Saving lives by failing to save lives.

Tom Forth,

England is more centralised politically than any similarly large country. This has affected how it has dealt with the Covid-19 pandemic. England’s death rate is one of the highest in the world.

55 million English live in a country with a single national government (confusingly the UK government) that manages testing, control (lockdown), and healthcare. Almost uniquely among large nations there is almost no regional or local government involvement in these three key areas of the Covid-19 response.

I believe that this large and unresponsive system has cost lives. I cannot prove it, and you cannot prove that it hasn’t. There are plenty of counter-examples. A large factor in the variation in death tolls across countries is due to random chance.

With those caveats shared, I believe that England’s centralisation has contributed to the country having a death rate from Covid-19 that is currently nearly three times as high as France and nine times as high as Germany . There are many excellent pieces of journalism that share the mechanism by which I believe this has happened. Here are three.

Centralisation has advantages too.

But England’s unusually centralised system of governance has advantages. The UK’s ultra-centralised healthcare system has proven much better at doing trials than other large pharmaceutical innovating nations such as France, Germany, Japan, and the USA. This article in Science argues that well.

Without a single centralised health service (the NHS) and a centralised scientific funding body (UKRI), discovering drugs that are now saving lives from Covid-19 such as Dexamethasone and Interferon Beta would be much more difficult. England’s centralised systems allow data analysis such as that by Open Safely that has quantified risk factors and improved clinical decisions. The current leader in the race to create a vaccine for Covid-19 is developed in Oxford, England. All of these advances are available to the whole world, instantly, and are saving lives right now.

A complex interaction.

The advantages and disadvantages of centralisation within England have interacted in a grimly fascinating way. Of the five large countries with significant pharmaceutical excellence, three (Germany, Japan, France) have controlled Covid-19 sufficiently better than the UK that they have struggled to find patients to conduct trials of treatments and drugs. In the USA, absent a single universal healthcare system like the NHS, trials are harder to conduct and collate even where there are patients to conduct them on.

Thinking about this leaves me with another grimly fascinating question. Is it possible that England’s poor performance in controlling Covid-19, while costing tens of thousands of English lives, has saved even more around the world?

Some very rough maths

The positive trial results for dexamethasone were published on 18 June 2020. It reduces death rate for patients on a ventilator from 41% to 29%. How many lives has this discovery saved in the month since publication?

There is a huge amount of uncertainty in the figures that follow. I’ve looked at the French open data on hospitalisation, intensive care admission, and death, and these estimates from the USA . These are my rough estimates.

1 in 5 people who catch Covid-19 will require hospitalisation.

1 in 5 people who require hospitalisation will require intensive care.

41% (about half) of people who enter intensive care will die without advances in treatment.

These rough estimates suggest that England’s death toll of around 60 thousand means that 3 million, about 6% of the population, have had Covid-19 so far. In keeping with estimates published in New Scientist.

Since 18 June 2020, in all countries, approximately 6 million people have been diagnosed with new cases of Covid-19. My estimates suggest that about 1 million will require hospitalisation. Of this 200,000 will enter intensive care. And if 41% die, that will be 82,000 deaths.

But the discovery of dexamethasone in England means that we can now reasonably expect only 29% of these patients to die. Instead of 82,000 deaths we can expect 58,000. That is 24,000 lives saved. In another month the number of lives saved will be higher than all lives lost in England from Covid-19.

The ethical question.

Of course there is much else going on with Covid-19 treatment. Other discoveries are being made all over the world and shared. Better testing, earlier treatment, better and more customised treatment, and much more all play a role in global improvements in outcomes. In the UK we see that the survival rate in intensive care has increased substantially in recent months from below 55% to 80%. Additionally, people are avoiding hospitalisation and intensive care altogether.

But what if medical discoveries made in England, made more likely by the centralised political system in England, the same system that I think has cost tens of thousands of lives in England, are likely to save many times more lives around the world than they cost here?

Would it be ethical to have planned that from the start? I’m almost certain that the answer to that is no. But my training in ethics is very limited. I’d love to hear some experts talk about it.

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