All those years ago, my return to school was a time of mixed emotions, some of which involved fear – fear of failure to reach expected standards, fear of some teachers and even of some fellow pupils, fear of the unknown. I don't recall wondering how my teachers would have felt, as each term started, at the prospect of confronting their classes of challenging adolescents but, especially for the younger ones, fear must have been part of their emotions. But quickly the fear disappeared as we got on with our lessons and games; familiarity, friendships and the need to learn overcame it.
Fear of the unknown future must be part of all of us, something we learn to cope with through experience. Now we all share a common fear – fear of COVID-19 – and we must learn how to overcome it. The best way is by understanding it, as military officers and sports coaches learn; know your opposition. In this series of articles, I have tried to explain something of this new disease, how it is spread and how we can protect ourselves. It is difficult to be reassuring in face of accounts in the media of deaths and grieving families, the obvious incompetence of some politicians, the uncertainty of scientists, the rumours circulating on the web, and indeed our own family experiences. But there is some good news and we now know much more about the disease and how to control it. As our Government in Scotland is considering the restart of schooling, here are some positive thoughts.
The risk of catching the disease
In Scotland over the last weeks, with over 15,000 people being tested daily, only on average 17 of them are found each day to have a positive test and this number is declining. A large online survey suggests that about three or four people in Scotland per thousand have symptoms suggestive of the disease at present – also a declining number. The highest rates are in Glasgow and West Dunbartonshire (five and 14 per 1,000 respectively). While this is still far too many, it shows that each individual's risk of catching it from personal contact is low and depends on how many people we are in close contact with.
As I said in early March, avoid crowds. In a football stadium, there could now be about 40 or 50 people who could infect you and those close by, so such events are banned. At a concert, there may be two or three, so better not go yet if you are over 50. The same in a large school, so segregation measures are necessary. Churches are rarely full, so individual risks are correspondingly low, but some congregations tend to be elderly so have a low risk of catching it but a high risk of serious disease if they do. We are at last now at a point when test, track and trace can largely rid Scotland of the virus. Apps are not necessary for this and never have been.
Something politicians find too difficult to explain
You catch the disease from physical contact and by inhalation of someone else's breath; loud talking, shouting, and singing increase the risk of that breath containing an infective dose of virus. This is the basis of the two-metre rule; you will understand that it is arbitrary as the amount of virus in the exhaled air you breathe depends on many other factors. These include the infectiousness of the people you are near, the size of the space you are in, the ventilation rate of that space, whether you and they breathe through the mouth or nose, the number of people in the immediate space, and how many are wearing face covering. Knowing these simple facts makes it easy for you personally to judge the risk. In vain will we wait for an epidemiologist to prove that 1.5 or two metres is 'safe'; your risk depends on many other factors as well. Use this common sense and conduct your life accordingly. Keep out of spitting distance of anyone's face, and keep your hands off things, other people and your own face, and wash them frequently.
The risk of death or severe disease
Personal risk factors are now well understood, though how they operate remains a mystery. Age is the dominant one, the mortality of an 80-year old being hundreds or even a thousand times greater than that of his grandchildren. Indeed, the chances of a healthy schoolchild getting seriously ill are very small indeed and much lower than from a car accident. This is obviously relevant to schools. However, children often go home to see their grandparents and so pose a risk to them as well as to their teachers. Other risk factors for serious illness are obesity, poorly-controlled diabetes, male sex, BAME ethnicity, anti-cancer treatments and chronic heart, lung and kidney illnesses, but in the context of children these are of little importance; they are, however, relevant to teachers and some may need to avoid classroom work if over 50.
Schools, pubs and places where we meet
Let's try to work out some risks logically, taking two examples – a school and a pub – and remembering that physical contact and inhaling others' breath are the means of catching an infective dose of virus. The greater risk in schools is the teacher's on account of age, gender, ethnicity and perhaps obesity and chronic illness. That risk is increased in proportion to the numbers in the room, the noise (yes, as it will be from shouting or singing) and inversely to the ventilation of the room.
For children, risks are very small indeed of getting serious disease. The same factors apply to them for catching a mild or sub-clinical attack that they could pass on to adults, so moves toward opening schools should include advice on avoiding close contact with grandparents, I'm afraid. The spacing of children is probably less important than the numbers in the room and the ventilation of the space, and the difference between one and two metres is likely to be trivial in risk terms. I would be inclined to have children facing the same way rather than each other, if possible with windows open to ensure good ventilation. If each child has a chair and desk, this would automatically ensure a reasonable amount of spacing.
Outdoors is pretty safe generally, so long as they avoid contact and don't shout in each others' faces – easier said than done. Frequent hand-washing and sanitising should be enforced. Children with sore throats and coughs should be advised to stay away until better, but teachers and other children would be well advised to wear face coverings until the epidemic is over, as it is known that the virus can be transmitted before symptoms occur.
Pubs, clubs and restaurants provide more problems, though the principles of risk reduction are the same. Often ventilation is poor and there seems no restriction in practice on the numbers allowed in. The responsible owner would think in terms of requiring face covering and hand sanitisation on entry, limiting numbers, especially in self-service areas, providing more seating at tables to avoid standing and jostling, and increasing ventilation, especially in toilets. Perspex partitions should be used widely to separate groups at tables and to partially isolate cashiers and other staff where practicable.
If I were a legislator, I should think of certifying spaces in terms of numbers allowed in, as for fire safety, rather than talking about metres. The lucky venues with outside space should erect awnings and councils should encourage this at the expense of traffic. Regular disinfection of furniture will remain important. Regulators will realise that there is no way of enforcing distances in metric terms and concentrate on public health messages not to move within extended hand-shaking distance of others. People are already used to this.
Theatres and cinemas are likely also to have to restrict numbers to ensure spacing, and should consider increasing ventilation rates, encouraging the wearing of warm clothing (to save heating costs rising too much) and the wearing of face coverings. There are particular problems with choirs and choruses who may require special public health advice and testing for antigen or antibody. Churches can generally expect to take similar hygiene precautions to other places; their problems will be greatest at the big religious festivals and in keeping contact with elderly members. The recent provision of online services points to a means of overcoming some of these problems.
Of particular concern are those who work in contact with the public in all these places. They are mostly relatively young and fit so at lower risk of serious consequences but, like children, can transmit the disease to the more vulnerable and among customers. In this, they are like NHS staff, so need to take particular care with frequent hand-washing and avoiding personal contact. Again, face coverings and visors are advisable and perhaps will be required. The public will soon realise that prices of everything will go up as we crash out of this epidemic and of Europe, and beer and spirits will be no exception. Many grocery shops have remained open and are coping well with these restrictions and there is reason to suppose that other retailers will be able to manage. The public is now used to shopping online, so numbers are likely to fall anyway.
When will life go back to normal?
I have a simple answer; I don't expect it to, but this is not likely to be due entirely to COVID-19. We are being subjected to two concurrent disasters, Brexit (self-induced) and COVID-19. Neither will go away and the latter is most likely to become a recurrent minor public health threat manageable by immunisation or antiviral drugs. Both are combining to destroy our economy and we can hardly expect much sympathy from Europe (where it has on average been managed better than by the hapless UK Government) nor disinterested help from China or the USA. Somehow, the economy needs to recover, and this is a challenge for an ideologically constrained Government. Consider how we can pay for the NHS, social services and education, as well as support the unemployed and pensioners, as factories close and the money people see from their investments fail.
Perhaps they will think back to Roosevelt and Keynes. If they do so and borrow to invest in public works related to cleaner energy and a greener, environmental approach to our lifestyles, we could come out quickly and stronger, but the carefree days for most are over. On the other hand, we shall learn to economise again, to exercise more, to consume and waste much less and recycle much more. At best, we have a realistic hope that a vaccine and effective therapy for COVID-19 will be produced. If the former is effective and available in sufficient amount, mass vaccination may largely solve that problem and I hope that, when the next pandemic comes, we will act more promptly and have better Government.
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