I'll start with a true story, though you may find it hard to believe. Many years ago, when Richard Nixon was President, I used to do a monthly tuberculosis clinic in the wilds of West Virginia. I drove 50 miles along narrow country roads to a small town called Moundsville which was notable for two things: a huge prehistoric mound and a jail. One day, a small and inoffensive-looking man was brought into the clinic handcuffed to two burly warders. Having assured myself that his illness was responding to treatment, I asked the nurse, a local lady, what he was in for. Armed robbery, she replied. It turned out that he had gone to the only bank in the town and, at gunpoint, had demanded the cashier hand over money. Taking what was offered, he went home to count it on the kitchen table. There the police arrested him, having been informed by the cashier who knew him because he had robbed his own bank.
Life, of course, is full of risks and we all make risk assessments every day, for example in deciding when to cross a road. My patient, had he made one before the robbery, might have realised that the risk of capture after robbing one's own bank would be too high to attempt it, but he was reckless and could only plead stupidity in mitigation. The bank clerk, confronted by an armed robber, made his risk assessment, and decided that it was safer to hand over the money than to resist.
Caution and recklessness are personality attributes that may co-exist in the same person but most of us err towards the cautious end of the spectrum, particularly as we grow older and experience the slings and arrows of misfortune. We see evidence of contrasting risk behaviour every day, particularly now we have been sensitised to its appearance in response to the threat of COVID-19. But, to make sensible risk assessments we need to have some information, and this is the main reason that I have been writing these articles.
The importance of personality is obvious from consideration of the behaviour of politicians. For Caution
, read Mette Frederiksen, Angela Merkel and Jacinda Ardern. For Reckless
, read Boris Johnson, Jair Bolsonaro and Donald Trump; just those six names tell you which personality is better suited to dealing with pandemics. It is indeed remarkable that female leaders have been associated with huge benefit to their countries' populations through this pandemic. On the contrary, in an aggressive war a greater propensity to taking risks, especially with the lives of others, may lead to temporary advantage. Churchill was suited to the war, Attlee better to the recovery during the peace. But even the most cautious of politicians come eventually to the knotty problem of competing risks, and this is where we are now with COVID-19 when the risk to the population's health has to be balanced against the risks to the economy.
It is perhaps encouraging that even the world's most reckless leaders are slowly confronting reality in realising that populist ideology has its flaws in addressing public health issues. This is most noticeable from the consequences of the eventual divergence of tactics between England and Scotland, as discussed in my last article (5 August
). The contact tracing system put in the hands of huge private companies such as Serco, and its leadership by someone with no public health experience, is now clearly dysfunctional – a danger to the health of the UK. This needs urgent reform, to a locally-based service with proper support of those isolated who cannot afford time off work.
Personal risk assessment
Now we are in a phase of the epidemic in the UK, in which cases of infection are generally milder and occurring in younger members of the population, with relatively few needing hospital admission or intensive care. Nevertheless, in Scotland seven died in the last week in July and currently three are in intensive care and around 270 in hospital. Many deaths are still occurring in England and the risk in these islands, especially to the previously shielded elderly, is still a serious one. How should we make our own personal assessments of that risk? There are two layers of risk: that of catching COVID-19 and that of falling seriously ill or dying. We should consider both, remembering that the aim is to reduce risk; there is no such thing as absolute safety.
The risk of catching the virus
This depends on two factors: its prevalence where we are and what we are doing. For example, it is estimated that at present between about 0.3 and 2 per 1,000 people in Scotland may be walking around not knowing that they carry the virus yet able to infect others. If you are out walking, it is very unlikely that you will meet one or more and spend long enough talking to them to catch the disease. If you go to a concert attended by 1,000 people, there is a reasonable chance that some of them might be there and each could infect five or six people sitting close or at the bar in the interval.
As I explained previously (27 May
), being indoors increases risks as the virus can survive suspended in minute droplets for hours, especially if the space is small, crowded, and poorly ventilated; this is why pubs and nightclubs are increasingly important centres of outbreaks and should be avoided by the prudent. The same potential risk applies at present to crowded public transport, large shops, and hospitals, so any necessary time spent in them should be limited and, if possible, kept to quieter periods.
Travel is an obvious issue. Use of public transport is essential to many and both those who run the system and we as passengers share responsibility for our safety. At the least, windows should be kept open to ensure good ventilation and face coverings must be worn. Non-essential public travel should be avoided, including for holidays; infections with COVID-19 are now increasing in almost all countries where lockdown is being relaxed and detection and isolation of cases and contacts is still the only method of controlling this.
The risk of harm from the virus
This is the other component of your risk assessment: how likely are you to fall seriously ill if infected? The most important considerations we now know to be age, BAME status, the presence of any chronic significant illness such as of heart, lungs or kidney, diabetes or a cancer that requires chemotherapy. If you are seriously overweight the risk is much increased, and these risks add up. As an example, an 80-year-old is almost as likely to die as to survive if infected and the risk falls steeply below 65. Almost nobody under 45 will die of it, though some with other risk factors can suffer a nasty illness. Between these ages, the risk factors above are most influential.
Less well established is the importance of dose in determining the severity of illness once infected, since it is virtually impossible to establish epidemiologically how many viral particles people have been exposed to. Nevertheless, it is likely by analogy with exposure to other toxic agents that the higher the exposure, the greater the risk of serious infections. Exposure takes account of both the numbers of viral particles and the duration of exposure. The more people you have conversations with, the more likely you are to meet an infected person, and if an infected person coughs in your face, as happened to a colleague of mine, you will be likely to get a big dose and have a severe illness. The longer you spend talking to someone infected, the more likely you are to inhale a big dose. Many people talking loudly in still air in an enclosed space is a recipe for problems. Knowing these simple facts allows you to take your own preventive actions.
The role of the State is obviously crucial, in giving good advice and avoiding trivialising the risk. We have seen plenty of examples of the latter from the UK Government, from individuals ignoring their own advice to giving silly names to serious issues ('Whack a Mole'). Scotland's welcome return to effective testing and tracing has a reasonable chance of keeping control of the epidemic so long as we cooperate; its efficacy is now being tested in Aberdeen.
If we develop fever, a persistent new cough, or loss of taste or smell, we should get an antigen test and self-isolate. If we are informed that we have been a contact of someone found to be infected, the same applies. While we are well, we should behave as if everyone we meet is a potential source of infection and use the social distancing and hand/face hygiene we are now well used to. We should wear face coverings when in enclosed spaces with other people, as if everyone does this spread of the virus will be much reduced.
And everyone should try to avoid crowded places and public transport as far as possible. Failure to observe this simple advice will continue to lead to outbreaks, such as in Aberdeen, and any outbreak can lead very quickly to a resurgence of the epidemic across the nation and beyond. A couple of people on a pub crawl has the potential to lead to the death of hundreds and breakdown of the NHS.
We need to become used to the idea that the world has changed, and I shall return to this in a later article. Viruses respect neither national borders nor politicians. King Canut did not think that he could stop the incoming tide; rather he wished to demonstrate his lack of such powers. SARS-CoV-2 has one biological imperative: to find a suitable cell in which to reproduce, and unfortunately, it has found a very suitable host in elderly people. It is likely to be among us as a threat for a long time and we must get used to it and adapt our lifestyles accordingly.
Mr Johnson will not 'beat this thing' any more than he will realise his 'glorious future' after Brexit (though he may end up comfortably seated in the House of Lords with his friends). He needs to get his act together on contact tracing, but we must play our part in keeping the virus at bay.
As we venture into shops with a face mask on, the fact that we look like bank robbers may remind us of my poor West Virginian patient and of the need to make the risk assessment and take the precautions that he failed to do. And, come to think of it, I never thought to ask the clinic nurse if he had worn a mask.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own