Health rationing and Covid

Over 30,000 people are in hospital in England with Covid. What does this mean?

The British Medical Association says doctors are stressed, anxious about their own health and that of their families, working more than normal hours and possibly beyond their competence in order to avoid serious harm. Final year medical students are fast-tracked, retired doctors are returning to practice. Doctors are working outside their normal specialty. The BMA drily states, “The skills of these professionals may not meet pre-pandemic expected standards of fitness to practise”.

The General Medical Council, appointed to govern doctors’ fitness to practise, reassures doctors that their careers will not necessarily be affected. They will take into account “the stress and tiredness that may affect judgment or behaviour”.

Hospitals lose their ability to admit patients for other matters. It is a terrible time to have a heart attack, stroke or cancer. GPs will be dealing with most health need, and so will cancel non-essential services, and use telephone or video consultations.

Where all facilities, equipment and staff that could be used to meet patient need are at capacity, “resource allocation decisions between individuals would become inescapable”. Rather than meeting individual need, the health service has to “maximise overall benefit”. This means refusing treatment to some patients. Normally, there is an “obligation to persevere in the face of an extremely ill patient”, leading to breaking ribs attempting to resuscitate a patient on ventilation. Some patients may have treatment withdrawn, even if they are slowly improving, to enable others to be treated, who have a “higher survival probability”.

It is lawful and ethical for a doctor to refuse potentially life-saving treatment where someone else is expected to benefit more from it. Doctors are not assessing the suggested value of a person to the community- younger or older, family responsibilities, work eminence- but their capacity physically to benefit. Individual doctors should be making these decisions according to rules set by their employers. The rules should be open and transparent.

Where care is withdrawn, patients will receive symptom management and end-of-life care for the dying. These decisions have a significant emotional effect on health workers.

Triage is a form of rationing of scarce resources. It sorts patients according to needs and probable outcomes. It can identify those who are so ill they are unlikely to survive, who will be given symptom relief. Priority “will be given to those whose conditions are the most urgent, the least complex, and who are likely to live the longest”.

These decisions should not solely be based on age or disability but likelihood of benefiting from available resources. Where patients cannot be admitted to intensive care they will not receive cardio-pulmonary resuscitation (CPR).

Where large numbers of people have apparently equal chances of survival and length of stay in ICU, at first there will be a queuing system- first come, first served. If patients are not improving, there may be a time-limited trial of therapy, and treatment withdrawn. In overwhelming demand, where a patient’s prognosis worsens care may be withdrawn.

Sometimes a patient’s contribution to essential services, where the workforce is severely depleted, may be taken in account. This means that sick doctors may be prioritized. Well, I would not object to that.

Hospitals are reporting shortages of oxygen. Blood oxygen saturation of 95% is considered normal, but in Southend the target was reduced, to 88-92%.

Cases in England are still rising, because of the Conservative government’s ridiculous promises of association indoors over Christmas, and failure to implement lockdown until after schools were opened on Monday 4th January. Deaths will continue to increase for four weeks. Hospitalisations will continue to increase for two weeks. Hospitals in London are overwhelmed. People who could have been saved with normal health resources will die.

The BMA’s FAQs are here. Their detailed guidance is here.

Fat-shaming and Healthism

Fat people can be as uncomfortable walking down the street as newly transitioned trans people- as vulnerable to abuse, and as hurt by it. Fat-shaming does no good: the advice “You’re too fat. It’s bad for you. Eat less, exercise more” sounds good, but everyone knows that stuff. It is a hurtful way of blaming fat people for their problems.

Don’t tell me the answer to my problems, it just gets me to self-blame more. I know what I ought to do, but cannot believe I would succeed, or motivate myself to try.

Though I noticed in my teens that my father would make helpful suggestions, I would dismiss them, and six months later be doing what he had proposed. I transitioned. It involved a lot of work with no certain end, over months, and I was motivated so I did it. Some people lose weight and keep it off.

I am swithering here. I need hope, and belief in possibilities. And I work on other things. But saying it is up to a traumatised person to deal with their problems creates a huge burden for them. Society should work to deal with our collective traumas.

The Guardian had an article against fat shaming, and the comments were almost all dismissive. Most upvotes went to dismissive comments:

-So being fat is an identity now?
-And medical advice is offensive.

“They know that stuff”, I commented. Someone replied, “So why do some people choose to ignore it, then?” “Sounds like common sense to me.” These decent, ordinary people don’t realise they are being hurtful, or perhaps believe they have to “be cruel to be kind”. “Normalising an unhealthy lifestyle is a ridiculous thing to do.”

Comfort eating does not tempt me. I do not overeat. A friend with a long apron and years of variable but too great weight would have a whole packet of biscuits, and “joke” to me about it- “You can’t have just one.” This was a person retired from a highly paid professional job. So I work my way into empathy: I know I have my own self-destructive avoidance behaviours, which I perform because they have value for me. They give me relief. I recognise the harm, and crave the relief. I have many problems, and am working on them, and do not need someone to point out just one and tell me, in a condescending manner, that I should work on that one in this obvious and simple way. And, I take that belief into myself: that I have not dealt with my problems better is a sign of weakness in me. I condemn myself, and my powerlessness increases.

Being fat can come from two distinct causes: comfort eating, an addictive or trauma-suppressing activity, and poor environment with lack of choice. And other things.

I am a taxpayer. Some of that tax goes to the NHS, which includes the profession of dietician. Dieticians give advice on diet and exercise to patients, especially when newly diagnosed with diabetes or other diseases, but also overweight. I like to think that the NHS has ways of promoting health. I hate to think that the work of dieticians might be useless, that they might not get the fat person healthier after all. Thin is not always healthier. Muscle is heavier, by volume, than fat.

And we have a pervasive cultural idea that keeping yourself in shape is a moral issue, and doing things which might hinder that are sinful. Eating cakes is “Indulgent”. I was fascinated to come across the concept of Healthism. It is a belief system that the pursuit of personal wellbeing is an individual moral obligation. Like other belief systems, it seems obvious, just common sense, to those within it. Each individual has the obligation to stay healthy, and some even argue that medical treatment should not be given to people who bring their problems on themselves.

What causes non-communicable diseases such as hypertension? Healthism explains it by diet and physical activity, but research shows racism increases hypertension. If instead of calling diabetes a non-communicable disease we call it a power-related disease, affected by the powerlessness and oppression people suffer, we see better solutions, which might actually mitigate the disease rather than blaming it on the sufferer.

Lack of control over your own life, as in a zero hours contract, causes stress. Racism, trauma, fat-shaming, loneliness and misogyny damage health. Exposure to pollution in air or water or substandard housing reduce life expectancy. Lack of power causes disease. Patriarchy imposes disease on its victims.

Lifestyle, from “bad choices”, is not the main cause of ill health. Oppression is. The answer is a social response, being kind and caring to each other, tackling the problems of pollution and oppression together as a society. We have an “obligation to help amplify others’ voices”.

The word “healthism” helps me see the belief system of personal responsibility and the solution of holding the powerful to account. It improves my self-worth: my situation is not solely my fault, a sign of weakness. Still, the chance of improvement is mostly down to me; but no-one has the right to impose that responsibility on others.