Opinion Articles

Hospital visiting in epidemics: an old debate reopened

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COVID-19 is exerting massive pressure on health care systems across the globe. While social distancing and self-isolation have been adopted as ways to ease such pressures, regulating visitors to healthcare institutions is another. There is a compelling epidemiological reason for visiting rules: a visitor is a potential disease vector between those with an infection and those without. Controlling visitors to hospitals, hospices, nursing homes and even domestic spaces can help ‘flatten the curve’, by protecting the most vulnerable, reducing the volume of COVID-19 critical care admissions, and buying vital time for hospitals in their search for adequate quantities of hand sanitiser (which visitors have been accused of stealing), PPE, and ventilators. 

Should we now add mobile devices to this list of necessary supplies? The tightening of visiting restrictions in some UK hospitals has provoked one group of doctors at an NHS Trust in London, ‘to collect devices specifically to help loved ones communicate with the dying’. In anticipation of further stringent measures, the distribution of iPads, tablets and mobile phones to patients’ close relatives likely will become a feature of the hospital admissions process over the coming weeks. 

Assuming people actually can bridge the digital divide to take advantage of such devices—COVID-19 is exposing stark inequalities in access to broadband, wireless, and mobile connectivity—phone calls and videolinks can bring much-needed solace to both the patient and the remote visitor, something that palliative care experts have been telling us is important to the dying patient.

But jarring stories of visitors being frog-marched out of hospitals by security guards and gut-wrenching accounts of virtual grieving, are leaving their mark on our collective memory of this pandemic in ways that deserve a non-pandemic perspective. Rules for visiting patients have a long history. At various points, visiting by relatives and friends has been prohibited, discouraged, policed, or positively welcomed. Rules have differed from nation to nation and from institution to institution, depending on the prevailing cultures of care, the type of diseases or illnesses, and the attitudes of health care professionals.

By the late nineteenth century, regulating visitors to the sick was part and parcel of the modern, well-ordered hospital’s identity. Disruption to ward routine was minimized by restricting visiting to one hour in the day (often just once a week), limiting the number of visitors at the bedside and searching visitors to prevent food and other prohibited items coming into the hospital.

In 1944 the UK Medical Research Council recommended all visitors to children’s and isolation hospitals should wear face masks and gowns to prevent cross infections. By this point, visitors to these two kinds of hospitals had long been considered problematic. Fever and isolation hospitals cared for patients with infectious diseases such as scarlet fever, diphtheria, typhus and polio. On the eve of the First World War, there were more than 750 isolation hospitals across the UK, catering mainly for children. A hospital stay for a scarlet fever sufferer could last as long as nine weeks. Such prospects generated passionate opposition in Nottingham, where 16,000 people signed a petition in 1890 protesting the city’s Infectious Diseases (Prevention) Act, ‘which converts our hospital into a prison and deprives us of our right to nurse our sick and claim our dead’.

Legislation like this was enacted across the country and visiting patients in isolation was even more controlled than in general hospitals. Mothers were sometimes allowed to accompany a sick child, but a variety of methods aimed to keep visitors at arms’ length. ‘Window’ viewings were common and as late as 1966 a paediatrician told The Guardian that, ‘88 per cent of children in isolation hospitals could only be seen by parents through glass.’ Some hospitals left daily updates on each patient at the porter’s lodge. Many hospitals only allowed the family to visit when the patient was at death’s door. Edinburgh’s isolation hospital gave each patient a number that was known only to the family. Daily updates were published in the newspaper: ‘dangerously ill’ patients were allowed visitors; a sure sign that their number was well and truly up.

Visiting patients in children’s hospitals was encouraged in the mid-nineteenth century, not least because it provided an opportunity to educate poor mothers about childrearing. But by the 1900s, medical and nursing staff believed visiting not only carried the risk of infection but was traumatic for the children and jeopardised their recovery. On the eve of the Second World War, most hospitals limited visits to 1 or 2 hours per week, some none at all. Pressure groups such as the National Association for the Welfare of Children in Hospital, concerned doctors, medical journals, and the influential researchers psychiatrist John Bowlby and psychoanalyst James Robertson all campaigned against the tyranny of ‘hospitalisation trauma’. The recognition of ‘separation anxiety’ and changing social views on childcare helped liberalise visiting hours for children from the 1950s. Now, under normal circumstances in most hospitals, the parents of sick children can visit whenever they wish.

In a matter of months COVID-19 has flattened out hospital visiting practices from Southampton to South Korea and desperate families are finding themselves excluded and struggling to obtain information about loved ones. The elderly in care homes have borne a painful brunt, dealing with the twin crises of mass infections and staff shortages. Ironically, the generation that experienced some of the most restrictive hospital visiting rules during their childhoods are now most at risk of death from COVID-19.

Depleted health care systems and confused government mitigation strategies have allowed coronavirus to prey on our fear of dying alone and surviving families are left to pick up the emotional pieces. On 29 March 2020 the Department of Health and Social Care gave mental health charities £5 million to expand support services to help people cope. There are, as yet, few specifics about where this money will go, but it is clear that additional social support, grief counselling and psychiatric assistance is urgently needed for those dealing with the loss of a loved one under estranged circumstances.

Please note: Views expressed are those of the author.

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