We are failing miserably at protecting those at greatest risk and have failed to focus enough attention on giving those populations the protections they need and deserve. There is not enough money or even thought being spent on protecting them. There has been NO excuse to not have ample PPE for both residents and staff of nursing homes. No excuse at this point (other than funds not provided and cost) to not have staff cohorted to very specific care teams instead of travelling between homes, to have staff, including asymptomatic staff, tested somewhat regularly, for a host of better practices to be in place.
And I know that “contact tracing is harder than it sounds”, even when it dealing with a small spark landing on dry grass of non-immune individuals, and harder yet when dealing with over 20,000 new confirmed cases per day. Contact tracing can be successful part of a plan, and in a culture like South Korea (rules following, less individualistic, relatively recent memory of SARS as a big item), starting as first cases make landfall, you can get a critical mass compliant. I’m a bit more skeptical that such will be the case here, especially now that the disease is already so widespread.
I am not arguing against contact tracing as an element of an approach but the idea that it is THE critical ingredient. If I had to choose between spending a given dollar on better direct protection for those in nursing homes or on contact tracing, I’d choose the direct nursing home protections without a microsecond hesitation.
What is hard to know is what the return on the dollar is for either tracing or direct protection. It isn’t going to be a hard and fast comparison. There is a point where aggressive tracing and quarantine can actually drive the epidemic out. But if you can’t achieve that with the resources available and the state of community infection, it is likely money wasted. Other times it is absolutely the best use of funds.
I must confess I’m not even sure what direct protection is possible with much additional money. Most of the problems in nursing homes seem to stem from institutional problems rather than lack of funds. I guess some funds allocated to stop staff moving between homes would do the most good. That seems to the the biggest vector. Further funding might provide for greater isolation. Part time staff are a problem. Eventually you might reach a regime where the staff all live in. That would be expensive.
Otherwise I assume lots of PPE for all staff and much more rigorous procedures. That can’t be that expensive. Again it seems to be more institutional behaviour issues than lack of funds.
As we saw, Sweden had an explicit policy of protecting the vulnerable, and failed. What they actually did to implement that policy is another question. Not a great deal it seems. Here in Oz visitors to care homes was banned. Which was pretty drastic and heavy handed. We see stories of families and partners denied the opportunity to farewell loved ones. We have still had a couple of really bad outbreaks in care homes with many dead. The vectors always seem to be staff. Whether this is lack of compliance, lack of institutional procedures and process, or something else is to be seen. But I don’t think simply money is the issue or the solution.
Aged care is a difficult area. Most of us don’t have much contact with it until our parents reach the end, and even then many of us are lucky enough that our parents don’t need institutionalisation. I have friends that were in the industry, and insights from them, as well as having had to manage loved ones in care. It gives some perspective. The sad reality is that in the top level care homes, 80% of the patients are end stage Alzheimers. Patients are often admitted at the point where they can no longer take care of themselves, and as the condition progresses they become more and more dependant. The end is distressing. Other degenerative diseases account for much of the remainder. But dementia is dominant. This makes aged care homes a difficult and special place to manage. Managing patients, providing them with comfort and dignity, reducing distress, and all the while protecting other patients and staff is not trivial, and is not like a conventional hospital.
…If I had to choose where to spend the money I would spend that money locking down hard and early to both protect those in nursing homes **and **to enable us time to set up testing and contact tracing. I’m not arguing that contact tracing is “the critical point.” Its one of several things that need to be done. I listed seven of them in a previous post and contact tracing was only half of just one of those points. There is no reason we have to have a binary choice.
And yes: contact tracing isn’t as easy as you think. Its even harder if it isn’t treated as a priority, if it barely gets any budget, if you leave it to the states instead of an appropriate Federal response, if you leave your borders (both international and at the state level) open.
The response in America is chaotic: (as in butterfly flaps its wings-level-chaotic). You need to ramp up your contact tracing. But you also need to ramp up your testing, lockdown properly to break transmission cycles, protect the vulnerable and protect healthcare workers. I don’t think anything I’ve said is particularly controversial.
The implied belief in this statement is clear and endemic: it’s an institutional problem, so nothing can be effective.
To me the opposite is more true.
There are a few basic principles to improving quality and outcomes and one of the primary ones is to determine which structural factors are resulting in a greater number of adverse outcomes with serious analysis of the processes, and to then implement structural fixes, then measure changes in outcomes and figure out what to do better from there. Sometimes implementing those fixes, once determined, takes spending resources, but the bang for the buck is biggest when structural (systems) items can be identified and addressed.
To the best of my read there is no serious effort being made to both identify the structural factors that are resulting in such horrific outcomes, let alone to come up with improved processes to reduce them or to implement those improvements.
[Looks up and remembers that this is the Sweden thread] Sweden’s intent to protect the elderly especially those in nursing homes was the right objective. Their execution though was horrible. There was no comprehensive system analysis by leadership of how to have them protected best, there was inadequate PPE, inadequate testing of nursing home staff, and inadequate training of staff. Institutions can be guided and improved upon, regulated as need be, not just resigned to.
Broken institutions that are failing to protect our most vulnerable do have be accepted as the best that can be done.
I hope I didn’t give that impression. I think we largely agree. My complaint with institutional problems is that they get ignored because they require people to change behaviours and often implicitly lay blame. Of course they are soluble. My main point was that solving them isn’t usually a matter of money. It is a matter of will and leadership.
Fixing the institutional problems that has led to aged care deaths could, and should, have been effected by a small team in a matter of less than a week. Identify the reasons for the outbreak and enact the needed changes in the homes. Providing PPE in sufficient quantities and mandating that staff may not work in more than one home would probably have reduced the number of outbreaks and death toll by a huge amount. And be almost free.
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I see far too often problems and their solution being reduced to a question of money. Politicians are one the worst in this respect. Allocating taxpayer sourced funds to a problem is a simple and convenient substitute for leadership. They can blame the implementation if it fails. Fixing institutional problems with money is almost guaranteed to fail. I see this far too often. Snouts to the trough is the usual reaction when such money comes available. Very expensive consultants, long study times, reports, recommendations, more reports. And then nothing. You end up with a new staff member whose job is compliance, and they spend their days filing compliance paperwork with public servants who’s only job is to check that the paperwork is properly filled in. One public servant for each compliance officer. Two full time jobs per institution to try to fix a problem that could be solved with nothing more than leadership and a willingness to take responsibility. But paperwork means you can claim “best practice” and disclaim actual responsibility. A few million dollars later, jobs are created, and nothing else changes.
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The comparison between tracing and protection was where we came in. I don’t think there is any tension between the two. Sure, in a world where there was almost no money at all, protecting the vulnerable gets first priority. But that isn’t where we are in most nations. Effective protection of the vulnerable doesn’t need huge spending, it needs will and leadership, and an acceptance of responsibility. Contact tracing needs farms of workers manning telephones and email acting as detectives. In our world that is expensive. But it isn’t an either/or.
Besides your accusation and your incredulity, if you have a point, you’re going to have to state it, if you care to bother.
I really do not understand why listing the death rate of Sweden, Finland, Denmark and Norway gets this reaction in the context I used them. As explained twice in both those posts, I used the death rates as reference points when linking an article about how those countries will be considering whether to restrict travel from Sweden. It’s the point of the article that Sweden’s death rate is increasing while the other countries are on the decline is why they’re refusing entry to people in Sweden.
I think it’s safe to say at this point that Sweden screwed the pooch on their decision. Last week they had bragging rights that they led Europe in deaths per capita. Not only did they fare far worse than their neighbors, they are once again going in the wrong direction in that metric. Unless it turns out that they magically hit herd immunity in the next few weeks and therefore avoid a second wave (they won’t), I don’t know how one could defend their decision. But, contrarians gonna be contrary.
If you really want to try to find something to hang on to, I guess you could say that they might not have a second wave, since the first might just keep on keepin’ on.
The UK has not been the poster child for success, and yet it has lower per capita rates than Sweden over the last 2 weeks.
The position of the Swedish authorities had a tome of superiority about the ethics of the Swedish population, that somehow they were more responsible than those of other nations.
Worth pointing out that Swedish population density is very much lower than the Euro nations with higher fatalities and very much higher than Denmark whose population density is also higher - heck even UK with its poor record is doing better and it has a way higher population density.
The only comfort that Sweden might draw is if it has not taken as big a hit on their national finances as other major Euro nations, but then there is the balance between finance and life - which is the more ethical approach?
7.3% of the population in Stockholm having the antibodies in the week ending May 3rd is the highest number that I’ve seen to come from a legitimate study, and the rest of Sweden is lower than that. If you think they’ll be at even the relatively modest level of 60% in the next few weeks, I’d like a cite, as even Tegnell doesn’t believe that.
If you really want to try to find something to hang on to, I guess you could say that they might not have a second wave, since the first might just keep on keepin’ on.
I’m not hanging on to anything. Unlike some people, I recognize how much we don’t know about this disease. We were told back in March that this was a long road and we have to worry about future waves. Now 3 months later and you’re ready to type up the final report.
I should add, the number of people with antibodies is probably higher than that. Unfortunately, like everything with this disease, there is a lag between events and data. From what I’m seeing, the better antibody testing is most accurate ~3 weeks after onset of symptoms.
So 7% on May 3rd may only reflect people who got it before mid April.
The United States has far lower population density than Denmark, so by that “logic” they should have about zero cases. Or perhaps you need to look at the most affected areas and find that Stockholm has almost as high population density as London.
Comparisons between countries are hard because people behave very differently and live differently. some countries have better ‘normal case’ hygiene.
More useful would be to compare states within the country, or to compare countries that have broadly similar densities, patterns of movement, etc.
And when you aggregate all the state results into a ‘United States’ result, you hide an awful lot of differences that are important. For example, if you just take out New York State, the numbers for the rest of the U.S. look pretty good compared to the world.
So maybe the best question to ask is, ‘What is different about New York?’ High population density and reliance on crowded subways might be part of it. Cuomo’s order to house contagious COVID-19 patients in nursing homes may be responsible for a large percentage of the 10,000 deaths in New York nursing homes. De Blasio telling people to get out in the streets and party in March could not have helped.
While Cuomo was forcing COVID patients into nursing homes, Florida did the opposite, locking down nursing homes, not allowing workers to work in multiple homes, and quickly removing COVID patients into hospitals or special nursing homes just for COVID cases. The result is that despite having a larger population and even larger older population, Florida had 1/10 of the nursing home deaths as New York.
Well, yeah, that was kind of my point there. It doesn’t exactly matter that Norrbotten County has less than ten inhabitants per square mile when most of the cases are in Stockholm with 13,000 inhabitants per square mile.
The baffling thing about COVID-19 is how clustered the cases are. Here in Canada, Quebec has more cases than the rest of the country combined, and they are mostly clustered around Montreal.
Montreal has about 25,000 cases. That’s about the same as the entire province of Ontario. Here in Alberta, Calgary has 4800 cases, while Edmonton has had 527. The two cities are almost identical in size, and the populations are demographically similar.
So before we condemn one country over another, we should be humble and accept that there is a lot we don’t know about the huge disparity between regions when it comes to COVID-19.
Going back to the topic of New Zealand and countries with success for a moment, it’s not just the lockdowns, testing, and tracing that have mattered, but it’s also when these steps took place, and the degree of cooperation authorities have received.