By Ezio Di Nucci
The COVID-19 pandemic is of our own making – but maybe not in the way you think. Let me explain why, taking Italy as case study. COVID-19 overwhelmingly kills vulnerable people, older or chronic multi-morbidity patients: the mean age of COVID-19 fatalities in Italy according to the most recent data was 80 (median age 81). Around 60% of fatalities had three or more co-morbidities, around 36% had one or two co-morbidities and only 4% had no co-morbidity and only 14 out of 31,096 fatalities in the latest report were both under the age of 40 and had no-comorbidity – that’s 0,04%.
What these data mean from an epidemiological point of view I don’t know. From a more philosophical perspective, though, these data mean that, one or two generations ago, we might not even have noticed COVID-19, because most of its potential victims would have already died of other conditions. To stick to data for Italy, the most recent life-expectancy measure for Italy for 2019 was 83.5 and we only have to go back to 2005 for Italian life-expectancy to fall below the mean/median age of COVID-19 fatalities. What this means is that, while we didn’t create COVID-19, it is only through our own successes in nutrition, sanitation and healthcare that COVID-19 has been able to become the major problem that it has turned out to be.
Do we then have – with COVID-19 – another case of over-medicalization? That consequence would be grotesque, given that currently the most pressing worry is rather the lack of healthcare resources. So could it be that the current under-medicalization crisis is the result of a broader trend towards over-medicalization? In itself this wouldn’t be bad news, given that what we are really saying is basically that a generation ago we wouldn’t have had either the resources or the need to fight COVID-19. That those vulnerable patients are still around today, offering our healthcare systems a chance to save (some of) them, must be surely good news. And that our healthcare systems do today have a chance to save (some of) them, must again be surely good news.
The only problem is that – as all of us have now experienced first-hand – this chance to save (some) vulnerable multi-morbidity patients doesn’t just depend on our improvements within healthcare over the last couple of generations, which have both kept those vulnerable patients alive and also given us the resources to save (some of) them; the chance to save (some of) them also depends on social distancing and other restrictive measures that most liberal democracies had until recently forgotten were even possible, let alone legitimate.
This is not a simple dilemma between survival for some and jobs (and mental health) for others – even though clearly the economic costs of social distancing and other containment measures are unprecedented. The point is rather that our (rich) societies might have set themselves up for failure by improving and extending the remit of healthcare just enough to make it possible and morally urgent to save the lives of (some) vulnerable patients but not enough to do so without undermining their own socio-economic functioning – and thereby also undermining their healthcare systems’ long-term sustainability.
Let me be specific through an example, again taken from Italy’s COVID-19 data: there are already many early speculations about the high CFR in Italy. One such hypothesis is exemplary of my argument here, namely the fact that Italy has the highest rates in Europe for antibiotic resistance deaths and almost a third of all EU/EEA antibiotic resistance deaths. Once the COVID-19 pandemic is over, I wonder whether reversing the antibiotic resistance deaths table will give you the final COVID-19 CFR table for the EU; but that’s beside the point of my argument here. In fact, I am not interested here in whether there is a link between antibiotic resistance and COVID-19 CFR; I am only interested in how that possible link would provide an example of my theoretical argument, namely that we are collectively setting ourselves up for failure.
The basic story would go like this: in catholic Italy, vulnerable older patients are pumped up with antibiotics because life is sacred and it must be prolonged at all costs. That in turn results in an older population and higher life-expectancy in Italy – second oldest population in the world after Japan. And this also results now in a population that turns out to maybe be more vulnerable than average to COVID-19. This simple story might turn out to be unwarranted once there is enough evidence on the COVID-19 pandemic to start drawing epidemiological conclusions. But here my epidemiological hypothesis just serves the purposes of a thought-experiment, because it provides a clear example of how we might be setting ourselves up for failure through healthcare innovation, medicalization and over-treatment. The problem, obviously, is not the patients that were kept going through too many antibiotics last year and that died this year because of COVID-19; the problem is rather the patients that died this year because of COVID-19 and the undue pressure on the healthcare systems caused by an older more vulnerable population. This latter group of patients could have namely been saved if we hadn’t collectively set ourselves up for failure by over-treating the former patient group. And clearly over-treatment has put another group under undue pressure: healthcare professionals.
This has clearly nothing to do with Italy specifically or any other particular country or healthcare system, as the antibiotics in my above example are just a place-holder for medicalization and over-treatment in general, both being cases of – at the same time – things we can (and therefore must) do now to save lives and that will statistically also cost lives in the future. The question, again, is not primarily how much we ought to do today to save lives from COVID-19: there can be genuine disagreement on the extent and legitimacy of social distancing and other restrictive measures during this pandemic. The issue is that we might have set ourselves up for failure by medicalization and over-treatment and that we are now paying the price. And a price must be paid, importantly, regardless of the actual distribution of burdens, it’s just a question of how much of it will be shouldered by the medically vulnerable minority (plus healthcare professionals) and how much will be shouldered by the socio-economically vulnerable majority.
In conclusion, then, the COVID-19 pandemic might ultimately show that the medicalization rates of rich healthcare systems were unsustainable; and importantly this outcome might turn out to be independent of how much of the burden is shouldered by different demographics. I wonder whether the same way in which over-treatment has the medical side-effect of antibiotics resistance, it couldn’t also have the ethical side-effect of setting moral standards that we cannot live up to.
Author: Ezio Di Nucci
Affiliation: Centre for Medical Science and Technology Studies, University of Copenhagen
Competing interests: None declared