Sunday May 31, 2020

Focusing singularly on Covid-19 puts other patients at risk

The emergency response to the coronavirus means vulnerable patients with other issues are missing out on care with potentially serious implications

13th April, 2020
Radical action has been taken to respond to the Covid-19 outbreak, but it is still unlikely to be the lead cause of death worldwide this year. Picture: Rolling News

The number of deaths being predicted from the Covid-19 pandemic could well exceed a million globally. Despite this, it is unlikely to be the lead cause of death worldwide this year. The old reliables – cardiovascular disease and cancer – will be far ahead of any Covid-19 deaths, but they too will surge due to the disruption of normal healthcare services.

In preparation for the pandemic, Irish healthcare as we know it has been disrupted in a manner never before thought possible. As a result, elective surgeries and other crucial diagnostics and treatment pathways have been put on pause.

Let’s consider a very conservative scenario where mortality rates from the leading causes of death, such as heart disease and cancer, increase by only 5 per cent due to the disruption of healthcare service provision in order to “fight” Covid-19. With 30 million deaths annually from cancer and cardiac disease, 5 per cent is 1.5 million people, so we’re suddenly dealing with very big numbers that easily eclipse deaths from Covid-19.

Unfortunately, we’re already starting to see anecdotal evidence of this in Italy and Spain. In Italy, an informal study has been reported showing that in some regions of the country the total death count in the first quarter of 2020 was up to six times that of previous years, with Covid-19 deaths accounting for less than a quarter of the increase.

In Spain it has been reported that mortality rates in some regions have almost doubled, again with officially attributed Covid-19 deaths accounting for only a fraction. It is likely the discrepancy is due to people dying of “normal” conditions in greater numbers because they can’t access normal healthcare. Admittedly a portion may be untested Covid-19 patients, but the figures give pause for thought for all those who were battling various chronic diseases and are now left in healthcare limbo.

Reliable global data establishing which deaths are directly caused by Covid-19, and which are caused by struggling healthcare systems as a result of Covid-19, may not be available for months or years. In the meantime, a valuable guide for how to think about these trade-offs may be earlier epidemics, such as Ebola. Several studies have tried to quantify the indirect effects of the Ebola epidemic on mortality by factoring in interruptions in malarial control programmes such as the distribution of bed nets. They have found that more people died of the indirect effects than the virus itself. Between 2014 and 2016, during the Ebola outbreak in West Africa, 10,000 people died from Ebola but 11,000 people died from malaria, despite the previous significant progress made to eradicate the infection in the region.

Since the emergence of this Covid-19, and for the first time since World War II, the world has focused singularly on all-out pandemic planning. In many countries this has succeeded in flattening the curve and putting robust systems in place to protect healthcare workers and other vulnerable groups. Indeed, never before has the international community been so singularly aligned in dealing with a healthcare crisis.

In a reimagined world where hand sanitiser and N95 masks are the new currency, intensive care consultants are an extremely valuable commodity. In Ireland, the number of intensive care consultants, or intensivists, per head of population is far lower than the international norms. We are specially trained and prepared to deal with this unprecedented situation. Covid-19 patients who suffer from respiratory failure – the medical term for breathing difficulties – are no different to the cases we deal with day in, day out. There are just greater numbers than usual. Intensivists are trained, experienced and ready to do whatever it takes to save as many lives as we can in this pandemic.

Equally, non-intensivist colleagues – from orthopaedic surgeons to vascular specialists –are equally keen to use their clinical skill sets to help with the surge as and when it happens. Indeed, a great many of our colleagues from diverse specialities have spent the last weeks voluntarily retraining in new roles related to supporting critically ill patients.

For the last 10 days, around 600 private consultants have been left unable to work because of the temporary nationalisation of the private hospitals. The state has not yet been able to reach agreement on the urgently needed contracts of the 600 consultants who staff these facilities. Without these, consultants have been clearly told by their insurers that they are uninsured to work with any public patients. Proceeding in light of such a warning could lead to erasure from the medical register.

Indeed the State Claims Agency, the state’s insurer, issued a statement to private consultants on April 3 confirming they were not currently insured to treat public patients.

So, at a time when they are needed most, doctors who want to work and are key to treating those afflicted with Covid-19, are prevented from doing so.

This has an immediate effect on patients. Personally, my colleagues and I may no longer treat patients who have attended private hospitals, in some cases for decades. A patient who had an urgent cancer operation planned for this week has had to be referred back to the public system, where no surgery is taking place. We don’t know when they’ll get their surgery. What we do know is they will likely have more advanced cancer and a lower chance of survival if and when they do get their surgery.

In emergency situations, there will always be loose ends. The government needs to act quickly and decisively in mitigating as best as possible the national response to the crisis. However, the “loose ends” in this situation are, sadly, people’s lives. The unintended consequence of putting all our efforts into reactive decision-making in an effort to “fight” Covid-19 is that patients with pre-existing conditions will suffer and in some incidences die.

Dr Stephen Fröhlich is an intensivist and anaesthesiologist and is managing partner of critical care partners (, a group practice of 14 anaesthesiologists and intensive care consultants who operate across seven private hospitals in Ireland.

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