Spring in London with Covid-19: a personal view

Introduction

As Covid-19 spreads across the world, normal life ends. “The past is another country; they do things differently there”. ¹ But this past is less than a month ago. Although Brexit loomed, the UK Economy was buoyant. Then, in a few days during mid-March, normal behaviour changed fundamentally and with it our way of life. People became nervous; they cancelled events and stayed away from shops, restaurants and theatres and parents kept their children from going to school for fear they would bring the virus home to them. Even before the official lockdown we were in the new dystopian reality. Millions lost their jobs overnight. Workers in the “gig” economy were hit first and record numbers are applying for “universal credit”. Vibrant and good businesses, large and small, wobble still on a cliff edge hoping for a rescue before it is too late. The massive unprecedented Government financial support pledged is yet not enough. Phone lines and online access for help are jammed. More help will have to be provided soon. Everyone who can is now working from home – time for exercise and shopping is limited and our city streets are deserted.

Panic buying

By 23rd March the Coronavirus Act 2020 had been passed (in a single day by Parliament which then closed for a long recess). We are in lockdown. Frantic panic buying continued for several weeks with supermarkets failing to limit purchases initially; shelves emptied and people crammed against the tills until 2 m spacing was enforced. Online delivery slots are gone in mainstream stores and many items are still in short supply: toilet rolls, frozen and dried foods and there is no hand sanitiser anywhere. Fortunately some wholesale suppliers to restaurants and local smaller shops are offering more choices now.

Capacity and flattening the curve of infections

The Government’s policy aims to flatten the rising curve of infection and hospital admissions. Each day we anxiously compare our progress against other countries: China, Iran (said to be under-reporting), Italy, Spain, France and the USA. In mainland Europe they are two or three weeks ahead of us as we plot the graph’s upward curve.

We are an island; there is of course a tunnel to France, but British people are very keen travellers. They travel in their millions every year: winter sports in Europe or flights and cruises to warmer destinations with the high spot being the half term school holidays in mid-February. Either people book early or late in February to avoid half term in the middle when families with school children take skiing trips to Northern France, Italy, Switzerland and Austria. And Britain welcomes many foreign students who return home at half term or whose families come over here to visit them. By the end of February there was unease as we learned the virus had spread far beyond China. People were ill with the virus and we learned it was present in cruise ships which now floated helplessly waiting to dock while the numbers affected increased rapidly. Turned away from port after port, these vast liners begged to be allowed to anchor and disembark their crew and passengers.

The NHS normally runs almost at maximum capacity all year round and now there was an urgent need to free many more hospital beds and staff; this was done by cancelling most routine operations and appointments for non-urgent cases. In a remarkable nine days, assisted by the military, an enormous temporary Nightingale Hospital was constructed inside a conference centre in East London opened on 3.4.20 with 400 ICU beds. It is designed with 40 bed “Nightingale” style wards (but ironically, Florence Nightingale herself disapproved of these) where all patients can be seen from the central nursing station and which allows one nurse to manage six patients at a time. It is to admit the overflow from mainstream hospitals and patients will be sent already sedated and with intubation. Most of them will be over 65 (often with underlying health problems) but they will rarely include people from Care Home who will be too frail. There are a further 1.5 m people self-isolating at home for 12 weeks who are particularly vulnerable. Survival rates after intubation are less than 50%.

As Covid-19 can be a death sentence for Care Homes residents (no visitors are allowed in) but staff providing social care are still not being tested and many complain they do not have good PPE.

Closed businesses, schools, universities, leisure centres, museums and other public places and restricted time for exercise are most harmful for the many living in cramped accommodation with no private outside space. Worse still if they are on the financial brink and very stressed; already there are many more calls to help lines. Domestic abuse has risen and is terrifying for those with violent partners or parents who are unable to escape. There will also be raised stress in households where one or more family members is a key or health care worker more exposed to Covid-19. Only essential workers and those unable to work from home are allowed to travel to work or be out for more than an hour of exercise or shop for food and medicine (though exceptions are made for divided families with young children who can move between the two households).

Many find pets are a comfort and company for people living alone. Adoption levels for both cats and dogs have doubled with dogs offering an excuse to get out for a walk.

Warm spring weather tempts people to go out for longer and sit around which is not permitted by patrolling police officers; nor is travelling to a lonely beauty spot to go for a walk or moving out to a holiday home as this may further spread the virus. People who fail to keep 2 m away from others when outside can and will be fined in future. For now, the British lockdown relies on the willing compliance of people to stay home but there may be draconian measures around the corner.

Policy shifts

At 5 pm there is a regular Televised Press Briefing from 10 Downing Street followed by questions via the internet. Boris Johnson (the PM), the Chief Medical Officer and other Government ministers are off the air as they themselves have caught the virus and on 5.4.20 the PM, who has been feverish and unwell for 10 days was admitted to St Thomas’s Hospital critically ill (he has since recovered).

We need more contact tracing and testing of health care staff. After criticism mounted, private sector laboratories are to assist with developing different tests as well as a vaccine – but why the delay? The NHS needs more oxygen, more ventilators and more and better PPE to be delivered faster to hospitals around the UK which is being assisted now by the military. Why not organise a “click and collect” system from local depots for hospitals, general practitioners (GPs) and social care workers?

There has been an emergency relaxation of cumbersome and expensive regulations that slow the development and trials of new and repurposed drugs and new vaccines. Consequently, trials are being set up with extraordinary speed. Will all or some of the former regulatory rules be re-imposed in future? Will the world of science continue to cooperate differently and better?

Calling up reserves

The Government asked doctors and nurses who retired “up to 3 years ago” to come back to the NHS and help with the crisis and 20,000+ have already returned to work. But how about those who retired earlier? How far back? Is the GMC (General Medical Council) reinstating some of these doctors too? One doctor who is 81 and retired for 9 years was surprised to learn he had been re-registered for practice. Older professionals may help but from the back office or by video link and should not volunteer for a Covid-19 ward. Dentists, pharmacists and peripheral health professionals have been asked to assist as well as furloughed aeroplane cabin crew who are trained in first aid. Will vets be summoned next? (Their practices, like dentists, are closed for all but emergencies).

The call for 250,000 volunteers to support the NHS and help vulnerable people socially isolating at home was met within 24 h. After four days it had reached 750,000 and the site was shut down. At the start of the crisis, the government reached a deal with the private sector to make their facilities and staff available to the NHS if needed and some cancer patients are now being directed there. Hotels closed to normal guests may be taken over to accommodate essential workers and in some instances the homeless.

Is there an upside?

The Covid-19 lockdown is beneficial for air quality, the natural environment and reducing toxic emissions and global warming. Less traffic means cyclists, pedestrians and pets are safer and the number and severity of road injuries and there will be fewer admissions to hospitals. Insurers will welcome reduced numbers of road accidents as they are dealing with record numbers of claims for spoilt holidays and travel plans.

“Necessity is the Mother of Invention” and the pandemic is spurring ingenuity and inventiveness, in all directions. In medicine, science, design, production and has to a degree encouraged global collaboration on the need to find a way out of the lockdown. Scientists seem to be sharing data in the hope this will speed the discovery of key drugs and reduce morbidity and mortality and there are many opportunities for smaller laboratories and universities to shine. Projects that would normally have taken several years to even set up let alone complete are already in hand and being tested. Hospital bed and screen makers and other key suppliers of ventilators are busy. Small and large UK manufacturers are showing their flexibility and retooling to produce different products that are most needed, e.g. making hospital gowns and scrubs instead of sportswear and adapting diving equipment to create innovative oxygen supply masks and face protectors.

More fast-build temporary hospitals (start to finish in under two weeks) temporary hospitals are planned for Manchester, Birmingham, Bristol, Harrogate and Glasgow and other cities if needed.

The UK Government has found a Magic Money Tree from which it will provide and distribute a huge sum of cash to keep the economy afloat enabling tens of millions of employed and self-employed people to survive during lockdown and hopes to rescue wobbling businesses and people from falling into “the slough of despond”.(Pilgrim’s Progress by John Bunyon).

Some businesses are doing well: supermarkets, online deliveries, grocery and baker shops. Alcohol sales are very strong – but the real winners are internet providers of virtual entertainment and conferencing services, undertakers, manufacturers of hospital beds and trolleys, testing kits, makers of vaccine and other relevant drugs and devices.

Community spirit

Community spirit has had a boost. Volunteers are delivering food parcels and medicines and keeping food banks topped up. Online meetings and phone or video chats have replaced normal events and help combat levels of loneliness and depression caused by the pandemic. People of all ages can benefit. WhatsApp messages and emails are constantly flying round the world like a perpetual hailstorm. Religious groups and charities, social clubs and government agencies are organising help for those who most need it. But there have also been some unedifying incidents of greedy and selfish behaviour and help lines are overwhelmed.

Virtual examination and prescribing

Within two weeks many doctors, most especially GPs, have fundamentally changed their way of working and see most of their patients online if possible. Reducing surgery attendances will continue in the future (see the article by Dr Adrian Wayne). Doctors will increasingly talk to and virtually examine and prescribe for patients remotely and indeed a virtual “home visit” (if the patient shows the doctor his home by camera) may offer the chance to assess how a home environment assists or adversely affects their health problems. Virtual appointments are likely to replace some hospital outpatient visits.

However, for invasive treatment, e.g. giving an injection or physical manipulation by a physiotherapists or osteopath, attendance is mandatory. The “laying on of hands” will be rarer, but perhaps for this reason, more desired. These changes will save on wasted time and travelling (and may incidentally also help the environment). Dentists (who are currently not allowed to use their high-speed drill) will have to continue face to face gloved hand and close contact in future.

Lawyers and the internet

Internet conferences will be the norm and change professional methods of working. The conduct of trials, both civil and criminal will adapt, but before this can happen on a grand scale the courts will need new technology and more staff and judge training to function efficiently. For now, with juries not able to sit and to avoid undue delay, criminal trials may move to a remote process and where the judge sits alone. (The rate of conviction is likely to be higher and trials shorter and cheaper for the Treasury but defence criminal barristers are understandably not keen on this proposal.)

Less travel in future

Many businesses and academics have regarded travelling to conferences as a perk. They are often agreeable but often not really necessary and could be managed well by video link. At present they qualify for a tax break but if fiscally discouraged would quickly decline unless they can be truly justified. That said, there are some advantages apart from a paid for trip. For example, at a large conference what is said from the podium will not include what one hears during the coffee break or a chat over dinner or a quiet drink in the bar when something confidential or indiscreet is whispered in private. Some words cannot be sent over the internet.

The Dystopian downside of the pandemic

Thousands of people have died and continue to die prematurely and alone. ² New mortuary facilities have been created to hold the bodies while they wait for cremation or burial. While most of the deceased were aged over 65 and had other health issues, there have been many much younger victims with dependent families and rarely and tragically even children. Residents of Care Homes, however, are at the greatest risk of death from the virus. Many have Do Not Resuscitate (DNR) in their care plans and they would not be sent to hospital but given only palliative care.

Our personal freedom is curtailed with no end in sight; all sporting activities, theatre and restaurant outings, concerts and parties are banned and there is real fear hovering everywhere. London has the highest rate of infection in the UK but may be slightly tapering in the last days as at 6.4.20. We share jokes and a lot of black humour, ridiculous cartoons and videos but aside from these brief moments of laughter there is real sadness, gloom, anger and frustration. Many are truly suffering from claustrophobia, despair and the dysfunctional relationships but trapped with no money and nowhere to go. The lockdown is destroying our way of life and the Economy more every day it continues. It is sucking most of the joy out of millions of lives. The graphs of infections and deaths are still rising here but we see a levelling off and a modest fall in numbers in Italy, France and Spain who are further along the graph and we hope things will improve in the next few weeks. In the USA the graph is rising faster, but we hope that will not be our fate.

Lack of normal physical contact is hurting us all; it is upsetting and detrimental to our relationships with grandchildren, children and others who are lonely, feel sad or are bereaved as we cannot give the usual comfort. We cannot welcome them to our homes or visit theirs and party to share a celebration. Weddings are cancelled along with so much else. We cannot visit our loved ones in hospital or be with them when they are dying. We may not be able to hold a funeral or attend in person.

Are hospital doctors too specialised?

Are our doctors so over-specialised that they are no longer useful in a general health emergency? Routine operations in the NHS have been cancelled to free staff who are being moved to A & E and Covid-19 wards; many of them training to re-skill or up-skill on general and respiratory medicine to care for seriously ill patients admitted to the expanding numbers of ICU beds. Indeed, a thoracic consultant surgeon whose operations had all been cancelled was interviewed on the radio and explained why he felt more useful acting as an intensive care theatre nurse! But I suspect that he has already been moved on.

Fear of contracting the virus makes a hospital visit worrying, but there are reasons to go other than Covid-19. A women giving birth may be denied her partner’s presence and if they are allowed to attend the delivery they will be sent home immediately afterward. Many women are afraid for themselves and their new babies. For example, a consultant in London said she had seen “much less appendicitis, bowel perforations and abscesses” conditions that occur at a constant rate and often require urgent surgery. Obviously, while the virus continues to be a major risk treatments that lower the immune system are suspended but there are concerns that patients are not receiving treatment for serious ailments such as strokes as they are afraid to go to hospitals.

Triage

The cancellation of so much routine hospital care to make space for Covid-19 patients is adversely affecting other patients whose health along with their state of mind will deteriorate the longer their treatment is delayed. They frequently suffer from co-morbidities. We accept that Justice delayed is Justice denied and this is happening with closed courts but it is also true for patients whose operation or other invasive treatment is delayed to make way for a flood of new patients deemed, en masse, to be in greater need.

This form of remote triage is diverting major resources away from other patients. Indeed in The Times (2.4.20), an article was headed: “Doctors are told not to give Covid-19 patients priority”. This new ethical guidance is backed by the Royal Colleges and based on papers written with influenza pandemics in mind. If resources are limited then there has to be rationing but this must be done fairly and patients should be individually assessed taking account of their general health as well as their age. Sadly, it is becoming clear that people from black, ethnic and minority (BAME) groups are being badly affected or dying from Covid-19 in greater numbers than average -- and many work in the health service or care sector which has taken its toll. Statistically women have demonstrated far better survival rates than men – but will this factor be taken into account?

Anxiety and depression

Anxiety and depression are increasing. Some are living with pain and fear due to delayed or cancelled care though others will be sent to private hospitals if their need is more urgent. Financial worries for now and the future are a major driver of suicidal thoughts and attempts. Government cash is not arriving fast enough and will not be enough anyway for many to cope day to day or feel more reassured. Millions of people are lying awake at night and stressing by day and perhaps drinking to drown their sorrows while stuck indoors. This may be a dangerous mix.

School closures

Children are generally bored and unhappy that they are not allowed to see their friends or grandparents or spend time having fun in parks and playgrounds or even play ball games outside their family. School closures meant more children may be induced or commandeered into running drugs for gangs.

Lessons and homework before the end of term was being remotely provided and will be again when schools notionally reopen. This is generally not very agreeable and requires a lot of parent input and supervision particularly for smaller children. Meanwhile the holidays stretch ahead, though children of essential workers are continuing to go to school or if they are “vulnerable”. As they have a higher than average risk of infecting one another they may develops faster herd immunity but with few or no symptoms? Hopefully there will be testing for this soon. School closures seriously affect parents’ ability to work productively from home. Some students are disappointed that public exams are now cancelled but others are relieved. They will all be judged on mock exam results and class work.

No house sales

The housing market is frozen during the lockdown. ³ A source of frustration for people who were prepared and desperate to move. The ban includes people who have signed legally binding contracts and form part of a chain – or who had an offer they intended to accept and which could vanish with the pandemic. No sales means no sales tax receipts for the Revenue at a time when it is badly needed. There are worries that prices may drop due to lack of consumer confidence which works for those not yet legally committed but may auger less well for those who are bound. Rentals can still go ahead (easier if furnished) but viewings of property are only online and moving more than what can be handled personally will not be possible.

Why ban the sale of plants and flowers?

Garden centres are (idiotically) included in the list of banned businesses. This is counter-productive in protecting people’s health, happiness and keeping active and the hardworking owners of these businesses and plant nurseries face disaster as they are missing the key time for planting (spring). As we can select and pay for plants outside and at a social distance using a touch-only credit card why is this shut down logical and justified? Millions of new spring plants will be unnecessarily destroyed that could have brought joy to their purchasers.

This ban needs to be immediately reversed. Gardening even in public parks (suspended in many cases) can be done working outdoors and 2 m spaced apart and there is no reason for it not to go ahead.

Stranded travellers

Thousands of British travellers abroad are or were left stranded, including health workers who are needed and eager to return home. The Foreign and Commonwealth Office have been heavily criticised. On the defensive it says the numbers are large and logistics very difficult; it is true that tourists abroad were and still are unable to get to an airport due to a local ban on movement even if there is an available flight for them.

The worst holiday choice for many in 2020 was a cruise; and most especially if booked in a windowless cabin. Ships with Covid-19 positive crew and passengers have been wandering the oceans seeking a place to dock like the Plague ships of old. While they cannot discharge crew or passengers, passengers have been confined to their cabins for more than 23 h a day during which time the ship’s air conditioning system is arguably spreading the virus further. Many ships are registered at “ports of convenience” because it is cheaper but these ports are technically where they should now return. None will be capable of dealing with the situation. Should we from now on require that ships are only allowed to register at a port that is capable of dealing with a future problem or disaster?

Future litigation

Litigation is surely being seeded by the pandemic even as I write and there may be claims for disastrous holidays that were mishandled by their tour operator or cruise ship, etc.

However, the Coronavirus Act 2020 may prove a bar in some instances to claims from health care workers working in Covid-19 wards or claims by that the care given to some patients was less than optimum and led to their preventable death. Other articles in this Coronavirus issue will deal with this issue in more detail (refs Alec Samuels and Toby Riley-Smith QC).

Is the cure worse than the disease?

It is not just President Trump who asked this: the lockdown is having a terrible impact and there is as yet no quick viable exit strategy. The UK government is borrowing at unprecedented levels for Tomorrow and building a heavy burden of debt on the next generations. But with no restrictions on movement and leaving it free to spread in order to gain “herd immunity” without effective drugs is a very grim and unacceptable option for now. It would certainly result in many more deaths – (mostly elderly people who have lived the majority of their lives) but who often provide many hours a week of child care as well as love, affection, advice – and financial help when they can afford it. After this pandemic there will be a feeling of exhaustion by clinicians but there will also be surge of pent-up demand; the NHS must remain well funded and staffed to deal with it.

Will we be better prepared for a future pandemic?

We must accept that in the modern world viruses travel fast and know no borders. China refused to admit to the virus spreading and by the time of the lockdown in Wuhan it was starting its travels to the rest of the world. President Trump initially dismissed the threat of the virus saying it would go away; the USA has already more deaths than China with New York worst hit so far and ventilators and other equipment in short supply. Difficulties for the USA are compounded because it has no universal free health service and there are millions of citizens (not to speak of illegal immigrants) with no health care insurance at all. The numbers expected to die in the next few months are shocking.

The existence of a capable and modern national health service is a hugely valuable asset when dealing with a pandemic but President Trump, who designated gun shops should remain open as “essential” stores along with suppliers of food, is unlikely to create one.

Where did the pandemic begin?

It began in Wuhan in China and earlier than official sources admit. In Wuhan there is a chemical research facility as well as a disgraceful and cruel wild animal market that was blamed as the source and closed. (Will it be allowed to reopen?) In this dreadful market, captured, wild and wretched animals were kept in disgustingly, dreadful conditions to be bought and sold for food or “medicines”. It is suggested that the virus moved from distressed animals to their human tormentors and on from there. This must be thoroughly investigated. But will we ever be allowed to know the truth now?

Should the UK government have acted sooner?

The Government repeats its mantra every day: we are following medical and scientific advice. Initially it was “Wash your hands for 20 seconds”. Now it is “Stay at home, protect the NHS and save lives.” But has this advice been consistent and sensible from the start? Was the original idea to develop herd immunity – but dropped like a hot potato when the modelling from Imperial College showed 250,000 to 500,000 would die even if Britain’s most vulnerable citizens were in lockdown for 12 weeks? Valuable time was lost to contain the disease to ramp up testing capacity and to track and isolate those who were spreaders. Then came lockdown for all but essential workers. Still there was inadequate testing and tracking of people returning from Covid-19 hotspots. Was it a mistake not to cancel the Cheltenham races? Nervousness among the public began to grow amid increased hand washing and buying hand sanitiser gel. The numbers of people who were dying continued to mount while the PM and his advisers reassured us from podiums at close quarters that “for most people Covid-19 is a mild illness – less dangerous than flu – and children are at no risk and may get no symptoms at all if they catch it.” Yes. But hospital admissions and deaths tell a different tale.

War against the virus

“We are at war against an unseen and silent enemy! We will fight this virus and win this War, whatever it takes!” War changes the rules so the Government demanded it be given further emergency powers unprecedented in peacetime and the Coronavirus Act 2020 was passed. But as Harold Wilson (former PM of the UK) once memorably said, “A week is a long time in politics”.

War brings with it draconian rules: the right to take over people’s private assets, their livelihoods and occupations, their lives and security and the loss of personal freedoms. We need to rise to new challenges; be brave and selfless – and at times ruthless – all for the good of the country! But we will differ about what is justified and what is not.

Defeating Covid-19

Around the world, scientists are working 24/7 to find antibody tests, useful drugs and vaccines to deal with Covid-19; reportedly many are sharing knowledge and data but the profit motive may in time reduce this collaboration. As the virus has only been around for a few months, it is not yet well understood though progress is being quickly made. As discussed above, there is fast-tracking of new trials and research products but this must still be rigorously checked out. We still do not know how long immunity will last after the virus. Is it less than a year? If there is no vaccine when can the lockdown be raised even partially. Suggestions are for end of April and May at the earliest. Will there be a further outbreak? Will this be in summer or winter? Effective drugs that control or reduce the impact of the disease path and best of all a vaccine will give us an exit strategy.

Covid-19 is not the Plague

Covid-19 is not comparable to the Black Death, the Plague, and only to some extent to the Spanish flu which killed more people than the slaughter of the First World War 1914–1918. Unlike coronavirus, it was most deadly for those aged 20 to 40 and then there were no antibiotics, and medicine was less advanced. But there are still lessons to be learned from how it was managed and the effect of a lockdown imposed in some areas but not others quite nearby, e.g. in California. But I am ending with an excerpt from the Diary of Samuel Pepys, written during the great Plague of 1665 which affected London horribly. It was followed the very next year by the Great Fire (and humiliatingly, at this time, the enemy Dutch fleet managed to sail up the Thames).

Even after such catastrophic events London quickly recovered and flourished. And Sir Christopher Wren built our wonderful St Paul’s Cathedral on the ashes of the building destroyed in the conflagration.

(Pepys visits London for the day)

“16 October. But Lord, how empty the [city] streets are, and melancholy, so many poor sick people in the streets, full of sores, and so many sad stories overheard as I walk, everybody talking of this dead, and that man sick, and so many in this place, and so many in that. And they tell me that in Westminster there is never a physician, and but one apothecary left, all being dead - but that there are great hopes of a great decrease this week: God send it.”