As I stood for the one minute’s silence this week, honouring our heroic health workers, I wondered whether we were inadvertently giving them an impossible task. The numbers suggest that we might be.
One of the more challenging aspects for the government in managing the coronavirus strategy is the sheer unreliability of the numbers. Different countries collect the data in different ways, so something as fundamental as the number of cases will be different depending on whether you use test, track and trace techniques, or simply use self, GP and institutional reporting. Different approaches can easily yield figures that differ by 50%, and the absence of an accurate antibody test mean that this confusion will last for some time. It makes the job of the most skilled statistician or data analyst very difficult, and complicates the task of assessing the effectiveness of any strategy.
Nevertheless, it is not entirely impossible, partly because the differences between some approaches yield such enormously different results.
The absolute test of the medical strategies is the death rate for every million of population. Even this is not perfect, because some countries may classify the deaths slightly differently, and there is the question of whether we include other deaths perhaps caused by treatment delays arising from coronavirus. But if we confine ourselves to the direct coronavirus fatalities, the difference between national strategies is so stark it overwhelms even the errors in the data.
The most famous case is of course South Korea, which has held its death toll to just 244 by an extraordinarily active interventionist policy. But so far the most astonishing success story is that of Taiwan. A densely populated country of nearly 24 million people, it had a total of six deaths. These amount to 4.7 deaths per million of the Korean population, and an astonishing 1 death per four million of the Taiwanese population. This compares with at least 316 deaths per million of the British population, as of Tuesday, and 348, 501 and 447 for France, Spain and Italy. And for Britain those are just the hospital deaths, not including those that happen in care homes.
There are two possible reasons for these differences in fatalities. One is that the Asian countries kept the infection rates much lower than the Western nations. The other is the so called case fatality rate, the number of deaths per thousand cases of coronavirus in a population.
Clearly the Western nations have not controlled the infection as closely as the Asian group, and that will inevitably lead to a much higher immediate death toll. The Swedish government would argue that high levels of infection, up to the herd immunity level, are inevitable, so all the Asian countries are doing is delaying the inevitable. We will not know whether they are right for some years, but the Swedish approach is a gamble we have decided not to take.
But the Swedish argument is irrelevant to the second component of the calculation, the deaths per thousand cases. This will be affected by factors such as the pre-existing illnesses in the population, and by the medical care available to coronavirus victims. It is the ability to deliver that medical care that has driven our government’s strategy, keeping the infection rate at a level that would not overwhelm the NHS.
Again the numbers vary by an extraordinarily amount. The Asian countries range from 1 death per thousand victims in Singapore, to 23 deaths per thousand in Korea, with both Hong Kong and Taiwan (and, interestingly, Australia) in the middle of this bracket.
We are in a different place altogether. On the reported deaths, Britain is losing 134 people per 1,000 victims, France, Italy and Spain 141, 135 and 103 respectively. This is an astonishing difference from the Asian average of about 10 deaths per thousand cases, too large to be explained by data errors. It is also too big to be explained by differences in preexisting population health levels. Along with the fact that there is a middle group including Germany and Norway of about 36 deaths per thousand cases, this strongly implies that something about the treatment strategy is not working.
But what? Clearly our front line medical staff are doing a heroic job. And unlike the Italians we have managed to avoid the system being overwhelmed. ICU utilisation stands at a relatively normal 81%. Many of our temporary Nightingale hospital beds are empty.
Last week, we got a clue from New York, which like us has a distressingly large number of coronavirus patients who die on respirators.
Richard Levitan, an expert respiratory specialist with 30 years of experience, had been volunteering in New York emergency medicine. In the New York Times he observed that the coronavirus patients he was observing were very different from normal pneumonia victims.
“A vast majority of Covid pneumonia patients I met had remarkably low oxygen saturations at triage – seemingly incompatible with life….. Although breathing fast, they had relatively minimal apparent distress, despite dangerously low oxygen levels and terrible pneumonia on chest X-rays.
Patients compensate for the low oxygen in their blood by breathing faster and deeper — and this happens without their realising it. This silent hypoxia, and the patient’s physiological response to it, causes even more inflammation and more air sacs to collapse, and the pneumonia worsens until oxygen levels plummet. In effect, patients are injuring their own lungs by breathing harder and harder. Twenty percent of Covid pneumonia patients then go on to a second and deadlier phase of lung injury. Fluid builds up and the lungs become stiff, carbon dioxide rises, and patients develop acute respiratory failure….
By the time patients have noticeable trouble breathing and present to the hospital with dangerously low oxygen levels, many will ultimately require a ventilator.
Silent hypoxia progressing rapidly to respiratory failure explains cases of Covid-19 patients dying suddenly after not feeling short of breath.”
In essence because the early stages of the coronavirus and its associated pneumonia were almost symptom free, patients were arriving very late at hospital, after their lungs had suffered potentially fatal damage, and therefore too late for medical care to be able to rescue them. The question that we must ask is, is the same happening in Britain? And can we prevent it?
We also now know that to minimise the strain on hospital resources we have been discharging patients too quickly back into care homes, thereby probably propagating the virus into the most vulnerable groups. Could it be that with the same aim, of reducing the pressure on the NHS, we have been accidentally rationing access to hospital until it is too late to treat the disease, presenting our doctors and nurses with an impossible problem?
Dr Levitan recommended mass use of pulse oximeters to detect the onset of the “silent” pneumonia. Almost inevitably this led to a shortage of pulse oximeters in New York.
It may be that the Korean approach, of requiring coronavirus cases to take their own temperature three times a day, and report it, is another way of catching the disease before it passes a critical point.
Maybe we can use the Nightingale hospitals that seem to be sitting empty as an ante room to the main hospitals so that we can spot the critical symptoms in time.
Either way, before we move on to the next stage the Prime Minister should be looking very hard at the practices in Asia, and in Norway, Austria, Finland, and Germany, to establish how they have maintained a death rate less than one third of ours, and adapt it to our own use as fast as possible. And give our NHS a better chance of victory.
David Davis is MP for Haltemprice and Howden and a former cabinet minister.