One analogy between the COVID-19 pandemic and total war is that the effects are felt by everyone both at the War Front, in the NHS and social services, and at the Home Front, especially by the families of essential workers. This is a severe test of the resilience of the whole population and it is essential that we all play our part; only by full cooperation with instructions to isolate ourselves from contact with others can we hope to slow the progress of the pandemic within the next few weeks. Those who are working to keep us safe and well deserve as much support as was given to our servicemen and women during the Second World War. Let us recognise the altruism of the many people who are helping us through this crisis in the hope that a better and more just society will come out of it.
An earlier experience
Self-isolation has provided an unexpected opportunity to sort out some of a lifetime's photographs. Among them was a picture of one of the authors aged two with his godmother. The Second World War had just started and within a year the two-year old was becoming used to the air-raid sirens, the crash of bombs, and the nightly trips to the shelter. His godmother, a nurse, was shortly to find herself on the beaches at Dunkirk, tending the wounded and comforting the dying. It is sad that he now finds himself and his family living through an analogous experience 80 years later.
The BBC was the unifying medium in those days, and this explains why older people are so appalled at attempts to constrain it in any way. We relied on it to tell the truth, clustered round the wireless listening to the stories of sacrifice, defeats and cities bombed, until the tide started to turn. We wondered what there would be to hear on the news after the war. We also listened to the BBC for relief; workers' play time for the women in the factories, ITMA with the incomparable Tommy Handley, to keep us going.
For our mothers it was an awful time, their men away in the services (our neighbour's husband never returned), making do with food and clothes shortages, and rationing. It was called the Home Front in recognition that total war affected those that remained as well as those who went to the War Front to fight and die.
We did not sleepwalk into war, but we were not as well prepared as we might have been, and we all now know that had it not been for the RAF at the Battle of Britain, for the scientists who gave us radar and broke the Enigma code, and for the arrival of the US forces, the end result might have been very different. Inspired and resolute leadership was behind all this; Churchill, a previously flawed politician, was the man for the hour. We listened to his speeches, the news became more positive, and in 1945 we got a day off school to celebrate victory. Churchill was voted out and Attlee and the Welfare State were voted in; all subsequent generations have benefitted from this, so much more than most realise.
The competition between species
The biological competition between and among species for nourishment and territory is sometimes referred to as a war, and the aspect most familiar to all of us is that between mankind and micro-organisms. We have been brought up to regard microbes as the enemy, although the large majority are either beneficial or of no threat, many living happily in our bowels or on our skin helping keep us healthy. Others keep our soil healthy and provide us with food and drink; where would we be without wine and beer?
But sometimes the microbe gains advantage in causing its host, animal or plant, to fall ill, perhaps the better to ensure its own survival. These are the ones we call pathogens. Here, we are at a serious disadvantage, as bacteria and viruses reproduce very rapidly and in doing so mutate in response to their environment. Within hours, they can adapt to surviving in us, defeating our defences. We have only our collective ingenuity to defeat them; our conquest of many serious diseases has depended almost entirely on the skills and imagination of scientists, discovering vaccines and medicines, understanding the mechanisms of toxicity, describing and leading strategies for our protection, and so on.
We are now locked in one of the biggest battles yet seen between mankind and micro-organisms, and all of us are in either on the Home Front or the War Front. We are all engaged in fighting a pandemic.
The War Front preparation
It is a truism of warfare that the generals always prepare for the last war, and this is probably inevitable since human imagination can dream up too many possible scenarios for us to be fully ready for all. However, the current pandemic was anticipated and prepared for well in advance, since one such has long been known to be inevitable and several smaller outbreaks of a similar nature have occurred recently.
The response was well understood by the World Health Organisation: identify the organism, identify affected cases, trace contacts, isolate and treat them, hope to develop a vaccine and a cure. But between theory and practice there are many obstacles, as we have seen across the nations; political short-termism and religious ideologies, obtuse leadership, national poverty, poor health services, sheer ill-fortune, and so on.
From the time of the first reports from Wuhan, it has been apparent to scientists that this was going to be the big one we have been dreading. Any mistakes that have allowed this to take hold are the learning material to prepare for the next.
Most importantly on the War Front have been the experiences of the noble Chinese health workers and scientists, who told their leaders, fought and gave their lives looking after their fellow humans, and have provided the scientific information on which the possibility of a vaccine and anti-viral therapies can be based. For us in the West, we have been able to learn from their endeavours; they have bought us time at great personal cost. We have been able to watch the pandemic evolve in different countries and to get some idea of the efficacy of the contrasting measures taken.
Early on, it was apparent that COVID-19 infection would be widespread amongst communities, although the true extent and rapidity of spread has until recently been less clear. Whilst there has been discussion over the risk of severe illness and death between countries with differing healthcare resources and responses, it has become clear that severe illness would be borne primarily by those who already are most dependent on a functioning National Health Service: the elderly, the frail and those with significant underlying health problems. Minimising infection and transmission to these groups and preparing for casualties has been our Governments' and healthcare providers' main strategy.
Those of us working in the NHS recognise the already significant challenges of busy surgeries, limited appointment times, overburdened emergency/ admissions departments and hospital discharges delayed due to lack of suitable accommodation or care available in the community. These challenges lead to pressured decision-making and a daily balancing of patient need against available resource. Users of the NHS will recognise the expression of these pressures as waiting times, waiting lists, delays and cancellations. With numbers of new cases of COVID-19 expected to double every three or so days, with many hundreds of additional GP visits and hospital admissions anticipated every day, the health service has had to adapt quickly and innovatively.
Triage
Triage is defined as 'the assignment of degrees of urgency to illness to decide the order of treatment of a large number of patients'. This is commonly applied in the practice of emergency medicine and on a larger scale in response to mass casualties of war and is crucial in the battlefield assessment of the wounded. The health service and research community are now applying triage principles to scale.
The first line of defence is community care which has been transformed, with NHS 24 performing a crucial triage facility by advising and directing the public to the appropriate community or hospital assessment area when required. GPs and practice nurses are performing an essential role in the newly-formed community assessment centres, identifying the significant proportion of patients who may be at higher risk of complications and require more detailed evaluation in hospital. At the same time, GPs, practice nurses and community pharmacists continue to provide vital, but currently pared down, primary care and medicine provision for patients in the community.
In hospitals, non-urgent activity from routine clinic visits and tests to non-life or limb-threatening surgery have been postponed to free up healthcare workers, organisational capacity and, crucially, mechanical ventilators prioritised for the inevitable consequence of this infection. Hospitals are being reconfigured to allow safe assessment and flow of patients to appropriate clinical areas where they can be safely monitored and treated. Roles and responsibilities within clinical teams are changing and are geared towards the challenges of COVID-19.
In hospitals, there is a sense of 'battle readiness'. In parallel, the medical research community has postponed non-essential research and many who are able have returned to support acute care in the hospitals. Research bodies have prioritised research funding towards COVID-19 treatments and vaccines, and scientific journals have enabled rapid publication and dissemination of key research findings as they arise.
Whilst social distancing, cough etiquette and hand-washing are key to limiting spread of this infection in the community, personal protection and hand hygiene are of critical importance in healthcare facilities to prevent transmission to, from and between healthcare workers. For the most part, this involves simple measures including the wearing of a plastic apron, gloves and a fluid resistant surgical mask combined with good hand-washing and attention to careful removal of gloves and apron. The more extensive protection so often seen on television reports is reserved for the much smaller proportion of patients in hospital with the most critical illness, where breathing support or interventions are required.
Care of the severely ill
The most challenging aspect of triage in the context of COVID-19 is determining treatment plans for individual higher-risk patients. Fortunately, most high-risk patients will recover after a period of hospitalisation with oxygen therapy. In a small number of patients, oxygen requirement will be beyond that which can be delivered in a normal ward setting. Careful assessment and discussion of benefits and limitations of the next level of treatment in the individual, in this case breathing support on a mechanical ventilator, is required.
Mechanical ventilation in COVID-19 is usually prolonged and experience from both China and Italy have shown that poor outcome can be predicted by assessment of factors including older age, frailty and the presence of other medical conditions. The terrible risk is that, if careful assessment and discussion is not performed and mechanical ventilation is used for those in whom the chances of success are very small, it may prevent access to other patients with a much higher probability of success. This is an extremely difficult ethical situation and necessitates shared decision-making between doctors and the patient. Prior discussion within families of anticipatory care planning would make such decisions easier.
(see, for example:
www.nhsinform.scot)
The decision on accepting the likelihood of death and agreeing its optimal management, although made in an acute situation, is not unlike those decisions made with patients with advanced cancers and other life-limiting conditions. As in other such conditions, even if curative treatment is not possible, there are no limits on or 'ceilings' of care for those with severe COVID-19. Palliation of symptoms is a vital part of the treatment of severe COVID-19 and there are both community and hospital-based palliative care doctors and nurses who are well prepared to support those approaching the end of life. Some, or perhaps many, might prefer to accept a gentle death to spending weeks on a ventilator with little prospect of recovery.
The Home Front
As we have pointed out in our previous articles, the difference between this war and conventional ones is that the enemy is among us, indeed is in every one of us. Anyone could be carrying the virus that attacks us, necessitating the strategy of social isolation. This has raised many difficult questions for individuals, most of which can be answered very simply: avoid standing so close to people that anything in their breath can be inhaled by you. Six feet is a reasonable distance in still air, remembering that the longer you converse, the greater the risk. And, of course, no touching and wash your hands frequently and properly.
The current obligatory isolation in one's home is a real problem for many. There are difficulties in obtaining food and essentials. There is the problem of loneliness, while endless reports on the media can lead to a feeling of hopelessness and depression. On the other hand, news of volunteers and cards offering help coming through letterboxes are an encouraging reminder of the essential goodness of people, especially our young folk. But, as in the war, these are nothing compared to the anxiety of those whose family is involved in health or social care, mixing almost inevitably with infected patients. From their perspective, there are real challenges and it is an anxious time for many.
Many healthcare workers in Scotland have already been absent from work as a consequence of COVID-19 measures. Current guidance is for symptomatic healthcare workers to refrain from work whilst unwell and for a minimum of seven days or 14 days if there is illness in another family member. These measures prevent the risk of further infections within the hospital or GP practice, but put additional strain on the remaining team members. Those working in intensive care units are working in a particularly pressured environment and are acutely affected by staff shortages.
For some, the work of caring in these new and unusual circumstances can be both psychologically and physically draining, and it is important that this is recognised and addressed through adequate rest and psychological support when needed. The widespread use of testing for virus and later for antibodies will support workers and help to alleviate some of the pressures.
Where are we heading?
At the time of writing, the rate of increase in cases of COVID-19 is still increasing but it is hoped that current isolation measures may slow that increase within two weeks. It is still true that the elderly and ill are most at risk and children are rarely severely affected, and that the very large majority of those infected recover fully. Slowing of the rate of new infections is dependent on the isolation measures being strictly adhered to, and it seems that in Scotland this is happening. We all have our part to play. Nevertheless, it is unrealistic to hope that the severe disruption to our lives will cease in the near future; we should prepare for several more months of restriction of activity and we hope to discuss this later.
This is a war, not a battle. We need to come together in support of those who are working in the NHS, social services and all essential occupations to see us through. It is encouraging to see the outburst of altruism in the population; this has always been there, but we now need to celebrate it and use it to build a better future.
Anthony Seaton is Emeritus Professor of Environmental Medicine at Aberdeen University
Andrew Seaton is Consultant Physician in Infectious Diseases in NHS Greater Glasgow and Clyde and an Honorary Associate Clinical Professor at the University of Glasgow (@raseaton66 on Twitter)
The views expressed here are those of the authors and do not represent the views of their affiliated organisations or employers
