Coronavirus Response - What Happened to ‘First Do No Harm’?
“First do no harm” is a phrase attributed to the Hippocratic Oath, taken by new physicians upon medical school graduation, but those words do not actually appear in the oath. This is much like “separation of church and state” or the “right to privacy” that are constitutional concepts yet not actually appearing in the US Constitution.
It is a wise guiding concept for much in life, especially large government mandates or programs. Proposed solutions may actually be worse than the underlying problem such solutions are supposedly solving.
What harms will result from stay-at-home orders, banning elective surgery, shutting down businesses, and other restrictions?
These measures are designed to “flatten the curve,” a term now commonplace, moving beyond diet clinic promises. A steep curve means more cases in a short period of time, potentially overwhelming the healthcare system. Then again, a steep curve gets through the pain much faster, like ripping a band aid off.
A flatter curve keeps the number of sick below the capacity of the healthcare system so that ventilators aren’t rationed, and people denied care. But the pain goes on longer. This was relevant when models predicted a surge of cases and ventilator shortages, yet these predictions failed to materialize.
A flatter curve doesn’t reduce the number of deaths or sick, it only spreads out the pain and restrictions for a longer period of time. Eventual herd immunity is delayed with a flatter curve. Deaths represent the area under the curve, which is the same whether the curve is steep or flat.
A flat curve however means the restrictions stay in place longer. The virus may spread more slowly, but COVID doesn’t care about curves, only viable hosts. Eventually most or all of the population will be infected with the Wuhan virus, which tells the world, “you can run but you cannot hide.”
What is the harm heaped upon America by flattening the curve? Is this the best approach under a “first do no harm” doctrine? What are the harms caused by weeks or months of “stay at home” orders and closed businesses?
Michigan and Sweden have similar populations of about 10 million people. Sweden has open businesses and few societal restrictions. Michigan is locked down, residents unable to travel to their cottages up north and not even allowed to buy seed and plant their gardens. Sweden has had 2200 deaths thus far compared to 3100 deaths in Michigan. Are restrictions doing more harm than good? Time will tell.
Elective surgery and medical procedures are on hold in the US. Physicians still open for outpatient care are running on a reduced schedule. Many hospitals are near empty, caring for only the COVID infected.
What happens post COVID when now empty hospitals and medical practices are closed and unable to provide routine medical care?
Elective surgery is not just convenience. It is also the financial lifeblood of our medical system. Look at a few scenarios.
Younger patients with colon cancer may be identified early via colonoscopy. 98 percent of cancer cases had not had early screening. How many malignant polyps are not being identified early since colonoscopies fall under elective surgery? How much coronary artery disease is being missed due to stress tests and cardiac catherizations being delayed?
Total joint replacement is also considered elective. For those in pain, unable to walk, how many develop a deep vein thrombosis due to immobility, leading to a pulmonary embolus and death? How many recent orthopedic surgery patients are not receiving physical therapy, leading to worse outcomes, falls, and potential death?
Falls are the leading cause of fatal injury among older adults. What if poor vision leads to a fall? Someone awaiting cataract surgery may miss a step and fall due to poor vision. Patients having cataract surgery “were 60 percent less likely to die from all causes.” Yet this is considered elective and is on hold.
Most cancer therapy is given under various clinical trial protocols. Much clinical research is shut down due to medical resources reprioritized to COVID, meaning many cancer patients are not receiving optimal treatment.
I could go on, but these are some of the harms caused by bans on elective treatment. Perhaps a reduction based on facility circumstances, adequacy of staff and PPE, and other factors might have been wiser than simply a ban. First do no harm.
We have now become Canada, which has a 20 week wait time from GP referral to a specialist, and an 11 week wait from specialist consultation to treatment. How much excess death will result from the current restrictions?
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Then there are the socio-economic costs of flattening the curve, shutting down the US economy. Unemployment may hit 20 percent, with tens of millions of Americans suddenly out of work, and soon out of money. What harm does this lead to?
The National Bureau of Economic Research, “Finds a 3.6% increase in the opioid death rate per 100,000 people for a 1% rise in unemployment.” 20 percent unemployment could lead to as many as 30,000 additional deaths from opioids.
Whether it is the direct unemployment effect or the potential poverty produced from the economic shutdown that leads to greater suicides, an increase from the 48,344 suicides and 1,400,000 suicide attempts in the United States in 2018 should give decision-makers pause during their response to this pandemic.
There is also homicide. “The unemployed are over 50 percent more likely to become homicide victims than the employed.”
In an effort to stop people from catching the Chinese Coronavirus, an impossibility based its contagiousness, what secondary harms are being unleashed on America?
New York Governor Andrew Cuomo argued against reopening the economy in a recent press conference, saying the failure of the economy is not death, but instead, “The illness is death. What is worse than death?”
Plenty is worse than death. Postponed medical procedures and surgery turn the US into Canada or the UK with their long waitlists and resulting poorer medical outcomes. Substance abuse, domestic violence, homicide, and suicide will increase in line with unemployment. The death toll will rise and at some point, likely surpass the COVID death count.
New York City has 10,746 confirmed Wuhan virus deaths. 21.2 percent of NYC residents are estimated to have contracted the virus based on antibody testing, meaning 1,780,800 people out of the 8.4 million population. This calculates to a case fatality rate of 0.6 percent. This number is likely lower as many so called confirmed deaths are only presumed to be due to the virus.
And NYC is the hardest hit region in America. This contradicts Governor Cuomo’s claim that “the illness is death” since fewer than 1 of 100 infected will die.
The basketball player and scarf queen certainly understand the concept of socio-economic determinants of health. It’s not just keeping people from catching a virus that the vast majority will recover from, but also keeping the economy healthy enough to avoid unnecessary death and destruction, pain, and panic. First do no harm.
Brian C Joondeph, MD, is a Denver based physician and freelance writer whose pieces have appeared in American Thinker, Daily Caller, Rasmussen Reports, and other publications. Follow him on Facebook LinkedIn, Twitter and QuodVerum.