Weekly Report from the Bellingen Covid-19 Clinic: Dr Trevor Cheney

Dr Trevor Cheney gives his weekly report from the Bellingen Shire Covid-19 Clinic

Dear Bellingen Shire

19 October 2020

Another week of no local (or Regional Cases) Covid19 cases, another week of low numbers in the state, another week of political scandals and conflict and duck shoving between our Federal and State Governments. Such is the nature of politics and such is the nature of our Federation – for good and for bad. I have lived and worked in all States except Tasmania, and would identify as a “federalist”, as an Australian. Borders are fraught constructs. And yet humans also need a concept of boundaries to feel safe and comfortable to get on with life. As our Federation has delegated the management of health care – ie hospitals and public health management – to State governments, then I respect their obligation and therefore right to manage as best they can. Ultimately for each jurisdiction that only extends to the weak line in the sand, or over a mountain ridge, or riverbank, or watershed etc– ie the State border.

I remember as a kid going on family holidays to northern NSW from The Gold Coast and stopping for inspection at the “Tick Gates” in Tweed Heads. We all had to stop and open the boot and car etc for a state quarantine officer to check we weren’t carrying tick vectors or banana plants into the beautiful, clean NSW. Well it worked for a while. At least it probably worked better than the rabbit proof fence. A vain attempt to cut across the continent and keep marauding Lepus out of pastures. I recall cartoons of rabbits on either side leaning up and telling each other jokes about it. The bottom line is that all things human made fall down eventually – if they are not torn down first.

So why are we still spending so much resource and time on trying to keep viruses out of each state, and out of Australia. Because ultimately, we deem it worth the effort, and the consequence of dismissing the risk of invasion is too great. I will get back to the Risk topic.

To help keep perspective, as always, we have living laboratories around the world of the evolving progression. In Europe, the UK, USA, India and so many others, I fear we will now ultimately see the development toward the “herd immunity” that so many professionals warned against allowing. That means a surviving population after huge loss. On the news this weekend was the grim statistic of 30000 cases of Covid 19 reported in one day in France. France has a population around 65 million – a bit over twice Australia. Victoria’s daily numbers are now in the single digits.

On the same report was a dropped morsel that the health system of the Czech Republic is near collapse with their new upswing in cases. Meanwhile Italy is seeing a resurgence. A special mass was held on the weekend for the 160 doctors who have died because of Covid 19 this year, so far. (Sorry I haven’t heard the number for the nurses). I only repeat these points yet again because on the same News bulletin this morning was a business woman in Victoria demanding we just let go and learn to live with the virus, we’ve waited long enough, let people do what they want! Each time I hear this kind of opinion it appears that people think that this is a linear issue – ie if there is an increase in cases then we live with the increase and just respond with an increase in medicine.

Pandemics are not linear. Firstly, the mathematics of a pandemic is exponential – Kind of 1+1=4, then 14. In contrast the capacity to respond to sick people in any health service is the opposite. Because ya just can’t make health workers (or equipment) in a day! They get sick, they also die. Then the capacity that is full overflows, and there is not an endless run of resources. I tried to make this point on the very first of these posts at the start of the pandemic, especially targeted at young people who thought the problem is not for them but just older people.

We can manage a few cases as we are now. But once your ventilators are occupied they are out of reach for the next young person who had a surfing or car accident or drug overdose or epilepsy or fall off a horse etc. Australia is living with Covid19 but at a rate we can control with pop-up responses to outbreaks. We will keep doing so for another 2 years at least. Hopefully, we will keep doing so till there is a good treatment and a safe vaccine. In Europe, the UK, USA it is too late. They will, I fear, ultimately head to herd immunity now. The responses are too late, too little, too subject to political gamesmanship, and the cat is literally out of the bag.

I ponder on a curious prospect on this topic – if the virus goes right through the population of many countries outside Aust, New Zealand and the Pacific, and at the end of a couple of years it is endemic there, how will they respond to our border controls? Will the fact that we have missed their suffering and still try to stay safe, mean loss of patience or anger or jealousy of Australia?? How will we manage our own need to keep trading with countries who no longer can try to suppress it, yet particularly keep preventing virus infected goods or people re-entering?

There is a ship standing off Fremantle Harbour now with cases of Covid 19. We have an international maritime law responsibility to care for those sailors. We might want those goods, or more importantly for the farmers of the Great Southern district of WA, they might be very keen to load that ship with exports. But if we don’t care for those sailors will their home countries take a different attitude to our trade? We have already seen what can happen when a large trading country takes exception to Australian attitudes with China slowly finding reasons to pull a sudden holt on a growing range of Australian commodities.

 

A quick rip through some Covid headlines in the medical press:

The first formal trial of Remdesivir – (the antiviral drug given to President Trump and touted as the first effective treatment) has been reported, and reinterpreted by an “on the ground” professor of Emergency Medicine in the UK. He was equivocal. The good news is that patients who were not so severe recovered quicker, had a less severe illness, 11.4% died Vs 15.2% without it. Unfortunately, it cost about $3300 US per patient, didn’t help those on ventilators, and there is a growing body of reports of side effects. His statement – We do not yet have a silver bullet.

The Federal Budget has provided some Money to improve or maintain Telehealth infrastructure. You may have noticed that your GP has been more able/willing to sort things out on the phone. You should know that before Covid GPs were banned from doing “phone medicine“ under Medicare. For good reasons. There will be some ongoing feature of this. I have to confess – it is not my preferred method, and there are huge risks associated. I am forced to accept that for now, less face to face and more telehealth is still a valid risk reduction tool. I have often wondered whether people really understand how Medicare rules, and Dr’s fees and referrals work – perhaps a topic for a future bulletin.

Sex workers in Victoria have been having a hard financial time. They mostly are not able to claim “Jobkeeper” but point out they still have to eat and have rent or mortgages to pay. On the up-side the activity in the STD clinics has almost completely dried up. The STD doctors however are bracing for a big rebound as the night curfew protection comes off. Casinos and brothels will be amongst the last businesses allowed to open up.

A word on Risk. I would like people to have some answers ready for friends and family who read the extreme blogs or listen to commentators on certain foreign owned, sensationalist news channels. I have touched on this before. I learnt this life lesson in Outdoor education and the concept is no different when dropping someone over a cliff on an abseil rope or deciding to start a medicine in a patient.

You start with your objective. And you never stop with that. If you can’t justify being where you are, doing what your doing, with the tools you have – then stop doing it.

Next assess the risk. The risk of a Terracotta flowerpot sitting on my veranda and then falling off is pretty high if it is near the edge. But then what are the consequences? A flowerpot on its side is of minimal consequence (except to the plant and even that can be easily fixed). However if the veranda is 2 stories high and sits over the footpath in the middle of town – the risk is the same but the consequence of it hitting someone’s head is huge.

Conversely, the risk of a modern airliner falling out of the sky is incredibly low, but the consequences of that event are catastrophic. So, we address a huge amount of planning and effort and multiple levels of redundancy to prevent that tiny risk from ever happening.

Together, the risk of falling while dancing is small but foreseeable. The consequence of this risk manifesting – ie falling while dancing – is small . If you change that to dancing on the edge of Ebor Falls the whole equation changes.

So, the risk of getting Covid 19 in Bellingen, Dorrigo, Urunga right now seems really low to the point I have suspended my mask use in the shops. But not my social distancing.  However, the risk of softening our alert levels and getting bored with our responses to suppressing Covid 19 is that we will have it brought to the region, not notice, and there will be exponential spread within 2 weeks. That risk of lowered attention is increasing. The consequence? Overseas the above examples demonstrate that the consequence at this juncture in world history of allowing an outbreak to open up in our community and run unfettered is potentially catastrophic.

Conversely the risks of failure and income loss etc associated with restrictions on prolonged travel and business certainly are significant and measurable in economics and mental health, but their consequences, I would argue, are fixable, adaptable, are not nearly as catastrophic. We will still have a healthy population to invent a new economy and way of doing things. We will not be nursing an unpredictable, possibly overwhelming, growing tragedy of Post Viral Syndrome disabled people – young and old. We will not have lost our excellent health system to widespread collapse.

I seem to see less people out and walking/running than the amazing time of our first lockdown. The truisms that you are made to move, and exercise is the best medicine, are just as powerful as 6 months ago. It will always be our best medicine!! And this is the best place to imbibe it.

Our Covid 19 testing clinic in Watson St, Bellingen is now opening in the morning – weekdays – 9-9.30. it was already starting to get too hot in our Giggle suits, so this is a purely self-preserving shift. We are seeing a few people with adenovirus and Respiratory syncytial virus. -You can look these up.

Keep safe. Enjoy summer and the Outdoors. Remember this is just one perspective. Please check any detail with your own GP.

Dr Trevor Cheney

3 Comments

  • John May says:

    Thanks once again, Trevor….

    Borders ?….

    I think we are fortunate to have them….

    ….they divide the country up into natural quarantine zones, and make control and suppression (preferably elimination) that much more feasible…..

    ….I would not be surprised if, ultimately, our state borders prove to be one of the key factors in Australia negotiating this crisis in a relatively successful fashion…

  • Jane S says:

    One reason we managed during another national extended crisis in the form of WW2, was temporary abolishment of the states, it created a more efficient streamlining process. Surely useful for our current emergency.

  • Warren Brisley says:

    Thank you for such a calm discussion

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