Thursday, 21 January 2021

The NICE formula and the coronavirus

 The National Institute for Health and Care Excellence (NICE) has a formula for determining how much money the public purse can spend on treatments. It is twenty thousand pounds for one additional year of heathy life.

I do not know how much money has been devoted to combating the coronavirus, but it is a massive number. To take just one measure: the government’s response has ensured that the government will add almost four hundred billion pounds to public sector borrowing in this financial year. Another measure is the negative effect on the economy, which is the worst in three hundred years. Whatever the financial cost, it can only be represented in the kind of numbers used by astronomers.

Just as I do not know how much money is being devoted to combating the virus, neither do I know how many additional years of healthy life are being bought by all this money. However, I do know that life expectancy is eighty-one years, and that the average age of a coronavirus related death is almost eighty-two and a half years. The implication of this is that at a population level no years of additional life (healthy or otherwise) are being bought by all that money.

In fact, the situation is, of course, far worse than this because the money being spent on combating the virus is not only not buying additional years of life, it is costing years of healthy life as a result of all the harm caused by this misallocation of resources. Money spent on track and trace, for example, is money that cannot be spent on anything else, including health care.

Just thinking about the government’s response to the coronavirus, even without the detailed numbers, in terms of the NICE formula shows it to be completely irrational, irresponsible and incompetent: that is, if we take the government’s claim to be solely motivated by a concern to save lives.

Our government is at best irrational, irresponsible and incompetent. It could be worse.

Saturday, 9 January 2021

Preventing viral transmission by lockdowns: a lesson from Antarctica

The Antarctic research stations had for many decades shown the value of isolation as a means of preventing the transmission of viral respiratory illnesses. A small group of individuals are isolated until months later there arrives new personnel and supplies. When this happens, the station personnel are susceptible to colds for a period of ten to fourteen days. Then they are untroubled by colds, until the next arrival of new personnel and supplies. This is the usual pattern. However, it has happened that even after months of isolation the group can contract colds. One such outbreak was studied in depth, and the conclusion was the cause was unknown. The study is worth reading https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2130424/pdf/jhyg00082-0026.pdf

The obvious way the above study is relevant is in relation to the government’s commitment to the use of non-pharmaceutical interventions to control the virus, specifically its commitment to minimise social contact: stay at home, social distancing, face masks, shut downs, etc.

These interventions can never come anywhere near the complete isolation that occurs in the Antarctic research stations. No matter how draconian the measures a government introduced, there would still be millions of social contacts every day. These contacts would inevitably provide a virus (any virus) with a far more conducive environment for replication and disease causation than an isolated Antarctic research station. In other words we have had many decades of real world experience of the potential of lockdowns to prevent viral transmission, and that experience shows it does not work even in the most strict possible incarnation.

Lockdowns do not and can stop a virus. But the harms of lockdowns are obvious for all to see – which is probably why the government explicitly introduces each iteration of lockdown without any impact assessment. The lockdown policies cannot prevent transmission of the virus, but they certainly can and do kill people.

Sunday, 3 January 2021

Admitted to hospital in the time of the coronavirus

On Wednesday I fell off my bike and I could not get up. An ambulance was called for. I lay on the ice for an hour an a half before the ambulance arrived. I was put on a stretcher and taken to the local hospital. I spent three days and two hours in the hospital. This provided me with the opportunity to make a number of observations of how the responses to the virus have effected hospitals.


Shortly after arrival I had an X-ray. This showed that my hip was broken. An emergency doctor informed me that I needed an operation and would have to be admitted. A little later a young woman turned up and said she needed to take a test. I asked what the test was for. She told me it was a covid test. I said I did not want it. She told me I had to have the test. I said I did not want the test. She repeatedly asserted it had to be done and told me I had no choice. When she eventually realised that I was not going to submit, she stormed off, stating that she would report my refusal. A little later the emergency registrar arrived and told me that the test was mandatory. I told him about health care ethics (specifically the requirement for informed voluntary consent). He responded by talking about the time we a living in. So, I said, I have a broken hip and I can only get an operation if I submit to the test. Yes, he said. So I said that under protest I would submit. He told me that he would note my protest. A little later, a nurse (probably a senior practitioner), turned up. She very gently swabbed a nostril and the inside of my mouth. The result would take the lab a couple of days. I was then admitted to the hospital and transferred from the emergency department to the orthopaedic ward.


My trip (on a stretcher) through the hospital revealed a scene very like the Emergency Department. This was not a bustling hospital. There were very few patients, the staff were anything but busy and whole sections were clearly not in use. In contrast, the Orthopaedic Ward appeared fairly normal with not too many empty beds. I was allocated a bed in a bay (room) for four beds, one of which was already occupied. The occupant was a ninety year old, who had fallen at home and broken his hip. The other beds were vacant.


The next day another patient was wheeled into the bay. He had fallen on ice (coincidentally very close to where I had fallen off my bike at almost the same time - he had attended as on out-patient the previous day). He had apparently torn tendons around his knee and needed an operation. 


Later that day the surgeon in charge of orthopaedic surgery visited the ward. He was very satirical about the covid 19 safety protocols, making much of how he donned and changed plastic aprons for each patient. When he spoke to me, he was very matter of fact and simply explained the options and asked which I preferred. I chose to have the break repaired by a plate and screws. And later that afternoon I was wheeled over to the operating theatre.


I was placed at eye level, strapped down and given a local anaesthetic. The surgical team consisted of at least fifteen people, although, as I could subsequently tell, at least a couple of them were there for training purposes. This team clearly had a high level of esprit de corps. There was little actual task focused talk and a substantial amount of repartee and banter. This helped to reduce my stress level. a little. Before they started the operation, I was asked if I would like some music to listen to. I asked for Carmina Burana, and received a blank look. So, I asked if they had Fleetwood Mac. They did and so I got to listen Stevie Nicks et al whilst they conducted the operation, which really helped with the stress.


After the operation, which had taken just over an hour or so, I was wheeled into the Recovery Room. There was one other patient, and I could see there were stations for a dozen patients. Other than for the purpose of complying with standard procedures, I could not see why I had been taken to the Recovery Room and I was only there for a few minutes before I was again being wheeled across the semi-deserted landscape that the hospital presented.


Back on the ward, I now had my first experience of hospital food. It was terrible. I ate it, not because I recognised it as food or out of hunger, but because I was seriously dehydrated, and one cannot rehydrate just by drinking water. I do not put down the awfulness of the food to the coronavirus responses, but the responses had got rid of all the means that patients had previously had of getting their own food - visits from relatives, bearing food from home or those charitable tea rooms that hospitals used to have.


There were many other things that were missing from a modern hospital. There were no televisions, news-stands, areas for patients to socialise, etc. And these absences were all clearly coronavirus responses.


In the morning I was briefly visited by occupational therapists. This started with surreal moment of amusement (for me, not the therapists). I was told they wanted to ask me for some personal information, so would I like the curtains around my bed to be closed. I pointed out that the curtains did not prevent the transmission of sound and invited them to ask away. They wanted to know about my home circumstances. I gave them the information and told them I wanted to go home. I asked for some crutches. They gave me a Zimmer frame, and promptly disappeared.


I practised walking around the ward. This resulted in the staff quickly offering me some less revealing clothing - they had cut off my clothes after the X-ray had revealed the broken hip and had only supplied me with theatre gown.


The next morning the therapists reappeared, this time with crutches. They expressed doubt about my ability to be able to get up and down stairs, which I would have to at home. I suggested we put it to the test. So, I was given the crutches and some instructions on how to use them, and invited walk up and down the ward, which I did. We then went off the ward to the nearest staircase and I used the crutches to ascend and descend. As these tasks were satisfactorily performed, I was told I could be discharged. This took several hours, due to booking an ambulance slot, completing the paperwork, and getting the drugs I would need from the pharmacy.


A big take away for me from this visit was that the staff were all compliant with the covid safety procedures that the hospital had put in place. But there were obvious differences in the level of enthusiasm for those procedures.


Just before I was discharged, the patient who had been admitted for the torn tendons was about to leave the hospital. It had started to snow and he was worrying that his sister-in-law, who was coming to collect him might have an accident in her car. I asked him why he hadn't opted to be taken home by ambulance in the first place. He told me that they (meaning the hospital) are overwhelmed. I obviously looked surprised because he immediately referred to a BBC story that he had viewed on his phone. The story showed a line of ambulances outside a hospital, which "proved" the NHS was overwhelmed.


"You have been in this hospital for days, and you been all over. You have seen parts are closed down. You seen there are hardly any patients. You have seen the staff are not even busy," I said.


"But its on the news!" he interjected.


"So, you see an image of ambulances outside a hospital and a reporter claiming that the image shows the NHS is overwhelmed and you prefer to believe that to the evidence for your own senses?"


"Well, no," he said.


"So what was the reason for not getting an ambulance in the first place?"


"What I said. They are over..." And then he shook his head. Cognitive dissonance is hard to see from the inside.