What I’ve seen as an epidemiologist on the Covid-19 frontline.

Dr Raghib Ali is a Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust, and a Clinical Epidemiologist at the University of Cambridge.

March 19

“Your NHS needs you!” came the call from the General Medical Council.

As a clinical epidemiologist, I had been closely following the developing Covid-19 pandemic, but now I had an opportunity to actually help on the frontline.

Although I had spent most of the last decade in academia as a public health researcher, I was still licensed to practice as a consultant in Acute Medicine.

So I immediately volunteered to help out at the hospital, where I already had an honorary contract – as well as at the soon-to-open Nightingales.

I won’t pretend I wasn’t worried by reports of the deaths of so many doctors in Italy, and the potential risk to my wife and children, but I knew that I couldn’t just stay at home while my NHS colleagues were overwhelmed in the coming storm.

We had all seen what was happening in Italy and some of the models for England were predicting up to a 500 per cent increase in admissions in April.

I was happy to swap my home office for the emergency department for a few weeks to serve in the war on Covid-19.

March 30

My first week back at the hospital and things are very different to usual – large parts of it are deserted with no outpatient clinics, no elective procedures and no visitors – but huge amounts of activity in the newly configured Emergency Department and Covid-19 wards.

I was pleasantly surprised to see how quickly the hospital had managed to re-configure services, including massively increasing Intensive Care and High Dependency Unit capacity and re-deploying hundreds of junior doctors to deal with the expected influx of Covid-19 patients.

Although NHS bureaucracy can be frustrating at times, senior managers and clinicians had worked together to achieve changes in weeks that would usually take years.

April 9

News comes in of the tragic death of Dr Abdul Mabud Chowdhury. At 53 he was only a few years older than me – and had written to the Prime Minister three weeks ago urging him to ensure that every NHS worker had adequate PPE.

Personally, neither I nor any of my colleagues faced any shortages of PPE in our hospital – although of course I was fully aware that is was not the case in some care homes and or other healthcare settings – and I was therefore pleased to see that having adequate PPE was one of the tests before lifting the lockdown.

Protecting frontline staff must always be a priority for the NHS and no-one should be expected to see patients without adequate protection for themselves.

April 16

“All these people are clapping for your daddy,” my wife explained to my six year old daughter as we joined our neighbours in the weekly Thursday night clap for carers.

These occasions had certainly been a great boost to morale, but although – understandably – a lot of the focus was on the doctors and nurses, in many ways I felt the real heroes were the health care assistants, cleaners, porters and catering staff. – those who continue to come to work despite being poorly-paid and under-appreciated. I hope that will change in the future.

I also couldn’t help but remember the many colleagues who we had lost over the last few weeks – including two porters in my own hospital, who made the ultimate sacrifice in order to help others.

It was also becoming apparent that the vast majority of doctors – and, to a lesser extent, other healthcare workers – who had died were from ethnic minorities; a poignant reminder of the contribution that immigrants make to the UK, but also something that needs urgent investigation to understand why.

April 27

By now, I have seen dozens of cases of Covid-19 of all ages and severities with lots of difficult conversations about resuscitation and tragically many deaths – one of the saddest things I have ever experienced was seeing our patients spending their last moments alone without their loved ones.

But in many ways the storm we feared never really arrived, thank God.

The number of Covid-19 patients never reached the numbers expected and so we always had enough beds and Intensive Care was never overwhelmed.

In fact, it soon became clear that we were facing another, unexpected problem – most of our usual patients who would have been coming in with heart attacks or strokes or other infections were simply not presenting to the hospital, presumably too afraid to come in for fear of contracting Covid-19.

The emergency department was the quietest I had ever seen it, with occasions where there were actually more doctors than patients waiting to be seen – something I never expected to see.

The same pattern was being seen nationally with unprecedented reductions in emergency admissions and tragically it seems that many of our usual patients were suffering and even dying at home.

I agree that the lockdown was needed to buy time and stop the NHS being overwhelmed by Covid-19, but I am now beginning to worry that it may be causing more health harm than we expected and the weekly ONS death figures seem to confirm this with the increased non-Covid deaths in the community.

NHS leaders and the health secretary rightly remind people that the NHS is still open for all emergencies – not just Covid-19 – but it seems many people are still too scared to come in.

May 6

My last day at the hospital for now – the good news is that the number of new Covid-19 cases has really fallen significantly, our usual patients are starting to come back and the emergency department is looking more normal again.

The last six weeks has certainly increased my respect for all my NHS colleagues and I was impressed by the way in which the whole team from the senior consultants to the newly qualified junior doctors dealt with very stressful situations with fortitude, calmness and good humour.

I am certainly ready to go back as and when needed, but for now I need to focus on a new area of research for me – in trying to understand why this virus affects people in such different ways, and how to reduce the impact of this deadly disease on the whole population going forward.

As I drive home, I am also pleased to hear the Prime Minister say that some lockdown restrictions will be lifted from next week – and dare to hope that perhaps we have reached the end of the beginning.

Looking ahead

After what looks like the deadliest month since the Second World War, the Government is an unenviable position and facing some of the most difficult decisions taken in peacetime.

But as more data has become available, the case for lifting further aspects of the lockdown seems to be getting stronger.

First, I find it hard to see how the NHS will be overwhelmed now as it is so much better prepared and no-one is proposing to back go to how things were pre-lockdown.

Also, the majority of people are now afraid of catching the virus and so will continue to heed Government advice on social distancing and self-isolation.

The actual daily death rate peaked on April 8 suggesting that the infection peaked three weeks before that – i.e. before the mandatory lockdown, but after social distancing and self-isolation came in.

Second, although it seems strange to say this as we pass another grim milestone of 30,000 deaths, overall the virus seems to be less deadly than first feared, particularly among children (where it may be even lower than flu) and those aged less than 50, but also in general.

Based on the evidence so far, it appears that more than 99.5 per cent of people will survive infection, more than half won’t even know they’ve had it and even those that do will have a mild illness.

Roughly speaking, Covid-19 infection doubles your background risk of dying this year – but for most people that risk is extremely low in the first place.

Covid -19 is not flu, but neither is it Ebola and we need to ensure that the public understand that the vast majority of them are at very low risk of dying from it.

And third, as mentioned above, the lockdown may be beginning to do more health harm than good.

Some of this is a direct effect and already apparent, as mentioned above in relation to emergency admissions, but also in adverse impacts on people’s mental health, delays to cancer diagnoses and screening, among other problems.

But the indirect longer-term health effects may be even greater as millions lose their jobs, which we know will potentially lead to tens of thousands of premature deaths in the future.

This is not a choice between saving lives and saving jobs – saving jobs now will saves live later.

There has been a proliferation of armchair epidemiologists over the last few weeks with noisy, often un-informed debates between those who are convinced we went into lockdown too late, and those who say it should never have been put in place.

The truth is that we still don’t know – and won’t know for some time – which strategy will prove to have been right in the longer term.

The Government has rightly said that is has always been led by the science, but that science is uncertain.

Scientists disagree and I think there needs to be more honesty with the public about that uncertainty.

It seems to me that there may be a case for further easing the lockdown, but without full access to the SAGE documents, data and advice the Government is receiving – as they receive it – it is impossible to know for sure.

I think that increased transparency and putting more trust in the public will actually help the Government.

People need to understand that there are no easy answers here, and that going forward we will need to try different interventions and see what is effective.

Finally, I hope everyone across the political spectrum will remember that this is not the time to score political points, but to work together so we can defeat this virus as quickly as possible.

To paraphrase Bill Gates, ‘this is a war, but we are all on the same side.’