Looking beyond lockdown

There is little doubt that the Covid-19 pandemic has raised numerous challenges for health services, governments and wider society and the international community. If anything, the debate on climate change and its effect on public health was just gathering momentum¹ when late in 2019, Covid-19 was identified as the microbial agent causing a severe viral pneumonia in several patients epidemiologically linked to a seafood market in Wuhan, in China’s Hubei province.²

Since then, there has been rapid spread, particularly but my no means exclusively affecting Iran, Italy, Spain, France, Germany, the USA and of course the UK. As I write this, it is surreal that in scarcely four months since the first confirmed cases were identified, and less than two months into lockdown, around 800 people are dying daily from the disease in UK hospitals, a fairly precise figure due to high inpatient testing rates yet a significant under-estimate of total excess mortality, given that many deaths occur in the community without virological confirmation.

This poses two related questions; firstly, how mentally prepared were we for this, and secondly, how well have the authorities responded once it became obvious that the worse public health crisis in over a century was gathering pace? Opinions on both points vary widely, and I can only offer my generalist’s perspective.

Were we mentally prepared for Covid-19?

On the first question I believe, with the wisdom of hindsight, that we have collectively become too complacent about infectious diseases. The rapid progress of medical science during the 20^th century, especially vaccination and antibiotics allied to broadly improved socio-economic conditions, is largely responsible. There was renewed interest in infection with the HIV / AIDS epidemic during the last two decades of that century, though the success of anti-retroviral drugs heralded another dip in public interest.

If anything, two factors €“ the professional and public focus on recognising sepsis, and concerns over antibiotic resistance €“ may be helping to keep a modicum of interest in bacterial infection, whilst viruses have become relatively sidelined. After all, a not uncommon gambit in our consulting rooms is €˜it’s just a virus’. Recent epidemics of SARS, MERS and swine €˜flu may have raised greater awareness had they significantly affected these shores, which they did not, leaving Covid-19 to test our response to a major crisis.

How well have the authorities responded to the pandemic? 

On the second question, I believe that there have been numerous positives, but also a few negatives, both of which provide lessons not only for future pandemics, but also living with Covid-19 after the peak has passed. The response from the NHS has been magnificent, with staff showing a commitment above and beyond the call of duty and sadly, at the time of writing, over 100 have died from the illness. The clouds have, however, had some silver linings and the adaptations in primary care to use the phone and video-link may reshape future communication.³

We have also seen the rather antiquated processes of death certification and cremation relaxed, respectively making it necessary to personally attend a patient within four weeks rather than two weeks of death to issue the certificate, and jettisoning the Part 2 doctor for cremation;⁴ common sense should dictate that these changes become permanent.

The public have shown the Dunkirk spirit, overwhelmingly respectful of the tenets of the lockdown and social distancing. The government, which has received much negative press and should, arguably, have implemented the lockdown slightly earlier,⁵ must nonetheless be credited with positive responses, including opening a number of temporary Nightingale hospitals to attend the most ill patients.

However, the slow delivery of personal protective equipment (PPE) definitely inhabits the debit column.⁶ This probably has its origins in the erroneous policy of ceding so much manufacturing, including this, to China, whose own crisis meant that they were less keen on exporting PPE.⁷ 

The UK government cannot automatically assume goodwill

Indeed, a noteworthy observation about the wider international response has been the deafening silence of those given to effusively and unquestioningly praise globalisation. Not only have they been reluctant to concede that a global pandemic represents a downside, but they appear oblivious to the rise of nativism, with Vladimir Putin, Viktor Orban, Narendra Modi and Donald Trump amongst many leaders pointedly putting their countries first. They are also amongst those least likely to be dethroned by their electorates. The point of my meander into wider politics is that it behoves the UK government, generally a fair player on the international stage, to recognise that it cannot automatically assume goodwill, and must redevelop manufacturing to become self-sufficient in all domains pertinent to any national emergency.

Testing for definitive confirmation or exclusion of Covid-19 has also proved frustratingly slow outside the hospital setting, and Health Secretary Matt Hancock’s promise to carry out 100,000 tests daily is, by common consent, utterly unrealistic.⁸ At this stage in the trajectory of the pandemic, the government should be making plans for a graded easing of the lockdown. I fear, however, that with uncertainty about transmission patterns, actual degrees of community spread and herd immunity, the government will have no choice but to impose a prolonged lockdown. If that proves true, I believe the unintended consequences for both healthcare and the wider economy will prove devastating.

Health is not a one-dimensional concept, nor is healthcare. Whilst it is reasonable to park all elective work for a while to man the Covid-19 coalface, the reality is that other health problems do not vanish, and public health will deteriorate if significant other diagnoses are missed, delayed or under-treated. We must have an open debate about when to end our €˜medical lockdown’, accepting that in the absence of a vaccine Covid-19 will be with us for a while.

The UK is already a very unequal society

The oncologist Karol Sikora has been vocal in his estimate of an extra 50,000 cancer deaths from this oversight.⁹ Given the ubiquitous nature of mental health problems even in the best of times, a worsening of public mental health including increased suicide rates is quite plausible. David Gunnell and his colleagues have cited financial stress, domestic violence, increased alcohol consumption, loneliness, isolation and bereavement as particular lockdown-related hazards.¹⁰ These are but two vital areas, at opposite ends of the techno-medical spectrum, which cannot be parked indefinitely. Above all, a prolonged lockdown will be devastating for the economy, particularly small and mid-sized businesses, for the self-employed and for already struggling areas such as the licensing trade. This has come at a time when the baseline of the economy was sluggish, far from recovered from the financial crash of 2008 whilst also contending with post-Brexit uncertainty and unwise levels of personal debt.

The UK is already a very unequal society, and a particular concern of a prolonged economic downturn is its potential to worsen those wealth inequalities, and the health inequalities which inevitably ensue, as indeed happened during the post-financial crash austerity.¹¹ Essentially, over the last three decades a quartet of occupations – finance, real estate, entertainment and professional sport €“ have enjoyed exponential reward whilst all others have stagnated or declined, a trend with which successive governments have appeared complicit.

The plaudits given to healthcare and other key public sector workers has been a heartening feature of recent weeks, but I wonder what percentage of the public are aware that it is precisely those key workers, some of whom barely earn the minimum wage, who suffered a decade-long pay freeze during the aforementioned austerity, whilst bankers kept their bonuses? Amongst the many lessons to emerge from the Covid-19 crisis is that it is time to redress the imbalance in our perception of priorities, worth and reward.

Competing interests: none

Dr Edin Lakasing, General Practitioner, Chorleywood Health Centre, Chorleywood, Hertfordshire WD3 5EA

Email: [email protected]

References

1. Salas RN, Jha AK. Climate change threatens the achievement of effective universal healthcare. BMJ 2019; 366:
2. Zhu N, Zhang D, Wang W et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020; 382: 727-733.
3. Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for Covid-19. BMJ 2020; 368:
4. Luce T. Covid 19: death certification in England and Wales. BMJ 2020; 369:
5. Cowburn A. Coronavirus: Majority of public believe Boris Johnson imposed lockdown too late, polls show. Independent 2 April 2020 https://www.independent.co.uk/news/uk/politics/coronavirus-uk-boris-johnson-lockdown-positive-tests-cases-latest-a9442561.html (accessed 24 April 2020).
6. Rimmer A. Covid-19: Third of surgeons do not have adequate PPE, royal college warns. BMJ 2020; 369:
7. Merrifield N. Ban on Chinese exports of coronavirus PPE restricting supplies to UK. Pulse, 19 March 2020 http://www.pulsetoday.co.uk/clinical/clinical-specialties/respiratory-/ban-on-chinese-exports-of-coronavirus-ppe-restricting-supplies-to-uk/20040385.article (accessed 24 April 2020).
8. Devlin H. Impossible for UK to meet Covid-19 testing targets, scientists say. The Guardian, 19 April 2020 https://www.theguardian.com/politics/2020/apr/19/impossible-for-uk-to-meet-covid-19-testing-targets-say-scientists (accessed 24 April 2020).
9. Harris K. Coronavirus’ horrifying HIDDEN death toll: Expert warns of 50,000 extra cancer deaths. Express, 23 April 2020 https://www.express.co.uk/news/uk/1272835/coronavirus-news-cancer-diagnosis-treatment-Professor-Karol-Sikora (accessed 24 April 2020).
10. Gunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N et al. Suicide risk and prevention during the COVID-19 pandemic. The Lancet 21 April 2020 https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30171-1/fulltext (accessed 24 April 2020).
11. Reeves A, Basu S, McKee M, Marmot M and Stuckler D. Austere of not? UK coalition government budgets and health inequalities. J R Soc Med 2013; 106(11): 432-436.