Nightingale Hospitals, Hospices or Workhouses? What is the Exit Plan?

Now that we’re about to enter a second lockdown in England, we should all be asking what the exit plan is?  Last week the Office for National Statistics announced that 568,000 people have had Covid.  In one way, that’s good news; if we can keep that infection rate up, we’ll all have had Covid within two years, so we can get back to normal.  If it’s an underestimate and more of us caught it in the first wave, we might even manage to get to herd immunity by Christmas 2021.  (I’ll come back to the “h” word later on).  But nobody else seemed to welcome the news.  Such is the level of fear which has been spread in the last year, that the very mention of these big numbers has been taken as evidence that we all need to lock ourselves down again.  Epidemiologists are being wheeled out with scary predictions of just how bad it will be.  Nobody seems to be giving any serious thought to how we might be able to live with Covid.

There’s never been a better time to be an epidemiologist.  To paraphrase Harold Wilson – a former Prime Minister, “epidemiologists have never had it so good”.  Nine months ago, few people had the faintest idea of what they were.  As Covid hit, that all changed.  It’s the one profession for which there is absolutely no need for a furlough scheme as, until Covid is over, epidemiologists have cast iron job security.  It’s never been easier to publish – it’s just down to how fast you can write your report; peer reviews are out of the window and you might even get a chance to appear on national TV. 

At the beginning of the pandemic, I pointed out that politicians are using the epidemiologist’s data in a very crude way.  They look at the number of deaths, and when it reaches a certain point, they flip the lockdown switch.  A refinement of that is to look at the number of ICU beds occupied and use that instead.  It’s a slightly more nuanced approach, as the first wave helped to learn and develop better treatments, which means fewer patients progress through to intensive care.  It also led to the building of the Nightingale hospitals, although they’ve largely been left empty.  Which raises the question of what we do with them?

We can keep to the current policy, which will probably start to fill them up, assuming that we can staff them, which is another question.  We could rely on better treatment to reduce the number of patients in intensive care and the time they spent there and use them for convalescence.  Or, given the side effect of the current lockdown policy of massive unemployment, we could repurpose them as workhouses for the destitute.  None of these seems a great idea.

One of the major problems I see is that everyone is still concentrating on that single approach of preventing hospitals being overloaded to the point they can’t cope.  Messages of “Save the Nation” or “Save the Economy” are trumped by “Save the NHS”.  We have to do that, but the strategy has to look wider than just stopping the number of infections.  There is a pint half full / half empty situation here, which is being ignored because everyone has been programmed with the negative outlook, so half-empty reigns.  Beyond that, the rhetoric is about eliminating Covid, which is a fiction.  To see why, remember that it took the best part of two hundred years to eliminate smallpox and with the growth of the anti-vax movement, we many never again eliminate a disease.

I prefer the half-full attitude which recognises that lots of people have had Covid and can presumably get back to a normal life.  Earlier in the year, Public Health England (PHE) have detected antibodies in 17.5% of blood donors in London.

The figures are based on a limited sample of self-selected people.  They also exclude anyone younger than 17.  They are nowhere near herd immunity, but suggest that it’s quite possible that by now, a quarter of Londoners have some level of immunity.  But they don’t know, because we’re not doing widespread antibody tests.  Instead all of these people are being needlessly locked down.  For the sake of the economy we should be identifying these people and doing our best to make sure they get back out to work and start the economy going.  If a quarter of Londoners were out and about it could do a lot to restart the arts and hospitality sectors.

There are some big issues in doing this.  The first, practical one is that we need to find out who has had it.  We know around half a million, as they’ve already tested positive for Covid.  The next step is to encourage everyone who thinks they have had it to have an antibody test.  If you have antibodies, you can get on with life.  Instead of small, personal support bubbles, we can start to generate economically active local bubbles.  But to do that we need to perform millions of antibody tests.

There is an equally big secondary problem, which it that it will encourage some to fraudulently claim they have antibodies.  Rather than policing student parties and fining them, we should put our efforts into developing penalties to deter antibody fraud.  As vaccines move towards testing, we will need volunteers to be injected with Covid to see if they really work.  Anyone falsely claiming they have antibodies obviously wants to have them, so they could be the first “volunteers” to test the new vaccines.

We still need to protect the vulnerable, as well as exposing those at lowest risk.  The current policy of continuing schooling reflects that balance, without admitting it, lest it pricks the bubble of lockdown policy.  In contrast, the lockdowns in Universities may end up killing more students than Covid would have done.   If they are let home for Christmas, it may be the last time they see their grandparents.  Time will tell, but it might been wiser to let them do what students normally do during fresher week and get antibodies along with the more normal hangovers and STDs.

There have been calls for a different approach.  A few weeks ago we had the Grand Barrington Declaration, where a group of contrarian epidemiologists suggested that we should move to a focused protection approach and let life get back to normal for everyone else, with the view of acquiring herd immunity.  Rather than inspiring a new debate, almost every epidemiologist and science journal has been shooting it down in flames.  It didn’t help that the video of the “declaration” included a not very socially distanced, congratulatory champagne toast, but the subsequent condemnation had all the animal fury of a group of epidemiologists who saw their gravy train being derailed.  It seems that “herd” is now a four-letter word.  Graham Norton, writing in New Scientist’s Comment column, stated that we have never achieved herd immunity without a vaccine, hence should not try now.  We have certainly never eliminated a disease without a vaccine (and we’ve only done that once), but humanity has survived multiple pandemics to the current point of over-population.  No pandemic has ever been pretty, but life has carried on. 

It is certainly possible that anti-bodies may be short-lived or not provide full protection, but if that is the case, it is likely to be true for vaccines as well.  We don’t know.  But we cannot hide under the bedclothes for ever.

The reason we can’t hide is already apparent.  The lockdowns are bringing massive unemployment.  Businesses are going bust.  We hear arguments about the positive response following Spanish Flu, where we had the roaring twenties, but the difference is that Spanish flu and the preceding war killed a lot of people, providing plenty of employment opportunities.  In contrast, whole segments of our economy are being wiped out.  Unless we find a way of restarting them now, rather than ignoring them and hoping they will miraculously return, we will be bearing painfully high unemployment rates for years to come.  The knock-on effect of which is that future employment will gravitate to minimum wage.  If you think working from home is an attractive option, ask yourself whether you’ll ever be promoted again?  A struggling economy with a massive debt burden and high unemployment rate is not a great environment for career enhancement.

The message here is that we need to learn to live with Covid, not least because it may be with us for years.  Repeated, rolling lockdowns move us towards an acceptance that once you retire, you spend the rest of your life isolated from friends and family until you die.  That is inhumane.   We do need to be guided by the science, but not solely by the science of the fear of infection.  That denies evolution.  We have to balance it with the science of recovery and immunity.  Plus, we need to make hard decisions.  Boris has said that he does not want doctors to have to be in the position of making the hard decisions about who lives and dies.  Nobody does.  But, as with our politicians, that is a responsibility they took on when they made that career choice.  It’s not an excuse to shun them.  There will be hard decisions to make, and they may turn out to be wrong, but to avoid making them because they’re hard is a dereliction of duty. 

This is the first pandemic to hit a post-industrial society which has believed in opportunity for all and the marvels of medicine to protect it.  If we want to preserve those ideals we need a more balanced approach.  We will not eliminate Covid, but we are doing a good job of eliminating jobs and building up mental health problems.  We’re about to lock up a quarter of the population who are immune.  Surely it would be better to take advantage of that and find a way to allow the growing number of people who have been infected to lead us back to something closer to the old normal.