Faced with the horrific threat of turning away babies from hospital in a Covid outbreak, paediatrician Dr Renee Liang is dismayed at Sir John Key’s blithe talk of patients’ ‘choices and consequences’.
When I read this weekend’s comments from Sir John Key, my heart sank. As a senior doctor who has worked through NZ’s pandemic response, and seen the careful machinations of our preparation up close, I know our Covid 19 response works.
But Key’s piece is riddled with errors at both policy and scientific level. It was careless and cheap. It disrespected a huge number of people who have been working hard for all of us. It was deeply disappointing, and it may yet do us enormous unseen harm. Let me explain.
I’m making this piece personal because this pandemic has been personal for all of us, in ways that are similar yet individualised.
For me, my first response was fear when it became clear just how serious the pandemic was in the summer of 2019/20.
Fear because I had already heard that healthcare workers were often the ones dying, due to preventable system failures such as lack of adequate protective gear. I was also scared I would have to isolate myself from family to protect them, and worried that I would not have the resilience and stamina to cope with the long hours I knew were coming. I was anxious for my colleagues, who were already exhausted from the stress of working in a healthcare system that had been fragile and overloaded for some time.
We all know what happened next – the first lockdown and subsequent elimination strategy has been enough to keep us relatively buoyant economically and socially – at least in comparison to the rest of the world.
It was also enough to keep from overloading the healthcare system this time round, and crucially bought us time to cobble together better physical structures to deal with potentially hundreds of critically unwell people.
If you’ve heard the metaphor about building the plane while flying it through a storm, this is indeed true of every country’s response to Covid 19.
It isn’t just physical buildings and specialised equipment that our health system lacks. Due to chronic underinvestment by successive governments – including Key’s three terms – our IT systems are ludicrously outdated. For example, I’m still using Microsoft Internet Explorer decades after most organisations ditched it.
But in NZ’s case the image can be extended. Think of trying to build this state of the art machine using vintage tools and materials that can charitably be described as worn. That’s our health system. By the time we reached 2019, the system had already been struggling for several decades.
The physical structures were leaky, with corrupt sewage systems, rooms without piped oxygen or proper ventilation, and ward layouts incompatible with modern infection control standards. You’ve probably heard that part – the media loves headlines like ‘Sewage coming through the ceiling’.
But that’s the relatively easy part to fix, as evidenced by the sudden pandemic enthusiasm for building new wards and partitioning up existing ones. Equipment, too, is an easy fix – buying beds and ventilators is just a matter of releasing more funds, and this happened.
But it isn’t just physical buildings and specialised equipment that our health system lacks. Due to chronic underinvestment by successive governments – including Key’s three terms – our IT systems are ludicrously outdated. For example, I’m still using Microsoft Internet Explorer decades after most organisations ditched it. The reason, we’re told, is that our security systems were ‘built to work with this browser’.
IT and physical structures can be quickly fixed, if there is money. But staff are not as easy to replace or update. This is why suggestions such as ‘build up our hospital capacity and workforce’ not only come off as blithely ignorant and simplistic, it also ignores the chronic and systemic issues underlying our health system.
Being forced to use a laggy program where cumulative hours are wasted each week waiting for it to load doesn’t protect us from IT breaches – as seen in the Waikato DHB malware crash only a few months ago. Waiting for computers to load crucial results is just one of the many micro stresses that affect staff during a normal workday. Well, at least we don’t have to fax any more – they were phased out as a routine form of communication last month.
Which brings me to the point. IT and physical structures can be quickly fixed, if there is money. But staff are not as easy to replace or update. This is why suggestions such as ‘build up our hospital capacity and workforce’ not only come off as blithely ignorant and simplistic, it also ignores the chronic and systemic issues underlying our health system.
Let me provide an illustration of just how fragile our current health system is.
Just six weeks ago, before the current lockdown and with no Covid-19 in the community, all the hospitals around the country were chock-full of sick kids and elderly. They had seasonal viruses which had reached deep into vulnerable lungs. The ‘RSV outbreak’, as it was known, was a slightly heavier version of something that happens every winter (except 2020 when we were in lockdown and no one was transmitting anything.)
Our wards were slammed. The intensive care units in every regional hospital were full of kids on assisted ventilation (typically kids will recover after a few days of extra support.) The tertiary paediatric intensive care units (Starship, Christchurch and Wellington) were full too and not accepting any transfers. We started ward rounds early every morning, trying to discharge anyone who was ready so we’d have room to admit the afternoon wave of patients.
We coped and the kids got good care, and one silver lining to the lockdown is that it stopped transmission of all viruses (yes, science works). But there was a knock-on effect.
Staff got sick from having patients cough on them and took time off. We reshuffled rosters to get more staff cover, which mean cancelling outpatient clinics.
I spent hours on the phone trying to convince colleagues at a tertiary receiving hospital to take my patient, who was very unwell and needed to be in a Paediatric Intensive Care. They told me their beds were already full.
Meetings scheduled to keep us up to date with best practice and give peer feedback to keep everyone making safe decisions were cancelled as we were too busy to attend. Experienced nurses were taken off outreach duties – visiting our sickest and most vulnerable families in the communities – because they were needed to staff the wards. Elective surgeries were cancelled.
If it wasn’t clear when I mentioned this the first time, this kind of event is not unusual – it happens to a greater or lesser extent every year. At an individual level, this means I might have to tell the mother of a baby ready for discharge that he can’t go home because his hernia surgery has been postponed.
A few weeks ago, I spent hours on the phone trying to convince colleagues at a tertiary receiving hospital to take my patient, who was very unwell and needed to be in Paediatric Intensive Care. They told me their beds were already full and we’d have to manage her ourselves – so we asked our already fatigued nurses to work a double shift so we could provide the one on one care needed.
Imagine what would happen if even a small spike in Covid-19 occurred. Our ICUs and wards would quickly fill up. A ventilated Covid-19 patient can occupy an ICU bed for months. Regional hospitals typically have 10 to 12 beds in their ICU. The system wouldn’t take long to crack open.
Would I then have to tell the parents of a baby that needed ventilation for a different reason, that I couldn’t offer that treatment? Would I have to offer less than optimal care? The thought is horrific, but it already happens overseas.
Enough kids are becoming infected that we’re starting to understand the range of symptoms they present with. Our New South Wales colleagues tell us that kids with Covid-19 often need admission to treat vomiting and dehydration. They also get the respiratory issues, albeit not usually to the point of needing ventilation (though deaths are now commonly reported for children in the US and UK).
What if we also had to look after kids with Covid-19? There’s a perception still floating around that kids can’t catch Covid-19 – but they can. Recent figures from the US show that 15.5 percent of all Covid-19 cases are children, and this is likely to be under-reporting due to the fact that kids aren’t swabbed as often. (Kids make up 22% of the US population).
The Delta strain doesn’t seem to affect kids worse than other strains of the Covid 19 virus, but it’s more transmissible. Enough kids are becoming infected that we’re starting to understand the range of symptoms they present with.
Our New South Wales colleagues tell us that kids with Covid-19 often need admission to treat vomiting and dehydration. They also get the respiratory issues, albeit not usually to the point of needing ventilation (though deaths are now commonly reported for children in the US and UK).
What is worrying are the post-viral effects: an unknown multisystem inflammatory condition known as PIMS-TS or MIS-C, and a poorly understood set of symptoms known as ‘long Covid’.
The information around this is still evolving but a paper released last week which analysed available studies suggested that children with Covid-19 suffer from long term physical effects such as difficulty concentrating, fatigue, sleep issues and sensory issues for months and possibly longer.
Having Covid-19 in communities has been shown to affect the social fabric protecting children, leading to long term mental, physiological, behavioural and academic disturbances. We just don’t know the full extent of the issue, and there’s currently debate about whether long Covid affects kids less than adults – early data suggested this but new data coming in suggests kids and adults suffer at similar rates.
As long as the vaccine can’t be given to children (although signs are hopeful that the current Pfizer trials underway will soon prove the vaccine safe and effective in children), we paediatricians worry. We worry about the strain on our already fragile healthcare system. We worry that the longer term effects of Covid in children are still unknown and could be underestimated. We worry that if borders open too hastily, our kids will be sitting ducks along with the elderly and the immuno-compromised.
There are other concerns too.
As paediatricians, we see the effects of inequity and child poverty daily. It is well established that worldwide, the populations most affected by Covid and most likely to die from it are those living under socioeconomic strain and indigenous populations.
John Key’s statement that “we each make our choices and live with the consequences” betrays his white privilege. It is all the more galling that the people who have been working the hardest throughout our pandemic response are those working to care for Māori, Pasifika and migrant groups. They know their people and should be the ones advising on strategy, not a rich private citizen with far too many reckons. Key’s suggestion of offering an incentive of $25 is not only simplistic, it is insulting.
From what I have seen, the communities themselves understand the issues and the urgency and have already used many innovative strategies to engage with their most reluctant members. A token payment may be part of the solution for a few hard to reach groups – but that is because $25 might pay for petrol to get to an appointment, or cover a basic bill.
Trust and understanding are more what is needed, and this takes time and insider knowledge. We must let those who know their communities lead the response to stamp out the few remaining pockets of community transmission. We must resource them accordingly.
Key’s ignorance shows in other ways. His comment, “if you are vaccinated, your chances of being hospitalised or dying from Covid are slim” is factually correct, and I applaud him for promoting vaccination at least.
But he is incorrect in implying that vaccination alone will keep us safe. All other pandemics have ended only after people also acted socially, looking after each other for the good of the group – I’m talking masks, contact-tracing, and judicious use of isolation and lockdowns.
I’m heartened by Minister Chris Hipkins’ assertion that “even if the vaccination rate reaches 90 per cent, what the government would then look at is who is in the 10 per cent group that isn’t vaccinated”.
Minister Hipkins also repeated that lockdowns and strict border controls aren’t a long-term plan going forward. But having a scheduled “opening time” as Key has suggested is like making a rash promise before all the facts are known.
It’s a delicate balancing act. Far too easy to criticise from the outside.
Cheap political shots aside, Key’s use of emotive terms such as “ruling by fear” is irresponsible and risks undermining our collective resolve just as our goal is in sight. Key knows he still has significant social capital. To use it to spread inaccurate ideas and play on our worries shows the type of leader he was, and remains.
I’ll end by echoing Key’s closing paragraph, with a few changes.
For those who say our current strategy is too hard, or too risky I ask this:
One day, when we are in the middle of a Covid surge and someone has to explain that your child can’t have the health care they need, what will you think? Will you wish that you had known the effect opening up too soon would have on our healthcare system? Would you wish you knew more of the risks of Covid in children?
We can succeed. We’re already acting with urgency and creativity. We just need to walk in the shoes of others and look after each other.