There’s a term we use in epidemiology to capture the essence of increases in deaths, or excess mortality, above and beyond normal expectations: “harvesting”. During heatwaves, or a bad season of influenza, additional deaths above what would be normally seen in the population fit this description. Harvesting usually affects older people and those who are already sick. Generally, it is viewed as a tragic, unfortunate, but largely unpreventable consequence of natural events. It carries with it connotations of an acceptable loss of life. It is, in a sense, what happens as part of a normal life in normal times. But the word also has darker connotations: those of sacrifice, reaping, culling. As such, while it may appear in textbooks of epidemiology, it doesn’t occur in national influenza strategic plans or national discourse. The concept of harvesting is restricted to epidemiological circles.
But what if politicians promote the notion of harvesting (while declining to use the term) where it is not a “natural” consequence of events but a direct consequence of government policy? What if the medical and nursing world do not accept harvesting in these circumstances?
What if a policy that results in harvesting cannot be articulated because it is unacceptable to the broader population? This is where we have got to with the coronavirus pandemic. Nowhere better exemplifies this tension between a policy and its popular acceptance than the effects of coronavirus in nursing homes.
Coronavirus is tearing through our nursing home population in the UK. Even if official statistics are opaque, we know this anecdotally. More than 400,000 people live in UK care homes. We are only now beginning to see the statistics in terms of confirmed cases. Estimates that more than 3,000 people had died in care homes by mid-April are likely to be gross underestimates. We can see this when we look at national excess mortality numbers. These statistics, especially when we look at the elderly, paint a horrifying picture. Enormous numbers of deaths among our most frail citizens are the result, both directly and indirectly, of the coronavirus crisis. The UK is leading Europe in this most awful of league tables. When more data about care home deaths becomes available, I predict that we’ll see how care homes have taken the full force of this epidemiological tsunami. We have to predict, because the numbers aren’t yet available to inform us.
If herd immunity was the initial strategy outlined by advisers, they would have known that harvesting older people could not be part of the equation. This isn’t about science or politics – it’s a simple question of humanity. If the government’s strategy was to allow the virus to spread through the wider population, albeit at a slowed pace, residents in nursing homes would need to be protected.
But this is not what happened. The initial strategy of allowing herd immunity to develop in the wider community was pursued, but the most vulnerable people were not protected. Though harvesting may not have been the government’s intention, it became the de facto policy in the absence of adequate protections for older and vulnerable people. Had the government monitored care homes, supplied adequate PPE, rolled out testing in care homes and reduced the exposure of their residents to visitors and other carers, the islands of vulnerable and elderly people would have been protected.
The government’s initial strategy, therefore, was herd immunity and harvesting. Operational implementation follows a strategy, not the other way round. Only belatedly did the government’s strategy morph into one that sought to protect the elderly and reverse the harvesting, through widespread testing and contact tracing. But by then it was too late. Operations could not catch up.
In the discipline of public health, we often use what are known as “lenses” to explore how health systems function. Lenses are ways of looking at a health system that offers insights into its strengths and its weaknesses. I’ve spent over 30 years analysing the intersection between health systems and infectious diseases in my research. During this time, I’ve drawn upon influenza, Sars, tuberculosis, and HIV to examine health systems’ frailties around the world.
Today, if you need a lens to examine any country’s response to coronavirus, look to its nursing homes. To understand the scandal of the UK’s response to Covid-19, consider that it is the most vulnerable people who were sacrificed to an unacceptable, unarticulated strategy. Look to the hidden populations residing in nursing homes, those falling through the gaps between the NHS and the social support function of the state; look at what our government has done in our name, without our agreement. If you want to understand why older people had to “take it on the chin”, look to Boris Johnson’s government.
• Richard Coker is emeritus professor of public health at the London School of Hygiene and Tropical Medicine