In this article, I track the course of the pandemic and how it has affected the UK and Scotland, noting that we have suffered the highest mortality in the world so far in spite of the magnificent efforts of the NHS and of those who have worked to keep us safe and well. As Governments prepare to ease the necessary restrictions on social interaction, I explain the rationale behind protective measures and how to make a personal individual risk assessment. I finish on a note of optimism but point to the need to examine why our nations have failed so badly to protect their population.
Watching the epidemic
In the first article in this series (4 March
), I wrote: 'In the UK, our Government was originally curiously silent, leaving us with two sources – expert comments from public health officials and inexpert, sometimes alarmist, comments in the media. As the epidemic reaches these shores, our cooperation with public health advice is now essential to limit its spread and possibly duration; that advice must be clearly endorsed by ministers, but side by side with health experts to give them the credibility they have regrettably lost. Solo appearances by the Prime Minister will remain unconvincing'.
In discussing epidemic management, I added: 'As time passes, it is apparent that COVID-19 infection is being widely distributed by travel around the world, but spread is being controlled reasonably effectively in countries with good public health systems. Such countries are in the minority worldwide and so further spread seems inevitable as it takes hold in less well provided places such as Africa, India, the United States and the Middle East'. Little did I realise that Scotland and the UK should have been added to that short list.
In that article, I confined myself to giving advice on personal protection from the virus, including avoiding crowds, and added that I had decided not to go to the Scotland rugby international. I was generally reassuring about the likely size of the epidemic in UK since I expected the WHO method to be used by our public health system, though I had some concerns (that I did not mention) about the ability of the NHS to deal with large numbers of seriously ill patients if this became necessary.
By the time of the second article (18 March
) the Government had given clear advice on social distancing and crowds, but the epidemic was rapidly taking hold and the article was headed by the following: 'Our risk of contracting COVID-19 relates to the number of people with whom we are in close contact, the duration of such contacts, and our personal hygiene actions. Our risk of serious consequences of infection relates to the efficiency with which our Governments prepare and support the NHS to cope with the inevitable increase in cases over the following weeks and months... We are thus active participants in a test of both governmental competence and population compliance such as has not been seen in the UK since 1939'.
The article proposed some ideas on the need to rapidly expand the NHS intensive care capacity and take over private hospitals, but within days the Government had acted decisively and introduced the current lockdown. It had also taken action to expand the capacity of the NHS to deal with the expected demand from huge numbers of very ill people. This action was commendable, though very late, and resulted from a dramatic report predicting that without such action up to half a million people in UK could die of the disease. It also predicted that even drastic action might be accompanied by as many as 50,000 deaths.
By the time of the third article (1 April
), there had been fateful developments. The NHS was under serious pressure but coping, and we drew attention to the pressures on staff and their families at home. The issue of personal protective equipment (PPE) was becoming a major talking point and the fourth article (15 April
) discussed this in detail, explaining the rationale behind the use of masks and respirators by the public. It pointed out that this was based on a lot of hard science but at a press conference shortly afterwards one of the scientific advisors agreed with a minister that the evidence was weak. This was a good example of the dangers of the narrow focus of the advisory committee (SAGE); they were presumably referring to the epidemiological evidence of their value in reducing spread of infection, which was then inevitably sparse but suggestive. However, the evidence of the value of PPE in protecting workers from inhalation of particles was well known and based on physical experiments, strong science.
This article began to look forward to a time when the epidemic would come under partial control and to the political decisions that would be necessary to enable this. It pointed to the need to reintroduce measures to identify patients early, and trace and isolate their contacts, and speculated that restrictive measures would be necessary for many months, if not indefinitely.
Where are we now?
The fifth article in this series (29 April
) was summarised as follows: 'This article examines the course of the COVID-19 pandemic as it has affected the UK and particularly Scotland. It notes that after five weeks of lockdown, the rate of discovery of new cases and of deaths had shown no reduction, indicating reservoirs of new infection. It draws attention to the large differences between the rates of death in the UK and Scotland, and in Finland and Norway, and to the need to examine the reasons for these. In looking forward to a point when rates start to fall, it examines the ways in which lockdown could gradually be eased, and points to the vital importance of re-introducing strong public health measures for detecting cases and identifying and managing contacts. In view of regional differences, it suggests that an independent pro-active approach would be appropriate in Scotland'.
This was an important point because the Government had by then introduced graphs in its press conferences to illustrate the progress of the epidemic and included in these one showing comparisons of death counts in different countries. These did not show the hoped for position of the UK in relation to Italy or indeed any other country, but our proximity to others was dismissed by ministers as being unreliable since death numbers were not comparable in countries with different demographics. Yet they did not try to turn the numbers into rates, deaths per million population, for example. When this is done, it shows us to be in a very unfavourable position, especially when comparing Scotland with countries of similar size.
Here, for example, is a list of COVID-19-related deaths per million population as of 23 May: Scotland 650.6, Ireland 324.9, Denmark 104.9, Finland 55.2, Norway 43.8, Iceland 27.5, New Zealand 4.3, Singapore 3.9.
For larger counties, similar differences are found: Spain 610.4, UK 547.1 (acknowledged to be an underestimate), Italy 540.4, USA 292.5, Germany 99.1, South Korea 5.1, China 3.3, Taiwan 0.3.
Obviously, these numbers will rise everywhere and many like the UK are probably serious underestimates. Relative positions may move as different methods of recording deaths are taken into account, though 10-fold differences can hardly be dismissed as trivial. Small countries present fewer problems than large ones, density of population and social demography are important, and there should be an advantage to being hit by the pandemic late. But Scotland is a small country and the UK had at least two months' warning.
Both UK and Scottish Governments need to admit that such stark differences look very bad for them. A fair question is what has been going wrong and what have we learned that will help us escape? It is already obvious that many mistakes have been made and it is not yet clear that our Governments have learned any lessons. I shall come to this in a later article, but first, what went right?
What went right?
It is now apparent that the hospital side of the NHS has responded heroically to the onslaught, but at considerable cost to both lives and physical and mental health. In particular, the policy of early discharge of patients to care homes surely contributed to worsening the epidemic. Otherwise, the success of the NHS in coping with the torrent of patients has been founded on good prior epidemic planning, the willingness of senior doctors and nurses rather than administrators to take control when the emergency threatened, and the extraordinary behaviour of those who left their specialties and joined their colleagues on the front line in intensive care and respiratory and infectious diseases. This has been unprecedented and equivalent to volunteering for the armed services in times of war.
Equally heroic have been the workers in the care sector looking after our vulnerable elderly. And let us not forget those essential workers who have continued to maintain public services, removing our waste, delivering our mail, ensuring we are fed, and the many who have volunteered to help the disadvantaged. We owe these people a huge debt, but they do not need medals, they too need protection against the virus and many of them have not had it. From this it follows that the virus found its safe haven among them, waiting for the rest of us to be released to feed it.
Economic anxieties are now forcing governments worldwide to consider releasing their populations from restrictive control measures. It is time for us all to try to understand how the virus is transmitted so we can make rational personal judgements while our Governments flounder.
Where does infection come from?
The process is very simple. Infected people initially have few or no symptoms, but the virus is multiplying in the lining of their nose, throat and lungs. As they breathe out, some viruses are expired in water droplets in the breath (you can see these droplets as a mist when you breathe out on a cold frosty day). They remain suspended in the air for a time that depends on their size, large ones for minutes, very small ones for hours (again, look at a beam of sunlight when you dust). In an enclosed space, the smallest ones will be diluted to a degree depending on the volume of air in the room but may persist for hours dispersed through the space. The largest ones with the greatest number of viruses fall quickly and are a danger to people nearby. These viral particles may remain infective for up to several days on the material where they land.
There is an old principle in medicine, dating back to the 16th century; the harm from a toxic agent depends on the dose. This is as true of micro-organisms as it is of coal dust or asbestos, and from it follows the principle of prevention; reduce the dose as far as is practicable, if possible, to zero. The dose to which we are exposed is the product of the concentration we are exposed to and the duration of exposure. It also depends on which bit of us is exposed and, of course, on how dangerous the toxic agent is and how susceptible we are.
How to make your own risk assessment
From this it follows that the time we spend in a place where the virus is in the air is an important risk factor. Another is the number of potentially infected people sharing that space. Another is the volume of the place and its ventilation. While some virus particles can be spread by simply breathing and talking (try pronouncing a hard c or f), this will allow far fewer viruses to escape than shouting, singing, or coughing and sneezing. To understand this allows you to make your own risk assessment if you are thinking of going out shopping or to the cinema, for example, or going to work as a shop assistant or lawyer.
It is also obvious that activity in the open air is much less risky than in enclosed spaces; exhaled viral particles are immediately diluted in the space around the infected person, and therefore the further from that person you are, the fewer you will be exposed to. You will understand from this that the two-metre rule is most protective outdoors; indoors, the risks relate also to the volume of the room, its ventilation and the numbers of people in it, whether or not they are talking, shouting or singing, and how long you spend there. The two-metre rule is, however, important in that it reduces the number of people allowed in the space. Wherever you are, hand and face hygiene is essential.
The implications for ending the lock-in
Clearly, the risks to those of us who have so far escaped infection also depend on the numbers of infected people in the population and thus on our likelihood of meeting one. The worst aspect of the UK and Scotland's responses to the pandemic has been the failure of local public and environmental health and workplace control of infection systems, owing probably to years of neglect by national governments. This has led to insufficient resources and expertise being available but also to the apparently arrogant focus on centralised political control of the pandemic response for the UK as a whole and for Scotland.
Local action should be central to us getting back to normal, by identifying pockets of infection and tracing contacts. In particular, in Scotland and the UK, it is urgently necessary to trace and isolate contacts in care homes and the NHS hospitals until the epidemic disappears, since this is where many new cases now originate. Other patients and visitors, as well as medical and nursing staff, can then catch the disease and take it home to their families. Hospitals have become feared as sources of infection. Shoe leather epidemiology organised locally must come back and, until it does, we older folk and many others shall have to remain in isolation.
For all of us, the hand washing and avoidance of physical contact that we have become used to are likely to be necessary indefinitely. Conversations should be held at two metres distance. It is rightly recognised that work outdoors is safer than indoors, but only if workers spend as little time as possible in close proximity to each other, avoid shouting and congregating in vans, canteens, toilets, changing rooms, and so on. Working from home is likely to become the norm.
In sport and recreation, contact team sports are more risky than individual sports (think of the front row of a rugby scrum versus a tennis match), gymnasia and changing rooms are risky, as are churches, cinemas, clubs and theatres. Wearing a simple mask indoors at work, and when travelling and shopping is likely to become general, if not mandatory, in order to protect others. Anyone with respiratory symptoms is likely to be advised to keep away from work. Increasingly, employers of people working indoors are going to have to pay great attention to the ventilation of their buildings, as do hospitals already. All this is obvious once you understand how the virus is transmitted.
Some words of encouragement
Epidemics are always worrying and those experiencing them often feel that they will never end, leading to depression. I expect we all have felt a bit like that. But they do end, at different speeds, and here are some reasons to feel optimistic.
• The large majority who catch COVID-19 suffer a minor illness; severe illness usually comes from high viral doses and is avoidable by good precautions.
• The response of so many people, especially the young, during lockdown has shown a spirit of selflessness that augurs well for future hard times.
• There is evidence that the lockdown measures have limited the worst effects so far and that the NHS has shown itself able to cope with the peak.
• There are already several trials of vaccines and at least one is reasonably likely to become available within a year.
• One or more drugs that cure or ameliorate the disease are likely to be discovered and several are now being trialled.
• Important and radical changes in working practices will reduce the infectivity of the virus.
• There are signs that our Governments are now beginning to get the message on tracing and tracking contacts and using local traditional public health.
• The lessons politicians, the public services and indeed all of us are learning from this epidemic should lead to a reconsideration of the ways we live our lives and are governed in future.
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.