National Review

A grim toll 

Every day, we focus the spotlight on new COVID-19 cases and the confirmed COVID-19 death count — which at last reports stood at 136 — but the true death toll caused by the pandemic, and the number of sick people who are not getting care due to an overburdened healthcare system, or their fear of visiting the hospital, have gotten very little attention.

Just looking at the numbers of bodies ending up in the morgue at Princess Margaret Hospital (PMH) over the last several months, when compared to normal years, is cause for concern, noted Dr. Marcus Cooper, president of The Bahamas Medical Association.

“They’re showing me a 30 percent increase in the [number] of deaths between March and September 2020 versus March and September 2019,” he said. 

The morgue is seeing more deaths even in a year when there has been a 30 percent decrease in murders, according to police officials. Between January 1 and September 30, 54 murders were recorded, compared to 77 in the same period last year.

On September 17, the Public Hospitals Authority (PHA) reported that the PMH morgue, which serves the entire country, was “operating under overflow conditions due to the increase in deceased individuals as a result of COVID-19”.

At the time, the PHA reported that the morgue had 150 bodies in storage, well beyond its maximum capacity of 66 bodies.

As of yesterday, that number had risen to 233 bodies.

Not everyone who dies at PMH ends up in the morgue. Some families arrange for them to be immediately collected by funeral homes.

Many people die at home and so they also never end up in the PMH morgue.

“I did my numbers,” Cooper said. “Just based on my own personal experience and the amount of death certificates I’ve signed since March, of people who did not go to the hospital or people who went to the hospital but they died at home — those people don’t get included in hospital statistics. 

“There’s a significant [number] of people, I feel, who died at home and went straight to the funeral homes.” 

Vaughn Jones, of Vaughn O. Jones Memorial Centre, also spoke to National Review about what he characterized as a death surge.

“I have been seeing a serious trend of increase in deaths, not underlying COVID cases, but there is a serious surge of deaths based on the fact that these people had some other conditions,” Jones said.

This is also reflected in the obituary sections in daily newspapers.

The Nassau Guardian’s sales manager noted a significant increase in obituary business compared to what this newspaper has seen over the last decade.

And Jones said he has been doing a weekly count based on death and funeral announcements in The Tribune.

“For the past several months, I counted obituaries in the Tribune and my numbers were like 90 something every week consistently,” he said.

“Ninety something funeral and death notices, I’ve been counting, so therefore there is an increase and, as I said, it has a lot to do with our health system, which has kind of broken down because of this pandemic, and then in addition to that, these people have a lot of underlying health conditions that are causing the increase in deaths.”

Recognizing that official death statistics from the Registrar General’s Department would be needed to give a fuller picture of our excess deaths, Cooper also opined that diminished access to healthcare is fueling a crisis far deeper than deaths directly linked to COVID-19.

In the absence of a monthly breakdown, death statistics from the Registrar General’s Department do not tell much. 

The statistics show that there were 2,428 deaths in The Bahamas in 2017; in 2018 there were 2,543; in 2019, there were 2,593 and up to August 21, 2020, there were 1,462.

In addition to the 136 confirmed COVID-19 deaths, the Ministry of Health on Monday reported 26 non-COVID deaths — people who died with COVID-19, but not as a result of COVID-19.

There were also 16 deaths under investigation.

While these daily numbers are important, they may be underestimating the real impact the pandemic is having on mortality.

The Centers for Disease Control and Prevention (CDC) notes that excess deaths are typically defined as the difference between the observed numbers of deaths in specific time periods and expected numbers of deaths in the same period.

The CDC notes that in the United States, overall, an estimated 299,028 excess deaths occurred from late January through October 3, 2020, with 198,081 (66 percent) excess deaths attributed to COVID-19.

There are implications for public health practice, the agency noted.

“These results inform efforts to prevent mortality directly or indirectly associated with the COVID-19 pandemic, such as efforts to minimize disruptions to healthcare,” it said.

Care

In The Bahamas, not unlike in many other places, the pandemic is placing a tremendous burden on the healthcare system.

That means many people who need care are not getting it, according to former Minister of Health Dr. Duane Sands.

“Ordinary people coming in with heart attacks, strokes, diabetes, kidney failures cannot get care,” said Sands in the House of Assembly on Monday evening. “That is happening in this country today.”

Speaking with National Review, Cooper also pointed to “the inability of people to access care in a timely fashion because of the situation with going to the hospital and the cancellation of elective procedures and the inability of [people] in the Family Islands to access tertiary care services that are only available in Nassau”.

“It’s important to focus on COVID but not to forget about those thousands of people with comorbidities who rely heavily on our tertiary care system for their care.

“We have to move the hospital clinics, if necessary, outside of the hospital. There’s still a concern about coming into the hospital even for ambulatory type things like clinics. We need to consider moving our ambulatory procedures possibly to outside facilities.”

Cooper said the failure to test people being admitted to PMH is leading to people on open wards and also hospital staff getting infected with the novel coronavirus.

“So, there are a lot of people who end up getting admitted who convert to positive on the ward and what you have are accidental exposures, which result in the quarantine of five or 10 staff members, that could be nurses and doctors,” he said.

Speaking on the subject recently, Dr. Nikkiah Forbes, director of the National HIV/AIDS and Infectious Disease Programme, said patients should be tested for COVID-19 before they are admitted to PMH wards.

“It’s not foolproof, but we have been advocating for a while that there can be testing for COVID prior to admission to the hospital wards at the point where you present when you’re in the emergency room,” Forbes said.

As a result of reports of people getting COVID-19 in hospital, some people who need care are afraid and choose instead to stay away.

“…So, in order to prevent people from not being able to be seen, not being able to have their surgeries, having their procedures canceled, perhaps we should consider moving some of these services outside of the hospital and triaging them based on urgency so that these people can still get the care that they need,” Cooper said.

He added, “We’re not paying much attention to these people. We all know how burdened our system is and we know we have exceeded capacity in how stressed and strained our healthcare workers are. However, we do have a duty to continue to provide care for those who have non-COVID illnesses. 

“The Bahamas was a sick country before COVID and we’re still a sick country, and so we still need to take care of these people. We still need to acknowledge the fact that we have lots of people who are not getting the care that they need and we need to develop some alternative strategies so not to lose these people as well, because we are losing them.” 

Cooper said difficulties arise when only emergency procedures are allowed in hospital theatres.

Cases that were not initially emergencies eventually become critical because some patients are not being dealt with in a reasonable enough time to prevent their illnesses from advancing.

“The prime example is cancer, so women with breast cancer, men and women with colon cancer, men with prostate cancer, a lot of these people have not been able to get their surgeries and what may have been a stage two disease in March, is now a stage four disease where the life expectancy is in months, even with chemotherapy,” Cooper said.

“The other example is patients who need dialysis and in order to get dialysis you need a vascular access and there is already a strain on the system trying to get access because we just don’t have enough operating time, but now you have cancellations and postponements. These people can’t get dialysis right away when they need it.”

Noting that the government and the PHA are stretched financially, Cooper said the lack of resources is not a reasonable response when sick people are contracting COVID-19 in hospital and when others are being denied access to care.

“I understand that the government is strapped as far as its financing is concerned, and I don’t neglect to think about those on the food assistance program, those receiving NIB (National Insurance Board) payments for unemployment and all the things that have to go toward education, having virtual schooling. I am very much sensitive to those things; however, we have got to find the money,” he said.

“We just have to find the money some way and it’s a challenge. I don’t point my finger at anybody and I’m not being critical of anybody or the decisions that they make. However, I do think that there is a need for us to pay more attention to the excess deaths and what that says about the burden to our healthcare system, and how we need to use that information to develop strategies because we do not think that this virus is going away anytime soon and we need not realize in January of 2021 when we’re still dealing with numbers that are significant that, you know what, we haven’t really planned for what we’re going to do with all of these people who have been backlogged for surgeries and procedures and the clinics, etc.”

In a more perfect world, PMH would operate better with improved, updated and more modernized community clinics where specialty clinic services could be appropriately relocated, PHA Managing Director Catherine Weech told National Review.

“We have lots of ideas and thoughts about how we make those improvements,” Weech said. “COVID-19 came and it has just placed a lot of those realities on the back burner.”

But she said a focus is being placed on the upgrade of polyclinics on New Providence to take the burden off PMH.

“The program is still high on the agenda and work is being done towards that end, but it takes time,” Weech added.

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Candia Dames

Candia Dames is the executive editor of The Nassau Guardian.

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