SHA COVID-19 Blog 4

The Socialist Health Association (SHA) published its first three Blogs on the COVID-19 pandemic weekly since the 17thMarch 2020. A lot has happened over the past week and we will address some of these developments from our ‘politics and health’ perspective.

  1. The global crisis

The pandemic continues to spread around the world and we are seeing that while Europe remains a global hotspot the new epicentre has now shifted to North America.

New York Governor Cuomo is showing some visible leadership and filling some of the space that the President should be in. It was always the case that the private health system in the USA would not be able to present a joined up emergency response and primary care has never been strong either in the States. The CDC in Atlanta has, like the UK public health system, been starved of funds during Trump’s Presidency but more alarmingly their advice has been ridiculed and ignored. Compare this to when the USA public health system, under President Obama, supported the international effort to control the Ebola outbreak in West Africa?

President Trumps best friend Mr Modi has declared a 3 week lockdown across India and in the process condemned millions of migrant workers to walk without adequate food or water hundreds of kilometres back to their rural villages. These dreadful scenes include police spraying them with disinfectant and stories of pushing wheelchair bound people 25 miles each day. Such news reports are matched only by the sealing off of ghettos areas in big cities such as Mumbai and Kolkata. Looking at how these people in dire poverty live without adequate housing, drinking water, food and sanitation is heartrending. Consider our government’s guidance on staying at home, washing hands and social distancing makes the prospect of widespread community spread, illness and death in these slums an absolute certainty. Let us hope that Modi’s BNP party do not further  fuel anti Muslim feeling in these poor and excluded communities.

So Africa will be next and looking at Lagos with a population of 21 million with a large shanty town and Kinshasa in DRC at 11 million there will be vulnerable populations with inadequate sanitation and housing for the virus to spread exponentially. African economies are characterised by local markets which like India are very crowded, in narrow streets where people struggle against various motor and animal vehicles as well as packed buses and taxis. The WHO and UN as well as the IMF/World Bank need to urgently do what they can to help African governments mitigate the worst consequences of the pandemic, which includes harmful longterm economic impacts. Many African countries remember have over the last 5-10 years enjoyed solid growth in their GDPs.

The pandemic will harm the poor more than the rich and although as Michael Marmot noted recently – at the beginning of a pandemic both prince and pauper are infected but over time the social conditions that the poorer populations are living and working in will mean that they suffer most. Securing income to live on for the many and somewhere to shelter for the homeless will be an urgent part of our pandemic response.

  1. The European picture

So what can we learn about how the pandemic is affecting Europe? The first thing to note is of course that Italy and Spain are and have been suffering badly with high numbers of confirmed cases and deaths reported. In parts of the country both their hospital systems have been overwhelmed with health care staff succumbing to the infections and overall death rates being high. The pictures of patients on corridor floors and overcrowded trolleys is distressing as are the reports of nursing homes left to their own devices exposing staff and residents to mortal danger. We do need to ensure that mutual aid is respected in the UK to avoid NHS hospitals becoming overwhelmed as this is dangerous and hugely demoralising.

Why is Germany apparently riding the storm better than their southern neighbours? The simple answer seems to be that they were better prepared than we are and have sufficient testing capability across the country, have a sound public health system at a national and federal level, sufficient numbers of hospital beds and ITU capacity, and supplies of PPE/ventilators to handle the load. There seems to be a better link between the national government and the federal institutions able to undertake public health action locally. There have been criticisms in the UK of the lack of coherent leadership at regional public health in England who are linked into the NHS and local authorities. The devolved system of national governments gets more coherence via the CMO roles at UK level and their links to First Ministers of devolved government.

Recent reports show that Germany with 97,000 confirmed cases has had 1,478 deaths compared to the UK’s 48,000 confirmed cases and 4,932 deaths (18 deaths/million population compared to the UK 65 deaths/million at this point in the pandemic). Compare these rates to Italy and Spain who have been ahead of us in terms of epidemic spread at 259 deaths/million and France at 117 deaths per million.

We have raised questions in earlier Blogs about the preparedness of the UK for a pandemic and the constraints on testing capacity, the shortage of adequate PPE for frontline staff and the inadequate supply of acute hospital beds (Germany 601 beds/100,000 and UK 211 beds/100,000) never mind ITU staffing and beds. We obviously commend the rapid building of the Nightingale Hospitals, which will be able to receive ventilated patients thus relieving local hospitals. We are pleased to hear too that the Abu Dhabi based owners of the Excel centre are withdrawing their charge of £2-3m per month for the venue, which would have been empty during the pandemic. We also commend the NHS for its preparation by increasing ITU capacity and redirecting staff usually working in other specialties. Let us investigate how the private hospitals are charging the NHS for access to their beds and facilities – our position has always been – requisitioned in a national emergency.

The private hospital sector in the UK will be protected through the pandemic unlike other businesses. Large players such as Circle Health and BMI have been making a loss in 2018/9 amounting to £12m for BMI and Circle’s £14m. During the pandemic they faced economic disaster as their Middle East customers and the NHS elective care referrals ceased. These private health care companies are controlled by US health insurance companies and private equity funds. Another large group, Spire hospitals, lost £24m in 2018. Spire’s share price jumped 15% on Matt Hancock’s announcement! The Wellington and Portland Hospital, owned by US group HCA, lost £74m last year and will also be pleased to have access to taxpayers’ money. It remains to be seen under ‘open book accounting’ how the expenditure will be audited. Note that the best paid executives at Circle, BMI, Spire and HCA earned £377,000, £452,000, £615,000 and £711,000 respectively according to Private Eye sources!

  1. The UK

The NHS has been making huge efforts to be as prepared as possible for the potential tsunami of COVID-19 cases. With the lockdown A&E departments have been relatively quiet and with elective care suspended and no visiting for inpatients many hospitals outside of London/Birmingham/Newport have been eerily quiet. Healthcare staff have been trained up to undertake different roles in anticipation of patients being admitted who require respiratory support – this seems to be the main serious impact of Covid-19. Let’s not forget however that heart attacks, strokes and childbirth will continue to occur, as will the treatment requirements of cancer patients.

In previous blogs we have referred to the care sector and how important they are in managing the pandemic. The recent guidance on PPE has clarified some of the queries and enabled more staff to feel more protected than before. However the supply of PPE to front line staff remains patchy and with the death toll rising of healthcare workers the government must ensure that supplies are readily available for community nurses and care workers as well as social care staff in the residential and care home sector.

While it is absolutely necessary to be transparent about the evidence of benefit from ventilation we do not think it humane or ethical to have strict age-based criteria for decisions to admit to acute hospitals for assessment. Frailty criteria published by NICE, for suitability for ventilation are of course necessary but the reports of people being coerced to sign Do Not Resuscitate (DNR) advanced directives is very dangerous and will lead to the perception that older and disabled people are being denied hospital treatment. Residential and Nursing Homes will also feel that they are being left to manage very ill residents who are on an end of life pathway without adequate resources and safeguards for staff. The same feeling will apply if domiciliary patients are transferred to nursing homes with a Covid diagnosis in large numbers. This is a very sensitive policy area, which needs careful consideration and an investment in resources to mirror that provided to NHS hospitals and the new Nightingales. There have already been examples of nursing homes having to deal with a relatively large number of residents with Covid-19.

  1. Looking forward

The pandemic will sadly spread across the UK from its hot spots in London, the West Midlands and Gwent. The government is being held to account for its failures in preparation – perhaps more attention to Brexit than Pandemic planning! The slow response has been noted, the lack of scaling up of testing and the poor logistics on PPE stand out in the story so far.

We still sense a racial/culture hostility to widespread use of masks yet many Asian countries that have controlled the spread have used them widely. We look forward to the WHO reviewing the evidence. The virus is transmitted from and to the nose and throat, so it does seem that there is a case that face masks have a role to play. However facemasks have not been available in the UK for weeks and have in a sense been rationed to health and social care staff!

As we have pointed out even without the widespread use of facemasks Germany has shown us the benefit of sound preparation, supplies and capacity in their health system and we need to learn that lesson from our European partner. Austria is already planning its exit from lockdown. There has also been clear political leadership in Germany without chopping and changing with promises announced almost daily as we have seen here.

The exit plan needs to be addressed and in the same way that we have not treated London as our Wuhan we do need to nuance our policies to match regional/metropolitan differences in where the pandemic has occurred and the readiness to relax the lockdown based on testing evidence of community immunity, protected populations and overall resilience.

Posted by Jean Smith on behalf of the Officers and the Vice Chairs of the SHA.