The curse of care homes

Internationally much has been said in the last week about a wave of COVID-19 in care homes. My Canadian cousin said it showed how dangerous they are, though of course it just shows that they are full of the elderly, the main target group of SARS-CoV-2.

As with so much of the current situation, it’s as if journalists are studiously avoiding the important questions, in favour of secondary matters like whether it shows Britain’s (or America’s or Canada’s) victim numbers have been fudged – which they haven’t, as numerous scientific people have explained – or why care home residents haven’t been protected by some talismanic effect of “more testing.”

The truth is, surely, that people are dying with Coronavirus in care homes because the hospitals, with plenty of spare capacity, have decided in each case that admission for intensive treatment would not not benefit them and would even be be cruel. Or maybe the care managers, the relatives, or the patients themselves have realized that heroic hospital treatment would be a non-starter. Given the present atmosphere of fear, when managers must be tempted to offload all the risks they can, keeping sufferers at home to die must be a serious decision in every case.

So the care home deaths, in general, are nothing to do with lack of proper treatment, but with the truth that, for many very elderly and frail patients, the serious manifestions of the virus are predictably incurable.

It’s worth remembering, once more, that assumed COVID-19 deaths are still not far above the excess deaths for an average winter (17,000 in the UK, compared to around 27,000 COVID deaths in this wave so far). Yet only 2 years ago, when the flu vaccine was relatively ineffective, the excess death figure was 50,000 – double that which is now causing economic and social chaos, though admittedly spread over a longer and colder period. I’ve said before that we were barely aware of Hong Kong flu killing 80,000 Britons back in 1968-9, and have long forgotten it. But my wife has even forgotten the bad winter of 2018, though she herself was a recipient of the useless vaccination: I only remember it because of my residual professional interest.

As I have said in previous posts, the only way to prevent care home deaths, prior to the this-year-next-year-sometime-never hopes of a vaccine, is to keep residents entirely separated from the virus by strict quarantine.

Government scientists point out that the current problem has been that residential care is intrinsically “leaky”: not only are there necessary lines of mixing within homes, but staff must come in from outside, as must support workers and relatives. This is compounded by sickness and chronic shortages in the system, making many homes dependent on “bank” staff, who like specialist services inevitably move between many such institutions.

The only remedy, then, is (in cloud-cuckoo land) an even stricter general lockdown of society, which has manifestly failed so far to protect care home residents. More realistically one could institute more effective local quarantine measures surrounding the homes themselves. It is hard to see alternatives within the latter to extreme “social distancing” between residents, and between them and staff. And of course, restriction of outside visiting means separation from families in the interests of preventing one infection sinking the whole ship again.

In my first, March 13th, post on this subject, I challenged the whole idea of lockdown on the basis that “society” and “economy” are not, in fact, useful optional additions to human existence: they are human existence. I was made aware of that in researching the business of original sin for my two books. I have often quoted the late Sir Roger Scruton on this:

Communities are not formed through the fusion or agreement of rational individuals; it is rational individuals who are formed through communities.

This is particularly significant when we are talking about the frail elderly, and especially (like a majority in care homes) those with various degrees of dementia. They are no longer involved in meaningful work, and they are incapable of much physical activity (unlike the fortunate minority such as the centenarian ex-soldier who has raised millions, and had a number one hit record, by walking round his garden 100 times on his Zimmer frame). Furthermore, the internal life of the mind is inevitably restricted with age, and seriously so in the case of dementia. Effectively, what gives life any human meaning whatever for these folk is the core activity of human interaction. When rational speech fails, the main modality for social contact is that of touch.

That was brought home to me as a new doctor by an elderly patient, usually living alone, whose illness and fear of hospital was offset by the joy that other human beings – the nurses, and even this examining doctor – actually touched her. Many readers will not only be missing hugs from family – even a handshake or the exchange of a few coins or a coffee-cup would be welcome.

Needless to say, this inbuilt need for real contact is, by definition, the antithesis of “social distancing.” I imagine that even chimps prevented from mutual grooming would soon become neurotic. “Protecting the elderly” by effective quarantine, then, is hard to envisage as anything other than torture by sensory deprivation.

But of course, we hear in vague terms, this discipline will only be necessary until we have “beaten the virus” by an effective vaccine, at which point we presume COVID-19 will sign an unconditional surrender treaty, whilst its ringleader will commit suicide in a bunker in Wuhan City. Demobbed NHS doctors will be photographed kissing girls in a bunting-bedecked Piccadilly Circus, and the street-parties postponed for VE-Day commemorations will be reinstated, only with 2 metres between each child’s banana sandwiches – we’ll have learned the permanent lesson that “”you can never be too careful” for appropriate social distancing.

It’s nonsense, of course. We have had influenza vaccination for decades, and a large proportion of the British population now receives it – not only the elderly and children, but all professionals in contact with them, those with chronic illnesses and diabetes, and even yours truly whose only crime, since leaving the medical profession, is to be over 65.

And yet, discounting the forgotten disaster years like 2018, flu vaccine protects only 40-60% of people across the board. That figure is far, far, lower in the elderly frail, which is why each winter sees a large excess mortality amongst them, despite their lining up dutifully for their flu vaccinations. In fact, last winter was a relatively light one for influenza: it may well be that the grim reaper is belatedly picking up through COVID-19 those whom he would usually have taken by flu.

Even if the first attempt at a COVID-19 were, miraculously, both effective and safe, it would on the evidence of history protect only a minority of those care-home residents who were, from the start of the pandemic, recognised as the most vulnerable.

So what realistic policy aims are being pursued here? The goal of protecting NHS capacity was a reasonable one, though already offset by the increasing deaths from people kept on hold for other conditions: one study suggests there will be 17,000 unnecessary UK cancer deaths next year, and many of those will be productive providers and carers for families, and key economic workers, rather than retired people).

But it’s not yet clear to me that there will be a significant decrease overall in deaths from COVID-19 by vain attempts to stop it doing what it was designed to do – to reproduce itself effectively through populations.

As I’ve said before, there are good reasons why nature gave the human race immune systems rather than effective social distancing.

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About Jon Garvey

Training in medicine (which was my career), social psychology and theology. Interests in most things, but especially the science-faith interface. The rest of my time, though, is spent writing, playing and recording music.
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