In a year that almost everyone will want to forget there is some emerging good news. Covid-19 related hospital admissions are undoubtedly falling. By the end of August there were barely over 300 people in hospital in England with coronavirus listed as a diagnosis, and only 46 in London. To put this into context, the figure was over 15,000 at the peak of the infection. The virus has not gone, of course, but positive data like this is a reminder of how the challenge is now very different.
As a doctor I have over the years come to realise a few different things. The more you learn, the more you realise the limits of medicine. The more experience you have the more reflective you become and are able to question your actions and be open to new ideas and approaches. When you first turn out on the wards fresh from university it can seem a frightening place and challenges to your thinking and knowledge can be viewed as threats. When you have a method to keep you out of trouble and keep people safe you want to stick by it, come what may. It is only when you start to have more confidence in yourself and a deeper understanding that you start to ask: can I do things better?
A lot of emergency medicine is protocol driven to reduce error and ensure patients receive optimal emergency treatment. But after that often the issue becomes more specific to each person and situation. Anyone who has been treated in hospital will know the difference between seeing a junior doctor and a consultant. With the clever but still green doctor you may get lots of tests but little actual explanation. Whereas it is almost the polar opposite with an experienced doctor – you get a few targeted enquiries and hopefully an explanation and management plan.
The response to Covid-19 around most of the world, originating from the World Health Organisation (WHO), was like a protocol driven emergency template This is not to decry it; several aspects are eminently sensible, such as good hygiene and self-isolation of those infected and attempts to trace close contacts. But other parts, including lockdown itself, were less evidence based and started to veer toward a ‘better safe than sorry’ outlook. If you are dealing with large numbers of serious infections and deaths then you understand this approach. What though must come soon is a reckoning of whether the measures actually helped.
Now though we have moved to the next stage. The emergency is different. It is not a ‘warzone’ in emergency departments with escalating death rates. It is now much less tangible and is primarily studied with graphs and statistics. A new term has arisen in this pandemic – the positive coronavirus case. You cannot ignore the number of positive cases, as it can lead to further infection amongst others, but this is very different to the severe hospital admissions that drove the original templated response. This is the conundrum we find ourselves in currently. We are in a loop of assiduously monitoring these positive cases but are struggling due to lack of experience or nous to understand them and therefore be proportionate in our actions.
The recent experience in Leicester is particularly revealing. The figures are very interesting and when one looks at the city there was no doubt that an increase in absolute numbers of positive cases emerged in June (from 255 in the week ending 5 June to 556 in the week ending 26 June). Interestingly there was also a mini-increase in hospital admissions at the main University Hospital (25 on the week ending 5 June to 40 by 19 June). I would, however, caution against over-interpreting this as the rise was small and numbers fell again the same week positive cases peaked. Nevertheless, concern was raised and the city’s plight hit the media. But by the time local ‘lockdown’ was enforced at the end of June the figures for both cases and hospital admissions were already on their way down and have continued to fall, with only five new Covid admissions reported for the week ending 21 August.
Many may recall initial pushback from the city’s mayor regarding the events and the seeming indiscriminate nature the area as a whole was treated with. When you look at the figures there is merit in this. There was no doubt an increase in positive cases, but this was not uniform across the city and was driven by clusters. There was contention about the drivers of these infections, but I would suggest that politics got in the way of one of the basic tenets of public health.
Anyone with a knowledge of history will know just how indebted even now we are to the Victorians and how sad it is that we have forgotten a number of lessons they previously taught us. Cholera was the major epidemic at that time and the brilliant John Snow, through meticulous mapping of cases and sound medical knowledge, was able in 1854 to pin a major outbreak onto a single water pump in Soho and convinced local health officials to take it out of commission. The well from which the water was drawn was found to be contaminated by a nearby sewer. Was there any serious attempt to look at the clusters in Leicester and see what could be done there? Was it just too easy to resort to city-wide sub-lockdown measures?
I think a learning process is happening. There does seem to be an attempt in the north west to be more granular in the measures taken but the fundamental problem still remains. We often do not completely understand what it means to have a positive test. It is much clearer if the situation is one of large-scale symptomatic infection: then we have our WHO template to fall back on. But now, with barely any correlation between test results and serious infection and with numbers rising and then falling in clusters even before further restrictions are put in place, the certainties we had when dealing with the spring epidemic are gone. Fundamentally we just do not know how infectious many of the people in this new group are, and we do not it seems have a sophisticated enough plan to mitigate it.
As winter starts to draw near a whole set of new problems may emerge, not least the re-emergence of other winter respiratory viruses and how that affects the current dynamic. It is possible that the WHO template will be called on again and have some currency as a tool to fight respiratory viruses as a whole. Caution and safety are appropriate but I hope what also comes is greater knowledge and sophistication with the ability to become more selective and proportionate.