It is only natural after a year of being confined to one's home to long for a holiday, but the closest most of us come to realising this is in reflection on past ones and in contemplation of brochures. The pleasures of the past and the uncertainty of the future.
The repeated presentation of graphic representations of numbers of infections, vaccinations and deaths, with which we have all perforce become familiar has taken me back to my youth, walking in the hills of the Lake District and hitch-hiking with my rucksack and little tent across France. All hill walkers will be familiar with the curious fact that on reaching a peak you find another higher one ahead, and so on until you reach the actual one you were aiming for, before the glorious decent into the valley below and the chance of a beer in the pub at the end of the path. And those of you who used to hitch-hike will remember the daily uncertainty as you set out the next day with an aim but no idea how you would achieve it.
These thoughts serve as metaphors for the current biological conflict between us and the virus, or indeed any virus. It is most easily imagined as two organisms engaged in the biological imperatives of reproduction and survival, in the understanding that eventually a truce will be achieved, both surviving. Each organism has advantages, and these are now plain to see; SARS-CoV-2 mutates very frequently to improve its infectivity and overcome obstacles put in its way, while Homo sapiens use self-proclaimed sapientia or wisdom to 'beat this thing'.
In the current pandemic, wisdom in its management has been most evident in China and the Far East, using well-developed public health measures, whereas in the West the development of effective vaccines has emphasised the role of technological expertise. But the uncomfortable fact is that for all our wisdom, the graphs in our part of the world show three peaks so far and we are still uncertain of the future. Every interview in the media, it seems, starts with the question 'Can you guarantee…?' or even tautologically, 'Can you absolutely guarantee?' There is a simple two letter answer to this.
The best a scientist or doctor can do is suggest a level of risk or chance. Unlike the situation of a hill walker, there is no Ordnance Survey map of the path of a pandemic. This is beyond the understanding of some backbench politicians who demand certainty of their leaders; they are the travellers who set out without a map or suitable footwear and urge their friends to join them. It seems it is also a common failing of many interviewers.
This uncertainty is central to the current dilemma in politics. How to balance the recovery of the economy with the inevitable toll of death and serious illness that comes from allowing more people to mix and spread the virus? Crudely, how do we balance the value of life and health with the need to have an economy that provides the goods that contribute to that value? And, of course, this is exactly the issue that I approached in my last essay in discussing the origins of the Welfare State (
10 February). A welfare state was the answer, a state which taxes its citizens fairly in order to provide security and employment for as many as possible. As we are seeing, this only works when fairness – equity – is widely perceived to be central to its operation. The current political dilemma will only be solved when the fundamental problems of the UK constitution are corrected, and this requires a hard UK-wide look at wealth, taxation and distribution of political power.
The pandemic has brought these issues into focus and shows we are in real danger of being sucked into the situation that has horrifyingly afflicted the USA. So, to return to the shorter-term issue of the uncertainty of dealing with the infection, again I must point out the dangers of listening to the sirens. We must not repeat the mistakes a third time by rapid change. This would be very much to the advantage of the virus which will seize the opportunity of reproducing and mutating. The closest we can come to certainty is that unless we act cautiously it will do this, though we cannot know whether the mutants will be more or less virulent.
We can also predict the likely rate of decline of the infection if we assume it will continue on the same path, and one way of measuring the efficacy of measures taken is by noting the numbers having to be admitted to hospital or intensive care. For example, if they have halved over three weeks and if we continue with the same measures for a further three weeks, they are likely to halve again.
We introduced more effective lockdown at Christmas and vaccination of the older population started at the same time. The effect of the lockdown would have been expected within two weeks of its start, but this coincided with the arrival of the new UK variant which led to a third unexpected peak. The primary aim was to protect the NHS and this has been only partially successful.
In Scotland, the numbers in hospital and intensive care had fallen from peaks of about 2,000 and 160 around 20 January to about 1,400 and 100 respectively on 14 February (24 days). Over this period, the new UK variant has been responsible for roughly half of new infections. In terms of daily admissions, average daily numbers halved in both England and Scotland between 10 January and 5 February, a period of four weeks. If this slow progress continues as it appears to be doing, there would still be around 250 admissions daily in England and 25 daily in Scotland by the end of March.
But here comes some good news. The most vulnerable have had an initial vaccination by now so we should expect a greater reduction in admissions and deaths within the next month from this measure, increasing after the second one has been administered. In addition, it is also now apparent that there are two effective drugs licenced for use that reduce the risks of death and severe disease in those in hospital. Short of other variant-related peaks, the decline in serious cases should now start to accelerate.
It will be noted that most of the gain so far is attributable to simple but restrictive public health measures, and the benefits of vaccination are still unquantified. Thus, it remains extremely important to continue lockdown. There is, however, an answer to the question, when can we be released? It is not a date, but a condition based on our compliance and the ability of our governments to get efficient and effective contact tracing set up and to prevent importation of new cases; that is, when it is apparent that the numbers of new infections are so low that an efficient test, trace and isolate policy can be applied. This is the question that journalists should ask ministers: What is the number of new infections that your contact tracing system can confidently manage? Once this is answered, it will be less difficult to predict when that number will be reached. At present, it is far from clear as to how efficient the tracing system is.
I am reasonably optimistic that vaccination will take most of the pressure off the NHS within a few weeks. Soon, I would urge governments to concentrate on vaccination of those obliged to go to work and thus mix with others, the workers to whom I referred in the last article. To return to my youthful holidays, I am pretty sure we are descending into the valley but the trip to the pub is regrettably some distance away. As for the uncertainty of hitch-hiking, my last such holiday in 1962 took me, a newly qualified doctor, from Le Havre to Perpignon and then to Callella in Spain to surprise my then girlfriend, who was on holiday there. I found her, we later married, and 60 years later are looking forward to our second vaccination in a month or two. Uncertainty does not necessarily imply an unhappy ending.
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
