WHEN IT COMES TO HEALTH, PRICE OF CAUTION CAN BE HIGH
One need only drive around to see the economic costs caused by the health response to the COVID-19 pandemic.
Favourite restaurants and neighbourhood pubs are permanently closed, boutiques are shuttered. The life dreams of those who owned and operated these small businesses are in tatters, their employees are out of work.
Society weighed the costs and determined the hardships caused by the economic shutdown were less costly than the many more people whose lives would have been cut short had the stay-athome orders not been in place.
When it comes to health care, the price of caution is less clear, writes Dr. David Zitner, in a new paper released by the Macdonald-laurier Institute entitled: Assessing the ‘price of caution’ during the COVID-19 pandemic.
“Reduced access harmed the health of those who suffered because important and vital care was delayed,” writes Zitner, a retired family physician and the founding director of the Graduate Program in Health Informatics at Dalhousie University, where he also worked as a professor.
“Tangential evidence suggests that in the United States there was probably an underestimate of both the number of COVID-19 deaths and the increased deaths related to rationing interventions aimed at reducing COVID-19 mortality and morbidity,” states the report.
Basically, more people died waiting for medical care than otherwise would have had health care not been limited so drastically throughout the pandemic.
I have interviewed and written about the grieving family of Jerry Dunham, who died in hospital from heart failure in Medicine Hat at the age of 46, after a procedure to install a defibrillator was postponed as a result of the COVID-19 lockdown that cancelled all “non-essential” surgeries.
On a Facebook post a couple of months before his untimely death, Dunham wrote:
“I was basically told that the government is willing to risk my life to save my life. Let me say that again, my government told me they’re willing to let me die, which according to them is for my own safety.”
Twenty-three days after Dunham’s death on June 7, a spokesperson with Alberta Health wrote in answer to Postmedia questions: “All urgent, emergency and cancer surgeries have been available throughout the pandemic. Albertans who need urgent surgery will get it. AHS has indicated that they are not aware of any deaths due to cancellations of scheduled surgeries.”
This obviously false information is a significant flaw in our medical system, says Zitner.
On Thursday, a spokesperson for Alberta Health Services said “we are conducting an internal review” related to Dunham’s death. “We are not aware of other patients who have died while on the wait-list for surgery, due to scheduled surgery postponements.
“We’ve continued to perform both urgent and emergent surgeries at a consistent rate and volume during the COVID-19 pandemic as we did during PRECOVID-19. In Alberta, AHS has continued to perform emergent and urgent surgeries. We reduced our overall surgical volumes by about 60 per cent.”
By comparison, the Ontario surgery resumption plan noted that some sites/areas of Ontario reduced surgical volumes by almost 90 per cent and focused on emergency surgeries only.
Modelling in Ontario estimated that the cancellation of elective heart surgeries would result in more than 30 deaths by early May, but there are no precise figures because that information is not collected.
In the United States, deaths between March 1 and April 25 “were substantially higher than would have been expected based on deaths in the similar period in previous years,” says Zitner.
One study documented that COVID-19 deaths accounted for only two-thirds of the increase in overall deaths. Another study, using data from March 1 to May 30, “and taking into account death reporting delays, estimates that the figure of documented COVID deaths accounts for 78 per cent of excess deaths, or three-quarters of the total. Presumably the remaining excess deaths are related to cases of undocumented COVID and deaths related to reduced access to appropriate care. It would be useful to know the extent of benefit or harm, in Canada, from reducing access to care,” he writes.
Frankly, it would be more than useful. It might, in fact, be vital for when the next global pandemic comes along. Perhaps next time we will leave entire hospitals open to perform more surgeries, so people like Dunham don’t die while they’re being protected from a virus they might have otherwise survived.
“A rational system, using the opportunity from COVID, would record and report the health consequences of these delays. What was the excess mortality (how many more people died) unrelated to COVID? What were the characteristics of people harmed because they had to wait too long? What were the characteristics of people on waiting lists for tests or treatment who spontaneously recovered and therefore did not receive superfluous or potentially harmful care?”
During a telephone interview on Thursday, Zitner pointed out that we’re all asked numerous questions any time we visit with a doctor. How much more onerous would it be to collect this pertinent data? He thinks it would be quite easy to collect but crucial for policy-makers.
In health care, politicians and administrators “operate in shade, missing the vital, nuanced information necessary to make and understand the results of policy choices,” states Zitner.
All information needs to be looked at to weigh the pros and cons of a pandemic response in the future.
“People who quarantine travel less. In California, traffic injuries and deaths decreased by 50 per cent following the state’s stayat-home order. It appears that quarantine and handwashing also reduced the frequency of other infectious diseases,” and
“reduced access to care also benefited those people who spontaneously improved while waiting for care. They avoided the harms of unnecessary tests and treatments,” states the report.
It would be worthwhile if communities adopted systems to inform the “price of caution.” What are the mental-health (including suicide) consequences of shutting down an economy? What are the health consequences of reducing routine hospital capacity to cater to potential COVID-19 cases?
“The COVID pandemic exposed deficits in existing Canadian health care and health information infrastructure,” states Zitner.
Dr. Deena Hinshaw, Alberta’s chief medical officer of health, along with health officials and policy-makers all around the world, are trying to come up with back-to-school plans that attempt to weigh the price of caution against the price of reopening. If we had more information about health outcomes caused by the lockdown — including mental-health ones — these tough decisions might be made a lot easier for all of us.