Dr John Ashton explains how the threat posed by the Coronavirus will be amplified in closed settings and communities.
In recent days, there has been increasing concern about the potential plight of the elderly and vulnerable residents of care homes during the COVID-19 outbreak.
Lack of adequate regulation, poor funding and often inadequate environmental and care standards have been identified as factors placing this group at particular risk. The large size of many of the recent care home developments, making them potentially akin to the institutions of old, is an added factor and it has been suggested that high rates of attrition are possible once the Coronavirus takes root. The report this week of Spanish residential home residents being found dead is a shocking reminder of what can happen.
Yet, care homes are not alone in being settings that should be high on the radar of those responding to this public health emergency.
When we are not moving around between them, or associating in the outdoors, we live our lives in settings of one kind and another: from homes to workplaces, bars and restaurants, leisure and sports facilities, schools and colleges, clinics and hospitals, and – for an important public health minority – prisons and places of containment including secure psychiatric facilities. As the Government has progressively taken action to reduce the threats of viral spread, many of these have been taken out of the equation – but several remain as potentially significant.
It is urgent that clear thinking should now inform what happens, particularly with regards to these places in the coming days.
Hospitals and Healthcare Environments
The report of the first case of a healthcare worker, in Newport, to acquire the infection in hospital and to subsequently die should act as a clarion call for all those who are putting their lives and wellbeing at risk for the public good.
The failure to test systematically for the Coronavirus, especially among frontline workers, and to protect them with proper personal protective equipment (PPE) and clothing, is combining with the enormous pressure of hospital admissions and reduced resilience from years of financial stringency to produce environments which are themselves a threat to public health – with the potential for them to become the focus of secondary epidemics.
It is embarrassing to have to point this out in the country of Florence Nightingale, whose pioneering use of mortality statistics in the Crimean war from 1854 and championing of bio-security in the form of hand-washing and other hygiene practices reduced mortality rates from 42% to 2%. Then, as since, serving members of the armed forces were at least as likely to perish prematurely from disease (including now self-harm) as from enemy action. The last of the Belgian round hospital wards, with central furnace and radiating beds so that the patients’ heads were adjacent to open windows around the circumference, can still be seen in Waterhouse’s Old Royal Liverpool Infirmary.
The announcement that the ExCel centre in east London has been converted into a 4,000 bed field hospital should cause us to stand back and question whether this is the right approach to mass infection at this point or whether it could make matters worse, conjuring up images of similar facilities from the 1919 Spanish flu pandemic, in which thousands of patients died in similar clinical environments. How can we be sure that a military facility of such enormous size will achieve what is asked of it when field hospitals’ raison d’etre is normally the handling of acute trauma, stabilisation and the conveying on of the injured to specialist military medical centres?
Surely it would make more sense to utilise such capacity for triaging and quarantining those at different levels of risk such as is happening in Bahrain where – despite the threat posed by thousands of potentially infected religious pilgrims returning from Iran – a combination of triage, screening and systematic testing, backed up by isolation and quarantine, including in a high specification camp for 3,000 people, constructed from scratch on an island in 10 days, enabled the country to keep the number of deaths to two out of 390 cases by 24 March.
As the number of Coronavirus cases rise inexorably, the present model centred around hospitals will have to be rethought and replaced by one from the bottom-up – based on community control, prevention, isolation and quarantine and care, with only the most severe cases going into hospital.
It has been apparent to any observer that overcrowded, environmentally degraded prisons pose a threat to whoever spends time in them – whether they be inmates, prison officers, maintenance staff or family visitors.
Outbreaks of the Coronavirus in prisons in China and Iran – and pre-emptive action in Bahrain – prompted the early release of large numbers of prisoners. Sadly, our inherent prejudice against enlightened action involving prisoners has prevented us from so far following suit and the boat appears to have sailed.
According to reports, there are now COVID-19 cases in 10 British prisons involving either prisoners or staff. Containing this through testing, triaging and quarantining with highly complex cohorts including extremely violent people will be the ultimate challenge, as well as managing the threat to the community at large posed by those who, of necessity, must move between prison and the community.
With the country now on lockdown, we are left with the home and its environs and the movement of essential frontline staff, including the armies of volunteers, as potentially weak links in the chains of infection and its control.
It is vital that the elderly, those with heart disease, diabetes and chest conditions – together with those with other vulnerabilities from long-term conditions and immune suppression – should be isolated in their homes and that bio-security in their homes should be second to none. Hand-washing; paper towels; regular disinfecting of hard surfaces, such as doorknobs, keyboards and other shared use items must become second nature.
Younger people who are frontline workers or volunteers and who are potentially exposed to the Coronavirus, should be found accommodation elsewhere, with the powers to undertake these measures devolved to the local level.
We are social animals if we are nothing else, and how we live in all the settings of everyday life becomes part of our fabric. We are faced with short-term cultural and behavioural change which is a real shock to the system. But, we must grit our teeth and press on, knowing that the prize is not only that of saving precious lives but also the satisfaction that comes from being part of a social mission of solidarity that could enhance all our wellbeing after this is over.
Dr John Ashton is a leading international authority on public health and a member of the Crown Prince of Bahrain’s Corona Task Force.