Many of us who write about COVID-19 or talk about it on television and the radio at present lead rather closeted lives, as do many of you. However, occasionally we get a reminder of reality. Several of my friends, including two of the five members of my family working in the NHS, have acquired the disease in hospital workplaces, though mercifully all have recovered.
Last week, I drew attention to the extraordinary number of evening flights that I had detected going to East Midlands Airport and the coincidence of persisting rises in infection in that part of England, a major centre for collection and distribution of goods presumably purchased online. This set up a train of thoughts.
We know that COVID-19 spreads mainly indoors when people congregate together. We know that particular people are at increased risk and this comes about in two different ways – intrinsic risk factors such as age, ethnicity, body mass and chronic ill-health, and extrinsic risk factors such as their living conditions, propensity to congregate, and need to go to work. You can do little about the intrinsic factors other than to be aware that they make you more vulnerable, take appropriate precautions against infection and take good care of yourself. However, the extrinsic risks are potentially manageable. We closeted ones are by now familiar with this, and it is demonstrated by the very marked prosperity gradient in mortality from the disease.
In Scotland, the latest available figures show that if, like politicians, TV pundits, most epidemiologists and me, you are in the most well-off million or so of the Scottish population, your risk of COVID-19 death has been about 8 per 1,000. In contrast, if you are in the poorest million, your risk until now has been about 15.3 per 1,000 – close to double. Poverty is obviously related to the inability to earn a decent wage and the difficulty of earning this is further limited by the effects of the pandemic, introducing a vicious downward spiral; the poorer you are, the more risks you are obliged to take in order to make ends meet and the greater your risk of falling ill. Illness then further reduces your chances of earning.
Many, probably a majority, of the better off have now discovered that much of their work can be done from home. But if you are obliged to go to work, what are the circumstances in which viral spread occurs? They are when you are off your guard, talking to others in groups. The hospital and ambulance staff who work with COVID-19 patients take care when exposed to them but can easily relax their precautions, even removing their masks, when having meetings with each other or on breaks. Large numbers of office workers manning phone lines cannot avoid breathing each other's expired air. Construction workers often work singly in the open air but may shelter together in a hut for their breaks. Transport workers may be safe in their cabs but not in the café where they have their breaks.
And then there is the problem for many of getting to and from work. Many poorer workers may have to take daily buses and trains in which they inevitably make contact with others. In many of these examples, the workers may perform their duties in an apparently safe workplace but be at risk from other necessary activities.
Imagine a scenario such as I mentioned in my last article, the major transport hub. A woman in her 40s with three teenage children, whose husband has just lost his job, finds work on night shifts doing repetitive work packing goods. During her shift she has two breaks in the canteen where she has the psychological relief of talking to others in the same situation. To get to work and back, she has to make a bus ride and a journey on a train in which she may well talk to other commuters. In a typical shift, she may be in contact with perhaps 40 or 50 other people, of whom it is likely that one or two will be spreading the virus. If she develops a cough or cold, she will probably hope it is nothing and, because she needs the money, she goes to work in spite of it. This is the reality of life. These are the people on whom we depend for our safety and comfort.
Now consider the role of those of us who do not have to go to work in this. Our day at the computer or doing our housework is periodically interrupted by the doorbell. A cheerful postie brings the bulky mail and mentions how overloaded the sorting office is in the early hours. Then a delivery service from the supermarket brings the week's groceries and you notice that the blueberries came from Chile and the strawberries from Spain. The young man making the delivery tells you through his mask that he graduated in psychology last year.
One of your grandchildren, an arts graduate, phones to tell you about her part-time work serving in a shop that is still open, and remarks that some of the customers refuse to wear masks. Your slippers have worn out because you have rarely worn anything else on your feet for a year, so you order a new pair online, not looking to see where they come from. Too late, you find they are made in China (actually, I just looked, and they were made in England, but someone packed them and they might have come by train via the West Midlands).
Then the book you ordered from Amazon arrives. It's time to come out of our closets and realise that the world of work, indeed the whole world, has changed. Over the course of a day, I may briefly meet one or two people at a distance to exchange words, while out on my walk. Our shift worker will meet tens and could be indoors with 10 times that, and her chances of infection are increased proportionately.
This extreme financial separation of the population was not inevitable, nor is it only a recent phenomenon. The two nations in one, the rich and the poor, was sufficiently well-appreciated in Victorian times for Disraeli to feature it in his novel Sybil
. It persisted through Edwardian times up to the Great Depression, was interrupted by the Great War and again by the Second World War but reinstated by the neo-liberal policies adopted by Western governments in the 1980s.
The concept of small government, relaxation of regulations on capitalist activities, and free trade (with wealth not trickling down), took us back astonishingly rapidly to two nations throughout Europe and USA. Within 40 years, a super-rich class had developed and obtained political power such that almost all members of our UK cabinet are millionaires while many more sit on government benches. Remember that Clement Attlee took to writing to make ends meet after he retired.
Our present UK politicians and their predecessors of all parties stripping away and selling off many of the health, safety and welfare roles of government set the scene for our shameful response to the pandemic. Their response to its management had been to make further gifts of billions to inexperienced huge conglomerates and their cronies rather than to support the run-down UK public health function.
I admit that this is a rather broad conclusion to my noticing the destination of aeroplanes flying over my house, but I am in good company dating back to Sir Edwin Chadwick's report on the sanitary condition of the labouring classes in 1842, Sir William Beveridge in the 1930s, the Shetlander Sir Douglas Black in 1980, and more recently Sir Michael Marmot in 2010 and 2020. The only significant response to any of these analyses of British society was Attlee's in 1945 which led to what my generation think of as normal but was in fact exceptional: a welfare state. But my conclusion begs the question, what can we do about it? In particular, what can we do in the immediate situation of the pandemic?
To answer this question, strangely, we need to look back to Victorian times, the horrors of the early industrial revolution, and the birth of public health. Poverty and ill health go together and are a stain on society. Remember Beveridge's giants on the path to reconstruction – disease, ignorance, squalor and idleness – and remember the response to his report by the Attlee Government of 1945. That response is what governments since Thatcher have been progressively dismantling and has led to our current inability to respond to the pandemic. All in the name of freeing industry from regulation and reducing 'the burden' of taxation. A path to deconstruction that led us not only to Brexit but also to a shamefully falling life expectancy among the poorest members of our society.
This historical understanding of the downward trajectory that has led the UK to our appalling failure in response to the pandemic points to the need for radical change. The problems Beveridge pointed to are echoed in all subsequent reports – Marmot in 2020 emphasising early life education, fair employment, healthy and sustainable communities, and stronger public health.
The solution is not greater involvement of profiteering private enterprise, such as Lansley (a man whose wealth seems to have been based on selling such services to the public sector) imposed on the NHS. Rather, the direction seems to have been noticed belatedly by UK governments in their appointment of mayors in English cities and by the Prime Minister noticing that the profit motive sits ill with the altruism implicit in the delivery of health and social care.
The failure of the response to the pandemic and the failure of politics to retain a just society are inextricably linked and relate to a desire of those in power at the centre to hold on to the reins long after they have lost control of the horses. The path forward is regional devolution of power and responsibility, and fairer UK-wide redistribution of the revenues from taxation. Reform of the system of taxation must be central to this, with more emphasis on land and accumulated wealth.
I shall end with two examples of things that have gone well in our response to the pandemic and two that have not. First, the NHS has managed the toll of illness extraordinarily well. Within weeks of the onset, doctors and nurses took control and reorganised the services, huge numbers voluntarily moving from their usual roles to help those at the infection front. They did so despite the obvious personal risks and the lack of sufficient adequate protective equipment, a consequence of failure by government to take heed of prior warnings.
Second, effective vaccines have been produced and distributed within a year of the start of the pandemic. This is a result of work over years in numerous university laboratories supported by both government and charitable funding, coupled with collaborations with the pharmaceutical industry. Central to successful release has been the expertise built in the NHS to organise the massive clinical trials to ensure safety and efficacy, and now to administer vaccination.
What went wrong was first a failure to prepare adequately for what we all knew to be inevitable: a future pandemic, together with delay in sufficient response each time it was necessary. This stemmed from complacency and a political failure to appreciate the science. Second, government failed to introduce an effective local public health response, instead relying on a centrally-organised privatised contact tracing system which became a farce. It appears they are now recognising this and increasingly reverting to this tried and tested system, as the need for local control of new variant viruses becomes evident. Again, this may prove too late, but we must hope it is not.
One thing seems to me very likely; that after vaccination has succeeded in suppressing the worst of the pandemic's effects on the NHS, we shall still require tight control of our behaviour and efficient local test and trace. As for the workers, any future vaccination strategy must take account of those who are obliged to congregate and interact with other members of the public.
Finally, how good it was to see that Scotland does not need a huge crowd of supporters passing COVID-19 around to beat England at rugby. I note that in doing so they were inspired by the skills of an ex-stonemason, the trade that built our great cities, often at the expense of their health and even their lives. A small light in a dark winter for many of us. Let us not forget the workers who support us.
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