all ‘Covid deaths’ should really be counted as such (see below).*

There is little that can be done to avoid many cancers; even those who don’t smoke, eat healthily and exercise fall prey to it.  Hospital treatment is necessary but can sometimes require less serious intervention if caught earlier, although this is precisely what is being deprioritised. Those most vulnerable to Covid on the other hand can take many of the measures we have all become accustomed to including social distancing etc.  The most vulnerable received shielding letters informing them of their vulnerability and measures they might want to take to limit exposure to infection.  Swann and his chief medical advisor have decided that these letters aren’t necessary this time but provided no real explanation why.  What has changed from the first lockdown?

Why is the protection of those most likely to suffer fatalities from Covid not the major focus of protection, support and prevention from these political leaders and bureaucrats?  Is it not really that, what both measures have in common – prioritisation of Covid patients within hospital and lack of focus on those most vulnerable – and what is being protected, as they have made clear repeatedly, is the NHS?   Protected from doing a job they know it will fail? And by their association, responsibility and accountability for it, protection of themselves?

The NHS in the North of Ireland is the worst in the UK.  There are, for example, more than 2,500 nursing vacancies.  As I have said before, Covid-19 may overwhelm the resources of the health service but is in itself not overwhelming.  It is only so because the NHS is already in crisis, and what we are asked to do is also to accept that we must collude in covering up this permanent crisis, including through regular speeches telling us how difficult it has been for the staff.

This message is all the more powerful, and successful, because it is largely true – many health service staff have been under enormous strain but this should not be an alibi for failure of the bureaucracy that is the NHS as an organisation.  As I have said before, the demand to protect the NHS, when it is supposed to be there to protect us, is an admission that this responsibility of the NHS will not be met.

The unjustified blanket prioritisation of Covid patients in hospital and the failure to issue shielding letters to the vulnerable are political decisions and have been successful because of a political campaign to justify lockdowns.  This has involved not only politicians but also senior health figures, who have given legitimacy to their decisions.  One such figure has been Gabriel Scally who has regularly intervened to argue that policies in the North and the South should be the same, as if two wrongs make a right.  He has stated that ‘the figures speak for themselves’ when it is well know that they don’t, and has stated that over 50,000 have died of the disease without recognition that dying with it is not the same as dying of it.  That such basic errors are repeated by a respected public health doctor illustrates the scope of the group think that has developed.

So egregious was the Health minister’s statement that the Department of Health put out a tweet entitled ‘Myth Buster’ with ‘myth number 1′ being “are Covid-19 patients being prioritised over other patients?” To which the answer was “No, they are not.  Patients are treated according to clinical priority.” Swann pitched in with “it is untrue and offensive for anyone to accuse frontline staff of prioritising one condition over another.”

Since it was Swann who said that prioritising was ‘black and white’ perhaps it is himself he is referring to as being offensive.  So who is right – the Department or the minister, and which version of the minister?

It would be difficult to deny that senior health staff would not be so stupid to as to admit such crass medical practice but easy to understand how Stormont politicians could grandstand with this level of idiocy and ineptitude.

The real problem is not that some politician has instructed hospital doctors to relegate individual cancer patients in order to prioritise Covid patients but that this is what has and will continue to happen by political decisions on allocation of resources that constrain individual medical assessments.  These individual decisions rely on higher level decisions on allocation of staff, wards and beds to deal with Covid that in the first wave witnessed empty Covid beds in the Nightingale hospital while other treatments were stopped.

Lockdown is a political decision involving an analysis not only of the disease but the potential impact of the response.  It is not a question of medical expertise determining the correct approach, even if one were naïve enough to believe that the medical profession is a paragon of virtue and wisdom.  The advocates of lockdown refer regularly to the number of cases, hospitalisation cases, numbers in ICU and deaths but rarely to the costs incurred by lockdown.  To do so would invite a critical debate they are ill prepared to have.  Swann’s mistake was to take soundbites to their logical conclusion and blurt it out.  It denotes the logic of the current approach but too crudely expresses its effects.

It is tempting to see in Swann’s first statement the chaos and breakdown of the functioning of the Stormont Executive that because of its reaction to the pandemic was seen for a while as an example of the political arrangements working.  No one is pretending they’re working now. However, the real political weakness lies not in the political primitiveness of Stormont but that such crass political interventions elicit no popular opposition. Unfortunately on this score looking for the left to offer one would be a complete waste of time, as we shall look at in the next post.

* HIQA: ‘The officially reported COVID-19 deaths may overestimate the true burden of excess mortality specifically caused by COVID-19. This may be due to the likely inclusion within official COVID-19 figures of people who were known to be infected with SARS-CoV-2 (coronavirus) at the time of death who were at or close to end-of–life independently of COVID-19 or whose cause of death may have been predominantly due to other factors.’

https://www.hiqa.ie/sites/default/files/2020-07/Analysis-of-excess-all-cause-mortality-in-Ireland-during-the-COVID-19-epidemic_0.pdf

 

 

Covid-19 – the random killer?

In a recent opinion column in ‘The Irish Times’ the writer asserted that the virus ‘has always killed randomly’, proving the old adage that opinions are like arseholes – everyone’s got one.  In fact, of course, Covid-19 doesn’t kill randomly and the fact that it doesn’t should be the starting point for understanding not only its effects but also how it should be dealt with.  And so, in many cases, it has.

For example, in this article in Nature Medicine the writers state in relation to the first wave that ‘in absolute terms, the total mortality toll of the pandemic was overwhelmingly in those aged 65 years and older, who experienced 94% of all excess deaths. In relative terms, older people were also affected more, with mortality in these ages being ~40% higher than it would have been in the absence of the pandemic in Spain and England and Wales and ~30% higher in Belgium, Scotland and Italy. The largest effect on those younger than 65 years was in England and Wales—26% (20–32%) for males and 22% (17–28%) for females—followed by Scotland, Spain, Sweden and Italy.’ 

It goes on to state that ‘the fourth group of countries, which experienced the highest mortality toll, consists of Belgium, Italy, Scotland, Spain and England and Wales’, which confounds the political spin that the Scottish Government did a good job.

‘The spread of infection within and between hospitals and care homes, and between them and the community, is itself an important determinant of infections and deaths in both the vulnerable groups and the general population. Where infection rates were high and care homes were not appropriately safeguarded—namely in Spain, the United Kingdom, Belgium, Italy, France and Sweden—a large number of care home residents died from confirmed or probable COVID-19. The initial seeding through discharge of infected patients to care homes was compounded by lack of testing and protective equipment for staff and residents and, especially in privately run care homes, regular movement of (temporary) staff across facilities.’

In the Irish state 93 per cent of fatalities have had an underlying condition according to the Central Statistics Office, with a median age of 83.  The most common underlying condition of those who died was chronic heart disease but the relevant conditions also included kidney, liver and neurological disease as well as cancer and diabetes.  In the North people aged 75 and over accounted for 78 per cent of Covid-19 related deaths in the year up to the end of October.

Health experts in Ireland, both North and South, and defenders of the lockdown approach more generally, have claimed that the only way to prevent death in these groups is a blanket lockdown that restricts everyone and justified their recent and current restrictions on this basis.  But it hasn’t worked.

In yesterday’s Belfast paper, the ‘Irish News’, it was reported that there were outbreaks of the virus in 146 care homes; in September it was only 20. At the end of last week the newspaper reported that 44 per cent of deaths were accounted for by care home residents.

Yesterdays ‘Irish Times’ reported that a letter from the Irish State’s health regulator to the Department of Health asked why residents at some nursing homes where staff had tested positive had not themselves been tested. “Luckily, to date most centres are reporting that these residents are asymptomatic.  However, we cannot rely on the situation continuing.”  In the month of October, 39 of the 103 deaths were of residents of nursing homes, while some of these homes have made persistent complaints of inadequate support from the health service.

Defenders of universal lockdown argue that you can’t protect the vulnerable without generalised measures, but these measures mean that not only has there not been a focus on, and resources directed to, those most in need but that there can’t be.

Lockdown brings temporary reductions in cases, hospitalisation and deaths that increase when they are inevitably relaxed, which earlier in the year was modified by the warmer weather during the summer.  This has led some to advocate stricter lockdowns and a ‘zero-Covid’ strategy, which sometimes doesn’t actually involve zero cases but only reduction to lower numbers so that test and trace then addresses new cases.  Since the majority of cases are asymptomatic it is never explained how these could be identified, and most of them wouldn’t; which also explains why the common metric to determine the severity of restrictions –  the R number – is a guess.  Given the wide range of estimates of this number right from the start it should have been obvious that imprecise metrics were being employed to justify an imprecise strategy.  It isn’t actually known how many people have had it or what sort of immunity has already been created.

The cost of the lockdowns has been enormous and the financial cost, which will be paid by workers in the near future, has been eye-watering.  The social and health cost has been less easily defined but we know it will also be huge. The Irish Hospital Consultant’s Association has estimated that almost 150,000 fewer people have had cancer screening in the first six months of this year compared to last, a drop of around 60 percent. In the North operations have been cancelled and cancer treatments delayed.  The graphic at the top of this post indicates the possible fatal consequences of such delay and was tweeted by a hospital doctor in Belfast.  Children’s and young people’s education has been badly damaged, domestic abuse is expected to have dramatically increased and children’s safeguarding has been endangered by the closure of schools and restricted access by healthcare professionals.  Mental health is expected to have suffered, something that can only get worse over the winter.

Huge sums of money have been announced and dispersed that previously were denounced as the ravings of a lunatic Jeremy Corbyn and the left of the Labour Party.  The difference however is that while the latter put forward increased spending as investment to deliver more and better jobs, the Tories have spent money to pay people to do nothing, or to pay out to their incompetent and corrupt friends through competition-free contracts.

The Left has long been aware that the best way to get people to do as they are told is to scare them, so the threat of terrorism has been used to spread fear and act as cover for attacks on democratic rights.  These attacks are as nothing compared to the restrictions imposed by general lockdowns.  We are invited to look down on Sweden and its policy of largely voluntary measures to restrict virus circulation and to accept that we aren’t responsible and sensible enough to do likewise – we are both too stupid and too smart.  Too stupid to be trusted and too smart to try.  Alternatives have come to be seen by many as the preserve of the far-right and assorted anti-science nut-jobs who sometimes deny that there is any threat at all.

The Left would normally have been expected to oppose this transparent attempt to scare the population into restrictions on their civil liberties, but instead they have joined in the moral outrage at those who aren’t doing as they are told.  So young people having a rave become ‘granny killers’.  They would normally have been expected to take an approach based on a materialist analysis.  Instead, they have demanded that massive sectors of the economy shut up shop and their workers get paid for doing nothing, workers who are overwhelmingly young and not threatened by the virus.  Pieces of paper or numbers on a computer screen are supposed to be a substitute for the production of real goods and services.  Everything Marx taught about capitalism is dumped in favour of illusions in money and the state.

The alternative of an intervention through which jobs are kept, the economy can continue to function and targeted measures are taken to protect the vulnerable are labelled herd immunity as if these were some sort of swear words.  The language of much of the Left has become dominated by definitions that are uttered as if they were insults.  So, in Scotland, unionism and unionists are by definition reactionary.  But do these words denote reaction by definition?  Would the description ‘rebel’ have denoted a reactionary during the American or Spanish civil war and would socialists therefore have rejected the description ‘unionist’ or ‘loyalist’ in these struggles?

Of course, it may be said that it all depends on the context, which is precisely the point.  The words herd immunity, which denote a real phenomenon, has become a term to dismiss consideration of a different way forward.  Any and all speculation that acquired immunity is inadequate has been published without recognition that these objections apply equally to vaccination. 

So, it has been noted that covid-specific antibodies have declined rapidly in those infected, without recognition that the immune system will have reduced these naturally because they are no longer required but will have developed the capacity to generate them again if required.  The possibility of achieving some sort of herd immunity was dismissed but it has been reported in ‘The Economist’ that in Northern Italy the most badly hit places including Bergamo now enjoy some degree of immunity: ‘Serosurveys show that antibodies there are not only common, but especially so among the old and health-care workers, who need them most.’

Less reported than the possible existence of antibodies and their rapid decline has been the potential of T-cells to provide protection.  This is only partly because they are harder to measure and less studied; they haven’t fitted the narrative.  Except  now they do.

One research project directed at health care workers in England may have found that six months after infection all the patients studied, even those who had mild symptoms, still had detectable levels of T-cells directed against the virus, even if their anti-bodies had disappeared.  This, it is speculated, might be why reinfection cases seem so rare.  It has been found that for some people T-cell response lasted over a decade in patients with the original SARS-COV-1 outbreak from 2002-03.

It is through seeking this type of response that the much-heralded Pfizer and BioNTech vaccine is based, and was reported in ‘The Economist’ before it became a headline in the mass media.

News of a potential vaccine doesn’t make the debate over the correct response irrelevant.  There will be no mass vaccination until well into 2021, as even the Northern Ireland Health Minister has said, even if it goes through all the necessary testing and authorisation, which it hasn’t as yet.  The avoidable cost of lockdown, which governments don’t seem to know how to get out of, is a big added pressure to rush vaccine approval, with all the risks this might involve.

Governments have narrowed down their options and, allied with their favoured expert advice, have given every appearance of the proverbial person who only has a hammer treating every problem as a nail.  Months of potential wasteful lockdown lie ahead and the issue of targeting the vulnerable doesn’t become less important because there appears a means of protection through vaccination.  Maybe then, finally, those pretending that the virus kills ‘randomly’, or that everyone has to be subject to equal treatment, will acknowledge that it doesn’t and they shouldn’t.