The limits of lockdown and lasting impact on health inequality

With the UK in the grip of another wave of Covid-19 added to the usual demands of the winter, Dr Edin Lakasing asks if the default government strategy of resorting to lockdown after a spike in cases is working.

 

Few can argue that with over three million confirmed cases and over 80,000 deaths, the UK has been brutally struck by the Covid-19 pandemic. I am concerned, however, that the default government strategy to each spike in cases, and more recently two new strains, is to resort to lockdown.

The first lockdown in March 2020 was vital to reduce the rate of transmission, death rate and serious burden on acute hospital services, which coped admirably. But subsequent lockdowns and tiered restrictions did not result in similar falls in transmission rates. I believe that these facts have not entered the public discourse or been subjected to due critical scrutiny.

Indeed, we may have reached a tipping point where the damage to healthcare from restricted access, and to the wider economy and society from reduced commercial activity and rising unemployment, is at least balancing out if not exceeding the number of lives saved from Covid-19 directly.¹

A further concern is that the attitude within our profession, judged by the content of the medical press, remains very conservative and rarely questions the established orthodoxy. Less so the wider press, where many are expressing views similar to mine.² My greatest concern is that every facet of lockdown is rapidly exacerbating inequalities, on which the UK has a poor record, which some argue may be a reason why the country is so badly affected.³

The Dunkirk lockdown spirit wanes with time

Lockdown protagonists argue that the only reason dramatically better results are not achieved is that subsequent lockdowns were not properly adhered to and, in a literal sense, they are correct. Even when officially sanctioned, they are necessarily more watered down; our children had to return to school at some point, after all.

At an individual level, just as the Dunkirk spirit wanes with time, so does vigilance, even amongst those who profess caution. It is well recognised in human psychology that when a behaviour or attitude is deemed unpopular, people may outwardly express views much nearer the mainstream than what they actually believe or do. It is same reason why, in general conversation, the proportion of people who admit to supporting Brexit is far lower than the 52% who we know voted for it. So the expectation of compliance with something as contrary to human instinct as lockdown must be tempered by reality.

As little as a year ago, few would have bet that a respiratory virus would have proved the greatest challenge to mankind in two generations; if anything, the health effects of climate change were galvanising interest. We may still be psychologically reeling not only from the surprise, but how it has bucked the trend of most received wisdom. For one, it has affected wealthy nations hardest, though worldwide it the urban poor who have borne the brunt.⁴

Add in the significantly greater risk to males, older people and ethnic minorities, and it equates to a risk profile remarkably similar to that for coronary heart disease.⁵ But unlike SARS-1 and MERS within recent memory, Covid-19 is clearly not a single pandemic destined to reach a peak and blow over, hurricane-like. A notable failure of the public discourse has been not acknowledging that it is now endemic, transmitting readily between people but in terms of clinical expression, covering the full range from completely asymptomatic to rapidly fatal.

Does Covid-19 have more in common with tuberculosis?

In this respect its behaviour has much in common with tuberculosis, which was a scourge for millennia, but the experience of which may provide food for thought for our political leaders. Robert Koch isolated the tubercle bacillus in 1882, but between then and the first edition of BCG vaccine in 1921, and then the discovery of streptomycin by Albert Schatz in 1943, the world did not go into lockdown.

The capacity of Covid-19 to mutate was well recognised early on, yet it is portrayed in the media as a new phenomenon, ratcheting up already gargantuan public anxiety. Whilst it may be readily transmissible, the key question is whether it really causes more serious clinical illness, or fatality, on which the jury is out. Sadly, death rates are rising, but again much of this may be normal for winter, which does not usually make headlines.

An inevitable consequence of the drastic reduction in commercial activity will be business failure, bankruptcies and unemployment, and furloughing cannot last forever. Unemployment is particularly deleterious for health,⁶ and most jobs already lost are amongst the lowest-paying.⁷

It is unlikely that a government comprising a Prime Minister and cabinet of extraordinarily privileged background appreciate that, for example, working from home – sold as a normal thing to do – is feasible for well-paid occupations such as banking, but not for key workers, many of whom have put their lives at risk helping on the frontline for a fraction of the remuneration.

The hospitality industry employs millions of workers, predominantly migrants, and how it has been managed since reopening after the first lockdown illustrates the didactic and unimaginative nature of so much government action. ‘Eat out to help out’ always had a reckless feel to it. That was followed by the diktat that to consume alcohol in a pub, one had to have a ‘substantial meal’, making no sense from either a business perspective due a reduced client throughput, nor a health perspective, with consumption of extra calories in a sedentary environment.

Unsurprisingly, infection rates were unaffected as catering had so little culpability in the first place; equally unsurprisingly, the Sword of Damocles fell in the form of swift re-closure. The industry understandably clamours the government’s financial help, but discussion of this in the media is often held in a way that may have the listener believe that the government has a bottomless pool of cash at its disposal, clearly not the case at the best of times, and Covid-19 hit whilst we had hardly recovered from the financial crash of 2008, nor scratched the surface of Brexit.

Generational health inequality from Covid-19 lockdown

One of the less appreciated inequalities is the generational one, and most children and young adults will enjoy nothing like the social mobility of their parents, let alone their baby-boomer grand-parents, with shrinking real jobs, student debt and insane housing costs conspiring against them. The rapid, unpredicted contraction of the economy due to Covid-19 will necessarily worsen these inequalities.

School closures and interruptions will hit poor children worst, due to reduced access to IT and the fact that higher proportions do not speak English at home. I am surprised by the degree to which a notionally pro-business government seems sanguine about this. Indeed, should optimists prevail and Covid-19 eventually be either defeated or kept in check by natural burnout, infection-acquired immunity, vaccine-acquired immunity or any combination thereof, plans for the future economy should already be in place, for there will be an awful lot of rubble to sweep and unfathomable government debt.

The correction should not be austerity, with restricted public spending and high taxation, given its deleterious effect on low and middle-income earners.⁸ Nor should it be another debt-fuelled consumer spending spree masquerading as growth.

The only sustainable way forward is encouraging an entrepreneurial culture that may help small and medium-sized businesses resurrect the eviscerated High Street. Tech entrepreneurs like Jeff Bezos and Mark Zuckerberg have acquired Croesus wealth by correctly spotting trends, but their companies are also allowed to operate in the UK paying barely any tax, Meanwhile, Covid-19 has accelerated the trend for online shopping and with more spare time, the population has increased its social media use, the net effect has been further enrichment of billionaires. We need a more level playing field.

There will surely be mounting public discontent over lockdown and its resultant economic damage and social restrictions. Our profession also needs to re-evaluate its role and be more participant and vocal in expressing its range of opinions by encouraging public debate, rather than this be confined to the government’s medical advisors, vaccine experts and a handful of media GPs, all of whom have a vested interest in being ‘on message’.

The clapping has long stopped, and we risk reputational damage if secondary care is perceived as purely a Covid-19 service, and primary care purely a phone service, irrespective of the truth. I see growing numbers of patients electing to self-fund specialist care, an option for many in affluent areas such as the one I practise in, but not for the majority of the population – yet another trend exacerbating inequality.

One of the key matters we help patients navigate in the consulting room is risk, which permeates all aspects of healthcare, so another disappointing aspect of the public discourse has been the implicit idea that risk is absolute and binary, rather than relative and nuanced. It is a stance that seems to uniquely convulse attitudes to healthcare: we do not, after all, lobby to have the speed limit on roads reduced to 5 mph, though that would all but abolish deaths and injuries in traffic accidents.

Meanwhile, it is increasingly clear that the only hope for meaningful containment of the virus is mass immunisation, and governments and healthcare organisations the world over should be pushing this. The World Health Organisation appears to have styled itself the prophet of doom; contrast this with its dynamic, earlier incarnation which rolled out smallpox vaccination so brilliantly that by 1979 the disease was eradicated, and that at a time well before the internet and mobile phones.

The economic and non-Covid-19 health consequences from interminable lockdown are accelerating, whilst The Law of Diminishing Returns is catching up with its efficacy in containing the virus. We need robust leadership, including public engagement on risk assessment as well as rapid rollout of the vaccine if we are ever to exit this mire.

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Edin Lakasing, GP and trainer, Chorleywood Health Centre, 15 Lower Road, Chorleywood, Hertfordshire

Email: [email protected]

Competing interests: none.

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References

1. Melnick ER, Ioannidis JPA. Should governments continue lockdown to slow the spread of Covid-19? BMJ 2020; 369:
2. Kuldorff M, Bhattacharya J. Lockdown isn’t working. The Spectator, 2 Nov 2020. https://www.spectator.co.uk/article/lockdown-isn-t-working (accessed 29 Dec 2020).
3. Griffin S. Covid-19: Failure to control pandemic and inequalities made England worst affected in Europe, says report. BMJ 2020; 371:
4. Hoernke K. A socially just recovery from the Covid-19 pandemic: a call for action on the social determinants of urban health inequalities. Journal of the Royal Society of Medicine 2020, Vol 113(12): 482-484.
5. Islam N, Khunti K, Dambha-Miller H, Kawachi I and Marmot M. COVID-19 mortality: a complex interplay of sex, gender and ethnicity. Eur J Public Health 2020; 30: 847-848.
6. Paul KI, Moser K. Unemployment impairs mental health: meta-analyses. J Vocat Behav 2009; 74: 264-282.
7. Brewer M, Cominetti N, Henehan K, McCurdy C, Sehmi  R, Slaughter H. Jobs, jobs, jobs. Evaluating the effects of the current economic crisis on the UK labour market. Resolution Foundation, October 2020. (https://www.resolutionfoundation.org/app/uploads/2020/10/Jobs-jobs-jobs.pdf (accessed 29 December 2020).
8. Stuckler D, Basu S. The body economic: why austerity kills. Allen Lane, 2013.