COVID CONCLUSIONS – DEATH RATES, MODELLING, AND CARE HOMES
- Hysteria around death rates must subside
- Statistics have to be seen in context and their weakness factored in
- Care home data is different, and care homes are a special case
- Non-Covid deaths may be the most worrying
TREAT MODELLING AND PREDICTIONS WITH CAUTION
Since 8th April, predicted UK death rates and other statistics published by The Institute for Health Metrics and Evaluation (IHME) in connection with Covid-19 (CV) received enormous publicity. IHME is a top-rated U.S. establishment for this activity. “UK death rate to exceed 40% of all Europe” said the Guardian, citing IHME’s expectation that by 17th April the UK peak will be reached with nearly 3000 daily deaths, the country needing 102,000 beds (falling short by 85,000) and falling short of intensive care beds by some 24,000. Today is 17th April, the daily death rate is under 800 this week, there are plenty of spare hospital and ICU beds and the CEO of UK NHS Providers is saying the NHS is managing well. In fact, the IHME predictions having gone viral, the IHME revised them downwards by a huge amount only 3 days later. Damage done, unnecessarily.
Social and other media latched on voraciously to miserable figures creating a furore of outrage that this might occur and of negativism, seeking to blame, undermining good faith efforts to combat CV, based on a selective and flawed presentation of models, which apparently in fact contemplated huge ranges. The much lower ranges were eitherdeliberately omitted to create shock and scaremonger, or the reporters were so recklessly lazy as to be incompetent. It is an extreme illustration and warning of the care and scepticism with which modelling, and prediction of the future must be treated. Data changes daily, affecting assumptions, changes to which can significantly alter predictions. That dynamism of the modelling has always been emphasised by UK Government (UKGOV) scientific advisers, driving advice. Questions about the Scientific Advisory Group’s thinking are appropriate, but conclusions at this point are dangerous. Hindsight should be used cautiously to question reasonableness.
SIMPLE DEATH RATES MUST BE TREATED RESPECTFULLY WHEN DRAWING CONCLUSIONS
The daily focus on death rates particularly is inevitable with regular comparisons between countries; but countries vary widely in how deaths are recorded and how causes of death are recorded. It is one thing to die “of” CV, it is another to die with “CV”. Comparing the experience of small countries with that of large ones is dangerous and a bit “apples and pears”. A recent report compared the Ireland CV death rate with the UK’s, highlighting that it is much lower. But Ireland has a small population, well spread out: it has some 186 people per square mile, the UK has 727. Is population density relevant to the spread of CV? It may be as CV is so infectious. Of major European countries (ignoring the likes of Monaco) England has the highest population density. Average age of population could be relevant, as CV in general hits the elderly harder. Compare Italy’s median age of 47 with Ireland’s 38. Demographics must be relevant. On a different tack, scientists are exploring a theory that perhaps the BCG vaccine can boost resistance to CV: it being notable that Japan and South Korea, so far with low death rates from CV, have universal BCG vaccination programmes, whereas many European countries with higher death rates ceased to do so long ago. The theory may or may not have validity- but it too illustrates the dangers of simple comparisons of country data.
It is clear however that if the rates are to be used to draw conclusions and form an important factor in making strategic decisions, consistency of calculation is critical. The UK, like many others, has used hospital-based deaths data for this purpose as they are the easiest and most reliable to obtain consistently.
CARE HOMES DATA
The latest journalistic obsession, apart from PPE distribution, is the absence of daily data on deaths in care homes. There was mischievous, if not maybe malicious, questioning on 14th April in the UKGOV daily press briefing and a general media groundswell, implying that UKGOV cares less about care home residents than others. The UKGOV explanation as to why care home data lags behind seems reasonable (they are not part of the NHS reporting system), with efforts being made to ensure faster reporting. While a death certificate for a person outside hospital may include CV on it, the person may not have been tested and so it may be wrong. 95% of care homes are privately run, small businesses; with a few groups running hundreds of homes each. Large numbers of these homes are in financial straits. The level and sophistication of management of these will vary enormously: anyone who has visited a number of care homes will testify that the standard of operations varies hugely, as do the needs of residents and level of active care: some care homes are nursing homes – they have medical staff present. Integrating them (say 12,500) all into one single reporting system is perhaps not necessary or desirable. The more data the better as far as UKGOV is concerned provided it is reliable.
CARE HOMES ARE SPECIAL
Care homes are the latest implement with which to clout UKGOV for its callousness. But not having data on a daily basis does not mean that care home residents are being ignored. The mischievous questioning mentioned above was to suggest that care home residents who contract CV will be the last in the queue for hospitalisation. The response made clear that consideration of hospitalisation for these people is ongoing all year round and the same criteria is applied to each individual case, CV or no CV. The fact will be that in some cases there will be no point, sadly, in taking the person to hospital as treatment would not help. Many a question seems to get asked as if, when there was no CV, death hardly occurred. Some 50,000 individuals die each month in the UK, from lots of causes, with all the grief that individual loss entails: the big difference with CV is the volume of cases of infection it produces and the pressure that puts on carers as well as the NHS. From much media, and commentary, one might imagine the effect of death by CV has special characteristics not there in other circumstances, but generally it does not.
To record some obvious facts. A stay in a care home nearly always ends in death. People are in care homes as they cannot look after themselves and there is not sufficient care provision at home. The reasons can be many, but dementia and sheer frailty are common. The average stay in a care home is around 2 years: and so, for many it is a lot less. The expression God’s waiting room is aptly used by some. If CV invades a care home, the havoc can obviously be considerable given CV is so contagious and the weaknesses of so many residents. When a resident gets seriously ill in a care home whether CV or otherwise, the result can well be fatal; sometimes it is a relief. While carers in these homes have to live with death regularly, an exceptional number of residents dying is likely to be particularly traumatic, even for the highly trained carer. Care homes should be analysed separately. To lump them in with hospital deaths may even distort a picture. Perhaps to do so would give a more accurate and lower percentage of deaths among younger people. The sadness of a care home death is there for the relatives, but it will always be for a person whose life has been long lived.
OTHERS DYING
The number of elderly people not in care but who struggle to look after themselves or who are cared for at home far exceeds by a multiple those in care homes. The death rate for such people who die at home during the CV crisis is also not in the daily data (being hospitals only): spotlight there soon? In any event the challenge of knowing whether such people die of CV or simply with CV will be considerable, another for the experts to do their best with. However, the most pressing worry is the number of unwell people (elderly or not) who are simply not getting treatment for ongoing or new threatening health problems and whose lives might be cut short not directly by CV but as an indirect consequence. The voluntary avoidance of hospital by those with serious conditions, whether through fear or not wanting to be a burden, is now attracting special concern. Lockdown death rates, and mental and other damage, not attributable to CV, become a major factor for ending lockdown so far as possible and as soon as possible.
ONGOING MAJOR PROBLEM TO SOLVE
CV has served to highlight the already recognised and unsolved problems of social care, particularly for the elderly at the latest stage of life. It must obviously be a major piece of future planning of healthcare. There is today a natural, but perhaps unbalanced, emotive focus on the agonies of individuals dying. The Social Care debate can only properly be had when the media remove from our screens and devices the daily showing of stories of grief, which should, perhaps, be kept private, as they are properly and normally for the 50,000 who die in the UK in the normal course each month.
IF LOCKDOWN IS RELAXED, THE ELDERLY SHOULD NOT BE SINGLED OUT
UKGOV rightly will not be drawn now into how restrictions will in due course be relaxed. It is possible some measures will have to stay in place until a vaccine is found – that is perhaps a year, or more – as there is no vaccine, it could be indefinitely. It has been suggested that the elderly and vulnerable should stay at home until vaccinated, given their vulnerability, while others may be freed. As long as that is but a recommendation for their own safety, not a requirement, it could be acceptable. The aged and vulnerable should perhaps remain as free as others to make a choice as to what risks to take compared to a life of internment. Some thorny questions of freedom may need addressing.
