This is the 7th week that the SHA has published a Blog tracing the progress of the Coronavirus pandemic globally but more specifically across the UK. Over this time we have drawn attention to the slow response in the UK; the lack of preparedness for PPE supply and distribution; the delay in scaling up the testing capacity and system of contact tracing; a too early move away from trying to control the epidemic and poor anticipation of the needs of the social care sector.
However we need to start to look at how we can reverse the situation we find ourselves in being one of the worst affected countries in the world. Our deaths in the UK now exceed 20,000 and we have been following Italy and Spain’s trajectory. It is true that while the lockdown came too late – London should have gone first – it has had an impact on suppressing the first wave and the NHS has stood proud and able to cope thanks to the unflagging commitment from all staff. It is good that Parliament has been reconvened so proper scrutiny can be given to government decisions on public health as well as the economy. We look to the new Shadow Team to pursue this energetically.
It is no surprise that Trump’s USA is a lesson of the damage disinvesting in the Centers for Disease Control and Prevention (CDC) has had. It has led to poor emergency preparation and poor leadership at handling the pandemic at a federal level. From a SHA perspective an example of the superiority too of a nationalised health system as compared with a private health care model in the USA. Compare how it looked in New York City during their peak and the relative calm in London on the 8th April. From his rehabilitation home at Chequers it was concerning that one of the first phone calls PM Boris Johnson allegedly made was to Mr Trump. They share many characteristics but let’s hope that we do not end up second only to the USA in the international table of deaths/100,000 population and tie ourselves too closely with the ‘Make America Great Again’ nationalist neo-conservative movement.
- Scientific advice
One of the characteristics of this pandemic has been the UK Government Ministers repeated claim that they have been making decisions on the best scientific advice. This claim has mystified some commentators who feel that the decisions being made by Ministers has not been in line with WHO advice (test, test, test) and not consistent with comparable EU countries who seem to have managed the pandemic more successfully (Germany and Denmark). We have never said that we cannot compare data published in Germany and Denmark before now!
Sometimes Governments make bad calls during an emergency and wanting to keep the membership of SAGE secret was one such. There has been mounting concern about the provenance of some of the advice leading to Ministerial decisions. For example the early misunderstandings about ‘herd immunity’ and the fear that the nudge behavioural psychologists were having undue influence leading to the crucial delay in lockdown. Some of these scientists work in government units, which is not good for an independent perspective.
The mixed messages about the modellers and their estimates of the likely deaths (20,000 to 500,000) which also surfaced before one modeller was allegedly responsible for pushing (thankfully) the belated decision on the lockdown.
Many public health trained people have begun to wonder who on SAGE had any practical public health experience in communicable disease control? These concerns were prompted by the sudden abandonment of testing and contact tracing, the lack of airport or seaport health regulations used by other countries such as Australia and New Zealand (Australian deaths so far 80 for a population of 25m and NZ 18 for a population of 5m).
Recently we have also been bemused by the inability to recognise how homemade cloth facemasks might play a part in easing lockdown. While there might be a relative lack of ‘gold standard’ evidence there is ‘face validity’ that a mask will stop most droplets and this will be important as we are finding so many people are infected for days before showing the classic symptoms and signs of fever and cough. Homemade cloth masks would not compete with NHS and Social Care supplies and these do seem to have been part of the strategy that countries that have been more successful at containment than the UK. We suspect that in time the recommendation to wear a cloth mask when going outside your home will become a recommendation!
After the initial planeload of British nationals from Wuhan, who had been appropriately quarantined, there are no measures in place at all at our airports. The explanation about incubation period does not hold if people are quarantined for 14 days. The precision of temperature measurements should be seen as part of a screening regime, which would include risk assessment of country of origin, symptoms reported on a questionnaire or observed as well as temperature measurement. It is obvious that if a passenger causes concern the less accurate thermal imaging technique can be augmented by other more reliable ways of taking a temperature! It does not seem right that such measures are discounted for the UK and we are one of the worst performers while other countries with competent public health professionals take it seriously. It is estimated that nearly 200,000 people arrived from China to the UK between January and March 2020 with no checks at all apart from general Covid advice. Empty hotels would have been suitable for quarantining people at risk of having the virus. This matters as it is a very contagious virus and can spread before symptoms appear. Such symptoms can also be minimal and hard to detect.
Now that the membership of SAGE has been leaked we can see that one of the Deputy CMOs is the only person who has had any ‘on the ground’ experience of communicable disease control in communities. This is important when we start to consider how we can get out of lockdown by using the new testing capacity optimally, contact trace effectively and introduce control measures locally. This will require Public Health England (PHE) to begin to strengthen its relationship with local Directors of Public Health (DsPH) located in Local Government. These DsPH can provide local leadership and work with Environmental Health Officers (EHOs) who to date have not been drawn into the pandemic management system.
The presence of Dom C in SAGE meetings raises concerns. Of course civil servant officials have always attended the meetings to ensure that they are properly organised, agendas circulated and minutes recorded. It is quite a different thing to have an influential Prime Ministerial adviser like Dom C attend the meeting and no doubt interject during discussions and help shape the advice. That should be the Chief Scientific adviser’s (Prof Vallance) job and his role to brief the PM. The trust in SAGE has been damaged by the disclosure of membership, the lack of jobbing public health input as well as the presence and influence of these special advisers (SPADs).
- Easing lockdown
One of the problems in the management of the pandemic in the UK has been the centralised London perspective, which has dominated the options and led to a one-size fits all approach. We have said before in these Blogs that Greater London was our Wuhan (similar population sizes). We should have shut London down much earlier and stopped the nonsense of those crowded tube trains and buses. We have seen from the Ministerial briefings that London has had an almost classic epidemic curve – rising steeply and then levelling off and declining. The devolved nations and English regions have lagged behind. Scotland and Wales got their first cases about 4 weeks after London and the South East. Regions such as the SW region in England, Northern Scotland and the Islands, rural Wales and parts of the North of England have been slow to have cases and even now have had few cases and few deaths. These areas did not need to be locked down at the same time as London and the South East and could have instituted regional testing and contact tracing which would have helped flatten the curve and protect the NHS. Such a strategy would have built up experience of doing this which we now have realised we need to do to get out of lockdown. However we have an asymmetric situation with the regions showing gradual and flat epidemic curves, which will be prolonged and frustrate a UK alone approach.
The challenge of easing lockdown will be quite different in metropolitan urban areas with heavily used public transport and metro trains and a more dense housing with fewer green spaces. The picture in more rural areas and small towns is quite different. There is a serious need to engage with local government more appropriately, pull back from central control and set out a framework as has been started in Scotland and Wales which local government partners can start to address via their Local Resilience Fora (LRFs) and emergency control structures.
There does still need to be a UK wide COBR approach but the strategy needs to be more nuanced to set out the UK framework and allow devolved nations who are a similar size to New Zealand and Denmark and English regions to plan locally sensitive approaches drawing on expert advice from Public Health organisations such as Public Health Wales, Scotland and PHE. Metropolitan areas such as London, Birmingham and Manchester will also want to be able to adapt measures to fit their local complexities. This will be particularly important as we start a system of community testing, contact tracing and control measures. National testing standards and quality will apply and any mobile apps that are developed will need to be agreed at a national level with all the safeguards on privacy and information governance.
Children have been remarkably resilient to this virus and it seems that back to school is something worth considering as an early venture as long as schoolteacher’s health is safeguarded by not exposing ‘vulnerable’ teachers, and implementing systems to make physical distancing more feasible. It is urgent to look at international best practice and be flexible in our approach.
Pubs and restaurants will be further down the list as will mass sporting events but widening the retail sector and getting some workplaces back should be planned. Again travel to work should only be necessary for some workplaces and physical distancing, masks and health and safety regulations will need to be updated to suit each work environment before permission to reopen is given. All these steps require enhanced local public health capacity.
- Recovery planning
An important part of emergency planning frameworks is the need immediately an emergency is recognised to begin the ‘recovery planning’. This will depend on the characteristics of each emergency. In the case of Covid-19 we will need to look at the build up of elective care, especially surgical waiting lists. It will also need to urgently review those people with long-term non-Covid conditions who may have had their continuing medical care disrupted. There will also be those casualties of the pandemic who have been traumatised by the pandemic and have mental health issues, burnout, faced economic hardship and PTSD. People who have had Covid-19 and survived a period in ICU and ventilation will also need weeks and sometimes months to recover. So all this adds up to a load for the NHS and associated services to address.
As we have seen the economy has taken a big hit and many businesses have found themselves having to close down or reduce their workforce/suspend manufacturing output. It is unclear how we measure what has happened to our economic base but we have seen the growth in unemployment, the rise in welfare applications and the stories of those caught out with a sudden loss of employment and income. We know that 12 years after the 2008 financial crash that the legacy remains. This is far bigger so we need to begin to agree how the economy can be rebooted safely while protecting those vulnerable populations and safeguarding the children returning to school or workers to the factory floor. Trade Unions must be key partners of this economic recovery planning challenge.
The other aspect of a recovery plan is to take advantage of good things we have experienced such as the reduction of air pollution with a reduction of car use and aviation and other transport. The global satellite pictures of Beijing, Delhi and Milan tell the story that life can be better if we reduce our carbon footprint. Working from home, the benefit of fast broadband should all lead to a reappraisal of environmental and other life changes. The growth in cycling and physical activity in green spaces should also be built on.
Finally the pandemic has once again thrown a light on inequalities with the risks of occupational exposure (bus drivers), risks in hospital environments (porters, receptionists to nurses and doctors) and retail shops (shop assistants/cashiers). Many manual workers have had to go out to work still and in the process through travel and the work environment been at higher risk. Those who live in over crowded households have been at greater risk with fewer opportunities to self-isolate. Many of those in poorer urban housing estates have also been exposed to risk and found safely going to shops, medical centres or exercise much more difficult. We know about the health inequalities gradient and when this pandemic is analysed fully these social economic and environmental determinants will show through. It is pretty clear that BAME communities have been more susceptible to the virus and while this may have some biological features such as cardiovascular/metabolic risks it will also be socioeconomic, cultural and reflect occupational exposure.
So recovery plans need to be set out to ensure that we do not revert to business as usual but grasp the opportunities that there are to build a better future after the C-19 pandemic. The Beveridge Committee was established relatively early during WW2 and the report was published in 1942 setting out the vision of an NHS and State Education for example. We have an opportunity to push for similar progressive changes after Covid-19.
Posted by Jean Hardiman Smith on behalf of the Officers and Vic Chairs of the SHA.