Healthcare, without guarantees of diagnosis and treatment, there is a risk of perverse effects

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Healthcare, without guarantees of diagnosis and treatment there is a risk of perverse effects

by Sara Gandini, epidemiologist/biostatistician, Fabrizio Tuveri, doctor, Pier Giorgio Ardeni, historian/economist< /strong>

A pharmacist who spoke at the doctors' protest demonstration on December 15held in Rome, she addressed the Prime Minister with these words: “Giorgia, believe us, the emergency is not the disease: the emergency is guaranteeing diagnosis and treatment”. No sentence, data in hand, could better sum up what has happened in the last three years. In September 2022, excess mortality in the EU stood at 9.3% more than the average for the same period of 2016-2019 (it was 13.0% in August). Approximately 30,000 more deaths occurred in September 2022.

The excess death rate was 8.1% in September 2020 (28,000 excess deaths) and 12.8% in September 2021 (44,000 excess deaths). In Italy, in the two years 2020 and 2021 and in the first 10 months of 2022, the total excess mortality, compared to the 2015-2019 average, was 211,000 deaths. The excess mortality was 15.6% in 2020, 9.8% in 2021 and 8.8% in 2022. What is causing these deaths? Why are they more than the norm?

Covid-19 is only partially responsible, directly or indirectly. L‘Office for Health Improvement and Disparities (Ohid) in the UK tracks deaths by cause, location and age group and detects an excess of deaths from cardiovascular causes, as well as an substantial increase in deaths from diabetes, urinary system diseases and other respiratory infections not related to COVID-19. In August 2022, 6.7 million people were on the NHS waiting list in the UK forelective and non-urgent care, an increase of more than 50% since the pre-pandemic period.

A report by the British Heart Foundation, released in November, found over 30,000 deaths that could have been spared in the UK from heart disease since the start of the pandemic. This is largely due to diagnostic and therapeutic delaysduring the closures. At the end of August, around 346,000 people were on waiting lists for heart treatment in England, the highest number on record (more than 7,000 patients have been waiting for a heart procedure for more than a year). The average response times of ambulances for suspected myocardial infarctions have risen to 48 minutes while they should be 18 minutes. Cardio-circulatory diseases account for a quarter of the life expectancy gap between the rich and the poorest.

Italy is no better. It is estimated that between 2019 and 2020 alone there were around30 million postponed services, including visits and exams, due to the pandemic (Ministry of Health data). A study conducted by the Italian Society of Cardiology (Sic) in 54 Italian hospitals showed that mortality in coronary intensive care units had more than tripled after the pandemic, due to the reduction of cardiology services and delay in treatment.

The 2020 Statistical Yearbook of the National Health System highlightsone million fewer hospitalizations in public facilities, for all causes, in 2020 compared to 2019. In intensive care units, the wards most affected by the Covid-19 emergency, hospitalizations linked to Covid-19 have actually registered a +16%with a slight increase in the average length of hospitalization but with a reduction in the rate of bed utilization (from 45.8% in 2019 to 40.5% in 2020), thanks to the increase in the number of beds. It is therefore clear that the emergency linked to the number of hospital admissions caused by Covid-19 during the pandemic is not such as to justify the marked reduction in health services that a less irrational organization could have avoided. A reduction that can also be explained by the cuts and definancing of the national health system in recent decades.

During the syndemicthere was a 37% reduction in health services internationally including reductions in visits by 42%, hospitalizations by 28%, diagnostics by 31% and therapies by 30%, as indicated by an analysis of 81 studies in 20 countries. Some argue that the problems that emerged with the management of the pandemic are due to the fact that we did not have an updated pandemic plan. Yet the United States, which on paper should have been the best prepared, has had more deaths from infection and a higher excess of deaths from all causes than 20 other similar countries over the duration of the pandemic, according to a study published today. on Jama (between the second half of 2021 and the beginning of 2022, the United States recorded 155,000 to 466,000 more deaths than other countries).

In a large part of the current excess mortality in the USA is due to obesity and diabetes (30% more mortality for the latter). Obesity and diabetes have also increased following the lockdown, as reportsThe Lancet. Furthermore, many studies have shown a significant increase in deaths from alcohol and drugs, especially among the most deprived social groups (the so-called “deaths of despair” increased particularly in the USA).

< p>In Australia alone, a one-year disruption of health services and a 26-week delay in treatment would lead to an average of 1719 additional deaths by 2044among patients with colorectal cancer. To put it in context, from the beginning of the pandemic to May 9, 2021, 7509 deaths directly attributable to Covid-19 had been reported in Australia. The risk of death from colon cancer increases by 6% for every 4 weeks of therapeutic delay (surgery and/or chemotherapy); similar delays in preoperative adjuvant chemotherapy increase the risk of mortality by 13%.

Before the pandemic, in Canada, the time interval between diagnosis and the start of therapy, in cancer patients, was about 4-5 weeks. The results of a survey conducted by the Canadian network of cancer survivors indicated that it took an average of 44 days to reschedule any procedure or surgery postponed due to the pandemic. Delay of surgery or adjuvant treatment for colorectal cancer (31 to 75 days) is expected more than double the risk of death. In general, each month of therapeutic delay in cancer treatment can increase the risk of death by about 10%, according to a literature review published in Bmj. In the USA, the Covid-19 pandemic has indirectly caused a 3.2% increase in the number of cancer-related deaths in 2020 compared to 2019 (source: American Cancer Society).

The pandemic has also led to the interruption of the vaccination campaign for the human papilloma virus-Hpv which is essential to reduce the risk of cancers of the neck and oropharynx, as well as cervical cancer screening. The effects of the modifications/interruptions of the vaccination and screening programs against HPV will probably manifest themselves for decades.

Finally, it should be remembered that an increase in the number of suicidesamong the youngest, between August and November 2020, from Japan, the USA and Europe. According to the WHO, suicide was already one of the leading causes of death among young people aged 15-29 globally well before the pandemic. A study conducted on 14 states in the US by the National Institutes of Health showed a further increase in the number of suicides even among adolescents.

We conclude by emphasizing, however, that there are exceptionscompared to excess mortality: Sweden, for example, has one of the lowest cumulative excess mortality in Europe. Thirty months after the outbreak of the pandemic, the death rate from Covid-19 in Sweden is among the lowest in Europe. We recall that Sweden is one of the few countries that has used less severe restrictions and relied on less terrorist communication.

Focus only on the risks of contagion and neglect other pathologiesit has certainly caused more harm than good in both the short and long term. Small wonder, then, at the general excess mortality from all causes seen in various countries. In essence, the inadequacy of health systems, already in serious difficulty after decades of cuts, has been reflected in bottlenecks, delays and inefficiencies that have reverberated on the treatment of all pathologies.Some health policy decisions, such as the closure of essential departments and services and staff shortages caused by an attempt to reduce the risk of contagion, are having serious consequences.

For this reason it is important to underline that this is a syndemic and not a pandemic. Diseases and deaths from Covid-19, but not only, affect people who have more chronic non-communicable diseases to a greater extent and these are more frequent in those who are less economically and socially available, both due to the different access to treatment and the lack of prevention, but also for the most precarious living conditions. But this condition concerns more and more people, no longer a minority, also due to the closures and the war. So it doesn't matter how effective a vaccine or a cure may be: if you face each crisis only with an emergency and purely biomedical approach and do not invest both in health care and to reduce inequalities, you can reach perverse effect of increasing mortality. And so it happened.