To understand the heartbreaking consequences of governments stuck in short-term thinking, listen to Christian Salaroli, the 48-year-old anesthesiologist who serves as the medical director of a hospital in the alpine city of Bergamo in northern Italy, where the novel coronavirus pandemic is peaking.
“Some of us are crushed – the primary physicians, the newly arrived young people who find themselves in the early morning having to decide the fate of a human being,” he told the Italian newspaper Corriere della Sera. His job every morning is to go through the packed emergency ward and decide who, among the scores of new patients, will be admitted to the few intensive-care beds and hooked up to the hospital’s extremely limited supply of ventilators – and which ones will be left to their fate.
“It is a terrible thing to say, but unfortunately, it is true – we are not in a position to attempt so-called miracles.”
It is, he says, exactly the sort of triage that army hospitals are forced to conduct during terrible attacks.
If virus victims are very old, or if they have cardio-respiratory problems or coronary-artery problems, then they are essentially left on their own, likely to die. No point using a scarce ventilator to save someone’s life if they aren’t young and healthy enough to have a good chance of making it. And it’s not just virus patients: When people come in with heart attacks, they’re now forced to wait hours rather than minutes. People with chronic diseases are being kicked out of intensive-care rooms for younger virus patients.
It turns out one of the key factors affecting the mortality rate of coronavirus disease, or COVID-19, appears to be the availability of intensive-care beds – and that means the availability of ventilators. Countries whose governments decided to invest in large numbers of ventilators appear to have half the mortality rate of countries that didn’t.
But it’s not just the COVID-19 death rate that rises when beds and ventilators are scarce. As Dr. Salaroli’s awful experience tells us, a bed shortage during a pandemic also dramatically increases the mortality rate of everything else.
In China, where the average hospitalized person required four weeks on a ventilator, hundreds of people in China died unnecessarily because of a lack of critical-care beds available there – just four for every 100,000 people. The Chinese government’s reported efforts to keep the virus outbreak under wraps for more than a month, while declining to rush crucial medical equipment to Wuhan, didn’t help. Some of the countries that have fared much better have done so partly because they invested in more intensive-care beds and ventilators years ago.
The world leaders in equipped-bed availability are the United States, with 35 beds with ventilators for every 100,000 people, and Germany and Taiwan, with 30 each. Italy has about a dozen. Canada, with 10 to 12 ICU beds for every 100,000 people (depending how they’re measured), does not fare very well – according to the Organization for Economic Co-operation and Development, Canada has about half as many intensive-care beds as the average developed country, despite spending 15 per cent more on health care.
But it’s often much worse than that. According to a 2015 study, the availability of intensive-care beds and ventilators varies widely by province and region. Newfoundland has an impressive 19 beds, with ventilators for every 100,000 people, whereas the governments of British Columbia and Alberta, at the bottom of the ranking, have a rate of seven and eight, respectively – not far from the rates of badly affected Iran and China.
This is not a matter of haves and have-nots. An ICU ventilator unit generally costs less than $10,000; the cost of supplying and equipping a room will be more, but this is not an eyebrow-raising budgetary decision. For poor countries, ICU beds are difficult expenses; for Canada or Italy, they’re negligible.
This comes down to the way governments think of future needs. Funding of hospitals by Canadian provinces tends to be calculated in order to meet current needs – and then sometimes only barely. The most populous provinces have severe problems with emergency-ward overcrowding even during quiet, non-pandemic periods. Canada’s shortage of critical-care beds and ventilators, and its lack of capacity to handle a pandemic, has been a known problem for years. But too often, provincial health departments instead worry about having too many unused ICU beds during normal times.
But we don’t live in a steady-state world. This century’s big lesson for governments should be that they should be planning and spending not for a gentle expansion of current trends, but for black swans and worst-case events. To survive moments such as this one, we need to invest in overcapacity.
We have a pandemic. And we have some catching up to do – not just in this crucial area, but in our whole approach to planning for an unstable future.
Doug Saunders, The Globe and Mail’s international affairs columnist, is currently a Richard von Weizsaecker Fellow of the Robert Bosch Academy in Berlin.