An AID[s] memoire to Covid 19 testing and tracing

I have been to a number of countries in Africa, but I have never been to the Democratic Republic of Congo. Its capital, Kinshasa, is famous for two reasons. The first is that it’s one of the world’s second-closest capital cities to another capital city (it faces Brazzaville, the capital of the Republic of Congo) with just the river Congo between them. The second reason is that a man living there was the first known case of someone infected with HIV-1. He tested positive in 1959. Over the intervening years, the HIV virus spread throughout the rest of the world. Since global surveillance and tracking of the epidemic began in 1983, 75 million people have been infected with the HIV virus and approximately 32 million people have died. Today it’s estimated that 19.5 million people are surviving and living with HIV thanks to antiretroviral treatment. However, it is estimated that there is almost the same number of people living with HIV, who don’t have access to any treatment at all. There is no cure for HIV.

In the early 1980s, public health doctors began to use the term ‘acquired immunodeficient syndrome’ or what we more commonly call to day AIDS. It has taken a long time for scientists and medical experts to understand the disease, and how it might be treated. I first became aware of AIDs in 1984, when a patient in the mental health service I was managing was admitted with an HIV positive diagnosis. He had acquired the virus through the contaminated blood product Factor VIII. Like many people at the time, we didn’t know a lot about the disease. There was a great deal of misinformation about whether you could catch AIDs from him by using a mug he had used, being in the same room as he was and so on. It was a difficult time, and he had certainly been subjected to much stigma induced anger and ignorance on the part of others.   

I don’t know what happened to him, as I left the service before he did. The treatments available then were crude in comparison to what is available today. These days there is a much greater understanding of how the virus might be transmitted to others, and rates of infection have dropped over the past five years in many parts of the world.  Sadly, sub-Saharan Africa, remains the most badly affected, and cases there account for over two thirds of all those living with HIV worldwide. The UK has made much progress in ending the HIV epidemic. In 2018, Public Health England published a report that detailed this progress and what still needs to be done. Testing for the virus remains a critical element in maintaining this progress.

Likewise, as the world learns to live with Covid19, a different type of virus but just as dangerous, testing will increasingly become an important part of dealing with the disease and containing the rate of infection. Whether we will ever get to a Covid19 version of the U=U stage is difficult to say as we simply don’t know enough about the disease yet. UK readers of this blog will be aware that a new track and trace testing initiative has been launched last week. The official description of what is involved can be found here, but if you, like me prefer pictures to words, have a look at this and perhaps this too.

Tracking and tracing those who test positive for Covid19 is of course, a ‘must do’ initiative in bringing the rate of infection under control. South Korea, Singapore, New Zealand, and parts of India have provided indisputable proof that this approach can have a massive impact on reducing the number of people who could unknowingly be the source of spreading the virus.

Will it work in the UK as well as it has done in these other countries? Two weeks ago, I would have answered with a resounding yes. Now with the Barnard Castle factor, I’m not so sure. And although I try hard not to do politics here, I just have to say that I, like so many others, am both angry and disappointed that Dominic Cummings chose to do what he did in the face of all those who made significant sacrifices in order to obey the rules. With hindsight, I perhaps should not have expected anything different from this man. He is part owner of the farm he went to in Durham. It’s a farm that has received over £235,000 in EU grants, despite Cummings being a decrier of the EU and being the major architect in developing Boris Johnson’s Brexit strategy. Hypocrisy doesn’t even begin to describe my feelings.

Anyway, now I have vented my spleen, back to the track and trace UK initiative. I sincerely hope that people do sign up for the app, and if contacted, do self-isolate and their families too. One of the major motivators that eventually led to the HIV epidemic being controlled was people seeing how easy the virus could be spread through engaging in everyday activities, including very loving and caring activities, and then seeing so many people succumb to AIDs and dying. Condom use, which at first was largely rejected, over time became the new normal. Nowadays, those people who can prove their adherence (that’s a good word – it’s a bit like authenticity) to antiretroviral treatment and who have an undetectable viral load, are affirmed as people unable to pass the HIV virus on. Hence the Undetectable = Untransmittable U=U notion. It’s an approach that’s based upon robust scientific evidence (we may have heard that before somewhere). If you cannot detect the virus in someone who previously tested positive for HIV, then they cannot transmit the virus to others.

We are still in the frontiers of understanding Covid19. We have a new antibody test, which will tell you if you have had Covid19 before. It won’t reassure you that you won’t get it again. There is not enough evidence yet to predict whether that might be the case. It also means we should not ignore social distancing measures. Even as the lockdown measures get scaled back, it still remains an imperative that if you don’t have to leave your home for work (or birthday celebrations), then stay at home, stay alert when out taking your daily exercise or shopping and if you get contacted by one of the 25,000 tracing folk, just be polite to them on the phone. They are back in employment and that has to be a good thing!

Your mind is a garden, your thoughts are the seeds you can grow – let’s party!

Last Tuesday, 19^th May, London had warm sunshine with a gentle breeze blowing. The temperature got up to 23C at the height of the day, and the evening stayed warm and fine until sunset. And I missed it all. I know this was the weather on that day thanks only to the London Economic weather site which logs the weather history of the capital. I should have been able to tell readers of this blog what the weather was like from personal experience. J and I had been invited to Buckingham Palace to attend one of the Queen’s Garden Parties. The invitation was in recognition of the contribution J has made to local politics and the community. I was going as the eye candy on her arm. Covid19 came along and all the Queens Garden Parties were postponed until next year. Given the Queen has reportedly cancelled her public engagements, and is staying at Windsor Castle for an indefinite period, I doubt we will now ever go.

The news, like our cancelled wedding, was one more disappointment to deal with this year. Of course, compared to the numbers of people catching the coronavirus, and the many people who have died, such disappointments may seem trivial. Against such an unprecedented global situation, they should rightly be thought of as being rather insignificant. Indeed, it somehow feels fitting that this year’s Mental Health Awareness week falls within the UK pandemic lockdown. If ever there were a time to consider the importance of looking after our mental health and wellbeing, it’s right now when so much feels out of our control.  

Since 2001, those fabulous folk at the Mental Health Foundation have organised this awareness-raising week. Every year a theme is chosen, and perhaps very appropriately, this year the theme is ‘kindness’. That is kindness that matters to others, but also the need to be kind to yourself. This can sometimes be a lot harder to achieve than we might think. Most of us develop a sense of right and wrong as we grow older and helping others is nearly always at the top of the list of what we might feel would be the right thing to do. For some people, putting others first unselfishly before themselves, is the way they have chosen to live their lives. There has been much evidence of this to be seen since the Covid19 pandemic started. 

And although those working in health and care services, fire and rescue, police and other emergency services might be the first to come to mind when we think about who this might include, there are others too. I was amazed to read last week that the Zero Suicide Alliance have reported that some 503,000 people have completed its online training course over the period of the lockdown. It’s a programme that helps people spot the signs that someone may need help in dealing with a mental health issue. Whilst it is a short training programme, it does touch upon how to promote open communication, and how to approach someone who may be considering dying by suicide. 

Globally, suicide continues to be a serious health issue. In the UK, England saw a rise in the numbers of death by suicide in 2018 and 2019. Whilst we won’t really know the true impact on people’s mental health until we are through these first phases of the Covid19 pandemic, the stress and anxiety of the pandemic will almost certainly have an impact upon people’s physical and mental health. The NHS Clinical Leaders Network published a report last week that warned of the possible devastating impact upon the long term mental health and wellbeing of health and care workers, particularly those working on the so called ‘front line’. 

Both the NHS Foundation Trusts with which I work have already put in place many initiatives to help colleagues deal with the immediate stress, anxieties and depressive consequences resulting from what they are being asked to do day after day. Great care has been taken to ensure sickness, absence, holiday and appropriate rest and recovery opportunities are monitored and acted upon. Whilst we might always be able to do more, I am impressed with the speed and quality of the professional responses that have been put in place. As I noted in my blog posting last week, many health and care colleagues are doing a fantastic job right now, but we will need them to continue doing so in the future. It’s the future mental health of our workforce that I worry about. Some of the experiences of responding to the pandemic will, for some people, have a long lasting impact. We know from many studies that often the impact of exposure to trauma (in all its forms) doesn’t begin to show for some time, sometimes even years after the initial experience.  

And it’s not just health and care workers who are likely to be touched by the experience of Covid19. The uncertainty and unpredictability which the pandemic has brought is relentless. The sense of being out of control and unable to tolerate uncertainty are common characteristics of anxiety disorders, and already there has been a rise in the number of cases being reported. True confession time, I have stopped watching the daily ministerial briefings. Partly because I think they have lost their credibility and partly because I’m trying to limit my exposure, and involvement with reading and watching news, including on social media. However, I am making more of a conscious effort to stay connected with people, neighbours, colleagues, family and so on. 

For me, and I’m sure for others, when negative thoughts and uncertainty come to mind, I try and take a bite of that mindfulness apple, and in so doing I:

Acknowledge – note and acknowledge uncertainty, as it comes into my mind

Pause – take a mental step backwards, and try not to react at all, pause and concentrate on my breathing

Pull back – acknowledge that actually I don’t need certainty in everything; these are thoughts and feelings I’m experiencing, not facts, so I need to avoid believing everything I think

Let go - imagine the thoughts or feelings floating away, as if they were twigs on a river

Explore – importantly, I explore the present moment, concentrating on my breathing, if it’s during the day, I take note of everything around me, what I can see, touch, smell, hear, and then move my thinking on. If it’s at night when I should be sleeping, I bring to mind the scene from my mindfulness bench, hear the waves, smell the sea, notice the colour of the sky, the sand and waves, and when I have that picture in my mind, I’m able to move my thinking on. 

Strangely, when I heard the news about the cancelled Garden Party, I tried to bring to mind my memory of the only other time I have been inside Buckingham Place. The occasion was my father receiving his MBE from the Queen. I can only actually remember the sheer luxury of the toilets and the fact I was proudly wearing my Greenpeace lapel badge in silent protest. However, I’m almost certain the Queen won’t remember me though. Perhaps I will be able to make an impression next year…. 

Nurses may be the heroes of the day, but we will also need them for tomorrow

Way back in March 1981, I happened to be out, driving on my way to milk my father-in-law’s herd of Welsh Black cows, when I saw a milk tanker drive off the road and plunge 20 feet into a fast-flowing river. It happened in the blink of an eye and for a moment I didn’t quite believe what I had seen. I parked my car and scrambled down the banking to the water’s edge to look at the lorry and see if I could help the driver. He wasn’t in his cab; the windscreen was completely gone. Looking up, I saw him wedged in a tree in the middle of the river.

Now I hate water. I can swim, in a swimming pool, but only if my feet can touch the bottom. I don’t like being on a boat, and would never contemplate taking a cruise. The tanker driver didn’t appear to be moving or responding to my shouts. I scrambled back up the bank and fetched a rope from my car. Using this, I was able to tie one end to a tree on the bank and wade out to the driver holding onto the rope. He was just about conscious, but clearly in shock. By the time I had reached him, other folk had appeared and together we were able to get the driver back to the bank, and with the help of the police and fire brigade, get him back to the road. He was taken off in an ambulance, and after giving my name and details to the police, I drove off to milk the cows.

The driver survived, but I never got to meet him again. A couple of months later, I received a letter from the Royal Humane Society to say that, at a recent meeting of their Board, the tanker incident had been discussed and I was to be awarded a Certificate of Commendation for my praiseworthy actions. This Royal society was founded by William Hawes and Thomas Cogan, both doctors who were keen to promote the techniques of resuscitation. Ironically perhaps, given my dislike of water, it’s original purpose was to recognise those who had rescued people who had apparently drowned or were in danger of drowning, but essentially, it rewarded those who put their own lives in danger in trying to save others.

I duly attended a lovely award ceremony, received my certificate and have been embarrassed by the award ever since. I don’t think my life was ever really in any danger and other people helped in the rescue. I was not, by any stretch of the meaning of the word, a hero. I thought about this incident last week, and it came to mind while reading the words of Ruth May, Chief Nursing Officer for England. She had been speaking at St Thomas’ Hospital, in London at an event to recognise International Nurses Day, which this year also marked the 200th anniversary of Florence Nightingale’s birth.

Indeed, 2020 had been designated the Year of the Nurse and Midwife by the World Health Organisation. Many events had been planned across the world to celebrate and honour the contribution nurses and midwives have made and continue to make to the lives of others. Then Covid19 arrived and sadly much of these celebrations had to be shelved.

It was something Ruth May said about nurses working in the pandemic that struck a chord with me, and made me think of that day all those years ago. She made the point that nurses are ‘expert professionals, not heroes’ whilst also acknowledging the critical work ‘that nurses deliver day in and day out’. I’ve had a growing sense that ‘heroes’ was the wrong term to use, but have struggled to articulate why I thought that might be the case. Indeed, back in early April this year, I wrote a blog that looked at those who might be considered ‘heroes’ today, which included many healthcare professionals. Unlike Ruth May, I’m not sure I even qualify in having an opinion. My contribution to dealing with the current pandemic is neither on the frontline, nor in ICU, nor in Covid19 positive wards or care homes. I sit in the relative safety of my home office, using virtual meetings and conversations in making my contribution.

However, Ruth’s words really resonated with my thinking. What she said, in full, was: ‘No, we’re not heroes – we are expert professionals who are doing our jobs and providing skilled, compassionate care, and nurses and midwives across England should be very proud of themselves right now’. There are, of course, countless examples of how people have gone the extra mile, have done extraordinary things to ensure services are kept running and people are cared for in the best possible way – each and all of these should rightfully be celebrated and acknowledged. The struggle that I have possibly stems from the use of the ‘war’-based narrative in the current political and contemporary public messaging. Unlike those in the armed forces, no healthcare worker agreed to risk their lives to do their job. Yet, to date, over 173 health care workers from all professions and backgrounds have died from Covid 19. The actual number is probably a lot higher.

But there may be something we can learn from the military and how wars are fought and the way we look after the mental health of our armed forces. Last week, I took part in a webinar that saw ProfessorSir Simon Wessely outlining his thoughts about the mental health of healthcare staff dealing with the Covid19 pandemic. He is undoubtedly one of the world’s leading authorities on the nature and treatment of medically-unexplained symptoms and syndromes, clinical epidemiology and military health. In one of his recent papers, he notes how the military have for hundreds of years, recognised the critical role junior leaders have in supporting the capability of troops to fight, even in the most stressful of situations. He argues that managers in the NHS, particularly those in supervisory positions, need to also acknowledge the challenges many staff are facing and find simple ways to minimise the psychological risks that will be present, as people continue to try and deal with the unremitting demands of the pandemic.

And there may be some early green shoots which demonstrate that this might be happening. Sir Simon noted that early results from staff surveys are showing that many healthcare professionals are doing very well. Whilst the consistent availability of appropriate PPE is still the single biggest factor in reducing their anxiety and anger, many are finding they are benefitting from the heightened supervision and effective team working that is becoming the new normal. In a strange way Ruth May is absolutely right. Our nurses are not so much heroes, as professionals who have the skills, knowledge, compassion and resilience to keep coming back and doing what they first chose to do in becoming a nurse, and in so doing, embrace all that being a nurse might entail. However, it will take more than a weekly gratitude clap to ensure they continue to be able to do so in the future. 

           

Streets filled with love and care: 75 Years remembered

Well, all the planning to celebrate the 75^th anniversary of Victory in Europe Day came to fruition on Friday. Our street, which I think might more properly be called a road, was decorated with red, white and blue bunting, Union Jacks and balloons. And then there were the scarecrows.  During the planning stage of the celebrations, I was both enthusiastic about the scarecrow idea, and also slightly concerned that in this day and age, anyone would be bothered to make one. I needn’t have worried.

People up and down the street got into the spirit of scarecrow making. These weren’t those old jackets and trousers stuffed with straw and placed in a field to scare off birds from growing crops – no these were works of art. There was a Winston Churchill, various military personnel, a nurse, a rather strange ET (complete with bike) figure, land girls and many more. Ours had a chicken theme (what else you might ask?), and although she looked slightly overweight, I was proud of her. There was a competition for the best scarecrow, and the winner was an absolutely brilliant cheeky land girl.

It was great fun; everyone had set up beautifully-decorated tables and chairs on their front gardens, and during the day we had afternoon tea parties, the odd glass of G&T and or bubbles, there was food, music playing, we even had a Zoom enabled game of bingo and a singalong to some old war time classics. Physical distancing was maintained, but we were able to walk up and down the road looking at the scarecrows, garden decorations and just to stop and say hello. Of course, we didn’t lose sight of what we were celebrating, and like many other people across the UK, we all observed two minutes’ silence at 11am to remember all those who had lost their lives, so we could enjoy the freedoms we have today. The day seemed a long way away from the constant coverage of the Covid19 pandemic.

I was aware that there will have been a great number of people who, because of their work, would not have been able to be outside in the sunshine and join in the celebrations. For all those on this new front line, and all those other people who keep us fed, safe and cared for, I say once again, a big THANK YOU. Just as there have been many changes to our lives since the first VE Day, so this new challenge to our sense of what is normal has and I think will continue to have, an impact on our lives. I chair the Wrightinton, Wigan and Leigh NHS Trust Pandemic Assurance Committee, and the discussions we have there indicate to me that Covid19 is not going away anytime soon. Like other hospitals and healthcare services, we are being asked to develop new ways of working for the future and to do so right across the spectrum of service provision.

This will mean continuing to keep the gains already made - remote consultations, new referral pathways, much more self-help being made available using new digital technology, including tracking and tracing. However, it will also mean developing further a system-wide approach to service management. It remains to be seen what the impact might be for individual NHS Foundation Trusts, but the central ‘command and control’ approach is likely to continue for some time yet. NHS England’s regional offices appear to be the bodies exercising this command and control management.

In some ways this makes a lot of sense. Whilst hoping that we won’t see subsequent Covid19 waves and peaks, experience of previous pandemics has told us this is likely to happen. System-wide capacity planning will need to go on for some time yet, if we are to be able to respond quickly and effectively to any future peaks. Likewise, the funding arrangements underpinning service provision are likely to remain in place until the end of this financial year. This is something that will also impact on the use of capital spends, as this will also need to be seen in a system-wide way. Local plans might be shelved in the taking of decisions to use resources for the greater good of an economy.

Both hospital and out of hospital care will need to be focused on Covid and non-Covid patients. This might mean developing the notion previously outlined in the NHS Long Term Plan of having ‘hot’ and ‘cold’ hospitals. In the plan this referred to urgent and planned care. I strongly suspect we will be looking at something similar being developed in the very near future, perhaps along the lines of developing clean and Covid19 pathways, with these being delivered in specified services. Clearly regaining some traction on rebuilding the NHS elective capacity might be best served using this approach. In some places, developing services along these lines might be easier to do than in others. I would be looking at London as an early adopter for such developments. There is already ‘group’ working (bringing individual hospitals into one centrally-managed group) in London and if one looks at the track record of the current NHSE London Regional Director, it’s easy to imagine a rapid spread of this approach.

All of this will require new forms of governance and oversight. I imagine that the Care Quality Commission will need to adopt a systems approach to their work and not simply look at individual service providers. Likewise, the Royal Colleges and other regulatory bodies will need to re-think their approach to education, training and professional standards.

Finally, it is clear from our experience of the Covid19 pandemic so far, that people living in areas of high deprivation are the one that have suffered the most during this pandemic. They are populations that also have a high incidence of chronic and long term health conditions, raising the risk even higher. So the new ways of working will need to address the inequalities across society in a way not yet seen in the UK’s recent past. And someone who has seen many changes to life in the UK since the original VE Day, the Queen, captured the zeitgeist perfectly on Friday as she made a speech full of hope and determination. She said: ‘our streets are not empty; they are filled with the love and care we have for each other’. Judging by the response I saw on Friday; I have to agree with her!

Chips with everything: including tracking the pandemic

As regular readers of this blog will know, as an academic, I have been both fortunate and privileged to have travelled around the world as part of my work. I have sometimes flippantly referred to these travels as ‘academic tourism’, but the reality is that more often than not such trips are hard work and exhausting. Now retired, I don’t have the same opportunities, although I was due to attend and present at a conference in Australia and one in Portugal this year, both of which have been postponed until next year because of Covid 19. I guess it’s unlikely I will now attend either. Life is different now and my enthusiasm for global travel is very much on the wane!

There are two places that I wish I had travelled to, which given a chance I might still do. The first is Israel and the second is South Korea. Indeed, we were planning on going to Israel for our honeymoon, as both J and I would so much like to see the various biblical sights of the Holy Land. But as our wedding has been postponed, the honeymoon planning has also come to a temporary stop.

I wanted to visit South Korea for entirely different reasons. Apart from the often magnificent scenery, much of which is mountains and rolling hills, I have long been intrigued by the history and culture of China, and Japan, and although I have been to both places, I’ve never had the opportunity to visit South Korea, which sits almost in between these two great countries. All three countries, China, Japan and South Korea have managed to preserve much of their heritage and culture, but have also been able to develop phenomenal industries, which are truly global in reach. South Korea is the 12th largest economy in the world, and the fifth largest exporter of goods, particularly technology, more of which later. It’s a very crowded country as the 55 million people tend to live mainly in large cities, due to largely uninhabitable mountains.

South Korea also has one of the best national health services in the world. Like the British NHS, it is free at the point of access. Its hospitals are extremely well equipped, with impressive doctor/patient ratios and beds per head of population. Interestingly, the health care system provides both Western medicine, and the more traditional oriental treatments. Many of the older population live with chronic illness brought about by the environmental pollution that was the consequence of earlier industrialisation, not to mention a culture where smoking was commonplace. Like the NHS, the South Korean health service is very much focused on treatment rather than health promotion and prevention, which in my mind makes their approach to the pandemic even more remarkable.

You may well have noticed in those Ministerial daily briefings, a chart that shows the flat line representing South Korea’s pandemic experience. Last Thursday, South Korean officials announced there had been no new cases of Covid 19, and Antonio Guterres (Secretary General of the United Nations) noted that other nations might do well to learn from how South Koreans had dealt with the pandemic. To date there have been a total of 247 deaths from the Coronavirus in South Korea. They have not introduced a lockdown.

South Korea had its first confirmed Covid 19 case back on January 20^th. The immediate focus was on testing the population. They were very soon testing 20,000 people per day, and able to rapidly identify those who were infected, but not necessarily displaying any symptoms. With reliable testing available, they were quickly able to adopt an extensive contact tracing strategy. In the UK we had to abandon this approach, as we had no reliable way of dealing with a growing and unmanageable amount of cases requiring contact tracking.  South Korea, on the other hand, not only asked people to record their own movements, using a smartphone app, but also used credit card transactions, CCTV and mobile phone tracing to monitor and track where people might have been.

It was a phenomenal piece of governmental intervention that will have Foucault turning in his grave. However, the intervention reflects the way in which new technologies, particularly digital technologies form the backbone of South Korea’s organisational, social and environmental way of life. Here in the UK, we are playing catch up with this approach, thanks both to population testing becoming more readily available and accessible, but also the announcement that 18,000 people will be deployed to track the movements of people testing positive for Covid 19. Like in South Korea, the general public will be asked to record their movements using a free automated tracking app. This app, when it becomes available is said to be able to record and track when users come into contact with each other. If one of these users develops Coronavirus symptoms, they will be expected to inform the NHS through the app. Such a disclosure will then automatically trigger an alert to other users advising them to either isolate or get tested.

Not everyone will want to download an app that they might view as the thin end of the wedge in governmental surveillance and possible control. It is estimated that for it to work, some 80% of the population with smartphones would have to sign up and use it. Personally, unlike the universal uptake in South Korea, I don’t think it will happen here in the UK. I was slightly worried, when this week, I was registered for my first NHS smart card. This microchipped card allows me to gain access to my payslip, mandatory training record and a wealth of other bits of information. But it’s a two way process of information exchange, and I took some time to read through how my data will be used. The information will also be available for 40 years after I stop using the card.

And from microchips to an infinitely tastier kind in the news last week. Food producers in Belgium, the world’s largest exporter of frozen chips, have asked that we all eat an extra portion of chips a week to help reduce a 750,000 ton potato surplus. Suits me, in the past, my favourite and oft eaten food of choice when I was travelling was chips and mayo!