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Is the cure worse than the disease?



What effect has Covid-19 had on you this year? Perhaps you’ve been unwell, or lost a loved one. Whilst I don’t know if the virus has affected you directly or not, there is one fact I can be certain of: lockdown measures will have – from small matters like cancelled holidays, to more significant ones such as an inability to see family overseas. Perhaps you’ve been unable to visit a relative in a care home, or had a loved one’s funeral or wedding disrupted. So many human connections have been fractured.

It’s important to question whether lockdown, as an instrument to control Covid, may now be causing more damage to our society than the virus itself. The issues outlined above may sound small and inconsequential. Yet, multiplied a million times over across our population, and coupled with the deep recession we’ve plunged the economy into, our country will undoubtedly feel the effects of lockdown measures for many years to come. Our children will bear the brunt of the Government’s expenditure and the financial damage done to businesses. 

The public services they use will be diminished. Their job prospects will be hampered.  The cost of their education will be greater. They’ll be more heavily taxed. Their pension ages will be pushed back. Increased rates of poverty will reduce life expectancy, from what it would otherwise have been. The lives of the next generation will be made more difficult as a result of the decisions made this year.

We now know that the majority of Covid deaths will occur in the elderly, or otherwise infirm. Many of these deaths would occur in the next year or two, even if they did not occur as a result of the coronavirus. In short, preventing these deaths will save comparatively few quality adjusted life years. As long as the NHS is not overwhelmed, the deaths from Covid are not going to be anywhere near as catastrophic as we first believed.

As GPs, we have a unique window into society. In a poor outcome, where 120,000 patients died this year from Covid, a GP at a 10,000 patient practice would on average lose 18 patients, with a median age of 82. This is sad, and distressing for those families affected. But how many more of our patients will have lost jobs, had businesses destroyed, missed months of education, or felt isolated – even suicidal? 

How many new mums have lost access to crucial support at toddler groups? How many of our elderly are no longer able to attend lunch clubs or coffee mornings? Many of my vulnerable patients are locking themselves in their homes, and haven’t been out since March. I speak to teenagers and young people who are anxious and depressed, despairing at what the future holds for them. How much mental illness are we storing up for the future?

We’re urged that Covid must be controlled at all costs. But what depth of despair, financial ruin, and damage to the rest of the NHS (having universally gone remote), are we happy to accept? I’m now far more worried about the health effects of our response to Covid, than about the virus itself. And what about our liberties? Earlier this year, it was technically illegal to sit on a park bench, or to leave the house with the purpose of buying DIY equipment. It’s still illegal for me to drive to my parents-in-law’s house in Wales. If a friend was distressed, it would be against the rules to give them a hug. How much control over every aspect of our lives should the Government have? This feels too much.

Our society and Government need to realise that we cannot save every life (after all, none of us is immortal). Rather, we need to lead the best lives we can in the time we have, while ensuring we do not unduly harm those around us.

Going forward, we will need to reclaim the freedom to hug, to dance at weddings, to cry together at funerals, to kiss behind bike sheds, to attend theatre productions or festivals. These activities provide joy, excitement, and togetherness. We need to prioritise our return to a collective society, where people meet, socialise and support one another again. After all, it’s much easier to close things down, than it will be to reopen them. When can we say that it’s 100% safe for parents and children to attend a toddler group? Never. Indeed, it was never completely safe, as there have always been infectious diseases. Still, such groups remain vital to our society, and national wellbeing.

Health isn’t just the absence of Covid, and life isn’t just the absence of ill-health.  If we continue to believe these myths, further lockdowns will make us all sicker and sadder.

Dr Katie Musgrave is a newly-qualified GP in Plymouth and quality improvement fellow for the South West

READERS' COMMENTS [14]

Edmund Willis 24 November, 2020 7:46 pm

‘Those who die of Covid are very near the end of life and would have died anyway in the next 1-2 years. ‘
Sorry but you are well outside your area of expertise. There was a whole bbc radio 4 programme on this several months ago with Tim Harford from more or less that clearly blew this sort of nonsense out of the water.
Yes lockdowns have problems but the alternatives are worse. Look at the Denmark v Sweden comparison for example

Colin Fitzpatrick 24 November, 2020 8:21 pm

“How a society treats its most vulnerable is always the measure of its humanity.” You will excuse me if I beg to differ. I was one of the few GPs who visited all of the worst affected care homes in our area during the first wave. It was the worst experience of my 36 years as a doctor. I saw frail, elderly people dying a lonely, undignified death. In some homes about a third of the population died in this way. Staff were traumatised and frequently in tears as they saw the patients they had cared for for many years and whom they saw as friends dying en masse. I was powerless. The only thing which would save these patients was intensive supportive nursing care. I accept that many of these patients would probably die in the next few years but surely after a lifetime of service (many were wartime generation and many had fought for their country) they deserve a good death and not to pass away unnoticed and lonely in an overstressed care home? Dr Musgrave is rightly concerned about the impact of lockdown on our society, but that is due to incompetent government with their on/off approach (stay at home, no, go to restaurants, etc). Look at countries with competent governments and see how they fare. I am sorry but if staying in and watching Netflix is the only way left to defeat the virus, I’m off to watch The Crown.

David Taylor 25 November, 2020 8:46 am

I agree with the above sentiments. It is a difficult balance, and I fully understand the difficulties within care homes and elderly patients suffering. However the issues surrounding people losing of livelihoods, the poverty gap widening, increased isolation due to lockdown not to mention increased deaths from other causes due to changes in healthcare provision should not be ignored. I am increasingly concerned that young people especially those from already impoverished backgrounds are making sacrifices that will not be apparent for many years and they may never recover from. Of course it is tragic that so many people in care homes died and where I work we have one of the highest care home populations and many died, however currently these patients still can’t see their families until they are on the death bed. And given the life expectancy of these patients many of them have gone since March without direct contact with their loved ones before dying. This to me is unacceptable. What is the point of ‘saving’ these lives if you take away the only thing that gives many of them joy (seeing loved ones).
I supported the first lockdown but this second one is something I simply could not get behind, especially as the data showed that the Tier 3 restrictions were starting to slow the spread. The damage to the most vulnerable in society has been enormous and something that many may never recover from and it is something we will be seeing for the rest of our careers.

Finola ONeill 25 November, 2020 10:03 am

Dr Musgrave. I don’t know why we are still having this discussion. The lack of comprehension baffles me. There is not an alternative to lockdowns apart from better containing the disease through Test and Trace and shutting borders early. What is it that you think is the alternative? We don’t lockdown, deaths go up, we have people dying and their bodies in the streets removed by police as in some Latin American countries where they couldn’t contain the virus or as per New York where the bodies are in freezer trucks still outside tent hospitals since April. Have you been watching TV this year. You either lockdown and stem the deaths to some extent or you don’t and they pile up. It is not just the very elderly and the fact you even think that would make it acceptable is horrifying. The NHS was overwhelmed first wave. ICU nurses in some areas were up to 1:8 rations from the usual 1:1. That will have affected outcomes. And once the NHS is fully overwhelmed you can save the children with sepsis, young RTA traumas, etc, etc. But that’s irrelevant. Those lives are not worth more just because they are young, the fact I have to make that argument to you makes me worry about your understanding of our inherent respect for our patient’s, all of them, without qualification . Lockdowns happen when you have no other choices. The countries that didn’t have to have them as severely, for as long, or at all managed the “close external borders, push Test and trace” early. If I were you I would not publish this kind of opinion because it doesn’t sit well with me as a doctor either in terms of knowledge and understanding or in terms of integrity and respect for our patients, colleagues and our profession.

Michael Mullineux 25 November, 2020 11:29 am

Finola ONeill – Dr Musgrave is perfectly entitled to publish her opinion which serves to open up debate. The fact that you do not agree does not invalidate her opinion just as those that disagree with you should not seek to supress yours. She raises perfectly valid concerns about liberty and personal freedoms with repeated lockdowns and the unintended consequences thereof and I for one would commend her for that.

David Church 25 November, 2020 11:37 am

Katie, I’m sorry, but you are outside your area of knowledge and have gotten a lot of this completely wrong.
70,000 excess deaths from Covid so far, plus 30-40,000 (estimated) from non-covid causes adversely affected by hospital service closures, which could have been minimised by a stricter isolation and prevention strategy.
On top, there are estimated 20% of cases lasting over 4 weeks with persisting malaise and reduced activity levels – ie not normal.
But about 10% of cases, SO FAR, have developed ‘long covid’ which is lasting over 12 weeks, with generalised debility and morbidity, seriously adversely affecting working potential, and potential for recovery, as well as blocking up NHS resources (not the patients’ fault, of course, but Government is definitiely to blame!).
it is NOT a ‘minor illness’ like a mild flu; it is like a very severe flu!
You will gain experience as a GP in dealing with this, gradually, but you will lose many friends along the way, who will die of it, or of consequences.

Douglas Callow 26 November, 2020 4:50 pm

oh if it were an easy binary choice.. it is of course not so simple
HMG have through inaction nepotism and some pretty awful leadership massively inflated the cost both in human and fiscal terms thats spot on and hopefully at some point they will be held to account
The T cell storm through bad luck low immunity/faulty immunity no immunity is causing the problem
Ahead of an effective vaccine the holy grail and game changer would be some way at a population level of identifying immunological susceptibility and an effective treatment until then we are stuck with all the frailties around testing and various degrees of lockdown

Matthew Jones 27 November, 2020 11:53 am

The irony must have been lost on those who are telling the author to wind her neck in as she is not an expert on the subject… only to themselves choose a few selective statistics to try to back the opposing view.

I don’t agree with questioning the authors integrity after she highlights the oncoming catastrophic consequences of lockdown. I think it’s absolutely essential to ask what the actual “cost” of this extreme intervention is – financial/social/psychological.

Regardless, I think Doctors are in a poor position to have hypothetical debates about economic hardship. Were the medical profession to collapse – each of us losing our jobs – requiring us to give up our medical license and retrain in something totally unrelated – on minimum wage – our perspective may be different – and perhaps more valuable to the debate.

Victoria Cleak 27 November, 2020 11:30 pm

There is definitely an issue with preserving life at any cost, even if that is quality of life and long term economic catastrophe. I think the balance isn’t right currently and those friends of the government seem to be gaining significantly financially from it. Seems there is a magic money tree after all.

Giles Elrlngton 28 November, 2020 10:11 am

The binary “lockdown v no lockdown” choice is incorrect. Look at how Taiwan coped with Covid.

Their success appears to have arisen form early border controls. Currently over 6 months with no new cases.

Taiwan’s population is about half that of the UK but they made the most of their island status as did New Zealand.

Our government makes much of our separation from Europe but sadly this otherwise pervasive dogma went astray in relation to Covid.

Andrew Bamji 28 November, 2020 12:42 pm

I regret that a number of the comments above indicate a lack of understanding that they themselves have criticised in others.

Let’s get some facts clear.

The number of excess deaths overall is relatively small, except for the initial peak, and this excess is heavily elderly-predominant. Part of the reason for this is that care home residents were not properly protected, either from infected patients being discharged from hospitals back to home, or from peripatetic staff spreading the virus about. Yes, there are deaths among the younger age groups, but not a lot. The question of whether people would have died anyway at some point post-peak is partly answered by the fact that deaths went below average during July and August, reflecting the likelihood that deaths were simply brought forward.

Initially no-one was at all clear what the virus was doing. Gradually it was understood that the serious illness known as Covid-19 was largely due to the development of a cytokine storm. The virus may be new but cytokine storms are not. They can be stopped, or mitigated, by early treatment – hence the suggestion that pulse oximeters be widely distributed so that significant falls in O2 saturation – an early sign of trouble – can be tracked, and if a fall to <90% is seen, dealt with by further investigation of an inflammatory flare (hence CRP, D-Dimer, fibrinogen etc). Steroids work. So do immune modulators such as interleukin blockers (anakinra and tocilizuma) and JAK inhibitors. The significant systemic disease is a combination of a vasculitis and a coagulation disorder. Steroids and low molecular weight heparin will stop this.

There are protocols out there (even the BMJ now has one, though it's not very detailed). Stopping the cytokine storm and its systemic complications will almost certainly reduce the risk of so-called "Long Covid" – which, if any of you have had infectious mononucleosis will know, is not a unique phenomenon in Covid-19. My post-IM syndrome lasted about 2 years.

The Far East has coped better not only because of rapid testing (and I would point out that the current use of PCR over here is markedly overestimating incidence because it is being wrongly used) but also because there is genetic resistance to SARS-CoV-2 and likely high levels of antibodies to other endemic coronaviruses that confer some protection.

What irks me is that I, among other rheumatologists with experience of immunological disease, recommended both investigation and treatment protocols back at the end of April, pointing out that as cytokine storms are a well-researched entity, drug trials for its treatment were not needed. However we were ignored. As time has passed it gives me little satisfaction to see that I was right.

I agree that the imprisonment of the elderly frail has been brutal and shameful, with fear and panic causing care and compassion to be thrown out of the window. Currently hospital beds are little more occupied than is usual at this time of year; if it can be predicted who is going to deteriorate (and it can) then those who will not go off can be spared admission. And the best forms of prevention of spread are handwashing and social distancing; it is a pity that the only way of getting the public to understand this is to force them to lock down. If they were more responsible and actually do these things, lockdowns would not be needed…

Steven Hopkins 29 November, 2020 10:37 am

Thank you Dr Bamji for such a helpful and thought provoking response. I agree with your sentiments regarding people not responding to simple measures of hand washing etc. Between lockdowns I witnessed thoughtless youthful golfers mixing closely with no masks, no social distancing and not even washing their hands after going to the loo. The hotel made no effort to correct the situation.

I found Dr O’Neil ‘s contribution unsettling and very reminiscent of Margaret Thatcher’s ” There is no other way ” latter referred to as the TINA mentality.
It may be this absolute certainty that provokes the backlash against the lockdown measures.

I am only a humble GP and do not profess any expertise with regard to virology or Epidemiology, but I aware of many of the difficulties listed by Dr Musgrave. Cattact surgery has been stopped such that elderly patients are being deprived of their sight , losing their independence and losing their driving skills. I did a locum hospital job to better understand Covid but the first patient I met was a 57 y/o dying of heart failure. She had been experiencing SOB for 5/7 but had been too frightened of catching covid to
call for an ambulance.
I understand that cancer diagnoses are down. Are the deaths that will ensue more acceptable because they won’t be noticed.

I would be much happier if the lockdown was accompanied by a reasoned discussion that does not focus just on Covid but examines the non-covid death rate, the rise in mental health issues, the loneliness amongst the elderly and despair of many who are no longer able to visit their loved ones in hospital. Maybe, if these statistics could be compiled and proof offered that the lockdown and the continued restrictions which will follow are not doing more harm than good, I might be more confident in these draconian measures. Certainly I am not reassured by Dr Oneil’s TINA mentality.
Steve Hopkins

Keith M Laycock 2 December, 2020 3:03 am

Dr. Musgrave, you are correct.

Salmaan Saleem 7 December, 2020 9:58 pm

Death is an unavoidable reality and, yes, the circumstances of people’s death can be quite sad, but using this alone to justify lockdowns is an emotional argument. Yes, this also applies if the case against lockdowns is based only on the emotional harms as outlined in the article. We can argue which emotional burden is worse for each side and reach a stalemate.

There are other aspects and effects of lockdown that need to be considered which the author is trying to do.

The science has indeed shown there was significant excess mortality at the height of the outbreak in April/May, but since then the mortality has been either below, at, or marginally above the expected mortality.

We locked down out of fear from the Imperial modelling, this has been proven to be wrong by a factor of 10. We went into lockdown again based on these models which are again proving to be wrong.

Hospitals weren’t overrun. The nightingale wards lay empty. A large number of Locum GPs are out of work. So the fear that the NHS would not cope were and are demonstrably untrue. In light of this the narrative for lockdowns has shifted from flattening the curve to now protecting the elderly. As healthcare professionals we are respected and expected to work in difficult situations, we don’t lockdown pubs or clubs due to increased demands on A+E on a Friday night , nor should we. The point being that medical professionals have no authority to force people to obey medical commands to make our working conditions easier, our role is to educate and advise.

This brings us on to the importance of autonomy. Elderly people aren’t a voiceless entity that we need to protect regardless of THEIR own wishes. They can assess their own risk and decide either to stay at home or not – this is their decision to make, not the government’s or NHS. Adults with capacity can and should make their own decisions, this is a foundational cornerstone of how we practice medicine. People can chose to live however they wish and take make their own assessments of risks, no one has a right to force an individual to destroy their life’s work / business / livlihood

We don’t lock smokers or alcoholics or any other consenting adult in their homes to protect them from themselves or for others. This is how we’ve always practiced medicine, by empowering people with sharing knowledge and informed consent to reach decisions, whether reasonable or not is irrelevant.

Why are we favouring possibility over certainty? The possibility of hospitals becoming full Vs the certain damage lasting damage to millions of lives from lockdowns. And no, the economy is not just money, it’s lives. The NHS needs money to run, tax revenue; tax regime that comes from people having jobs and working. So by locking down and destroying the economy we not only harm individuals but the future if the NHS itself.