Did we opt for amputation?

As we consider the range of responses to Covid-19 around the globe it is clear that some strategies are being more successful than others. Nations such as Germany and New Zealand are having experiences of Covid-19 which differ markedly from countries elsewhere. In the UK the approach appears to have shifted during the course of the pandemic. The mortality figures are now disturbingly high. One commentator refers to epidemiologists’ concept of ‘harvesting‘, and wonders if this was the de facto public health policy for the UK. He goes on to suggest that if we need a lens through which to understand Covid-19 there is an obvious candidate:

Today, if you need a lens to examine any country’s response to coronavirus, look to its nursing homes. 

‘Harvesting’ is a terrible word – but it’s what has happened in Britain’s care homes | Richard Coker

Nursing homes already offer a dispiriting insight into this particular harvest. As Covid-19 sweeps the world it leaves in its wake a catalogue of devastated care facilities. In February multiple deaths linked to the virus were taking place at Kirkland, Washington State. By March there were reports of abandoned care homes in Spain and the discovery of deceased residents found in their beds. In Italy the death toll in homes was astonishing and, in at least one case, is now the subject of a police investigation.

Examining the UK’s early response to events David J Hunter writes about the way British attitudes may have influenced decisions. Hunter recounts a senior academic’s response when they heard suggestions that the UK was talking seriously about herd immunity. The only way the academic could make sense of the idea was by assuming “that this proposal was meant as satire“. There is every indication that Britain was being prepared to accept a major loss of life, with the statement from the medical director of the NHS that anything under 20,000 deaths would be a good result. At the time of writing the UK is approaching a point where it will report 40,000 deaths and estimates of the true figure put this north of 50K.

There is every reason to believe that the UK government was prepared to accept a major loss of life and to see this is a tragic but necessary reality of Covid-19. New Zealand is reporting 21 deaths with a population about 1/13 that of the UK. If the UK had the same rate of loss we would now be recording about 273 deaths. The difference is monumental and, in time, we may understand more about why this has happened. Of course there are many variable factors which may affect the rate of deaths, ranging from social structures to physical environment. However, it is likely that in time we’ll arrive at a comprehensive and robust analysis of all the factors involved and which were the best, and worst, national strategies to adopt. At the moment we already know that there is a major loss of life among older people, and people at particular risk include those who are BAME; living with dementia and/or disability; and people who survive on very limited economic means.

In the light of this I wonder whether ‘harvesting’ is the right term, or if ‘amputation’ is a better description?

Field ready for harvest near Little Gidding

While harvesting implies a general and equal cut, amputation removes a part of the body in an attempt, very often, to save the whole. It is sacrificed. The emerging data and evidence suggests that sections of some communities in the UK are being surrendered as a necessary cost for the country. At the top of the list are people of advanced age with complex health needs. The people most likely to be in a place of residential care.

As a nation the UK chose a confusing path with the Prime Minster suggesting there was a balance to strike between ‘taking it on the chin’ and more extreme restrictions on personal life. The Government did not use comprehensive testing in homes for a considerable time, even though it was obvious that this is where there were people with the greatest vulnerability. Compared with the NHS most residential homes support people who cannot co-operate well with restrictions. As I know from personal experience, purposeful walking by residents is hard to manage. The situation of nursing homes in several countries offered evidence which the government should have heeded and acted upon. However, we must consider the possibility that the NHS – rightly encouraged to be concerned about its capacity – effectively seeded Covid-19 positive patients in care home communities. If this proves to be even partially true, there will need to be a period of national soul-searching followed by a commitment to comprehensive, dynamic and enduring reform in the relationship of health and social care. Reform that doesn’t just regard social care as an expendable limb of the body politic, but as an essential part of what makes up the services that ensure we are a compassionate and just society.

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