Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: The false dichotomies in pandemic commentary

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.m4937 (Published 06 January 2021) Cite this as: BMJ 2021;372:m4937
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com
    Follow David on Twitter @mancunianmedic

Much like the Brexit debate, the narrative on covid-19 has often been reductive, tribally entrenched, and polarised. This has sometimes led to false dichotomies between seemingly contrasting positions that are in fact compatible, consistent propositions that can be supported at the same time. For example, I’ve seen many commentators argue that what’s crucial is either covid health protection measures or their impact on jobs, the economy, mental wellbeing, and wider determinants of health. We have to choose: which will it be?

In reality, the two are not so neatly separated.1 If a pandemic respiratory virus is surging through populations, preventing people from working because of acute illness, reducing productivity because of long covid,2 or forcing them to take time off to care for family members, that’s a lose/lose situation. Meanwhile, Sweden—endlessly feted by libertarians and lockdown sceptics as the model to follow because it initially imposed far fewer behavioural restrictions—now has a death rate massively higher than its Nordic neighbours, an acute care system under serious pressure, and a GDP and economic forecasts worse than in some other EU countries that imposed more restrictions.3 By contrast, countries in South East Asia or Australian states that tackled the problem early and hard have now restored social and work activity to something closer to pre-pandemic times.4

A second false dichotomy concerns the tension between acute hospital care for people with and without covid-19—and between care for patients with covid and those requiring outpatient care and elective treatment. There are, of course, serious questions and academic analyses about why patients with acute heart disease or stroke seem to have stayed away from hospital during the pandemic’s first few months.56

Concerns about the impact of reorganising hospital care to cope with covid on care for people with cancer and other long term conditions are well evidenced, with waits increasing and access affected.7 Similar concerns have been raised over general practice shifting to more phone and web based models to protect patients from the hazards of physical appointments in the surgery.8 People with cancer or other underlying conditions—diabetes, hypertension, dementia9—are far more likely to die if they get covid-19, so concerns about bringing them into high risk clinical environments are legitimate. Currently, around one in four covid cases in England is classified as hospital contracted.

Meanwhile, if we fail to focus on pandemic health protection measures for covid itself and allow hospitals to be swamped with acute covid cases for want of adequate public health protection measures, non-covid patients will suffer. Beds will be filled to capacity, not least in intensive care. Staff will be self-isolating in greater numbers. Again, it’s lose/lose, and the “either/or” choice lacks all realism.

Third is the narrative that care home residents were deliberately sacrificed in the first weeks of the pandemic to protect the NHS. There’s no doubt that mistakes were made with this policy.10 Rarely set out, however, is the counterfactual about what might have happened if we’d allowed many care home residents to be stranded in hospital waiting for negative tests, putting their health and bed capacity at risk.

Finally, consider the restrictions on visitors to care homes or hospital wards. We can all see the considerable downsides for the welfare of patients and residents; many of us have seen the tragedies unfolding. But an open door policy could similarly have posed considerable health risks from avoidable covid transmission. These risks and benefits must be discussed in a measured, proportionate way often absent from the public conversation—although we do now have some sensible guidance.1112

It can never be “either/or” but rather “both, at once”—with a subtle reweighting of priorities as the pandemic context changes. But that would seem too nuanced, too measured a position for people who want to be, in the words of George W Bush, “either for us or against us.”13 And we know how well that worked out.

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