Nursing Homes: A Western World Tragedy - Dr. Joe Amaral
Friday, May 29, 2020
My head has been spinning since writing “A Western World Tragedy”. The implications of 30-80% of the now 100,000 deaths in the United States occurring in patients from nursing homes and long care facilities are staggering and surreal. Grandparents, parents, siblings, relatives, and friends are gone. Death under any circumstance is a tragedy to those left behind but it is even worse when they are not present in the final moments. How could this be? Mother Nature has a cruel way of showing her dominance over us. No matter how strong and smart we think we are, we do not rule.
My head is spinning for an unemotional reason as well. How can 30-80% of deaths from COVID-19 come from only 0.5% of the population? Furthermore, how does the fact that the location of residence is such an important determinant of outcome and death align with other information regarding COVID-19 we have received? The crowded indoor conditions of nursing homes do align with the notion that most outbreaks and cases are thought to occur primarily among people who congregate indoors. Churches, choirs, restaurants, and business meetings are cited as common sources for infections with COVID-19. The finding that COVID-19 is most deadly in the elderly makes me wonder if it is age or location that is the primary driver of death. In other words, are 80-year-old people living at home alone or with their spouse at as high a risk for death from COVID-19 as those in nursing homes? Is the viral dose they receive higher in the nursing home from the constant exposure to it in the environment of the nursing home?
Fifty-two percent of people who live in nursing homes are 85 years or older, 30.3% are 75-84 years of age, 11% are 65 -74, and 6% are less than 65 years of age. In comparison, the death rate for COVID-19 is 13.4% in patients 80 and older who are infected, 8.6%, for those in their 70s and 4% for those in their 60s. That is a pretty startling correlation, but still doesn’t answer my question. Of course, people have multiple medical reasons for residing in nursing homes, otherwise they would be in their own home. But what if comorbid disease is an association but not the cause. Could the environment of the nursing home or crowded space be more important than the pre-existing diseases a person has? Does a person who has hypertension and is living at home have the same risk of being hospitalized or dying from COVID-19 as someone living in a nursing home?
GET THE LATEST BREAKING NEWS HERE -- SIGN UP FOR GOLOCAL FREE DAILY EBLASTTo address these questions, I reviewed five large studies that documented the main risk factors for hospitalization and death following COVID-19. Hypertension, diabetes, chronic obstructive pulmonary disease, obesity, and dementia were the top five. Since these risk factors are also very common in the general population, is it an association or are people with these diseases at greater risk of dying? For example, hypertension in hospitalized and in the general population are about 30%. The studies did not give a clear answer. Additional studies identified diabetes and obesity did confer a higher risk in those that have the illness than in those that do not. However, what was astonishing was none of the studies considered where patients lived prior to admission or how many people lived with them as the reason for the difference.
As I continued to ponder the role of living conditions, another observation came crashing into my head. Blacks are impacted by COVID-19 much more often than the percentage of the population they represent. In many cities, black patients were hospitalized at nearly three times the rate of white and Hispanic patients. Hispanic people are also disproportionately affected in some states by COVID-19. For example, Latinos account for more than 20 percent of coronavirus cases in Iowa though they are only 6 percent of the population. Again, one of the reasons cited is the well documented higher prevalence of chronic conditions in these minority groups. However, one study found the difference in mortality remained even when differences in age, sex, income, and the prevalence of chronic conditions were considered. Yet, none of the studies compared living conditions prior to hospitalization and/or death.
Black and Latin people more commonly live in densely populated areas and have more people per household than the rest of the population. Furthermore, they disproportionately work jobs currently considered essential, but are paid non-living wages. Living conditions of these minority groups are speculated to be one of the reasons for the outbreak in New York.
Understanding the simple question of how and where people live is critical to understanding how to manage our lives safely as restrictions are eased. Do I have a higher risk of COVID-19 because of hypertension and diabetes or is where and how I live more important?
It is interesting to observe that when we are faced with an unknown such as SARS-CoV-2 we often excluded what we know about past epidemics and pandemic. We abandon good science and make guesses based on inconclusive results in the hopes we can resolve the problem as fast as possible. We focus on minute details like whether the disease can be spread as we speak and fail to recognize that the primary determinant of almost all prior respiratory epidemics is the social conditions under which people live.
Respiratory diseases are most easily transmitted by close personal contact. The book “How the Other Half Lives” by Jacob RIIS documents in words and photographs of how immigrants spread tuberculosis by living in crowded and despicable apartments in NYC. The essay I wrote on “Iceland and the Plague”, chronicles how the plague in Iceland was due to the respiratory spread of anthrax that was exacerbated by the close contact citizens shared during the cold winters in Iceland in their crowded homes. The Spanish Flu is remembered for the surge in cases following a Philadelphia parade, but we should also remember how groups of Eskimos all died in Alaska from crowding in their homes.
The importance of social conditions as the match that lights epidemics led to sanitary reform in the mid-1800s. The movement was established not by a physician but by a barrister from Manchester England, Edwin Chadwick. He collected extensive data to show that epidemic diseases correlated with the social backgrounds of sufferers and the localities where they lived. Poor sanitation and crowded housing were the root cause of many of the illnesses that plagued England. At the same time, John Snow, a physician in London, demonstrated that the source of cholera epidemics was not from bad air but from the drinking water. Sanitation was a revolution of living conditions by establishing sewers and running water to homes. The result was epidemic disease dramatically dropped.
An extreme view of living conditions based on an extensive review of history by the English medical historian and physician, Thomas McKeown, lead to two debated but important works “The Modern Rise of Population “and “The Role of Medicine: Dream, Mirage, or Nemesis?” in 1976. He argued that ultimately it is improvements in nutrition, wages, and sanitation that prevent epidemics and improve health. Medical science plays only a minor role.
I do not believe McKeown is correct in his view that medical science plays a minor role. We have witnessed the longevity of human life increasing with advances in medicine for the past fifty years. Yet I do agree that medicine alone cannot overcome Mother Nature. Without
Improvements in wages and living conditions, we will always be faced with the scourge of epidemics and pandemics. We will repeat the mistakes of the past and create panic and chaos as we face the unknown.
I am left dishearten to realize that after so many years we still have vast numbers of our population that do not live under better living conditions or even worse that these conditions are imposed on them.
Hopefully, after COVID-19 we will remember the words of Jonathan Nez, president of the Navajo Nation about the devastation Navajo Indians are experience with COVID-19.
“but now that we’re in the headlines, US citizens are finally realizing the deplorable conditions our people live in. We’re fed up. This has got to end.”
#Raisetheline
Dr. Joe Amaral is the former President of RI Hospital, the Founder of Tipping Point Healthcare Innovation, and the Chief Medical/Science Advisor at Venture Investors.
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