H5N1

China’s President Xi battles to save face as Covid U-turn weakens his grip on power

Via The Guardian: China’s President Xi battles to save face as Covid U-turn weakens his grip on power. Excerpt and then a comment:

China’s leader Xi Jinping told his country it stands on “the right side of history” in a new year address on Saturday, but experts have warned that the president starts 2023 diminished by his chaotic U-turn on Covid strategy.  

He may struggle to deflect blame for the human and economic costs of zero-Covid’s failure, and control the national narrative, even if public signs of dissent are crushed.  

Officially, China has registered just over 5,200 deaths from Covid, but there is a yawning gap between the picture presented by the usually efficient communist propaganda apparatus and the reality reflected in social media posts and anecdotes from across China.  

Hospital emergency wards are overflowing with desperate patients. Medical supplies are running low, with pharmacies selling out of drugs ranging from anti-viral to basic painkillers. Police patrolled one Beijing crematorium where Reuters reported long queues of hearses last week.  

In his first public comments to the Chinese people on Covid since his government changed course three weeks ago, Xi used his speech on Saturday to claim the government and Chinese Communist party (CCP) had “put the people first and put life first all along”.  

For many in China, that phrase will ring hollow, particularly those fighting for medical care for loved ones newly struck down by the disease.  

Questions about why the country clung so long to zero-Covid, at such heavy cost, and did so little to prepare for opening up are likely to undermine Xi, even if the damage to his authority isn’t visible beyond the walls of the secretive leadership compounds.  

“The fact that the CCP’s posture towards the pandemic has now completely reversed after a popular uprising can only mar Xi Jinping’s carefully cultivated air of infallibility,” said Orville Schell, director of the centre on US-China relations at the Asia Society in New York.  

“Xi is virtually immune from public expressions of criticism within China,” he added. “But my Chinese friends are all shaking their heads in incredulity at the contrariness of Xi’s policies.”

Foreign analysts, scouring the internet and official pronouncements for clues, estimate there are already thousands of deaths a day, with more to come.  

A first wave in urban areas is expected to peak in January, but a second, bigger wave will race through rural areas – where health systems are even weaker – in February and peak in early March, according to British health analytics firm Airfinity.

In a recent Tyee article, I argued that COVID-19 is only one of China's looming problems; economic uncertainty and climate disasters, especially water security, are making matters even worse.

Some hospitals in China overwhelmed in national COVID-19 wave

Via CBC News, an AP report: Some hospitals in China overwhelmed in national COVID-19 wave. Excerpt:

Yao Ruyan paced frantically outside the fever clinic of a county hospital in China's industrial Hebei province, 70 kilometres southwest of Beijing. Her mother-in-law had COVID-19 and needed urgent medical care, but all nearby hospitals were full.  

"They say there's no beds here," she barked into her phone.  

As China grapples with its first national COVID-19 wave, emergency wards in small cities and towns southwest of Beijing are overwhelmed. Emergency rooms are turning away ambulances, relatives of sick people are searching for open beds, and patients are slumped on benches in hospital corridors and lying on floors for a lack of beds.  

Yao's elderly mother-in-law had fallen ill a week ago with the coronavirus. They went first to a local hospital, where lung scans showed signs of pneumonia. But the hospital couldn't handle serious COVID-19 cases, Yao was told. She was told to go to larger hospitals in adjacent counties.  

As Yao and her husband drove from hospital to hospital, they found all the wards were full. Zhuozhou Hospital, an hour's drive from Yao's hometown, was the latest disappointment.  

Yao charged toward the check-in counter, past wheelchairs frantically moving elderly patients. Yet again, she was told the hospital was full, and that she would have to wait. 

'Terrified' over elderly woman's condition  

"I'm furious," Yao said, tearing up as she clutched the lung scans from the local hospital. "I don't have much hope. We've been out for a long time and I'm terrified because she's having difficulty breathing."  

Over two days, Associated Press journalists visited five hospitals and two crematoriums in towns and small cities in Baoding and Langfang prefectures, in central Hebei province. The area was the epicentre of one of China's first outbreaks after the state loosened COVID-19 controls in November and December. For weeks, the region went quiet, as people fell ill and stayed home.  

Many have now recovered. Today, markets are bustling, diners pack restaurants and cars are honking in snarling traffic, even as the virus is spreading in other parts of China. In recent days, headlines in state media said the area is "starting to resume normal life."  

But life in central Hebei's emergency wards and crematoriums is anything but normal. Even as the young go back to work and lines at fever clinics shrink, many of Hebei's elderly are falling into critical condition. As they overrun intensive care units and funeral homes, it could be a harbinger of what's to come for the rest of China.

Chinese doctors and nurses reportedly told to work while infected as Covid surges

Via The Guardian: Chinese doctors and nurses reportedly told to work while infected as Covid surges. Excerpt:

Chinese doctors and nurses are being told to keep working even when infected with Covid-19, staff and residents reported, as the virus rips through the population in the wake of eased restrictions.  

Some hospitals in Beijing have up to 80% of their staff infected, but many of them are still required to work due to staff shortages, a doctor in a large public hospital in Beijing told Reuters, adding he had spoken to his peers at other big hospitals in the capital.  

All operations and surgeries had been cancelled at his hospital unless the patient was “dying tomorrow”, he said, declining to be named due to the sensitivity of the subject.  

A senior World Health Organization official said on Wednesday that China’s flare-up started “long before” restrictions were lifted, but since the sudden shift in policy major cities in Beijing appear to have experienced a huge surge in cases of Covid-19. Authorities have said it is “impossible” to measure, since most people are not being tested.  

“The explosion of cases in China had started long before any easing of the zero-Covid policy,” WHO emergencies chief Michael Ryan said on Wednesday. “There’s a narrative that, in some way, China lifted the restrictions and all of a sudden, the disease is out of control,” he added at the UN health agency’s headquarters in Geneva.  

“The disease was spreading intensively because the control measures in themselves were not stopping the disease.”  

In Sichuan, a doctor surnamed Li told Reuters that their tertiary hospital was “overwhelmed with patients”.  

“There are 700, 800 people with fever coming every day,” Li said. “We are running out of medicine stocks for fever and cold. A few nurses at the fever clinic were tested positive, there aren’t any special protective measures for hospital staff and I believe many of us will soon get infected.”  

Claims of rampant infections among hospital staff are also spreading across social media. One Chongqing resident said primary care in their city had “imploded”.  

“80% of the newly admitted patients in our small third-level respiratory department in a remote city are positive,” they wrote on Weibo.  

“From December 8, when the first positive patient was allowed to be admitted, to today, December 13, at least half of the medical staff in our department were infected. At the beginning the infected were allowed to go home to rest, but now as long as it is not very serious symptoms, they are not allowed to go home.”

Keeping the front door open: Ensuring access to primary care for all in Canada

Via CMAJ: Keeping the front door open: ensuring access to primary care for all in Canada. The key points:

• Primary care in Canada is in crisis; 4.6 million people did not have a regular family physician or primary care clinician before the COVID-19 pandemic and the situation is getting worse.  

• Emerging evidence suggests that if primary care delivery does not change, a larger family physician workforce would be needed to serve the current population, let alone a growing and aging one. 

• Interprofessional team-based care, coupled with payment reform, has the potential to improve primary care capacity, access and outcomes for patients, and provider well-being.  

• Bold reforms could include neighbourhood-based clinics that employ physicians and have accountability to the local population and regionally organized after-hours care that would obviate the need for walk-in clinics and allow for better use of resources.

The next pandemic? More likely a polydemic

Last week The Tyee published my article The Next Pandemic? More Likely a Polydemic. After going through a number of unpleasant problems in global health, I concluded:

These are just some of the threats in the present polydemic, which itself is part of the present hot mess of economic decline, rising prices, war, climate change and political polarization that writers like Adam Tooze are calling a polycrisis. And it’s precisely now that Canadian health spending should be rising to support pandemic preparation and prevention, not levelling off.  

From a political point of view, lower spending makes sense. The system is still trying to catch up with all the knee and hip replacements postponed for the last two years. Inflation makes it impossible to raise taxes, and the deficit spending that kept everyone afloat in 2020 and 2021 is now politically unacceptable.  

Besides, governments have learned that they don’t have to take pandemics as seriously as they once did. Provincial governments that let COVID-19 rip have been re-elected. Public health measures like masks and vaccine mandates have triggered a populist backlash that some politicians are exploiting. Health-care workers are exhausted, underpaid and embittered.

So even if a government wanted to take the polydemic seriously, and to build up the system against future pandemics, it would face serious resistance from many voters, not to mention the business sector. Rebuilding health-care staff numbers and infrastructure would take billions, spent over more years than any government is likely to survive. Short-term emergencies would always take priority over long-term needs.  

And when the next pandemic arrived and became a short-term emergency, neither governments nor the governed would implement or accept even proven measures to protect public health. They’d recycle COVID-19 misinformation as precedent: “It was mostly mild, it only killed old people, we got through it.”  

But if it’s a pandemic as lethal as H5N1 or Ebola, which has an average case fatality rate of 50 per cent, the survivors will think otherwise.

Before 2020, the pandemic anticipators I called Flublogia were certainly worried about the impact of a new influenza or other virus. But we still had a naive faith that while it would be bad, we in North America and western Europe and Japan would have the technology and the experts to deal with it.

The response of the western nations, and especially the US, was and is a disgrace and a revelation: just as the fearsome Russian army turned out to be stupid and incompetent, so have the health systems and politicians of the "advanced" nations. If the next virus turns serious, I really doubt whether the public will listen to the advice of the health experts. Nor will healthcare workers be willing to resist another onslaught. And that, of course, will only make matters much, much worse,

A multinational Delphi consensus to end the COVID-19 public health threat

Via Nature: A multinational Delphi consensus to end the COVID-19 public health threat. The abstract:

Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic. Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health.  

The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities.  

In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches, while maintaining proven prevention measures using a vaccines-plus approach that employs a range of public health and financial support measures to complement vaccination.  

Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities in the management of pandemic responses.  

The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end.

Post-acute health care burden after SARS-CoV-2 infection: A retrospective cohort study

This helps to explain why our healthcare system is under such pressure. Via CMAJ: Post-acute health care burden after SARS-CoV-2 infection: a retrospective cohort study.

Background: The post-acute burden of health care use after SARS-CoV-2 infection is unknown. We sought to quantify the post-acute burden of health care use after SARS-CoV-2 infection among community-dwelling adults in Ontario by comparing those with positive and negative polymerase chain reaction (PCR) test results for SARS-CoV-2 infection.  

Methods: We conducted a retrospective cohort study involving community-dwelling adults in Ontario who had a PCR test between Jan. 1, 2020, and Mar. 31, 2021. Follow-up began 56 days after PCR testing. We matched people 1:1 on a comprehensive propensity score. We compared per-person-year rates for health care encounters at the mean and 99th percentiles, and compared counts using negative binomial models, stratified by sex.  

Results: Among 531 702 matched people, mean age was 44 (standard deviation [SD] 17) years and 51% were female. Females who tested positive for SARS-CoV-2 had a mean of 1.98 (95% CI 1.63 to 2.29) more health care encounters overall per-person-year than those who had a negative test result, with 0.31 (95% CI 0.05 to 0.56) more home care encounters to 0.81 (95% CI 0.69 to 0.93) more long-term care days. At the 99th percentile per-person-year, females who tested positive had 6.48 more days of hospital admission and 28.37 more home care encounters.  

Males who tested positive for SARS-CoV-2 had 0.66 (95% CI 0.34 to 0.99) more overall health care encounters per-person-year than those who tested negative, with 0.14 (95% CI 0.06 to 0.21) more outpatient encounters and 0.48 (95% CI 0.36 to 0.60) long-term care days, and 0.43 (95% CI −0.67 to −0.21) fewer home care encounters. At the 99th percentile, they had 8.69 more days in hospital per-person-year, with fewer home care (−27.31) and outpatient (−0.87) encounters.   

Interpretation: We found significantly higher rates of health care use after a positive SARS-CoV-2 PCR test in an analysis that matched test-positive with test-negative people. Stakeholders can use these findings to prepare for health care demand associated with post-COVID-19 condition (long COVID).

Medical associations confront Canada's healthcare crisis

Via Medscape.com: Medical Associations Confront Canada's Healthcare Crisis. Excerpt:

The Canadian healthcare system has reached a breaking point and requires immediate and long-term changes to prevent a total collapse, according to new recommendations from three of the country’s top medical associations.  

The Canadian Medical Association, Canadian Nurses Association, and College of Family Physicians of Canada developed an action plan to rebuild the healthcare workforce, reduce burnout, and retain healthcare workers who have felt strained for more than 2 years.

“We’ve really seen the challenges in the healthcare system brought much more to the forefront during the pandemic. It’s reaching a level of crisis that we’ve not seen before,” Katharine Smart, MD, president of the Canadian Medical Association, told Medscape Medical News.  

“We’re hearing daily from people across the country about how bad things are,” she said. “From primary care to hospitals to specialists, everything is starting to implode.”  

The organizations presented the policy recommendations to the House of Commons’ Standing Committee on Health and the federal/provincial/territorial Committee on Health Workforce in April. The action plan was published on the organizations’ websites on May 16.  

Collaboration and Support  

The Canadian healthcare system was struggling before the COVID-19 pandemic, the authors wrote. For more than 2 years now, healthcare workers have tried to keep the system from buckling under the strain.  

Now healthcare workers are burning out and leaving the industry, which has pushed the system to a tipping point, they wrote. Healthcare professionals are facing massive patient backlogs and cannot provide the care that is needed.  

“We’ve spent the last several months raising awareness of how dire things are,” Smart said. “Canadians have pride about our healthcare, but it idealizes our system and gets in the way of being realistic about what’s happening.”  

The Canadian Medical Association, Canadian Nurses Association, and College of Family Physicians of Canada developed health human resources solutions to address the healthcare workforce in a “proactive and sustainable way,” she said. The plan offers immediate, medium, and long-term policy recommendations for the federal government to adopt and share with provinces and territories.

Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study

Via The Lancet Regional Health - Americas: Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study. The summary:

Background  

Before widespread vaccination, the United States was disproportionately affected by COVID-19 with a mortality rate several times that of other affluent societies. Comparing regions with different rates of health insurance, we assess how much of this excess mortality may be due to the relatively large population without health insurance.  

Methods  

We use daily surveillance data from the US Centers for Disease Control and Prevention (CDC) stratified by region, age group, gender, and race in regression analysis of daily COVID-19 cases, hospitalization, and mortality. COVID-19 data have been matched with structural characteristics of the region including average proportion with health insurance. As checks, we have estimated regressions for different time periods, different groups of states, and by comparing adjacent counties between states with and without Medicaid expansion.  

Findings  

Groups with lower health insurance coverage had significantly higher mortality as well as greater case counts and hospitalization. Early in the pandemic, they were also less likely to be tested for COVID-19. Applying our regression estimates, we estimate that had there been full health insurance coverage of the population, there would have been 60,000 fewer deaths, 26% of the total death toll in the period of this analysis.  

Interpretation  

Our study demonstrates that a significant share of COVID-19 mortality in the United States, and much of the excess mortality in the United States compared with other countries, is due to our reliance on a system of market-driven healthcare. Providing universal insurance coverage should be part of our campaign to reduce COVID-19 mortality. It also suggests that these concerns should not be restricted to COVID-19 but apply across all diseases, contributing to many unnecessary deaths in the United States each year even apart from the COVID-19 pandemic.

COVID-19: It ain’t over ’til it’s over

Via Science, an editorial by Editor in Chief H. Holden Thorp: It ain’t over ’til it’s over. Excerpt:

The Biden administration is sheepishly waving a checkered flag on the pandemic. If you look closely, you can see its members cringing as they do so. 

Chief Medical Advisor Anthony Fauci told the PBS Newshour that the United States was “out of the pandemic phase” and then walked it back, saying he meant that the “acute compo­nent” of the pandemic phase was over. President Biden attended the likely superspreading White House Corre­spondents’ Dinner last weekend but skipped cocktails and the meal, opting to just give his talk. Fauci avoid­ed the whole affair. 

Meanwhile, Vice President Harris continued to isolate after her positive COVID-19 test, and many members of Congress and the administra­tion announced positive test results as well. All of this happened while the White House allowed a renegade federal judge in Florida (where else?) to end the nationwide mask mandate without much of a fight. 

These mixed messages have been emanating from the administration for months now, and although those with resources have tools to manage COVID-19, care needs to be taken that those without such means are not forgotten. 

When Biden pledged to “follow the science,” it was hard to imagine that the country could have ended up here. But the administration made a big bet that vaccines would provide sterilizing immunity and end the pandemic, allowing it to move on to other priorities. 

Leaving behind the insanity of ivermectin, hydroxy­chloroquine, and bleach was certainly a great step forward. However, evolution has had other plans, and variants of severe acute respiratory syndrome corona­virus 2 (SARS-CoV-2, the virus that causes COVID-19) have kept the pandemic going. This left the White House in a very tight spot: There was little political will to keep pushing nonpharmaceutical interven­tions, yet the pandemic was far from over. Add to this mounting inflation worries and concerns about the war in Ukraine, and the response has been a clumsy pivot to a message that politicians always turn to: personal responsibility. 

Get vaccinated, get boosted, wear a mask, get a prescription for the antiviral Pax­lovid—if you want to. This may be fine if you have a healthy immune system, great health insurance, and the ability to navigate the US health care system. But what about everyone else? 

COVID-19 is at a similar place to where the HIV/AIDS global pandemic was when the antiretroviral drugs came along. Yale epidemiologist Gregg Gonsalves told me about important parallels between both pandem­ics. “The HIV epidemic didn’t go away,” he said. “It just went to where people could ignore it. It went into the rural South, it went to communities that were already facing disparities in health.” 

At that time, confusion between medicine and public health was also an im­portant factor. “The discourse shifting to private choice and private adjudication of risk is really not what public health science is,” he said. “We work in populations. And if we’re talking about medicine, it’s about private risk and private choices.”