Covid 19 death figures and issues explained – a bit.
Ian Malcolm-Walker
It would be easy to write an article about Covid‑19 deaths that was full of inconsistencies and went round in circles. It would also be easy to write one which was full of statistics and technical points. It would be almost trivial to write one alleging all sorts of conspiracy theories and government plots. This article will do its best to avoid those traps, although it may not be wholly successful.
The difficult decision is where to start. I choose to start with a few basic home truths:
· Human life is more valuable than the capitalist economy.
· All deaths cause distress to the family, comrades and acquaintances of the deceased no matter the cause.
· In the case of Covid‑19, that distress is intensified by the genuine and at least partly justifiable suspicion that such deaths could have been avoided. Certainly, some of them could have been prevented by timelier and more coherent policies being pursued from the beginning.
How Many Have Died of the Virus? (See Appendix for more detail]
What is clear, and the Canary has made this point, is that the government figures announced daily are about as low as they get.
Because the UK tests so few cases, international comparisons of death rates are meaningless.
However, figures per million of population are helpful. In some cases they show better management and intervention for example in China and South Korea (4.5/m) , whilst in other cases such as the UK(207) they probably only mean that the worst is still to come whereas Spain(413) and Italy(367) have probably peaked. Belgium with less that 5 000 deaths tops the list at 425 per million. Neither China nor Cuba make the top 50.
The two biggest distorting factors in the UK are both man-made. I mean man-made and could name the men.
Care Homes
Let me start with nursing home and care homes. Many people in these homes have been dying and fewer have been admitted to hospital and more have been discharged prior to death. People in these homes have more underlying long-term conditions, yet homes stop testing when they have 5 cases and just assume that they have got it and stop counting.
According to the Guardian, Care Home owners have accused the government of vastly underestimating the deaths of elderly people from coronavirus, as they warned the disease may be circulating in more than 50% of nursing homes and mortality is significantly higher than official figures.
Official figures released on Tuesday showed just 237 people died from coronavirus in care homes in two weeks, suggesting government figures are failing to keep up with rising numbers of deaths outside hospitals.
There is also the impact of Covid-19 patients being discharged by hospitals into care homes filled with the frail and elderly in order to free up beds.
Why this is happening, when the Nightingale (in passing why not Seacole?) hospital in Docklands has received only a small number of patients – reported to be just 19 at the weekend – when it has capacity for up to 2,900 intensive care beds.
The Government is spooked by the issue, which is even being picked up by its usual allies in the mainstream media.
The Health Secretary, Matt Hancock, announced on Wednesday 15th April that everyone in a care setting who was symptomatic would get a test in future and patients discharged from hospital to residential care homes would get a routine test.
Currently only the first five symptomatic patients in a care home are tested.
Hancock said all care providers would be contacted in the coming days to offer tests to their staff with symptoms.
As ever there will be delay in implementation (watch this space!!)
As with the NHS, Personal Protective Equipment (PPE) is an issue both in terms of quantity and quality.
Caroline Abrahams, director of the charity Age U.K., said the government’s daily figures “are airbrushing older people out like they don’t matter.”
Do Not Resuscitate (DNR)
Another issue that affects care homes and people in the community in DNR.
The British Institute of Human Rights reports that it is already hearing reports on social media and in the news of people with learning disabilities and older people having Do Not Resuscitate (DNR) orders applied to them, with little consultation.
The preservation of life is now become part of the national mantra: “Stay at home; Protect the NHS; save lives”.
We must save lives.
But, whose lives?
Importantly, we all have the right to life (Article 2, Human Rights Act [HRA]).
The government’s analysis of the recent coronavirus legislation flags the need for action to protect the right to life in the context of the pandemic.
Clearly, this is not in dispute. But the decisions on the provision of medical treatment need to be on a case by case basis.
Blanket approaches, such as those which attempt to apply DNR orders to whole groups of people are rarely legal.
Such approaches signal a moral judgement about equality of life, not a medical decision about an individual’s treatment and prognosis, and as such will fall foul of the right to non-discrimination (Article 14, HRA)
Plus, there are the rights to autonomy and involvement in decision making covered by our right to respect for private and family life (Article 8, HRA).
This right can be restricted by public officials and frontline staff, provided their decision is lawful, legitimate and proportionate. This three-stage test must be at the heart of any decision that attempts to restrict people’s rights to make decisions about what happens to them, and to consider their wishes and feelings where they do not have capacity to make those decisions (which must be specific and assessed, not just an assumption).
Once again, Kerry-Anne Mendoza (in the Canary) has highlighted the issue reporting that one Clinical Commissioning Group (CCG) in Brighton and Hove has written to care homes for elderly people. It stated that:
· frail elderly people do not respond to the sort of intensive treatment required for the lung complications of coronavirus…
· We may therefore recommend that in the event of coronavirus infection, hospital admission is undesirable.
It also told care homes to:
· check they have resuscitation [DNR] orders on every patient
Four disabled campaigners are taking legal action to force the government to make it clear that they will have the same right to life-sustaining treatment as non-disabled people if they contract coronavirus.
Now it is obvious why issues like care homes and DNR matter but why do dry arguments about figures matter.
Well I can think of two reasons straight away
First is to end the buck passing. Hancock’s first response to the care homes death row was to blame to low figure on the Office for National Statistics.
Most importantly is epidemiology.
If you do not understand a disease you are unlikely to be able to treat it or respond correctly and, as the New York Times pointed out, determining what percentage of those infected by the coronavirus will die is a key question for epidemiologists, but an elusive one during the pandemic.
As the virus spread across the world in late February and March, the projection circulated by infectious disease experts of how many infected people would die seemed plenty dire: around 1 percent, or 10 times the rate of a typical flu.
But according to various unofficial Covid-19 trackers that calculate the death rate by dividing total deaths by the number of known cases, about 6.4 percent of people infected with the virus have now died worldwide.
Determining death rates is especially challenging during a pandemic, while figures are necessarily fluid. Fatality rates based on comparing deaths, which are relatively easy to count, to infections, which are not, almost certainly overestimate the true lethality of the virus.
And this matters because determining just how deadly the new coronavirus will be is a key question facing epidemiologists, who expect resurgent waves of infection that could last into 2022 or 2023 – more likely if people put profit before people.
And that is before we plan for the next pandemic.
We all know that coalition government planning in 2010 to 2015 after swine flu was way off the mark.
The government knew soon afterwards when Exercise Cygnus showed us woefully short of ventilators. The government’s response was to sit on the report and classify it.
BAME (Black, Asian and Minority Ethnic) impact out of kilter
There is substantial anecdotal evidence but as far as I can find little data about the BAME community and Covid-19.
A very significant number of key worker deaths are people from minority ethnic communities.
With patients from ethnic minority backgrounds over-represented in critical care units and among NHS staff who have died, the government on Thursday agreed to an inquiry into why they appear to be more affected by the virus.
But with no comprehensive data about the ethnicity of those who have died as a result of the virus publicly available, critics said the failure to publish the information could create the impression that the problem doesn’t exist.
A Guardian analysis found that of 53 NHS staff known to have died in the pandemic so far, 68% were BAME
Moreover, if there is a different in mortality rates then we need to understand it so it can be tackled irrespective of whether there are genetic or societal causes.
While the proportion of people from a minority ethnic background is higher in the NHS – 20%, rising to 44% for medical staff – the respective mortality rate, like the proportion of critical care admissions, is out of kilter.
Asian and black patients are over-represented in critical care and account for a third of patients in hospital, despite making up a quarter of the population in the same areas. A study of 3,883 patients in critical care with Covid-19 from the Intensive Care National Audit and Research Centre showed that BAME patients accounted for 33.6% of patients with the virus, despite accounting for just 14% of the population, according to the 2011 census.
Responding to the inquiry, Chaand Nagpaul, chair of the British Medical Association (BMA) said:
“We are pleased that the government has heeded the BMA’s call for this review. However, if the review is to have any meaningful impact, it needs to be informed with real-time data to understand why and how this deadly virus can have such a tragic disproportionate toll on our BAME communities and healthcare workers. This must include daily updates on ethnicity, circumstance and all protected characteristics of all patients in hospital as well as levels of illness in the community, which is not currently recorded.
“It also means taking vital steps now to protect our BAME communities until we can develop a detailed understanding of the threats they face. This could include that those at greatest risk, including older and retired doctors, are not working in potentially infectious settings.”
One truth is clear.
Don’t believe anyone who tells you to keep politics out of this. Who dies and how many die is massively political!!
The right wing does not keep politics out of it.
Let us remember that the Tory Toby Young wrote that:
“the cost of the economic bailout Rishi Sunack (sic) has proposed is too high. Spending that kind of money to extend the lives of a few hundred thousand mostly elderly people with underlying health problems by one or two years is a mistake.”
Appendix: How many have died?
Deaths have always happened on one day and been recorded in some cases on another. In many cases the causes of deaths are complex. Some causes of deaths are always at least partially hidden. Some deaths have always been avoidable. For example there is no logical reason why more people die in winter in southern Europe, but death rates are nearer to constant in the colder northern countries. It is mostly down to poor insulation and fuel poverty.
In the UK, Covid-19 has all these elements.
The Department of Health and Social Care (DHSC) release daily updates on the GOV.UK website, reporting the number of deaths occurring in hospitals in the UK among patients who have tested positive for coronavirus. So, to count you must die in hospital and you have to have been tested. And some hospitals’ reporting lags.
On one day, 17 March, there were 69 Covid-19 deaths reported on GOV.UK, 29 deaths registered, 89 deaths that occurred based on those registered up to 20 March, and 120 deaths based on those registered up to 25 March. This involves mapping registered deaths back to date of death.
On the other hand, Office for National Statistics (ONS) figures by actual date of death (death occurrence) tend to be higher than the GOV.UK figures for the same day. This is because they include:
· all deaths where Covid-19 was mentioned on the death certificate, even if only suspected: the GOV.UK figures are only those deaths where the patient had a positive test result
· deaths that happened anywhere in England and Wales, for example some might be in care homes: the GOV.UK figures are only those that happened in hospital.
How much higher the latest ONS occurrence figure is compared to the GOV.UK figure depends on how much time has passed for the deaths to be registered. For the more recent days, not even all the deaths reported by hospitals had yet been registered, so the ONS figures are lower.
OK so I could not avoid the boring statistical stuff.
Knowing the exact number of people whose death involved coronavirus (Covid‑19) is of great consequence, but it’s not a straightforward question.
The Office for National Statistics includes cases of suspected Covid-19, where there was no test, but these are only 1% of cases. When they talk of Covid-19 deaths they use the term “due to Covid-19” when referring only to deaths with an underlying cause of death as Covid-19, and use the term “involving Covid-19” when referring to deaths that had Covid-19 mentioned anywhere on the death certificate, whether as underlying cause or not.
Related Material
ONS
Canary
Care Homes
https://time.com/5820510/uk-coronavirus-deaths-nursing-home/
https://blogs.lse.ac.uk/politicsandpolicy/care-home-deaths-covid19/
DNR
https://www.bihr.org.uk/blog/the-fight-against-covid-19-whose-life-counts..
BAME
Ian Malcolm-Walker
