Is fat more than a feminist issue?
On 12 September, The Irish Times Health Correspondent, Paul Cullen, reported criticisms of COVID-19 restrictions by Dr. Martin Feeley, then Clinical Director of the Dublin Midlands Hospital Group.
Dr. Feeley contended that the seriousness of COVID-19 for our society has been significantly exaggerated. Based on the level of recent fatalities, as opposed to case numbers, he suggested that the virus was “much less severe” than the average annual flu, so the “draconian” NPHET and government response, fanned by hyperbolic media coverage, is an overreaction.
Dr. Feeley claimed that the evidence from living with COVID-19 for more than 6 months confirms that it does not constitute a uniform risk for all of us. Rather some categories of people are at material risk and other people are at little or no risk at all.
Age and the existence of an underlying condition are key differentiators in assessing risk levels:
…virus-related deaths among people aged under 65 who do not have underlying conditions are uncommon, and transmission by children while possible is also uncommon.
The presence of a “chronic illness” is the “all-important factor” in determining a person’s Covid-19 risk, he points out. “You can identify with amazing accuracy who is at risk, as with no other disease.”
His conclusion: the policy response by way of restrictions should be calibrated to these different risk levels. Younger people should be allowed to enjoy comparative freedom to live normal lives, exposed to the virus so that they can develop herd immunity. Older people should be guided and encouraged to protect themselves.
“Experience has taught us that at-risk and vulnerable individuals are identifiable with remarkable accuracy; and protective measures, hygiene, masks, social distancing and cocooning are effective.”
He points out too that younger people are most exposed to the economic costs of the restrictions despite being at least risk from the virus. By contrast, elderly people in retirement who are at greater risk from the virus are comparatively insulated from the economic effects of dealing with it.
Four days later, the newspaper reported that Dr. Feeley had stepped down from his post under pressure from HSE management “who told him his position was untenable”. The counterview to Dr. Feeley’s position was expressed in measured terms by Leo Varadkar in an interview with Claire Byrne on 24 September:
I don’t agree with what he’s saying. But I never think we should dismiss alternative views or certainly views that come from people of expertise because this is a new virus, it’s only around nine months. There’s a lot we still have to learn about it.
Ronan Glynn, the Acting Chief Medical Officer, always says that anyone who speaks with certainty on coronavirus is doing so out of confidence not out of knowledge because there is so much we have yet to know or learn about the virus.
One thing to me is that it is not like the flu. It is much more infectious and is much more dangerous in terms of a higher mortality rate and we don’t have an effective treatment for it and we don’t have a vaccine for it. So I think comparisons to the flu are incorrect.
Dr. Varadkar was responding to an opinion piece by Dr. Feeley in The Irish Times of the same day which had allowed him to set out his position in more detail.
I am going to leave the wider argument to one side to focus on one point which Dr. Feeley had mentioned only in passing in the earlier report by Paul Cullen but on which he elaborated in his opinion piece.
The best-kept secret regarding Covid-19 is the vulnerability of individuals who are overweight. For reasons unknown this is not publicised to the degree required.
He claimed that the HSE’s laxer threshold of “obesity” disguises the extent to which it is a risk factor for COVID-19: “…the HSE uses a body mass index (BMI) of 40 whereas most international literature uses a BMI of 30.”
Using a BMI of 40 indicates 3% of the adult population as at risk compared to 23% if a BMI of 30 was used. Dr. Feeley cites a study of 5,700 COVID-19 patients admitted to New York hospitals, of whom 88% altogether had more than one underlying condition. 41.7% had a BMI of 30 or more, making obesity the second most common risk factor after hypertension. Dr. Feeley continued:
It has been shown that the highest risk factor for ICU admission is obesity; in Ireland even when using BMI of 40 as the criterion, 19 per cent of those admitted to ICU had this risk factor.
I have no expertise in medical matters but Dr. Feeley’s reference to obesity prompts questions.
Is it right to consider obesity to be solely an involuntary illness and its origins immune to individual choice? Or is it to any degree at all the foreseeable consequence of actions that are the product of deliberate discretionary choice rather than compulsion? Is it a condition to which its sufferers are solely victims, never authors?
And if one thinks obesity can be about more than just bad luck but something for which the obese person is in some way responsible, does that have any implications for health policy?
There is something admirable about a health service that treats patients presenting to it as they find them without any discrimination based on a patient’s path to their presenting condition; a service that operates no hierarchy of dessert, that does not distinguish between patients who have simply been “struck” by their condition as if by act of God and patients who might have contributed to their circumstances by folly, negligence or other less than commendable behaviour.
You could justify that view of how the health service should work based on consideration of our common humanity implying an entitlement to equal treatment in spite of variations in circumstances, actions or behaviour. Alternatively, you could argue in support of that approach as being straightforward and simple rather than unnecessarily complex. Treating everybody the same without judgement or favour makes some administrative sense.
On the other hand though, health care requires resources; money, people, facilities. There is no society anywhere in this world in which those resources are unlimited and in which there is no rationing, whether explicit or implicit. There is a case for saying that those who lead their lives in such a way as to make recourse to the health services less likely should have easier or faster track access to the service when they need it than those who lead what once might have been described as “feckless” lives.
Does the state have the same obligation to the “large” citizen who spends their time recumbent in front of the television munching greasy chips as to the lean, toned, exercised ascetic who grazes on kale? Likewise, does the state have the same obligation to the citizen who persists in smoking 40 cigarettes a day as to the person who has never taken a puff in their lives?
This is not about shaming or blaming, but our management of our own health is not strictly a private matter but one with social implications and consequences.
My modest suggestion is this. As a nudge of encouragement to good behaviour rather than a cudgel of enforcement against bad, the state might offer every adult citizen a free medical NCT test every couple of years. While taking the test need not be strictly compulsory, it would be reasonable for it to be a requirement for access to the public health system, just as a valid NCT certificate is a requirement for driving an older car on the public highway.
In accordance with the current fashion for classification and segmentation, different “levels” could be established or “grades” assigned to reflect one’s degree of compliance with whatever recommendations regarding personal behaviour might emerge from the test. More compliant people would receive preferential treatment than their less compliant peers.
And the test might be valuable too as a straightforward “early warning” detector of incipient medical issues that might otherwise passed unnoticed until they became serious.
A nationwide testing infrastructure would also be drain on already limited “resources”. But it seems reasonable to imagine that the benefits in terms of preventing or reducing ill health by pre-emptive detection would at least match the cost of any reduction in the health service’s capacity to cure.
I don’t know either what the scope of the test should be to hit the sweet spot on the cost/benefit curve. Maybe a starting point would be to require all adults to do what many are already doing. Blood tests can already give a good indicator of where we stand on a wide range of health indicators. The process is established, simple, inexpensive and the results are available quickly.
Some day COVID-19 will either have disappeared from the screen of our lives or been tamed to a routine process. We shouldn’t lose the opportunity it has presented to learn and act on wider lessons.