The Evening Hill Diaries: Corona Diary Part 5. Thursday April 16th to Friday April 24th

Thursday April 15^th

After a momentary rain shower the weather steadily brightens until it is just as lovely as every previous day of this lockdown. A colleague in a major London hospital tells me that Covid admissions have plateaued, but that they have a number of staff members in Intensive Care, which is upsetting. He is a cardiologist and they have noted far fewer ‘primaries’ (acute MI, or heart attack). These are patients with acutely blocked coronary arteries who need (primary) emergency angioplasty. This is borne out by Government figures today which show heart and cancer presentations are down – and this will result in considerable collateral morbidity due to the virus.

In the meantime, 861 new deaths are announced today bringing the total UK death toll (in hospital) to 13,729. The graphs still show linear increase in deaths, though hospital admissions due to Covid-19, particularly in London, have gone down.

It’s beautiful day and we enjoy a bike ride. On a bicycle, particularly on roads, the distancing from everybody else is excellent – surely one of the best ways of exercising but keeping one’s distance?

Like many, particularly those who have experience in medicine and medical statistics, I have been thinking hard about the UK approach and I have come to the reluctant conclusion that bad logistics, and an incorrect scientific approach have done us a disservice. The undoubted knowledge and the gravitas of Professor Chris Whitty and Sir Patrick Vallance have, I think, misled us in our thinking. They are not entirely to blame, presumably the entire COBR committee and/or the SAGE (Scientific Advisory Group for Emergencies) committee is culpable. The Government are not to blame apart from their poor logistical response. We now have a huge 4000 bed hospital – The Nightingale – in London without very many patients, and a dearth of other measures and strategies to control the outbreak.

We had a huge switch in emphasis when we stopped testing people outside hospital. In any epidemic, identifying those carrying the virus – even if minimally symptomatic – is the key. Failure to ramp up testing, and focussing on testing in hospital (when it’s fairly clear who are the Covid-19 patients) has meant that opportunities for ultra-strict quarantining and isolation have been lost. PPE, irrespective of what type has been worn, seems to have been ineffective in preventing front-line staff from being infected. There has been no real co-ordinated contact tracing and testing effort either. Contact tracing has in the past been the cornerstone of detection, prevention, and in other diseases (I recognise there is none in this disease), treatment. This approach worked well in controlling TB, and in preventing spread of STD (sexually transmitted diseases) and latterly, AIDS. Even though there was no treatment available for AIDS for some years, the PPE was obvious and instantly procurable – the condom! Failure to test and prevent in Covid-19 has been clearly evident in the case of patients discharged from hospital back to Care Homes without testing – and a rampant march of Covid-19 cases and death has been the result.

The august professors would no doubt point to the decline in admissions with Covid-19 as evidence that their strategy is working, but at the cost of somewhere north of 20,000 deaths (taking into account the excess mortality outside the hospitals), and no other policy than to ‘wait it out’. Other countries with better approaches, following what I have outlined above, have seen far fewer deaths (South Korea and Germany – it has emerged today that China is probably concealing the true extent of the mortality there).

Friday 17^th April

Hard for any readers to accept this, but I made no entry today – so busy! But the biggest change today was the weather. For a few hours this morning we had drenching rain which is good of course for most things, and certainly must have reduced footfall outside. The air has been cleared of the ghastly ‘yellow dust’ which residents of Poole and Bournemouth have to suffer at this time for year because of our predecessors’ strategy of planting pine trees throughout the area. Then they promoted the idea of rest, sea air, and the scent of the pines as a panacea for all manner of things, not least tuberculosis, which is almost certainly the reason Robert Louis Stevenson came here. When I spent a summer (1970!) working in upstate New York, at Saranac Lake, I discovered that poor RLS also spent time there – attracted by the famous TB sanatorium on the lake.

But RLS also came to mind too because the Film Club decided to watch the NT Live broadcast of Treasure Island. This was so dire we had to discontinue watching it. I thought things might turn bad when we were treated to some ‘on trend’ transgendering – both Jim Hawkins and Dr Livesey. I couldn’t understand why Jim’s mother had turned into her ‘Old Granny’. ‘Not so much of the old' was the rejoinder… Oh dear. I was forced to give the book an airing and show Lindsay the exquisite prose of the original. We therefore returned to The Crown (Liz and Phil not getting on so well and Suez in the offing). The film club had briefly met in the afternoon to watch ‘Those Magnificent Men in their Flying Machines.’ As Lindsay observed, the pictures that we thought wonderful in the past just don’t stand up to the test of time (for the most part). It’s cheesy, stilted, predictable, and not very funny. The best part is Ron Goodwin’s score. We turned it off to turn over to the Government’s Covid briefing. This was given by the calm and assured Alok Sharma, business secretary. The mantra does get a bit predictable, ‘Stay home; protect the NHS; Save lives.’ But as I’ve indicated above, I think they are being wrongly advised. Rigorous (and multiple if necessary) testing, contact tracing, complete isolation of both symptomatic and asymptomatic patients. I will write more tomorrow.

Saturday April 18^th.

I am writing more, it is today, and a continuation of the above. Slightly overcast, rain during the night queues round the block at Tesco’s and M&S when I walked up to Westbourne. Delivered a newspaper to a ‘locked down’ friend. Stood outside his window without him noticing while he played the Schubert A_b impromptu. Lovely. Only a few notes that escaped Schubert’s notice when he penned it in 1827.

There was a good discussion (for once) on TV news this morning. A fairly distinguished academic GP from Oxford, Trisha Greenhalgh, spoke to the proposition that we should all be wearing masks. Although the evidence is mixed, she had ultimately been swayed by the very impressive laser light imaging of droplets from sneezes and the distance they carry and felt they should be worn. However, an equally impressive doctor from Scotland (who I think was Jason Leitch, National Clinical Director) pointed out that if symptomatic (e.g. coughing and sneezing) one should not be outside at all and the safest barrier to prevent infection was one’s own front door. The evidence therefore indicates that staying home and washing one’s hands are the best preventive strategies.

There is an impressive paper from Hong Kong, showing how they responded early and firmly (sorry, Boris and the Team), and achieved far better control than we have.

See: nejm.org/doi/full/10.1056/NEJMc2009790. If the link doesn’t work search Dr Gabriel Leung, ‘From a sprint to a marathon in Hong Kong.’

Another paper that is worth reading is ‘Not a Perfect Storm – Covid-19 and the Importance of Language’, by Allan Brandt and Alyssa Botelho published April 16^th in the New England Journal of Medicine. They say:‘…many commentators have described this emerging pandemic as a “perfect storm” – a vastly overused characterization that evokes a sense of anomaly and unpredictability.’ ‘The repeated emergence of new zoonotic infections… … underscores the reality that global epidemics should be expected and their harms anticipated.’ Need I say more?

Finally, before it passes into forgotten episodes, it’s worth documenting a very heavy thread that emerged the other day from Twitter. Apparently, the Editor of the Economist alleged that Boris Johnson’s illness was much milder than reported, and that it had been a strategy to garner sympathy. Understandably there was an avalanche of criticism, many writing to say they had cancelled their subscription to The Economist.

Sunday April 19^th

Weather good again. Today’s review of Covid-19 deaths shows 596, down from the previous day of 888, but likely due to the weekend and fewer recorded deaths reaching the authorities. Total in-hospital deaths now 16,060. Lindsay has a school reunion by Zoom. The most striking report is from her friend Lynne in Long Island, NY. They are literally terrified. Friends seem to be dying all around them. They don’t go out. They have everything delivered. Even after delivery they leave everything on the porch for at least 24 hours to enhance virus dissolution.

There is much scientific discussion today, and interviews with a Professor of Vaccinology. But there are at least 70 groups worldwide working on a vaccine for coronavirus. There’s no good indication of who will win this race, and how implementation will happen. Another topic deals with antibodies in recovered patients. I have seen two diametrically opposed views. One states that old people do not produce antibodies as well as young people. Another seems to indicate that the reverse is the case – young recovered patients have low titres of anti-coronavirus antibody. An immunologist suggests that this may be because young people produce virus-specific small lymphocyte killer cells rather than free antibodies.

Slight disappointment on the TV this morning where David Attenborough is being interviewed by Andrew Marr, when he refers to previous pandemics and says that the ‘Great Plague’ was caused by a virus. (It is of course a bacterium, Pasteurella pestis, since reclassified as Yersinia pestis.) David Attenborough is of course widely regarded as omniscient.

The film club reconvened, but one member seceded. The event was the 25^th Anniversary celebration of Phantom of the Opera, recorded in 2011. Lindsay didn’t watch it, having very special memories of having camped on the pavement in the West End to see Michael Crawford in the original cast. I have never seen it; I usually avoid musicals, but it was terrific. I read that the sinister organ riff was allegedly ripped off from a Pink Floyd number; not the first time that Sir A L Webber has been accused of plagiarism, though he has defended actions in the past successfully. Anyway, it was great.

Walk on Parkstone Golf Course and another The Crown this evening.

Monday April 20^th

I’m struck when reading my first post how much like Edgar Allan Poe’s Masque of the Red Death we were. We gaily went on our way, ignoring the warning signals, when suddenly, the Red Death was upon us. Not so inappropriate a name for a plague originating from the People’s Republic of China.

The weather is back to a high pressure system, but with rather cold north-easterly winds. Out of the wind it is pleasant enough to sunbathe in the garden. The death toll is again reduced, 449 for the last day (total now 16,509). Late last week daily mortality was in the 800s, but the last two days have been 569 and 449. Possibly encouraging. But there doesn’t seem to be any strategy other than ‘social distancing’. Professor Richard Peto is one of the statisticians interviewed on the Today programme (much better than our TV, which as mentioned before, focuses on human interest stories, and of course in the time of Corona there are plenty of those). Peto has a brain the size of a planet and is a highly original thinker. Unfortunately the discussion is cut short, but he makes the point that a snapshot of testing is no good – multiple tests in the same people will be necessary. He also points out that the situation is ideal for experimental sampling, focused perhaps on one town, to get real facts about the spread.

Otherwise, it’s a circular walk through Bournemouth Gardens and along the beach, and more of the Crown.

Finally, an excellent and funny article by Michael Hogan in the Telegraph asks ‘Parlez-vous corona? Brush up your “lockdown lingo”…’ An example:

Quarantinis: Experimental cocktails mixed from whatever random items you have left in the house. To be sipped at “locktail hour”, which gets earlier with each week.

I will try and slip some of these into future blogs…

Tuesday April 21^st

Can’t sleep. Up at 0500 doing useful jobs. Supergluing Lindsay’s magnetic disc back into a magnetic earring. Playing guitar. Writing blog. Reading scary article in the Economist about how the 21^st Century is going to be China’s century and emphatically not Britain/USA.

The day sweeps past as others seem to – at record speed. I’m successful in under-achieving in the under-achievements I want to tackle. Another beautiful day.

Early evening, we drive a short distance north of here, then walk; down a lane we have discovered where the wild garlic grows – what is it Shakespeare says about ‘I know a bank where the wild thyme grows…’? No ‘sweet-musk roses and with eglantine’ here. What is eglantine? But it is shady enough and moist enough for wild garlic to flourish. We walk on to the Stour Valley path. It is a lovely evening. At a small weir a swan upends itself into the turbulent stream, while a little egret watches from a perch in a tree. I have never seen an egret in a tree before.

H.M. The Queen is 94 today. It passes without the usual gun salute.

Wednesday April 22^nd

Another beautiful day. This weather seems something of a penance; a whimsical game that the Good Lord is playing with us to reward us for our hubris. (I should acknowledge that I have very little to no confidence that any God is really taking an interest in us – whether Allah, Zoroaster, Jehovah, Jesus’ Dad, or any of the thousands of deities that seem to complicate Hinduism. I refer you to Richard Dawkins). In this I am obviously unlike Donald Trump’s new press secretary who is mentioned in dispatches this morning about Trump’s new blanket ban on immigration edict. Having noted her name, Kayleigh McEnany, which seemed improbable enough [the only Kayleigh I know is Peter Kay’s colleague in ‘Car Share.’], I had to look her up. An impressive CV, fabulous figure, blonde, young, similar looking sister, you know that All-American cheerleader style – she looks very much the Donald’s type. On Twitter, she seems to be much given to many Christian messages of cheer, especially over Easter. How can anybody that intelligent be persuaded of the merits of Jesus’ Dad over any one other of the numerous deities on offer? Dawkins makes a plausible case for a correlation between intelligence and Atheism, but that might be taking it a bit far.) To return to the weather. I think I should precede every diary entry with just ‘ABD’ instead of another beautiful day.

Surprisingly, I have something in my diary for today. Having lost a bit of filling from a tooth a few weeks ago and tried to get an emergency repair kit, unsuccessfully, my dentist meets me at 1pm in his car park and gives me the stuff. Tricky putting it in yourself, especially into a lingual lower left seven cavity. The other main activity in the morning is washing the garlic leaves in a large cold bath and then whizzing them round in a salad spinner. The end result is an excellent pesto, with olive oil, pine nuts, and grated parmesan.

Evening finds us back walking in North Bournemouth, by the banks of the Stour. Yesterday evening’s egret has now taken the place of the swan in the weir.

Depressing suggestions that social distancing could last a year come from the advisers in this evening’s briefing. This brings on the feelings of the ‘Coronacoaster’ – ‘the ups and downs of your mood during the pandemic. You’re loving lockdown one minute but suddenly weepy with anxiety the next.’

(Please note I am trying to utilise at least one element of Michael Hogan’s Lockdown Lingo article each day, and I may not specifically reference him in the future).

Last act of the evening. The Crown (of course). That slippery so-and-so HRH The Duke of Windsor and his Nazi sympathies. I had never heard of the Marburg Files.

Thursday April 23^rd (St George’s Day)

ABD (Another Beautiful Day)

Wild garlic soup now available. Still, fortunately for us, no ‘Miley’ or ‘Billy Ray’ (Cyrus = Virus).

I break out a bar of soap in the bathroom which is embossed with the name of a lovely hotel we stayed in in Oman. People criticize the removal of such items from one’s hotel, but on this occasion it reinforces a wish to get back there as soon as possible (!) and is therefore highly successful advertising. Part of me wonders whether we will ever get back there, or even abroad, ever again… A sense of ennui and the mild depression which indicates that one’s life (of which there can’t be too much left), is slipping by. It would be nice to jump on a boat, take a picnic around Poole Harbour to the back of Brownsea Island and sit in the sun with a glass of chilled white wine…

In the death notices yesterday was an entry of the passing of Professor Tom Prankerd. He was my first chief in my first housejob at UCH, and highly influential to my career. He had a distinguished career in Haematology, but was also a good physician, as many haematologists were in the distant past. His original research, carried out in the 1950s, was on the role of the spleen in removing senescent red blood cells. When I returned from working in the USA to start my clinical training, he allowed me to continue my research in his laboratory. It concerned the phagocytosis (cells ‘eating’ objects or other cells) by monocytes isolated from peripheral blood, and the reasons this might occur. Sadly, it was rapidly superseded by more sophisticated isolation techniques and I went back to studying clinical medicine. It seemed inevitable that I should work for him as House Physician. This was a traumatic job, looking after people, many very young, with leukaemias and lymphomas. After a while, I was having nightmares, of a vague threatening kind – not necessarily involving my patients. In addition, like most of us, I was ‘living in’ the medical staff residence, and living work every day and all day. (Nowadays people would use the ghastly term – 24/7). A school friend rang me and said that we should get out together and go to the theatre. He had a brilliant idea: both of us had a crush on Judy Geeson, the actress. ‘Let’s go and see her on stage; she’s in the new RSC production of Titus Andronicus’. Great idea. Neither of us knew anything about the play. But T.A. is the bloodiest of Shakespeare’s plays, and there is doubt that he actually wrote all of it. Judy played Lavinia, who was raped and had her limbs and tongue cut off in Act 1, and thereafter crawled around mumbling meaninglessly. It was a relief to get back to leukaemias. I see from my programme that a younger Patrick Stewart was in the production. I also see from feminist analyses of the play that Lavinia is an ‘enduring presence, key to the play, and a reminder of woman as victim.’ On the other hand I believe that her presence is analogous to the ghost in Hamlet – a spur to revenge in a classic Jacobean revenge play.

Tom Prankerd was a very humane character, with a wide knowledge of medicine, and later became Dean of the medical school. After I had finished my surgical job at Basingstoke District Hospital, I was for a while an SHO at the Royal Marsden Hospital, and went to see him back at UCH for some career advice. I turned up near the end of his lymphoma clinic, and as the last patient left I went into his consulting room to find him looking drained and tired. ‘Don’t go into the Cancer business, my boy,’ was the main advice I remember from that interview. He, and a protégé of his, John Fletcher, who I worked for in Nottingham, were some of the last general physician haematologists. After this, haematologists had no beds and no general medicine input, until the era of intensive leukaemia therapies and bone marrow transplantation.

Tom had an occasional wicked sense of humour. During my second year I was desperately ill with glandular fever (‘mono’). I spent a month in UCH as a patient, on the ward where I would eventually be HP. Eventually, a secondary streptococcal throat infection was diagnosed and the intensely painful intramuscular benzylpenicillin injections were commenced. Prior to this, and with an impressive high swinging fever visible on the chart at the end of the bed, Tom Prankerd and his huge entourage of ward round attendees stopped briefly at the end of my bed. ‘What’s the matter, Andy?’ he asked in his slightly high-pitched voice. As I croaked out what my diagnosis was, he said loudly; ‘Oh, is that all? Looked like G.C. to me old boy!’ (G.C. is polite medical terminology for gonococcus, the cause of gonorrhoea). Once, during a ward round, he asked me to check the optic fundus of a patient. I was good at fundoscopy – all medical students at that time were required to buy an ophthalmoscope and to use it on every patient. Those days are gone now. He became impatient; I think he wanted to know if there were retinal haemorrhages in a patient with a very low platelet count. ‘Hurry up, Andy, you’re wobbling about all over the place.’ ‘No sir’, I replied. 'I am constant as the northern star, of whose true-fixed and resting quality there is no fellow in the firmament.’ ‘Bloody Hell!’ Came the reply; ‘This boy knows his Shakespeare.’ I became the 'Shakespeare Wallah', and was asked frequently thereafter whether the bard would have had anything to say in this circumstance. I couldn’t let him know that Julius Caesar had been my ‘O’ level play, and that I more or less knew it by heart – but that was the only one I knew, apart possibly from Hamlet which was the school play a little later on. I wish I had been the famous surgeon who produced what was probably the most apposite and witty Shakespearean quotation in the history of medicine: stopping to inspect a patient whose circumcision had been not that expertly carried out by the registrar the day before, he observed: ‘There is a destiny that shapes our ends, rough-hew them how we will.’

Tragedy struck in Tom Prankerd’s later life when two of his children, visiting their brother in Rhodesia, were killed by bandits who stole their car. Many years later I got to know him again in his retirement in Milton Abbas, Dorset, and he was briefly a patient of mine with a cardiac issue before he moved to Stinsford and I transferred his care to the new cardiologist in Dorchester. So, it is with sadness and respect that I remember him…

Friday 24^th April

ABD.

We walked on the sea front promenade last night. I feel twitchy about this because there are too many people for my liking. Bicycles whizz past with no warning. One idiot came right between Lindsay and I, brushing our sleeves. In addition there are lots of ‘coronarunners’, passing close by, breathing so heavily that the extra oomph in their exhalations could propel an unfriendly virus much further than if they were gently walking. These people and the cyclists are now known as ‘Space Invaders.’

Today a bicycle ride up through north Bournemouth to the Stour Valley way and along the trails to Throop, Holdenhurst, Christchurch, and Hengistbury Head. I will leave you with some images of England in springtime. One in particular is poignant – the Priory at Christchurch, which has been standing for over 900 years. What events have passed since it was built? It has seen everything.

Passing over the footbridge with the ‘Welcome to Bournemouth’ sign over it, I’m struck by how many cars are racing into Bournemouth at 1.20pm on a Friday afternoon. Seems like the traffic figures from the Government will take a jump.

Deaths from Covid-19 are slightly up compared to yesterday, but prior to that they had fallen for three days in a row. 'Confirmed cases' remains a flattened curve, and 'daily cases' has shown a substantial drop. It looks like peak daily death rate was reached on April 10^th. On CNN this morning, a US medical epidemiologist was lamenting how the USA had missed the boat at a time when case diagnosis, strict quarantine, testing and contact tracing had been possible, the United States, much like Britain, had been dozing, or in the words of some commentators ‘Sleepwalking into a Crisis.’ As the epidemiologist said, 'We are now left with the extremely blunt instrument of shutdown and social distancing.'

Only possible bright news on the horizon is that socially-distanced sports, like angling, golf, and bowls (lawn bowls for the US readers), might be ‘unlocked’ first.

Before the images, there is an interesting paper published online today in the New England Journal of Medicine. The accompanying editorial will give you all the information you need to know:

Asymptomatic Transmission, the Achilles’ Heel of Current Strategies to Control Covid-19, by Monica Gandhi, Deborah Okoe, and Diane Havlir.

They analyse why Covid-19 (SARS-CoV-2) has been such a successful pathogen, infecting approximately 2.6 million people, whereas the original SARS in 2003, was limited to about 8000 cases. The reason lies in the RNA virus multiplication and shedding, which in the current outbreak is from the upper respiratory tract, and in SARS-CoV-1 was in the lower respiratory tract, and therefore much less amenable to being coughed or sneezed out into the atmosphere and onto other people. Testing of asymptomatic personnel is therefore essential to prevent spread – AND WE ARE NOT DOING THIS!

Here’s to a better April 25^th et seq.