Let's start with the ugly. It was about 11pm on Saturday night and I, a final year medical student, was doing a locum in casualty. He lurched towards me, partly restrained by the nurse, fists at the ready, then suddenly he grinned. 'Bludy 'ell, itsh Tony Sheaton', he said. The aggressive drunk, who had been causing a real problem in the department, calmed down and allowed me to stitch the injuries suffered from a fight in the pub, having recognised that the person in the white coat was someone with whom he had been playing rugby the previous Saturday.
In those days, the pubs closed at 10.30pm by law and we knew that by 11pm the drunks would start coming into the hospital, some brought in unconscious but most injured from falls or fights. They did not usually sit patiently waiting to be treated, and they often caused mayhem. As a junior doctor, one was often called to casualty to restrain aggression and break-up fights in addition to treating injuries. Fortunately, my choice of career insulated me from this subsequently, but the problems seem to have got even worse and the relaxation of licensing hours has simply extended the time period over which the victims of alcohol come in. Aggression is the ugly side of collective drinking in those peculiarly British places called pubs.
Moving forward a few years, a man in his 40s is brought into the medical ward because he has vomited some blood. As I arrive, I see his hands are twitching and he says he feels sick. Suddenly, he sits up and blood shoots out of his mouth, all over the bedclothes and the nurse, who is holding his hand. He starts to shake and we have to force a large tube down his throat to compress the burst veins in his gullet from which he is bleeding. He has alcoholic cirrhosis of his liver and we know he is unlikely to survive but we start a transfusion and call the surgeons in the hope that they can operate to cut off the blood supply to those swollen veins. Physical and mental damage from regular heavy drinking is the bad side, to which pubs inevitably contribute.
The ready availability of cheap alcohol and a culture which encouraged drinking from a young age undoubtedly made alcoholism more common, death from alcoholic liver disease occurring in almost 30 people per 100,000 each year in Scotland in 2001, mostly in early middle age. Since the introduction of our Scottish national alcohol policy, this rate fell to just over 20 per 100,000 by 2018, though it was showing signs of rising again, hence the more recent pioneering introduction of a unit pricing policy. Over this period, 2001 to 2018, comparable rates in England rose slightly from about nine to 11 per 100,000 per annum.
Overall, the death rates in men are double those in women. The annual cost of alcohol-related illness is estimated to be £3.5bn to the NHS and to UK society £21bn each year, and some of the sad consequences can be seen on the streets of our cities. Clearly, the presence within capitalist society of a culture which encourages drinking will make a major contribution to this.
For decades after qualifying, I hardly entered a pub. The reason was not fear of alcoholism but rather the smoky atmosphere. Alcohol and cigarettes went together and even while smoking was gradually becoming an anti-social activity generally in Britain, it remained acceptable in pubs. Only when the risks of heart disease and cancer from passive smoking became apparent, did we start to worry about the health of those mainly young people who worked behind the bar and were forced to inhale other people's smoke. Again, Scotland recognised its unfortunate world-leading record in lung and heart diseases and pioneered legislation to prohibit smoking in pubs and other public places. The rich brewers protested about possible loss of customers, but the air cleared and once again I felt safe to venture in. The ban has made them more socially acceptable places – which brings me to the good.
For many people, a visit to a pub is a regular, if not essential, part of life, and for a minority, it must be the main thing that makes life worth living. In some communities, the pub is the centre of social life providing opportunities for conversation and friendship, for playing and hearing music, for darts, cards, quizzes and other games, and for eating. I have happy memories from student days of discussing the world's problems, apartheid, nuclear deterrence, Arab/Israeli conflict (how little has changed in six decades), over a pint or two, and of singing round the piano with friends after a day spent walking in the Lake District on holiday.
Over the years, I have occasionally spent an hour or two discussing research with colleagues after work in a quiet corner of a bar, and on one notable occasion this resulted in a paper being published in a medical journal,
The Lancet, a few weeks later. Many pubs have improved immensely over recent times, serving better food, and attracting people for these socially good things as much as for the drink. Slowly, they have become more like their European counterparts, where drink is only a part of the provision. But now we have COVID-19.
Since the pandemic reached us, I have tried to explain how it spreads from person to person and how to protect oneself from it. On a personal level, most of us should do all we can to reduce risks to ourselves and to others, and this will need to continue whatever our governments do or urge us to do, at least until a vaccine becomes available and is shown to be effective. I have explained the R number which in concept is simple, the number of people to whom an average infected person is passing the virus on, but the theoretical calculation of which is shrouded in mathematical mystery and some uncertainty.
However, in essence, during an epidemic the more people infected, the faster the disease will spread and the more likely we are to catch it from someone we meet, speak to or touch. This applies particularly indoors where the air around us is still and tiny virus particles will float around for much longer than outdoors where their numbers are quickly reduced by dilution in the air and removal by wind. The more infected people in any space, the more virus floats around waiting for us to breathe it in. Thus, indoor crowds in poorly ventilated spaces are the most dangerous; pubs unfortunately come into this category, no matter how much their owners protest, and should have been the last places to be cautiously opened up after lockdown, not the first. The little discussed but most important part of recent instructions relates to the need to have table service only and thus restrict numbers of both people and potential virus particles in the air. This is likely to be more effective than restricting opening hours, though both are, to me, desirable.
It is a most fortunate fact that healthy young people are at very low risk of serious consequences from COVID-19 and it is likely, based on scientific principles rather than epidemiological evidence, that when such adverse events occur the dose to which they have been exposed has been egregiously high, such as being coughed at or by being in a place with several infected people breathing heavily or shouting. Again, it is easy to understand why football matches, pubs and cafes, and sadly choirs attract special restrictive measures. But the risks to young people of return to school and university, if appropriate precautions are enforced, are minimal and likely to outweigh greatly the harm of losing vital months of education.
It is right that return to education has been a priority but it was predicable that an upsurge in cases among university students would occur from their return. The important public health message is to protect their older contacts, teachers and family, from them as far as practicable.
Like so many people and institutions during this pandemic, pubs are innocent victims. I hope you can see why. We shall, for some months at least, have to regard everyone we meet as a potential source of infection and not venture into any building in which obvious efforts to prevent close interaction between occupants are not being taken. The smaller the space and the more people in it, the greater the risk. For the owners of pubs, this will mean loss of income and further expenditure, and in this they are far from alone. We are all required to make sacrifices and adapt to a new and less comfortable world. As in nature, ultimately those best adapted to the environment survive the struggle.
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
