Nova Scotia’s long-term care facilities are closed to visitors, casinos are closed, public schools are closed and as of tomorrow restaurants will be restricted to take-out only and “drinking establishments” will also close. Why? To try to stop the spread of COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Most people who contract it will not need to be hospitalized (many might not even realize they are ill) but an estimated 20% of those infected will need to go to hospital and some portion of them will require treatment in intensive care.
The virus is particularly dangerous to the elderly and those with underlying medical conditions and it’s very contagious. Nova Scotians are being advised by the federal and provincial health authorities to stay home if they possibly can and I would like to do my part and share my top three reasons for doing so:
Reason #1: Healthcare System Capacity
Nova Scotia’s healthcare system is already over taxed, we did not need a pandemic to tell us that. Doctor shortages, hospital bed shortages and emergency department closures have been a subject of discussion for as long as I’ve been back in Nova Scotia, which means, for at least a decade.
Paul Schneidereit explored a pretty exhaustive list of factors that could affect our healthcare system’s response to the pandemic in the Chronicle Herald last week — including graphs showing that people in many areas of the province are still in search of a family doctor (although the Eastern Zone of the Nova Scotia Health Authority, which includes Cape Breton, represents a relative bright spot, with “only” 4,433 people on the waiting list.)
Another factor is hospital capacity, which I’m going to break down into a couple of sub-reasons:
(a) Ventilators
The US Centers for Disease Controls (CDC) is cautious about making definitive statements about COVID-19, but it notes that based on cases to date, 20-30% of hospitalized patients with COVID-19 and pneumonia have required intensive care for respiratory support. The reason we’re being encouraged to “flatten the curve” is largely to ensure there is no sharp spike in patients requiring ICU beds and ventilators.
In an October 2019 research paper entitled, “Preparing intensive care for the next pandemic influenza,” authors Taylor Kain and Robert Fowler noted:
Even in most well-developed countries, ICU beds are often close to capacity, and it is likely that in a severe influenza pandemic many patients who require a ventilator may not have access to one. Severe acute respiratory distress syndrome (SARS) gave a small-scale example of this. SARS resulted in 8096 cases globally, with only 251 in Canada [32]. Despite this, resources were critically stretched. In Ontario, every negative pressure room in the province was occupied with more patients awaiting at home during the height of the pandemic [33].
The last detailed survey of critical care capacity in Canada was conducted by the Canadian Critical Care Trials Group after the 2009-2010 H1N1 outbreak and concluded the country had 3,170 ICU beds capable of “invasive ventilation” (this means ventilation involving the insertion of a tube rather than simply the use of a mask) and 4,982 ventilators capable of invasive ventilation.
Interestingly (I mean, given our seemingly eternal “have-not” status), Atlantic Canadian provinces were better equipped than most 10 years ago:
Source: Critical Care Capacity in Canada
Robert Fowler, a scientist at the Sunnybrook Research Institute in Toronto and a co-author of that report, told the Globe and Mail this week that the ventilator supply was “stretched thin” during the H1N1 outbreak, but that he believed provinces have since increased their inventories.
This seems to be the case for Nova Scotia, which had 197 ventilators according to the survey and now, according to what Premier Stephen McNeil told reporters last week, has 240 and has ordered 140 more.
I found a Government of Nova Scotia request for proposals (RFP) for ventilators dated 22 October 2019 (as in, two months before the first cases of the pneumonia that would become known as COVID-19 were reported to the WHO.) Presumably, these are among the 240 we now have:
(b) ICU beds
During Tuesday’s coronavirus briefing, Premier Stephen McNeil confirmed that the province has 120 ICU beds, while the IWK has an additional 7 pediatric ICU beds and 40 neo-natal ICU beds that president and CEO Dr. Krista Jangaard says can be “repurposed” for sick adults. That makes for a total of 167 ICU beds. According to the Nova Scotia Health Authority’s 2018-19 Annual Report, the province has a total of 3,150 hospital beds “staffed and in operation,” which means ICU beds represent 5.3% of overall hospital beds in the province.
I’ve been reading about the brutal COVID-19 outbreak in Lombardy, Italy, thanks to a recently published article — Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy –and while I realize I must proceed with caution, there are a few points that seem worth making.
For instance, “pre-crisis,” Lombardy’s 74 hospitals had about 720 ICU beds which represented only 2.9% of all hospital beds, serving a population of about 10 million. But — and this is an important “but” — as the authors of the article note:
[T]hese ICUs usually have 85% to 90% occupancy during the winter months.
The Cape Breton Regional Hospital (CBRH) is home to the “second-largest” ICU in the province. When expansion plans for the hospital were announced last March, it was explained the hospital has 23 “intermediate and critical care beds.” The term “critical care” refers to the ICU, the Coronary Care Unit and the Intermediate Care Unit. So let’s say we have 23 ICU beds at the CBRH.
The Post, reporting on the planned expansion, quoted the medical director of the ICU, Dr. David Brake, who noted that the unit:
…looks the same today as it did when the hospital opened [in 1995], while the community’s needs have changed.
“We have more patients than we have beds, and that impacts patient care and impacts patients’ families,” he said. “Our ICU no longer meets the current standards.”
“We have more patients than we have beds” in non-pandemic times — as do many ICUs across the country.
In Lombardy, the COVID-19 Lombardy ICU Network, established to coordinate the critical care response to the outbreak, identified increasing ICU “surge” capacity as a priority:
…to quickly make available ICU beds and available personnel, nonurgent procedures were canceled and another 200 ICU beds were made available and staffed in the following 10 days. In total, over the first 18 days, the network created 482 ICU beds ready for patients.
Dr. Brendan Carr, president and CEO of the Nova Scotia Health Authority, said they are now in the process of freeing up capacity (beds and personnel). Non-urgent or elective surgeries have been postponed indefinitely; where possible, patients are being moved to safer places to free up beds; and hospitals are creating “cohort” units to be used exclusively for COVID-19 patients. (He didn’t offer any further detail as to what type of patients are being moved or where they were being moved, just that it was a difficult process, which I can well imagine it is.)
If you’re wondering how you can help, it’s easy: stay home (if you can) and practice social distancing (if you can’t) and wash your hands (in either case). Do what you can to ensure there is no sudden spike in hospitalizations due to COVID-19 because nobody said during Tuesday’s press briefing how many of those 23 critical care beds at the CBRH were currently occupied but it is entirely possible they all are.
Reason #2: Demographics
Schneidereit, in the Herald article mentioned above, also noted that hundreds of Nova Scotian doctors have postponed retirement “so as not to abandon their patients,” with the result that the province’s College of Physicians and Surgeons lists 282 licensed doctors over the age of 65 — including 115 over the age of 71.
But it’s the demographics of the population at large that are particularly concerning, given that COVID-19 is a disease that can be deadly for the elderly. Consider, for example, that Italy, the European country (so far) hardest hit by the virus is also the European country with the oldest population –23% over the age of 65 and a median age of 47.3
Now consider that in the Cape Breton Regional Municipality, 24% of the population is over the age of 65 and the median age here is 50.
Mind you, an ageing population in and of itself cannot explain what happened in Italy, as Haaretz noted, Japan’s population is even older, and it hasn’t seen as severe an outbreak — yet. I have to put an asterisk by this because Japan also hasn’t been testing extensively and as of Monday, the city of Nagoya was reporting that coronavirus patients were overwhelming its hospitals:
Confirmed coronavirus cases in Nagoya, the capital of Aichi prefecture, totaled 98 as of Sunday, the official said, far exceeding the city’s 27 beds at hospitals that meet conditions for patients with the highly contagious disease.
And Japan, in passing, has more hospital beds per 1,000 inhabitants than almost any country in the world — 13.1 compared to 2.5 in Canada:
As best I can understand, it’s not that old people are more likely to get the virus, it’s that they are more severely affected by it if they do get it and much more likely to be killed by it. So if you want to do what you can to help older people — pick up their groceries or prescriptions for them (while practicing social distancing and remembering to wash your hands) — drop their supplies outside their doors; call them; or visit them through plate glass:
A message from me and my dad, @Melbrooks. #coronavirus #DontBeASpreader pic.twitter.com/Hqhc4fFXbe
— Max Brooks (@maxbrooksauthor) March 16, 2020
Reason #3: Pre-existing health conditions
In addition to old age, having a pre-existing (or “comorbid”) health condition puts you at greater risk from the coronavirus. A study by the Chinese Center for Disease Control, which put the overall death rate of COVID-19 at 2.3% (again, I must add an asterisk, because it is too early to know the actual death rate from the virus) noted:
While patients who reported no comorbid conditions had a case fatality rate of 0.9%, patients with comorbid conditions had much higher rates—10.5% for those with cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer.
Cape Breton has high rates of all those underlying conditions, as Dr. Andrew Lynk, then vice-president of medicine for the Cape Breton District Health Authority, told the CBC back in 2014:
…when it comes to heart disease, high blood pressure, lung disease and diabetes, hospital beds are full — and aging baby boomers have yet to hit the health-care system.
COVID-19 illustration, CDC, via Wikimedia Commons
Monika Dutt, then the district’s medical officer of health, told the CBC that the island’s economic conditions played a role in this:
“Are they able to afford their food? Can they afford their medication? If we can address poverty that would be better for people’s health than almost anything we can be doing in the health-care system,” she said.
The connection Dutt made, between poverty and illness, is at play in the coronavirus pandemic, as an article in the New York Times made plain this week. The paper noted in its “Interpreter” section “people at the lower ends of society are about 10 percent likelier to have a chronic health condition” and they tend to develop such conditions earlier in life:
At the same time, people with lower incomes tend to develop chronic health conditions between five and 15 years earlier in life, research finds.
Put another way: Health organizations have said that people over 70 are at drastically greater risk of dying from the coronavirus.
But the research on chronic health conditions suggests that the threshold may be as low as age 55 for people of lower socioeconomic status.
That is brutal — and it gets worse, because people working low-income jobs are also the most likely to work when sick — or when told to stay home — because they can’t afford to lose the money.
In Italy…taxi drivers — already struggling on hourly wages undercut by the rise of ride-hailing services — scour for fares amid the outbreak.
“I have got a mortgage, bills and groceries to pay,” said Andrea Arcangeli, a taxi driver and father of two from Rome. “I can’t stay home.” He said he had made only 18 euros — about $20 — in a day’s work.
So if you have an underlying condition that puts you at greater risk from contracting the virus — or if you are in close contact with someone who has such a condition — stay home (if you can), practice social distancing (if you can’t), wash your hands in either case.
But most of all, in this situation, demand better from our society.
I have more to say about this, but I’m going to put it in another article.
Go wash your hands and I’ll meet you back here in 20 seconds…
