'Coughs and sneezes spread diseases' and 'Spitting strictly prohibited'; these informative and prohibitive public health messages were familiar to all of us in the 1940 and 1950s when our government was acting to eliminate the great endemic disease that Bunyan called 'the captain of all these men of death', tuberculosis. Cases were found by x-ray, their contacts traced, and the patients treated in special hospitals, sanatoria. The effective, nationally organised but locally based public health system served us well until, in the name of efficiency, it began to be downgraded in the 1980s. Throughout history, plagues like tuberculosis have changed the world; COVID-19 is unlikely to be an exception to this.
Every day we hear people's opinions expressed in the media of what is going wrong and why government should or should not do something. These are individual views and obviously coloured by individuals' prejudices. My own opinions are also of course subject to the same criticism but having published them it is possible to look back and reflect on them as time passes. As the initial stage of the UK's role in this pandemic appeared to have reached a plateau, I discussed the epidemiology and some ways in which coming out of the epidemic in UK would cause problems for politicians (6 May
). I hoped for a more local approach, using public health services and doctors on the front line as numbers of cases fell, and I stressed the importance of outbreaks related to certain places where people congregated, notably hospitals and social care homes.
What governments did
As was expected, the lockdown was successful in reducing the transmission of the disease (the R number fell below one) and, although cases and deaths were still occurring through the summer, the numbers became manageable. The NHS was able to resume more normal activities, although spread of disease within hospitals remained an issue the NHS was slow to tackle. The care sector did much better once it obtained sufficient supplies of protective equipment. But the UK Government continued to insist on micro-management from London and failed to use local expertise, relying on an ideological commitment (and spending billions that could otherwise have boosted the much more effective local approach) to using private companies such as the giant Serco, Sitel and Deloitte to administer its public health response.
This strategic error has predictably been an abject failure and new cases and deaths are now rising throughout the UK, making efficient track and trace impossible without further lockdowns. More victims are going into hospital and onto ventilators and retired doctors who have volunteered as contact tracers are tearing their hair out at the inefficiency of a system that does not use their expertise and local knowledge. Again, the difficult decision on balancing restriction of personal activity with maintaining economic activity arises, but this time it is clearly a self-inflicted injury by the government. How should they deal with this resurgence and what about the future?
What are the priorities?
Understanding what needs to be done is helped by stripping the problem to its basics: what are the most important issues and what is the best way of approaching them in terms of harms and benefits? At this point, it would be wise to set aside ideological concepts and grasp reality. Neither Brexit nor other forms of national independence is likely to be helpful in an era of pandemic. Nor is pandering to special pleading from political supporters or past funders.
There are two overriding priorities: to protect the NHS and social care from being overwhelmed and to maintain a sustainable level of economic activity. Although there is a reasonable hope of one or more effective vaccines being available later in 2021, we cannot yet be sure how long immunity will last nor indeed of the level of protection it will afford. Clinical management of COVID-19 has improved remarkably but discovery of a cure is very unlikely. It would be wise to base policy on the likelihood that COVID-19 will become endemic and we should anticipate a future of living with, and learning to manage, the associated risks.
Protecting the NHS and care sector
When I started in hospital practice, there were no intensive care units and during the winter months we expected elderly patients to come in with influenza and pneumonia. Many died and we gave them appropriate care over a week or so. Now, such patients may spend many weeks in intensive care and, if they survive, many further months recovering. Quite apart from common humanity, we need to protect the vulnerable from COVID-19 in order to protect the NHS and allow it to deal with all the other illnesses. In the early 20th century, tuberculosis was so prevalent that special hospitals were built to accommodate those with the disease. We need to be prepared to use and staff our Nightingale hospitals to care exclusively for COVID-19 patients.
We know in general who are most at risk: the elderly and especially those with chronic disabling ill-health. We, for I am one, must expect to be sheltered from contact with younger people as far as possible and take all the precautions that are now well-publicised. For the isolated, this means provision of adequate food supplies and contact with other services; mail, the telephone, television and the internet are vital to alleviate loneliness and protect mental health. The risk to the elderly from contact with chidren will be greatly reduced when fast antigen testing and vaccines become widely available.
Protecting the NHS does not only mean keeping people out of hospital but also means much better control of infection within hospital. Of course, great care must still be taken to reduce risks from those coming into hospitals and care homes to visit patients. In the first phase of the epidemic, it became clear that the disease was spreading to patients in hospital and the staff themselves had unknowingly become vectors of the disease, partly from inadequate provision of PPE but also by failing to adhere to hygiene guidance and social distancing when not on the wards.
Doctors and nurses spreading disease is a very old lesson in medicine, one that was recognised in Aberdeen in the 18th century but only seriously tackled by Lord Lister when he introduced hand-washing and use of disinfectants into surgery in Glasgow in the 1860s. It is a lesson that we and those responsible for infection control in hospitals need to remember. I believe the social care sector did not fall into this trap; their problems arose from the sudden discharge into their homes of infected patients from the NHS and insufficient provision of protective equipment.
Where are we now?
The huge dilemma now facing our governments is stopping the rise in infections in the community while keeping people in productive work. The Scottish Government took action in the central belt during the second week in October as new cases had doubled over about 10 days and were then over 1,000 daily. England has started in a less coordinated manner and now sees well over 20,000 cases daily. But on both sides of the border hospital admissions and intensive care use are still rising. The two numbers to keep your eye on are these.
At the time of writing, in England 7,850 NHS beds and 743 ventilators are occupied by COVID-19 patients; in Scotland the numbers are 985 and 84 respectively. In population terms, we have been somewhat worse in preventing significant disease but now is the time when some improvement is to be expected if our earlier application of control measures has been effective. I hope we are now at the turning point; the next two weeks will tell. Control depends critically on our compliance.
Protecting the economy: COVID-19 as an occupational disease
For most people, having a useful objective in life is essential to mental and physical health. This is not the same as earning a living, but the two naturally run together for much of our lives. In terms of protecting economic activity through the pandemic, we need to think both short-term and long-term. It is helpful in thinking of the future to recognise that COVID-19, like tuberculosis, is an occupational disease, one that spreads in the workplace as well as in transport and overcrowded homes.
Those responsible for workplaces are well used to regulations, whether they like them or not. Noise, temperature, ventilation, light levels, smoking, air quality, food hygiene, exposure to dangerous substances, and physical hazards are all currently regulated in places where people work, all for the protection of health. For the future, all employers need to think of reducing infective risks where their employees work or where their customers gather. Many are now doing just this, and occupational physicians and hygienists are well-placed to advise organisations on these matters.
One lesson from this pandemic is that the earlier lockdown is enforced, the fewer the deaths. Both initially and again recently, this opportunity has been missed. The other lesson is that an efficient, human-based local test, trace, and isolate regime while numbers of new infections are low is essential for control. Once again, the UK failed to initiate this and now numbers are at a level at which it is becoming impracticable. A nation-wide lockdown is probably necessary to get control again but, even if this arrives in the present piecemeal pattern of regional lockdowns, test and trace must be re-organised onto a regional base using local trackers.
Spread of the virus is most often occurring when groups of unrelated people gather and converse, usually indoors. Tight control of such gatherings is now essential everywhere if the spread of infection is to be reduced. A terrible mistake was made when Mr Johnson, perhaps influenced by lobbyists, invited us all to go out to eat and drink to save the economy. Exit must be gradual and selective, guided by understanding of viral spread.
It is apparent that many essential shops, hotels, and restaurants have proved in general able to cope with restrictions on numbers and ensure social distancing, mask wearing and hand sanitation. It is also apparent that many office-based organisations can manage very well if most of their staff work from home, and it is very likely that outdoor work entails little risk of infection if social distancing and masks are enforced.
Places that are well ventilated and of large volume, such as theatres and churches, are likely to be relatively safe if the numbers attending them are strictly regulated and masks and hand hygiene enforced. Control of numbers is already necessary for fire regulations, but these numbers obviously need to be reduced further in line with prevalent risks in local areas. Factories and workshops should mostly be able to ensure good ventilation and appropriate distancing of workers, again with masks and hygiene precautions. The role and expertise of the safety officer will need to be expanded.
Universities and schools are managing with these precautions and it is probable that a good deal of economic activity can continue in reasonable safety. This will depend on widespread compliance and an efficient quick test and trace system. My generation was used to queuing in the open outside shops and this, socially distanced, is becoming the norm again.
If politicians think in this way, it should become apparent to them that local decisions on which enterprises can open and in what circumstances are essential. This should prevent the present disputes between cities and different parts of the UK. Central control should consider national issues such as supply of adequate numbers of quick tests to ascertain absence of infection, public health advice, and availability of protective equipment, but most importantly should provide means of ensuring those temporarily unemployed and their employers' enterprises if viable are supported.
I'm afraid that there is bound to be increased unemployment, and this brings me to the longer-term issues. The sufferers are likely mostly to be from what I regard as the non-essential but, in terms of taxation, more productive parts of the economy. Non-essential in that they are either positively harmful save to their owners, like betting shops and tobacconists, or provide things which we like but don't need, such as alcohol and fashion items. Others to suffer will be catering outlets that rely on large numbers of workers coming into the town and providers of cultural activities that will need to adapt to smaller audiences and thus income. It is likely that the burden of unemployment will fall disproportionately on the least skilled and in the most deprived parts of the UK, and this will threaten the cohesion of society.
It must weigh heavily in the calculations of politicians who have persuaded people in such areas to vote for them in expectation of a glorious future, and I expect they will be considering measures to relieve the distress. The forthcoming divorce from our biggest market cannot make this any easier, but they will need to consider what a future UK (and indeed Scottish) economy will look like. The rapid onset of the damaging effects of climate change gives a pointer to them. All readers will have their own ideas, but while being very grateful that I am now too old to embark on a new career but old enough not to worry about making a fool of myself in public, here are some of mine.
My future economy
My economy would be based not on the impossible concept of perpetual growth but on a more equitable distribution of wealth, with taxation, balancing more fairly earned income, property, savings, and death duties. We have become a wasteful and self-indulgent society, and the imperative of arresting climate change will force painful behavioural adaptations.
Taxation should, for some years, focus on those activities which are damaging to the planet's climate and ecology, until the nation's need for fossil fuels is minimal. This would be aided by building up those industries necessary to achieve this aim. All railway lines would be electrified and no new roads built. The workforce that built roads will have opportunities in repairing the extant roads, installing charging points, and building flood defences and housing. Expansion of the recycling industry will create jobs across many sectors. Air travel must be minimised and the traditional seaside holiday in the UK should regain popularity in our warming summers. Fuel efficiency must be a primary criterion for aircraft and vehicle design rather than speed. As an island nation, better use should be made of our residual expertise in shipbuilding with an eye on fuel efficiency and materials transport.
A massive building programme producing energy-efficient but cheap housing should commence, focused on Council and Housing Association ownership. Banks would be encouraged to do what they originally did, lend money to entrepreneurs and promising small businesses, and take as much risk on this than they have been taking whilst speculating for their own enrichment. And they should be encouraged to lend to those whose ideas address the issues arising from a changing climate and disruptive weather.
The removal of fossil fuel from the economy will mean power almost entirely based on wind, solar, hydro, tidal, geothermal, nuclear and hydrogen; this is a tall order but must be achieved quickly. Nuclear is unpopular but still necessary as a back-up; however, much more investment in tidal and hydrogen is necessary. There are real opportunities here that UK governments are missing as they missed out on solar. All these will create jobs, from labouring to the highly technical.
It is encouraging to note the response to the epidemic of the cultural and sporting sectors, so important to our well-being and our tourist industry. Ways are being found to give us access to their products and sensible thinking about protection of performers and audiences should lead to progressive opening up of this sector. It would be nice, though perhaps optimistic, to think that those select few who have made vast fortunes in such activities might now start investing in them as they struggle.
It is also encouraging to see how our schools and universities are managing with the growth in online and blended learning. They are great money earners for the UK, but more importantly, they will maintain and enhance the international reputation of the UK at a time when we are widely seen to be in decline. They are also the fount of ideas that change the world; medicines, computer applications, engineering, and often philosophy, art and literature. Educators in schools and universities are to me among the unsung heroes of this pandemic, along with all those parents who aided home education.
Finally, with the ageing population, health and social care will continue to seek out more of the many good people whose aim in life is to help their fellows and whose desire is not wealth but a satisfying occupation and enough to have a fulfilling life. Many such people are undervalued by our society and deserve better of the new world ahead. The imperative of climate change is to construct one such new world and the sooner our politicians start to think about it, the better for all of us. Like so many great plagues of the past, COVID-19 is changing the world and could do so for the better.
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