A survey of 2,000 families in Bradford indicates just how bad lockdown is for health - and how being furloughed is enough to tip those on the lowest incomes into financial difficulties. Dr John Wright of Bradford Royal Infirmary considers how to achieve the twin task of protecting people from the virus, and from poverty.
The city is bracing itself for the next surge. The incidence for the last seven days has climbed to 270 per 100,000 but not as steeply as our neighbouring northern cities, where rates are approaching 600 per 100,000 - perhaps a result of early restrictions in Bradford, perhaps just a question of time. Testing in the community is also showing a higher rate of positive results - 17%, compared with 8% a month ago.
After three months of relative calm in the hospital the number of patients on the wards with acute Covid-19 has steadily risen to over 70. Our mortality rate is lower, due to more effective treatments, but sadly and inevitably it will also rise in the coming weeks. There is a physical and mental weariness among the staff, though no dip in the compassion that guides them.
Over the last six months my diary has tried to capture the remarkable stories of fear and bravery from staff and patients at Bradford Royal Infirmary. My lens as a hospital doctor has inevitably focused on the clinical and health impacts of Covid-19. But while the pandemic was receding we looked up from our drug charts and test results to explore the impact of the lockdown and the pandemic on the rest of the city.
Ten days ago we published the results of our survey of over 2,000 families in our Born in Bradford research study. As the virus continues to spread across our communities and the number of patients admitted to hospital continues to slowly rise, the results of this study provide a heart-breaking insight into the impact of lockdown on lives beyond the hospital walls.
These are some of the key short-term experiences of families living in the deprived and ethnically diverse city of Bradford in the period from 23 March onwards, as revealed by the survey.
- One in 10 said their food didn't last and they couldn't afford to buy more, so they were eating less or skipping meals entirely
- One in 10 said they had real concerns about being evicted or having their home repossessed
- One in three said they were worse off and 37% said they were worried about the job security of the main earner
- One in five mothers had clinically significant depression and one in six had clinically significant anxiety - many also raised concerns about the mental health of their children
- One in three mothers said they were lonely some of the time, and one in 10 said they were lonely most or all of the time
- One in six mothers said they were worried about their health most or all of the time
Financial, employment and housing insecurity were all particularly common in those where the main earner had been furloughed, was self-employed and not working, or was unemployed.
While the furlough scheme and support to self-employed workers was designed to provide support during this difficult time, our findings suggest that the loss of 20% of a low-income wage may be enough to tip families into financial difficulty, and potentially further exacerbate health inequalities.
Front line diary
Prof John Wright, a doctor and epidemiologist, is head of the Bradford Institute for Health Research, and a veteran of cholera, HIV and Ebola epidemics in sub-Saharan Africa. He is writing this diary for BBC News and recording from the hospital wards for BBC Radio.
The evidence from this study demonstrates the public health impact of lockdown on mental health driven by loneliness and economic insecurity. This epidemic of mental ill-health (on which we will publish more soon) is less visible than the acutely ill patients on ICUs, but may have longer-term consequences that outweigh the clinical harm of Covid-19. The challenge that policy makers face is how to balance the scales of clinical harm from the virus on one side against the wider social and economic harm on the other.
There are increasingly polarised views from the public and politicians but also scientists and doctors about how the government should tackle the emerging second wave of the pandemic. Should we reinstate blanket restrictions on everyone or target shielding at the most vulnerable? Should we keep businesses open or return to lockdowns?
I have written about the taxi driver Kaiser Zumeer before in this diary. One of his daughters, Marium, became seriously ill with Covid-19, but fortunately made a full recovery. Kaiser's elderly father, Mohammed, sadly died from it. At the same time, lockdown removed his source of income - the taxi company paid the drivers nothing, because they are self-employed, and a grant from the government was only sufficient to cover some of his bills. So first he and his wife spent their savings and money they had put aside for holidays, then they sank into debt.
Kaiser has now been back at work for five weeks, working seven days a week from 07:00 to 18:00, struggling to earn enough to pay back the £6,000 he owes. A credit card company has taken legal action, and he now worries about bailiffs arriving at his house. It's a new experience for him, he says, as before Covid he had no financial problems and no debt.
"If it goes back into lockdown again I've had it, I might have to sell my car. That will be my job gone - my car is my living.
"It's causing so much stress, I can't sleep on a night through thinking about it, but I can't show my kids what's happening as I don't want them worrying again. It's my job to handle it, which I will," he says.
"Lots of people are in my situation, especially when someone has had a loss. I think it's going to grind to a halt again with the lockdowns and I just hope it's not that long. If it's longer than a couple of weeks, I'm worried that I won't be able to make the repayments for what I already owe."
Salma Nawaz has worries of a different kind. After the birth of her youngest child five years ago, she suffered from post-natal depression. She had a year of counselling, and has since managed her condition by going on walks, and finding time to be by herself. During lockdown, with three children at home, that wasn't possible.
"It reminded me of when I had depression and at times I felt that I wasn't in control of the situation. There was too much noise, I couldn't think. I was worried that I would go back to the old me, the old me when I couldn't even change a nappy - it would be like climbing a hill, the anxiety of doing anything was overwhelming.
"I fear for my mental wellbeing if there's another lockdown. Even now I feel a lot more moved and worried about how people around us are managing, telling the children to be thankful and to value what you have."
Salma misses going out as a family - if they do go out, she says she is "constantly in fear". Her mother, in the US, is unwell and the family had planned to visit her this summer. Cancelling the trip was very challenging, she says. At the same time, she worries about the impact on her children's education.
"Will this last or will it go away?" asks Salma. "We don't know."
While one in three families in our survey said lockdown left them worse off, nearly one in 10 said they were actually better off. Leanne, who has three children and lives on Bradford's Holme Wood council estate, says she hasn't been spending money on going out or on takeaways, and instead of making repeated trips to the local shops she has been buying supermarket food in bulk online.
"It has been more stressful being here all together all the time, but at the same time we've done a lot more stuff together, so we're playing board games and watching movies together," she says. "I have really good neighbours and we can stand in our gardens and shout at each other. My neighbour sits out come rain or shine."
Leanne has rallied round with others on the estate to help families in need. She has also maintained contact with her large and supportive family using the internet - though she misses visiting her father, who is shielding.
So of course, the picture is mixed. There are some in this city who have coped well or even flourished with lockdown, but our survey suggests they are in a minority.
The debate about lockdowns and restrictions is shaped by scientists and politicians; the growing wariness of governments and science is fed by mixed messages and uncertainty. The missing voice in the debate is from the communities themselves and their priorities for responding to the pandemic. The immediacy of the harm of the virus at an individual level tends to take precedence, but the longer-term impacts on social and economic health are revealed in studies like this one that highlight the fragility of people's lives.