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Government and Covid-19: how responsible are politicians for our poor Coronavirus outcomes?
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This article was written after my own lengthy fight, which is still ongoing, with Covid-19 and its often-dramatic consequences. My experiences and interactions with several levels of care (local GP “surgery”, hospital, ambulance services) in the UK, as a result of this virus, have allowed me to form a patient-centric opinion of the workings of the system. In what is my first, albeit and thankfully, brief, hospitalisation as an adult (and in almost 50 years), I have also had time to consider the (often repetitive and irritating) news commentary that has followed the evolution of the virus.
If there is anything that this virus forces, it is a slowdown of activity levels. This provides most patients with time to observe and think. And during this period, it has been possible to observe how my own medical condition evolved, how the medical system and profession reacted to it, what information and messages the government was putting out, and how the press was reporting. The observation of these elements has demonstrated, without any doubt, the links that exist between government strategy, political rhetoric and medical decision-making.
As I listed in the description of my fight with Covid-19 (the first article can be found here: www.linkedin.com/posts/teixeiradasilva_covid-19-deep-vein-thrombosis-and-pulmonary-activity-6662686049715707904-89lR), there were four distinct moments where I felt action should have been taken by medical professionals, or should have been taken more quickly, but was not:
- The first doctor failed to recognise the symptoms, despite the increase in severity of both pain and breathing difficulty, and failed to make the immediate link to possible PE, or at least to a serious respiratory issue that required immediate testing. The reason for no action: the risk of Covid-19 contagion in hospital outweighed the need for diagnostics;
- A day later, the second doctor failed to act on the same symptom, plus an additional symptom, despite our mentioning possible causes. The reason for no action: the risk of Covid-19 contagion in hospital outweighed the need for diagnostics;
- A day after that, the paramedics failed, despite a referral from another NHS service with specific concerns, to make any link or recommend hospitalisation. Again, we specifically mentioned possible causes. The reason for no action: the risk of Covid-19 contagion in hospital outweighed the need for diagnostics. After all, they cited, even if an X-ray showed something, it would probably result in no action;
- The referral times for my diagnostics were well outside NICE guidelines and waiting times inconsistent with the severity of the possible prognosis
According to NICE (National institute for Health and Care Excellence) guidelines for PE or suspected PE, for people with a Wells score of 4 points or less (PE unlikely), [which was my case based on the fact that I showed no signs of DVT and had no history of any related illnesses], are to conduct a D-dimer test with the result available within 4 hours. If the test result cannot be obtained within 4 hours, doctors must offer interim therapeutic anticoagulation while awaiting the result. If interim therapeutic anticoagulation is required, offer apixaban (the anticoagulant that I am now taking) or rivaroxaban first line. There is no need for doctors to seek additional guidance: that guidance is well defined and publicly available.
It is clear from the guidelines we have read that doctors failed repeatedly to recognise the symptoms and make what should have been a fairly obvious link to the necessary, immediate medical diagnostics/treatment. Moreover, medical professionals also failed to follow NICE guidelines, which supposedly regulate the response times within the UK’s National Health System (NHS), as well as immediate action that must be taken.
Bearing in mind the obvious failures that have occurred in the timely diagnosis of my condition and the delays in implementing solutions, we must ask whether something other than the distraction (or worse) of medical professionals can be attributed as a cause, and what might be influencing the behaviour of medical staff within the UK’s NHS, and ultimately patient outcomes.
I have read statistics published by the BBC that GP Surgeries are now only doing 7% of their consultations in person, with the remaining via telephone, often with no visual confirmation of symptoms. This is a remarkable reversal of the trend of almost 100% physical appointments prior to the Covid-19 pandemic. Clearly, from a structural and efficiency perspective, the ability to screen, diagnose and prescribe remotely, could have a long-term positive impact on time and resource pressures on health systems, not only in the UK but elsewhere.
However, it is clear that medical professionals have not had sufficient experience in engaging as equals, with their patients, in particular when it comes to listening to the patient’s description of the symptoms and using that as a key driver of decision-making. In our case, the fact that we had a medical professional in the family (my wife is a pharmacist) and my own history of absolutely minimal visits to doctors, should have influenced the speed with which doctors reacted to the information being provided. In addition, there should have been a quicker recognition of the need for scientific, fact-based evidence to counter the ongoing concerns of the patient (one need only see the frequency of my calls to the local GP surgery).
I think our conclusion is that, while sympathetic in the main, the speed and appropriateness of action of the local doctors, was respectively slow and limited, whereas the emergency services, when finally actioned, were more responsive. Frequently, we felt compelled the need to guide doctors to explore or explain. At certain stages, and while not attempting to undermine their professional stats and opinion, we tried to use as much contextual knowledge to try to accelerate certain steps, such as hospital admission for diagnostics, but doctors were always reluctant to take that decision. Frankly, going to hospital to get an examination done, can be managed by communicating with the hospital and checking to see what volume of people are attending at any time. My observation once at the hospital was that, notwithstanding the aggressive transmission nature of Covid-19, the risks of contagion, subject to someone not touching surfaces and washing hands after a visit, was probably no higher than attending the hospital on a normal day when numbers are not limited by the pandemic. Not only were special precautionary measures being taken but the number of patients was considerably lower than normal, and the high-risk patients were concentrated in a single area.
Bearing in mind the failings and frustrations we observed in the process, and the clear influence of the Covid-19 virus on the attitudes and reactions of medical professionals, it seemed useful to analyse if and how the government’s approach to the pandemic might have influenced the behaviour of medical professionals and in turn, patient outcomes. It seemed sensible to turn to the first practical measure taken by many governments around the world: testing.
My own experience has been that the UK failed, and is failing, as regards its testing policy. Not only would increased testing help to obtain more statistically reliable information, but it would help to track sources of contagion and potentially exposed citizens. Desperately trying to implement a contact tracing app when the contagion curve is falling, seems a second-best solution to having implemented a full testing policy with contact tracing at the start of the epidemic.
Testing would have offer a degree of mental and psychological support to those who live with the uncertainty of whether they have contracted the disease or not, and when combined with appropriate further tests, would determine the level of resistance and antibodies in people who had Covid-19.
If one compares to Germany, in the week ending April 4th, Germany carried out 116,655 swab tests per day. The UK was hoping to reach 100,000 by the end of April (more on whether they reached the target below). Germany, 1.3 million tests versus UK 316,836. Knowing that so many people have probably had the illness, and doctors have confirmed I am one such person, the benefit of testing now is that an antibodies test requires a small blood sample with results available in seconds. The benefit of knowledge, for the health system and the patient, cannot be underestimated. The Huffington Post reports that “the UK’s testing guru professor John Newton has said it is “encouraging” that new evidence emerging out of South Korea suggests those who have fought off coronavirus might develop an immunity afterwards.”
The decision, therefore, for the testing “strategy” of the UK – in effect, the decision to stop testing outside hospitals almost immediately after the testing programme started, the exclusion of key workers from access to testing and the omission of the social care sector, both residents and carers, from both testing and statistics, is a decision taken at the highest political level. It cannot be explained as having been influenced by medical opinion or even global trends, because if there was one thing about which the first-affected nations agreed, it was that testing was crucial to managing the pandemic. One can conclude that from the very outset, the management of Covid-19 in the UK has been a political, as well as a medical, exercise.
The NHS in the UK is political and politicised. It is part of the reason why health (and social care) in the UK is a “hot potato” or “political football” (we only have to think back as recently as Theresa May’s forced U-turn on her social care manifesto commitment). When a politician such as Boris Johnson, whether specifically or by inference, establishes a tension or conflict between the need to preserve a UK citizen’s identity as independent and the potential loss of individual rights, and the limitations on these rights caused by social isolation measures relating to a pandemic, that politician plays politics against health. And loses weeks of precious time in combatting a disease that is to become rampant.
We must therefore taking very seriously the accusation made by a doctor, writing in the Guardian on the 10th December 2019, that “Johnson has contributed to thousands of deaths” because “the prime minister’s neglect of the NHS has resulted in too many tragedies”. Sonia Faleiro, writing in the Intercept Voices on April 30th, reaffirms that “Boris Johnson’s coronavirus lies are killing Britons” and in that article she analyses the multiple faux pas of the government, including reminding us of the fact that in early March, the prime minister was still shaking hands with Covid patients and bragging about it, and attending sporting events with thousands of people. No one likes to be reminded in such stark language of this causal link between political action and impact on the population, least of all those of us who have been accustomed for decades prior to 2016, to the measured language and tone used in this country.
For me, the article above contained a supreme irony: this was about the same time as I got infected, I think in a grocery store. Maybe, just maybe, with social distancing, I might have avoided contamination and not facing the uncertainty of knowing if my lungs will be permanently damaged as a result of the virus. If Boris Johnson had not treated the matter so lightly and implemented the measures which a few weeks later his team, and he himself, deemed inevitable.
But the political responsibility does not end there. As we have come to see in recent weeks, the shambolic handling of testing in this country, in my view as a result of a single-minded obsession with “reliable reporting” and statistics, has meant that those in critical need of being tested, such as key workers, residents and staff in care homes, and true Covid-19 patients like myself whose sole NHS recommendation was to self-isolate for weeks on end, have been completely abandoned, resulting in preventable death or avoidable serious medical complications. These outcomes are without doubt attributable, at least in part, to poor leadership, absolute lack of preparation, and the inability to implement a clear and consistent strategy.
We all know that the national debate which has raged since the referendum in 2016 has set the tone for discourse in the UK. Johnson’s rhetoric on health, interestingly, has a parallel to his, and his party’s, discourse on Brexit. Laud and applaud the many foreign workers who have created “our” British NHS but refuse to offer assurances to any of those key workers such as nurses, doctors, pharmacists and others, that they will be able to guarantee their rights regardless of length of stay in the UK (despite proposals by at least one MP to this effect). Even if their names are Luis Pitarma, an EU citizen who by the Prime Minister’s own admission, saved his life. Warm words, cold actions.
This shadows the approach of the Theresa May government at the time, where repeated verbal assurances about protection and preservation of rights were met, in practice, with a total rejection of any legislation that would enact the “warm” words. So too in this crisis repeated promised by ministers, headed up by the Health Secretary himself, to provide sufficient PPE to both key workers and subsequently social care staff, have failed to materialise. The policy of the government is to verbally assure, as a way of defraying attention and appeasing some of the audience (typically listeners of the news and readers of the mainstream or popular press). This habit of verbal assurance stems from an old parliamentary tradition that “assurances” are based on a system of honour among politicians. This has in recent years proved to be a thing of the distant past, but is nonetheless accepted by a sufficiently large section of the population to allow politicians to manipulate the message to their ends.
When ministers, including the heath minister, continue to promise that testing will reach 100,000 per day when the public can see that it is mathematically impossible, it reinforces the view that the country has accepted that politicians are entitled to publish fake news, and that news, even if an obvious untruth, will either be accepted as truth, or in time be swept under the carpet. It is pathetic that one day before the self-imposed deadline (much like other self-imposed targets such as the immigration target which again was never met), minister Robert Buckland, as reported by the Huffington Post on April 30th, “said currently 52,000 people were being tested per day, but added capacity was “rising” and ironic that even in the moment of admission of failure, perpetuates the myth of future success: “Even if we don’t hit it, and it’s probable that we won’t, we will in the next few days,” he said of the 100,000 pledge”. This technique, of defraying political responsibility by making what is perceived by the general public as a series of small “repromises”, is a method to which the UK public has become increasingly accustomed. So even the Huffington Post, when it states in an article on May 1st, that “Hancock’s brass-necked bid to put a positive spin on events could come back to bite him”, knows perfectly well it will not. The state’s spin machine is well-oiled and the public’s propensity for acceptance of small lies and statistical mistruths, is now a well-established parameter in today’s political landscape, within which politicians can manoeuvre.
What is more pathetic is the way in which the health secretary announces with much pomp and circumstance, on the 1st May, that the testing target had been met. As an article in the Huffington Post on the 1st May states, “there are lies, damned lies and statistics”.
The parallels to the workings of government spin machine during the Brexit debate could not be starker. Remember the promise of 40 new hospitals, of which actually only six to ten were new and the rest were plans based on seed funding? Recall the promise of the recruitment of 50,000 new nurses of which 19,000 were candidates that were going to be dissuaded from leaving the practice?
So too, Matt Hancock has managed to pull off the mother of inglorious fiddles. Everyone, even fullfact.org, a fact-checking site, can see that the Emperor has no clothes, except the Emperor himself. The health secretary reports 122,347 tests. He qualifies the number by stating that this includes 27,497 home testing kits mailed out. So mailed out, to arrive at some point in the future. Not on Thursday. Of course, in all likelihood, the government already has a way of ensuring that these kits, which may or not be used and may or not be used correctly, will be counted again as statistics when the tests are processed and results received. So we are down to 94,850. Or approximately 100,000. Then we must consider the 12,872 tests sent out to satellite sites, tests that may or may not be used, but most certainly will not be used on Thursday April 30th. So 81,978 tests. Repeat for public consumption: approximately 100,000.
Ironically, as my wife is a key worker and as I am self-isolating again due to possible exposure in hospital, the family was finally “entitled” to be tested. Months after I had caught Covid and after being in an out of hospital. When the government launched its online booking system, strangely the only day my wife could book, in a period of two weeks, was “super-testing Thursday”. In an age of fake news and conspiracy theories, it does not take a programmer long to configure the system to ensure that tests can only be booked on a single, statistically important day. Those conspiracy theorists…
Two days after “achieving” his target, test numbers were down to 76,000.
At this stage, the temptation is too great. That Brexit-Covid parallel again. Just as the press was totally partial during the Brexit debate, reporting along ideological (and therefore party-political lines), so too the same is happening in the reporting of Covid-19 statistics. When news of the target was published, Katy Balls of the i newspaper was quick to declare on the 2nd May that “Coronavirus testing target was mocked but Matt Hancock’s triumph is also a victory for Cabinet’s doves”. Ms. Balls appears to be suffering from the withdrawal symptoms faced by many political commentators post-31st January 2020, namely that they do not have enough topics through which to reassert their undimmed support for, or against, the government. Ms. Balls adds weight to my argument that the management of Covid-19 is indeed political.
The fact that multiple publications can view the same numbers, clearly explained and uncontested, as anything but a fiddle and a fib, is the reason why the press in the UK continues to exist in its current structure – each publication reinforces the view of its readership, with a known bias, and therefore ensures the relative stability and predictability of the readership. In this way efficient financial planning of the publication, based on largely stable readerships, ensures survival. Even the BBC, which has to go out of its way to seek neutrality for fear of criticism by any number of sources, has learnt the art of not-so-subtle ambiguity. Their health correspondent concludes, in an article on the 1st May, that the numbers are inflated and that “some [home testing kits], no doubt, will never be returned” (although counted). But the BBC writer is still unable to commit to a definitive opinion on the topic, despite his own analysis, and purposefully undermines his analysis by asking “has the government been a little creative with its counting”? This is one of the reasons why the regulator in the UK has a particularly delicate role, as any consolidation could skew the balance of power and reporting and therefore have an even greater influence (it does already given the imbalance between right-leaning and left-leaning press) on the democratic process in the country.
Fortunately, the impact of this biased reporting does not have the same influence on outcomes as during the Brexit debate, as the UK press have, with little exception, focused on reporting on dull (and as we have seen, for most of their reporting timeline, incorrect) Covid-19 statistics, rather than much investigative journalism. For a sector that is purportedly among the most independent in the world, the lack of global insight, the complete lack of ambition to set the reporting agenda beyond the obvious, is flabbergasting. Here the Brexit – Covid parallel, in my opinion, does not apply: in Brexit the influence on outcome was clear. In Covid-19 reporting the statistical reporting and commentary flowing from it is seen by many as largely strategically irrelevant (certainly I have no neighbours following a particular line of reporting by a one or more publications).
I am not alone in having predicted, some time ago, that the UK, based on its (in)action and ineffective testing plan, would be the European country with the largest numbers of Covid-19 deaths. As reported by Sky News on the 29th April, the “UK now has second highest number of Covid-19 deaths in Europe”. It always did, and possibly already the highest, because the country has failed to implement a broad-based testing approach such as that adopted by South Korea or New Zealand.
Immediately one draws comparisons, there are numerous opinions rushing to a defence: other countries are smaller and more isolated (is the UK not an island?), or the ratio in terms of the size of the population means we are only 4th or 5th. The Spectator typifies this type of response. On the 1st May, only a few hours had passed since Hancock’s inglorious announcement, proclamation-like, and the publication states that “it’s a mistake to compare our death toll with Spain and France”. In other words, with the two countries the UK had leapfrogged in the rankings. Comparing with Italy was, for the moment and until the UK passes that country as well, acceptable. Ditto the US, who are never going to be caught.
These are lives. Not relative lives. Deaths. And each death matters. The more deaths there are, the more it matters. When the UK government stops defending its actions using relative statistics, then we will know that those in government have grasped the point. And when the press stops aligning its discourse with an obvious political bias (whatever it may be), then the country may one day again reclaim a legitimate position among the leaders of the free press, and we may believe what we read.
It might seem a contradiction of what I have written before, but why is the UK suddenly bent on reintroducing testing to all sectors of the population, beating theoretical targets (set much like the immigration number, another Brexit parallel, and the same theoretical cap!) when it would appear that the peak of infections has passed? Does the country wish to cement its position as the leader of European infections, something that will almost inevitably happen anyway? Is it using this broad base of testing to defend itself against other country’s statistics by arguing that in the UK all sectors are now included in official numbers?
Why is the UK, given that it has been behind the curve at every step of the combat against Covid-19, not moving to antibody testing in order to determine the extent to which the population has actually caught the virus, and focussing on more research as to whether a Covid-19 antibody will protect its carrier against the second wave of infections that are likely to happen after the end of lockdown? Sung-Il Cho, professor of epidemiology at Seoul National University Graduate School of Public Health in South Korea, told The BMJ that the Korea Centers for Disease Control and Prevention is now trying to establish antibody testing in addition to the PCR [polymerase chain reaction] testing.” Why is the UK not using the experience of other countries that are further along the pandemic curve, to get ahead of the problem?
On a practical level, with so much generic information available (wash your hands, maintain your distances), why is more not being done to alert possible infected people such as myself, to watch for symptoms that are likely to lead to severe medical complications? Covid-19 is a respiratory disease. Globally, we see countries adjusting their treatment options to include, for example, anti-coagulants to avoid the most common serious consequence (the one I have and which was not immediately recognised by my doctors), namely blood clots in the lungs.
Why is more of the literature not focussed on helping and informing those who are likely to suffer serious consequences from this virus? And why, given that most diagnostics in the UK is carried out in primary care locations (hospitals), are doctors not being encouraged to better weigh up the risks of infection and exposure to Covid-19 in a hospital environment, versus the risks of undiagnosed medical emergencies? Why are doctors, who are now largely working remotely, not considering that most hospitals have never seen such low A&E admission rates and have never been so empty, with the separation between Covid and non-Covid patients so stringent as to make the risk of contagion probably lower than being in a hospital ward under normal circumstances?
And in one final parallel to Brexit, if it can be proved that Sir David Lidington’s quote to the BBC’s Radio 4 Is correct, namely that “the UK’s ability to import crucial protective equipment for NHS and social care staff would be damaged if there was a ‘no-deal’ outcome after the end of the year”, then the government has no option but to ask for an extension of the transition period. If this logistics hurdle is confirmed, then not extending the transition period will make a complete mockery of the Thursday clapping sessions in support of “our NHS”.
Why, why, why…? It is clear to me, that in a highly politicised environment that is the UK’s health system, in particular as embodied by the NHS, the government has failed to deliver a convincing policy and strategy for fighting Covid-19. Its dithering and delay have resulted in real harm and suffering. I see little hope of admission of wrongdoing – whether as small as PPE logistics or as serious as a death – based on the types of responses offered by Ministers in response to questions about shortcomings. However, I do hope that opposition politicians, society as a whole and most importantly, the conscience of the politicians in power, force the country to rethink its priorities across health and social care, and to rebalance its priorities in terms of protecting the health of its citizens and residents.
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