For so many young people, June and July would have been a time of excitement as they waited for their graduations, the happy culmination of years of effort, with their friends and families. Alas, this year has been different. Like so many proud grandparents, my celebration with two of my grandchildren has been electronic, after seeing their contributions to their final Art and Musical Theatre shows in Glasgow. Like so many, I was left with mixed emotions, pride and optimism from their achievements and enthusiasm, and worry about their futures.
Never in my lifetime has the future contribution of the talented young to the cultural life of the UK been so threatened. Few could have predicted this at the onset of 2020 when we first heard of the epidemic in Wuhan and wondered whether this could be the one we had been fearing for decades. Thus it would prove; the world has changed.
The first phase of the pandemic in the UK
The first admission to hospital in Scotland with COVID-19 occurred on 2 March and the numbers diagnosed with the disease rose to over 120 within a fortnight. On 18 March, the first death occurred in Scotland, by which time the UK had reported 2,000 cases and 60 deaths. I watched the numbers of cases doubling every two to three days. The trajectory was terrifying, and I had already decided to self-isolate. On 23 March, our governments followed suit and we all were put into lockdown. Systematic tracing of contacts was overwhelmed and largely abandoned. The numbers of cases in Scotland rose rapidly for another week then reached a prolonged plateau of over 300 new cases daily, lasting until May. By this time, 1,500 COVID-19 patients were recorded as having died in Scotland, and 27,500 in the whole UK. The lockdown worked and since 5 June the daily numbers of new cases in Scotland have been in the 20s and occasionally in single figures, but now appear to be rising.
The death toll has been even worse than the early official figures indicated. When account was taken of all deaths in which it was mentioned as a cause on the death certificate, by end-July 4,201 people had died of COVID-19 in Scotland and 46,084 in England. These represent mortalities of, respectively, 764 and 823 per million population – among the highest in the world so far. New cases are still occurring, at a daily rate of 580-880 in England and 17-30 in Scotland. Death rates, which lag some three or four weeks behind diagnoses, have fallen close to zero in Scotland and average around 50 per day in England, where there is no indication of a fall over the past month. They are, moreover, rising rapidly in other parts of the world where management has been even poorer and populations more susceptible.
The second phase
The second phase of this epidemic in most countries is one of continuing relatively low numbers of cases, usually occurring in sporadic local clusters, and fewer deaths, and this is the case now in the UK. This phase will last until an effective vaccine is found but could be arrested by strict application of control measures in individual countries. The risk is from relaxation of control to revive the economy, and we are now seeing this happen in Spain and England. It is a definite risk in Scotland, especially when the children go back to school, share the virus around without falling very ill, and pass it on to adults. We now have to put into effect what we have learned from our earlier mistakes in order to keep the pandemic under control here.
It is apparent that we did some things well and others badly. The response of the NHS has been magnificent, but at a cost yet to be realised. All non-essential work stopped and the whole service concentrated on COVID-19. Many lives were saved by relatively simple oxygen and nursing treatment as well as by the more dramatic intensive care, and this has rightly been celebrated. Although many necessary operations and investigations had to be postponed, it is noteworthy that so far there has been no excess of deaths from non-COVID causes since the second phase began. Indeed, the all-cause death rate is now lower than in previous non-COVID years. This happens after any epidemic which removes the most susceptible earlier than expected, an effect described by reference to the grim reaper, as ‘harvesting’.
The toll on the physical and mental health of staff has been considerable, greatly increased by inadequate supplies of protective equipment and testing facilities in some hospitals and most care homes, and staff have died of the disease. The early imaginative decision to try to ensure that as many NHS COVID-19 patients as possible across the UK entered well-designed trials of possible treatments with readily available drugs produced a dramatic result when dexamethasone, a cheap corticosteroid, was shown to reduce mortality in the more severely ill patients. Another drug, beta interferon, is also showing considerable promise but is much more expensive. The speedy discovery of candidate vaccines is likely also to be seen to be a very positive outcome of the UK’s response, and one or more could with luck be available within a year, when trials have been completed.
On the downside, the mortality in care homes has proved to be tragic both for patients and for dedicated staff, and the relative neglect of this sector in epidemic planning requires investigation. In particular, the decanting of untested patients from the NHS into care homes was a disaster. The delay in introducing lockdown was clearly a mistake owing to UK hesitancy in the face of evidence from other countries and led to many excess deaths. Behind most of the problems lies the fact that UK preparations were neglected by all recent governments and that the supply lines for antigen and antibody testing, protective equipment, oxygen and ventilators were neglected until reality hit. And, because of this record of apparent government incompetence, the question arises, how are we going to control the pandemic from now on?
What next?
It is easy to envisage the problems facing politicians; to continue damaging the economy and employment prospects or to risk many more lives? They need the wisdom of Solomon. And we have two (both committed to different nationalistic ideologies) playing Solomon’s role: the articulate and cautious Sturgeon and the bumbling, risk-taking Johnson. They face a very human dilemma: to return to a more normal life or to keep people safe with severe restrictions of our freedom, the latter course implying further economic disaster. There must be a compromise here.
Understandably, our governments have diverged as Scotland has seized the opportunity of reverting to traditional public health measures while England has pursued a completely different course based on an ideological belief in the superiority of the private sector in dealing with public problems. The prolongation of lockdown in Scotland has undoubtedly been of benefit to our health in bringing the epidemic under control and I hope a united approach will be very close to the Scottish one. It should be obvious that a different approach on either side of the Border will bring its own problems and our Governments should be urged to act in unison.
With a much smaller population the task is obviously easier in Scotland, but the English approach has led to confusion, including an inability to report death rates for the past weeks and poor communication between the centre and local public health officials. By end-July, Scotland was close to controlling the infection, with relatively few new cases, whereas England was still detecting significant numbers of both deaths and new cases daily. Most of these deaths were by then occurring in care homes for the elderly. I suspect that England will soon move to a more locally-based system of track and trace, since most of its problem with these numbers is occurring in local outbreaks, particularly in north-west industrial towns. But there is no room for complacency in Scotland. We live on the same island.
A warning: complacency among the young
There is now discussion of a ‘second wave’ of the pandemic while we are still wading through the water from the first wave. Almost all countries, including Scotland, are seeing a continuous low level of new infections, though death rates are now much lower where the pandemic has waned. This may largely relate to finding milder cases in younger people. Some countries, notably Spain, are seeing a slight upsurge and some like Sweden never really got control. Worse, the pandemic is still devastating the USA, South America and Africa. The message is obvious – the virus is still around, and the illness is essentially uncurable.
Here is a sobering fact. Last week in Scotland, 4,241 NHS staff were absent from work from COVID-19-related reasons, including 74 doctors and 2014 nurses. Think of this, then add to it the 1,523 care home workers absent from COVID-19 – 3.8% of that workforce. These numbers are not falling. While not all are ill, some being deliberately shielded, it is apparent that we have not got control of the epidemic in this sector and I am fearful that this must put all patients at risk. Medical and care staff are also a potential threat to their patients and families and may not always take appropriate care when meeting socially, including in non-clinical areas of healthcare settings. Wearing of face masks and basic hygiene measures should not be abandoned anywhere in these environments and young workers, especially, knowing that risk of serious complications for them is low if they catch the disease, should remember their duty to protect others, especially older relatives. Complacency is a serious risk.
The risk of a resurgence
If we lose control of the second phase, it is foreseeable that we could release a large number of elderly and vulnerable people at a time when the disease is increasing again. Our Scottish economy, so reliant on tourism, education, oil, and exports of food to England and elsewhere, could go into a vicious downward spiral just as we lose control of the pandemic, perhaps worsened by winter influenza. The NHS could be overwhelmed. This is what our politicians must try to avoid. Doubtless they are praying for a vaccine, but until then how do they get the economy going again? The answer must lie in a controlled return to a new normality combined with an effective local public health response, and this must be in all UK nations simultaneously.
And, much as we admire Nicola Sturgeon or deplore Boris Johnson, please let’s avoid arguments about independence for a while. Pandemics, climate change and Brexit may provide an opportunity to re-tune the Scottish economy for the rest of a troubled century. Indeed, I hope they will, but eventually any proposals for this re-tuning in the UK and in Scotland will tell us whether further political disruption is worth voting for.
The new normal will continue to include social distancing, hand hygiene, wearing face coverings, and avoidance of crowded places, at least until we are all vaccinated. If Scotland and the UK fail to retain control, the likely reason could be, ironically, the NHS. If England fails to get control, movement across the border for holidays and business could become the greatest risk to Scotland. It is to be hoped that the SAGE committee will act decisively if numbers start to increase south of the border. If you remember that the virus spreads by personal contact and the risk of severe illness is likely to be related to duration and numbers of close contacts, it is obvious that travelling to populous places in aeroplanes is a very good way of ensuring a second rise in cases and deaths. Sensible people (like Nicola Sturgeon) will forget about foreign holidays at least for the rest of 2020, but probably until and if a vaccine becomes available.
Schools and universities will soon be opening in a graduated manner and with appropriate hygiene measures; they will need to curtail much of their usual indoor social activity. Industrial policy should concentrate on what can be foreseen as future opportunities: sustainable house building, road conversions away from cars, safe green public transport, engineering and technology for renewable energy and prevention of climatic disasters, pharmaceuticals, electronic communications, arts and leisure activities. Serious thought needs to be put into how tourism and the arts can adapt to an age of epidemics and changing climate. These are sectors of huge importance to our economy, to employment and to the quality of our lives.
Most important of all, we the public must cooperate, as most have so far, both to protect ourselves and to contribute to the safety of others. We must expect further restrictive actions by our governments. We must acknowledge that we have made our world vulnerable to such shocks and work to build a better one, one in which our bright young graduates see opportunities, in which the arts and sciences can contribute to the welfare of all, and success is no longer equated with the accumulation of wealth.
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
By Anthony Seaton | 5 August 2020