Thursday April 15th
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 17th 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 18th.
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 Ab
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 16th 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 19th
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 25th 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 20th
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 21st
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 21st
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 22nd
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 23rd (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 24th 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 10th. 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 25th et seq.
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| Christchurch Priory - 900 years old and still going strong |
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| Beach Huts at Hengistbury Head |
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| The English springtime - wisteria at Wick Village |
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| "Just now the lilac is in bloom, all before my little room" |
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| Late evening looking towards Old Harry Rocks |
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| Old Harry |
