If we used to think our health was a personal matter, primarily down to genes, lifestyle and a dose of fate, the coronavirus pandemic has shown how wrong we were.
irishtimes.com/health
Suddenly we were all tied together in sheltering from the single, most contagious virus we had seen in our lifetimes. The risk of being infected depended on behaviour of others as well ourselves: family members, friends and strangers. We were also, to an unprecedented extent, looking to public health doctors and politicians for advice and decisions to protect us.
The increased health anxiety we’ve all experienced to some degree has changed human behaviour, for better and for worse. The challenge now within homes and healthcare systems is to try to capitalise on the positive and discard the negative as we travel towards a vaccinated world that can cope with the coronavirus – and prepare better for the next pandemic.
While Winston Churchill said “never let a good crisis go to waste”, almost every health professional interviewed for this article warns that humans like to “revert to type” and permanent change in behaviour is very hard to make.
“We move on quickly – you can see why, it’s a good defence mechanism,” says psychiatrist Prof Brendan Kelly of Tallaght University Hospital in Dublin.
Infectious diseases consultant Dr Eoghan de Barra would like to think that our experiences would herald a transformation in thinking around healthcare and that people would recognise public health has to be adequately resourced. Yet history tells us societal memory is short. Within two years of the Spanish ’flu 100 years ago it was largely forgotten. Right now, in this pandemic, people just want to get back to normal, he says. “They’re fed up with it.”
However, what are some of the lessons we could take from the coronavirus pandemic in looking after our physical and mental health, both individually and collectively?
Acknowledge the crisis
“Many people have learned a degree of humility over the degree of control we have over our lives,” says Kelly. “It was always something of an implicit illusion that we were all-powerful and our lives were inviolable – particularly in our part of the world.”
In other countries, people are more accustomed to the vagaries of nature. “This is a lesson we can and should take with us: to value the moment more than we did because it is more fragile and we are more vulnerable than we imagined.”
The first lockdown, in particular, gave people the chance to slow down and reflect but that wasn’t comfortable for everybody, suggests clinical psychologist Trudy Meehan, a lecturer at the Royal College of Surgeons in Ireland’s Centre for Positive Psychology and Health that was established in 2019.
“I think a lot of people faced the question of what were they doing with their lives. And a lot of people I think had crisis of meaning and purpose. Some people had a crisis and were in a situation they could change and other people just had a crisis.”
For the latter she says the first thing to do is to acknowledge the crisis and then look at the meaning behind it. If you hate your job or your relationship, what is that saying about your values? “That crisis is telling you something important about something you genuinely care about. Follow that thread and it will take you out of the dark hole into something that is more positive.”
‘Lifestyle medicine’
The desire to do what we could for our own health at a time when we had no control over the coronavirus has led to increased empowerment and a boost to “lifestyle medicine”, if only we can sustain and build on it.
“We want people to have that mindset, that they can control aspects of their health and are going to change behaviours,” says Meehan. The six pillars of lifestyle medicine are: healthy eating; exercise; sleep; management of stress; relationships/connection; and reduction of harmful substances. In European regions about 86 per cent of deaths in normal times are accounted for by partly preventable conditions, such as type two diabetes, cardiovascular disease, cancer, respiratory diseases and mental health issues, she says.
“They can all be impacted and reduced by focusing on those six pillars.” Covid-19 has been most deadly for those with underlying conditions – accounting for almost 94 per cent of fatalities here, according to the Health Protection Surveillance Centre. More than 40 per of those had chronic heart disease.
The “Covid stone”, added to by Christmas excess, is likely to be the first target for lifestyle change at the moment. Although dietitian Louise Reynolds says we don’t need to beat ourselves up about it, considering the psychologically tough year we’ve had. A return to more normal routines will help shift some of the excess weight. She recommends small changes for sustainable weight loss – making consistently better food choices and building exercise into your routine.
Habit gains
It is said to take 90 days to establish a habit, so we’ve had time to acquire new ones from nine months of living with a pandemic. We could use the next three months to edit the repertoire.
“Ninety per cent of what we do in our lives is habit,” says Kelly. If we have been able to shift any of our habits in a positive direction for the three months it takes to establish a new habit, whether it was in relation to diet, drinking, exercise or sleep, we should try to keep it up.
“Every inch that we gain that becomes a habit is incredibly valuable.”
He gleans hope from some of the latest CSO data around alcohol consumption, which shows that the rate of about one in five people drinking more than they did pre-Covid has remained similar between surveys conducted in April and then again last November, but the number of people drinking less went up considerably. More than one in four (26.8 per cent) of November respondents reported that they had decreased alcohol consumption from pre-pandemic levels, compared with approximately one in six (17.2 per cent) respondents in April
“If you’re one of those whose alcohol intake has reduced during the restrictions, my advice is do your level best to maintain that progress in the new year. That’s a real opportunity because it is so hard to change a habit like drinking.”
Weight gain in 2020 was often due to what nutritionist Gaye Godkin refers to as “situational eating”; people working from home were close to the kitchen, or indeed in it, making cups of tea or coffee and taking a snack to go with it.
“Food frequency is our biggest problem,” she says, explaining that nutritional science is changing, and past advice of three meals and two snacks a day was wrong. Now she recommends three meals and no snacking. “Know that every single thing you put into your mouth is going to positively or negatively affect your body.”
More cooking from scratch, meal planning for one big weekly shop and buying local produce are trends we’re encouraged to continue. Of the early craze for baking banana bread and sourdough, Reynolds says anything that involves a family learning cooking skills is very positive. Loss of these skills that used to be handed down by parents, has contributed to an over-reliance on takeaways.
GP Dr Margaret O’Riordan, president of the Irish College of General Practitioners, says she hopes that improved culinary skills would translate into healthier eating. She has seen a lot of “Covid stone” in her two-doctor surgery in Ballingarry, Co Tipperary. “I have seen two stone on people who never put on weight.” However, for a few, anxiety has been channelled into excess exercise, leaving them unhealthily underweight. And Reynolds also warns that malnutrition among the socially isolated needs to be addressed.
For some, working from home without a commute has offered the chance to improve their health, with more time for exercise, food preparation and family. The rapid switch to remote working, says Meehan, showed us that change is very possible in how we structure our day and could achieve a better work-life balance. “We need to remember that and push for the good on that.”
Follow the science
This applies to lifestyle change just as much as infection control. One of the big things we have learned on an individual level, suggests Meehan, is to take control by going to trusted scientific sources. In a global pandemic, the stakes are too high to be relying on social media quackery.
“There might be a turn away from celebrity and back towards science,” she adds optimistically.
Godkin says people need to look at food for its biological benefits. The prevailing paradigm in Ireland is that food is measured in calories and fat content, which is “absolute rubbish”. Research linking poor outcomes from Covid-19 with zinc deficiency and also the association with low vitamin D levels is, she suggests, a wake-up call.
She doesn’t hold with BMI but is concerned about fat around the middle. “What people don’t understand is that fat is a gland on its own and has the capability of driving inflammation without any Covid. If you have excess fat around the middle, it equals poor health.
“The whole thing comes down to metabolic health and you’re going to hear a lot of that in the future – how we metabolise our food and certain foods switch on certain things, such as fat storage hormones and insulin.”
Reynolds also highlights the importance of vitamin D for the whole family and the recent Department of Health recommendation that people over 65 should be taking a 15 micrograms vitamin D supplement every day in the winter.
Otherwise, while there is much talk of “immune boosting”, with people cashing in, “in terms of the research,” she says, “there is no one food or nutrients that you should now take on board in 2021. The best thing you can do for that is have a good, balanced diet, with regular intake of protein during the day.”
It’s not over yet
We don’t know how many more thousands will contract Covid-19 over the coming months before the roll-out of vaccinations. In a pandemic, one per cent is the pathogen and the rest is all about human behaviour, says de Barra, who is secretary of the Infectious Diseases Society in Ireland.
“Every infectious disease is a bug that has newly emerged but the reason it spreads is through human behaviour. The only tool we had was to change human behaviour, and it was a very blunt instrument of lockdown.” Yet, every time restrictions are relaxed a little, “the virus spreads because humans are social and do what they want to do”.
Even with a “brilliant” vaccination, he doesn’t expect Covid to disappear, but rather that we will achieve a “tolerable rate” of infection that will periodically cause trouble. “We have a brilliant vaccine for measles and we still have cases that cause chaos in certain areas.”
With any change in human behaviour tending to be transient, de Barra believes the focus needs to be on healthcare and social infrastructure. Are we willing to learn from this and prepare for the next pandemic, which might be sooner than we think? More “spillover events” of this nature, when a virus tips from animals to humans, are to be expected, he says, as we infringe further on the natural environment.
For those who have survived, or will survive, Covid-19, there may be lingering after-effects to contend with. “Overall, the message is people do get better,” says Dr Killian Hurley, a consultant respiratory physician who treats people attending a multi-disciplinary follow-up clinic for those hospitalised with Covid-19.
Research has shown that after three months, about half of all those hospitalised were more or less recovered, while the other half needed further follow-up care. One third of those admitted needed mental health follow-up for anxiety and depression.
“We are seeing a lot of people with persistent symptoms such as shortness of breath. Fatigue seems to be most common.” Even among people who didn’t need to be hospitalised, some are reporting persistent problems with, say, breathing.
Deconditioning is a real challenge, which needs to be addressed by exercise and a good diet, he says. A sentiment that is echoed by those treating older people for detrimental effects of “cocooning”. But people need reassurance, otherwise it’s a vicious circle of feeling breathless on exertion and being afraid to do more. A graduated exercise programme is best, not sitting around until you feel better, but do check in with your GP first.
Start with handwashing
We’ve had a stark reminder that infection control is still critical to the human race, from our hospitals down to our homes.
“Without infection prevention and management, none of the complex medical stuff can happen,” says de Barra. “Whether it’s putting devices or bits of plastic in or giving them funky therapies, it only happens if people don’t get infections because in the past that is what everybody died of.”
For a whole generation of children, infection control in the form of regular hand-washing has become normal, particularly as they have been taught it at school, says O’Riordan. If kept up, that on its own will lead to a reduction in the rates of minor infectious diseases.
“Hopefully we will have less gastroenteritis, [fewer] coughs and colds. That’s one positive.” She also believes people will continue to be much more aware of ’flu symptoms and less likely to go to work or send children to school with them.
Every age group has become better able to cope with minor illnesses through the pandemic and “less likely to seek medical intervention”, she observes, which could lead to a permanent drop in demand for antibiotics.
Care of older people
The pandemic has exposed the economic and social cost we’ve all paid for systemic failures in looking after older people. Consider for a moment that about 60 per cent of coronavirus deaths in Ireland occurred in nursing homes. That is not all down to advanced age making residents more vulnerable.
“When it comes to nursing homes, what we have built and invested in over the last 20 years is not fit for purpose: these large, congregated settings ended up being the settings Covid impacted,” says Prof Sean Kennelly, a consultant in geriatric and stroke medicine at Tallaght hospital. Compare that to the disability sector, which has fared much better and would have equally vulnerable people, he says.
But because they pushed for moving out of institutions in recent years, generally those with disabilities had a far better environment in which to weather the pandemic. We really need to reflect on what nursing homes are going to look like going into the future.
Kennelly, who does visits both in private houses and residential homes, has “significant concerns” that the human rights of people living in nursing homes are being violated, with their wishes to see family members being ignored – albeit that those making these decisions are doing so from a good place.
“The wrong stuff has been done in people’s best interests before,” he remarks. While the initial blanket “cocooning” advice to over-70s has proved “ultimately damaging”, he says we have to remember the huge fear that struck at the end of February from the things we were seeing in Italy.
“What was regrettable was that we were slow to unpick some of that early advice.” Prolonged closure of day services for older people has also affected the health of family carers who are under huge stress.
On the positive side, were the great efforts made by many communities in the first lockdown to support older people in their midst. “As a society I think we have to reflect on whether that was just one hit in the shock of a pandemic and we all rallied around,” says Kennelly. “We did tremendously well in this country but I wonder are we sustaining that? It’s really difficult to do.”
Health services innovation
A similar “esprit de corps” delivered change within the health services in a way Kennelly says he never expected to see in his working life. “There was a clarity regarding the goal and everybody working towards it. I think it has pushed us and I do think it’s better, but I sense a slight retreat back into our traditional silos of hospitals vs community vs primary care, as opposed to really capitalising and continuing to work on that collegiality.”
A lot of that is dependent on how the system is managed and funded, he says, so you don’t generate a competition between hospital and community services, but rather reward integration. “That is what Sláintecare is all about.”
As for the online innovation, there needs to be jurisprudence on what is retained. It brings to his mind the Yes Minister sketch in which the “perfect hospital” was one without patients. The risk is, he adds, that some of the efficiencies that were unavoidable in a pandemic get carried on, while “most people still need that face-to-face contact”.
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