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    This is now the 8th weekly Blog published by the Socialist Health Association (SHA) commenting on how the Coronavirus pandemic is progressing both locally and globally. The lens we use is a socialist worldview where we aspire to One World and Planetary Health and are as concerned to reduce global as well as local health inequalities. The Covid-19 pandemic has shone a light on local inequalities within the UK as well as stark global inequalities where people find themselves exposed and unable to follow the advice we receive in the UK and other rich countries to social distance and pursue rigorous hand hygiene.

    Health inequalities in the UK

    Last week the Office of National Statistics (ONS) published a report on Covid-19 deaths by local area and by socioeconomic deprivation (www.ons.gov.uk). This covered the period from the 1st March to the 17th April. During this period there were 90,232 deaths in E&W and of these deaths 20,283 involved Covid-19.

    Unsurprisingly London had the highest age-standardised mortality rate with 85.7 deaths/100,000 people involving Covid-19. This is significantly higher than any other region and almost double the next highest rate. In these SHA Blogs, one of our observations has been that London was the early hotspot and should have been shutdown much sooner and been our ‘Wuhan’. Remember all the press reports of bars and restaurants remaining open and people packed into London underground trains and buses?

    In London Covid-19 deaths were 4,950 amounting to 42% of deaths since the beginning of March compared to 1,051 deaths in the South West region of England, which was only 13% of total deaths there. The eleven Local Authorities with the highest mortality rates were all London boroughs with Newham, Brent and Hackney suffering the highest rates. Outside London rates are high in Liverpool, Birmingham and Manchester.

    Newham has the highest age standardised death rate with 144.3 deaths /100,000 population followed by Brent with 141.5 and Hackney with 127.4. In Newham 78% of its population are in BAME groups and 48% live in poverty after rent and household income are taken account of. The three London boroughs are in the most deprived group and across England the most deprived areas have a death rate of 55.1/100,000 compared with 25.3 in the least deprived (118% difference).

    The Index of Multiple Deprivation (IMD) is an overall measure based on income, employment, health, education, crime, the living environment and access to housing within an area. Each area of England is grouped into one of ten deciles and the most deprived is in d1 and least deprived in d10. As we know from work over the last 40 years since the Black report in 1980 – there is a social gradient for mortality and many other indicators of health and wellbeing.  Covid-19 has magnified the difference especially for those in the three most deprived deciles which shows a stark difference between Covid-19 deaths and all deaths. In the least deprived decile the mortality rate for all deaths was 122 deaths/100,000 population, whereas in the most deprived it was 229. The difference between all deaths (classic social gradient) was 88% whereas between Covid-19 deaths the difference was 118%, which is 30% higher.

    A similar picture emerges in Wales where they present the data as differently. The most deprived fifth of areas have a rate of 44.6 deaths per 100,000 involving Covid-19; this was almost twice as high as the least deprived area with 23.2 deaths/100,000.

    The other key finding from the ONS report was on urban versus rural areas. Major urban conurbations had a death rate of 64.3/100,000, which is statistically significantly higher than other categories including urban minor conurbations. The lowest rates unsurprisingly are in rural settings with rates as low as 9/100,000 population. There is a category ONS use called ‘major towns and cities’ in E&W which are built up areas excluding London. Of the 111 major towns and cities the highest mortality rate was in Salford with a rate of 112.6 deaths compared to Norwich with 4.9/100,00. One interesting prosperous market town that was hard hit is Cheltenham with a death rate of 49/100,00, which is significantly higher than the English average!

    Austerity and the slow burning injustice

    In his 2020 report of ‘Health Equity in England: the Marmot Review 10 years on’ Marmot found that the improvement of life expectancy which had been a consistent finding since the turn of the 19th century stalled in 2010 and years spent in ill health increased. He also showed that the social gradient in health became steeper and regional differences increased.

    The two features of Tory government policy during this period was to roll back the State – public expenditure went from 45% of GDP in 2010 to 35% in 2018 – and to be regressive. This meant that the poorer you were the more likely you would be to be disadvantaged by these changes.

    The excuse for the policies enacted from 2010 was the 2008 global financial crisis, which led to a decline in the global economy of 0.1% in 2009. The IMF  has predicted that the global economy will decline by 3% in 2020 on account of the pandemic. Already we have seen Universal Credit claims in the UK rise from 150,000 before the pandemic to 1.4m by the 13th April and rising daily. Marmot points out the risk that it would be a calamity if we face a new era of austerity after the pandemic. We need on the contrary to argue for a better society with less inequality and built by reducing child poverty, improving child health and education, improved working conditions ensuring that everyone has the minimum income to lead a healthy life and creating a sustainable environment in which to live and work creating the conditions for people to pursue healthy living.

    Places affected by conflict and humanitarian crises

    Inequalities are manifest globally as well as locally in the UK. For instance many of the estimated 70m forcibly displaced people worldwide live in insanitary and inhospitable conditions sometimes up to six families living in one tent in a 3sqm area. In these camps people share few latrines and washing facilities and have to queue for food each day. The Covid-19 mantra has been hand washing, social distancing and lockdown. People in conflict zones or refugee camps simply cannot follow this guidance and also have access to very rudimentary healthcare facilities.

    There is an urgent need to put international pressure on warring parties in Syria and Yemen to end restrictions on access to health care and humanitarian assistance. Public health support is needed to provide the conditions that do not allow the virus to spread and substantial financial support to overhaul the present conditions. This is more important and practical than supplying ventilators. The Covid-19 pandemic requires a global response for the most vulnerable populations globally as well as locally in the UK (David Nott Lancet 1st May 2020)

    Another globally vulnerable group are prisoners. In all countries including the UK prisons are a risk being closed communities with people living in crowded and in some countries squalid conditions. Conditions are worse in countries led by leaders like Duterte and Bolsonaro. In the Philippines for example there are an estimated 215,000 prisoners in prisons built for a capacity of 40,000 and in Brazil 773,000 prisoners are crammed into prisons built for 461,000.

    Whether it’s parts of the world with conflict and humanitarian crises or populations suffering from repressive governments there is an urgent need for rich countries to invest in international organisations such as the UN, WHO, UNHCR, UNICEF and AID organisations to try to mitigate the risks that Covid-19 poses on top of already stressed social conditions. It is possible to act locally on health inequalities as well as show solidarity globally.

    So what?

    In our earlier blogs we have been critical of some aspects of the pandemic response in the UK. It is sad to note that the UK is heading to have the worst outcome in Europe with us starting our epidemic behind Italy, Spain and France when Covid-19 hit Europe. The Government have been too slow to take measures such as locking down London and the South East rapidly and should have continued testing, tracking and isolating across the country – especially where the number of cases has been low and well within the capacity of local resources. This would have built practical experience and we would have learnt valuable lessons.

    Now that we have more testing capacity we need to build the programme from the bottom up. Local public health teams in Local Government stand ready to provide local leadership teaming up with professional Environmental Health Officers (EHOs) who have the skills and local knowledge to provide local leadership. Resources need to be targeted at areas of greatest need as we have illustrated through the excellent ONS report. Certainly smart apps will play a part as well as national leadership from COBR on the key features of the test, trace and isolate programme. However there has arguably been too centralised and London based approach to pandemic management. The time is ripe to allow local authority public health, supported by specialist PH resources to work with their Local Resilience Forum (LRF) using their local skills and knowledge to try to bring the pandemic to heel using classic communicable disease control methods of epidemic controls. This will help eliminate the virus, protect the NHS allowing it to reopen for normal business and enable the economy to start up again as soon as practicable.

    Pandemics kill in three ways says Jonathan Quick of the Rockefeller Foundation:

    The Disease kills,

    Disruption of the health service kills

    and the

    Disruption to the economy kills”.

    3.5.2020

    Posted by Jean Hardiman Smith on behalf of the Officers and Vice Chairs of the SHA.

    Comments Off on SHA COVID-19 Blog 8

    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.

    1. 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).

    1. 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.

    1. 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.

    2 Comments

    The SHA started to publish its Covid-19 Blogs on the 17th March and since then have issued weekly blogs. It is extraordinary to reflect on this being our sixth commentary on the socialist health view of the unfolding global pandemic.

    In earlier Blogs we have covered many different topics and each Blog reflects on particular issues that have sprung up over the past week and identified as emerging issues. In this week’s Blog we will look at social care, testing, and possible steps out of lockdown.

    1. Social Care

    This has rightly hit the headlines over the past week as the plight of our care services and their residents have been under the media spotlight. We knew from the early data from China mid January that the C-19 virus seemed to particularly harm older people and particularly adults with underlying conditions such as obesity, diabetes, heart and lung disease. Mortality rates in these at risk groups is comparatively high and 90% of deaths in the UK have been in the over 60 year olds with half of these deaths being in people over 80 years old. This has led the UK government to define vulnerable groups and also those ‘very vulnerable’ people who need to be ‘shielded’ from exposure to the virus. The very vulnerable shielded groups are estimated to a number 1.5m and are self isolating indoors for 12 weeks. Many but not all of these very vulnerable people will be in residential or nursing homes.

    Having identified these at risk populations, attention needed to be directed towards those sub populations of older or vulnerable people who were living in residential or nursing homes. These institutions are high risk as ‘closed communities’ accommodating a group of high-risk individuals who would be at risk of an outbreak of C-19 within that setting.  Decisions have had to be made by the management of these residential and nursing homes to, in many cases,  exclude relatives from visiting.  Some brave and extremely committed care staff have decided to move themselves into the nursing or residential homes to reduce the risk of them bringing C-19 in from their own homes and local community. It cannot be a surprise to hear now about outbreaks in these establishments causing disease and death to workers and their residents. Again like other aspects of this pandemic response – we had early warnings from Italy and Spain about the isolation and risks that this sector faced. Did we do enough quick enough?

    SHA President Prof Allyson Pollock published an Editorial in the BMJ on the 14th April, which identified that social services in the UK are amongst the most privatised and fragmented in the world, and have been underfunded for decades. Between 2010 and 2018 local authority spending on social care in England fell by 49% in real terms. The UK has 5500 providers operating 11,300 care homes for older people and 83% of these care home beds are provided by the for-profit sector, it is more privatised than the US.

    She also reports that care services employ 1.6m care staff (1.1m full time equivalent) of which 78% are employed by the independent sector. Pay is low; 24% of people working in adult social care are on zero hours contracts, and in March 2019 around a quarter were being paid the national living wage of £7.83 an hour or less. The sector is 120,000 workers short, and agency staff, are commonly employed and move from care home to care home. Social care has been a low priority for PPE supplies despite the high risks for residents and staff.

    Valiant efforts have been made by the sector with heroism shown by these low paid workers as well as stoicism by residents, many of whom may well be bemused and depressed as to why they no longer have visitors as well as the unusual PPE equipment being used by staff. It will have been difficult to plan for the various contingencies when cases emerged in homes, to access testing of staff and residents, to successfully isolate cases and discuss whether residents should be moved to hospital to obtain extra levels of care. Such admissions to more resourced NHS facilities should be an option even if cases would not meet eligibility for ITU care or wishing to be subject to that level of intrusive care. There should be options available, rather than simply assuming appropriate care will be delivered in that setting by stretched staff with relatively few registered nurses, no medical presence on site and few resources of PPE and other equipment such as oxygen supplies, oxygen delivery equipment and monitors such as oximeters.

    The SHA has been concerned about the social care sector for years and has developed policies to transform the sector under the banner ‘rescuing social care’. At the 2019 Labour Party Conference the SHA called on a future Labour Government to legislate for a duty to provide a universal system of social care and support based on a universal right to independent living. This should be based on need and offering choice; be free at the point of use, universally provided and fully funded through progressive taxation. This new National Care Service (NCS) should ensure that there are nationally agreed qualifications for staff, a career structure and enhanced pay and conditions of service. Recognition of informal carers is needed too with clarity about rights and support. The policy proposal has many other facets and stops short of integrating the NCS with the NHS. However close working would be built in and integrating data and information into a common system would be expected.

    As for many of the issues that have arisen so far with the pandemic the social care sector has not been in a strong position to push back C-19. The underpaid staff, the high vacancies and the often unsuitable, adapted accommodation is rarely fit for modern care needs. The fragmentation of the sector with ‘for profit operators’ finding it hard with constrained funding has led to vulnerability in the sector as well as the residents. Maybe this will be the time that showed how, rather than a shiny green badge, the social care service should be taken into a publicly funded national care service.

    1. Tracking, Tracing, Testing, and Treating (isolating)

    One of the criticisms we have made of the Government’s pandemic response has been the decision on the 12th March to pull back from testing for cases in the community and contact tracing. It may turn out that this was a policy decision driven by the lack of availability of tests rather than a decision made not to control community spread. On the 24th February there had been 9 confirmed cases of C-19 in the UK and the WHO had announced that countries should ‘ prioritize active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantining of close contacts

    By the 22nd March there were 5683 confirmed cases and yet even then the WHO advice was ‘ find those who are sick, those who have the virus and isolate them. Find their contacts and isolate them’.  In outbreaks you do not always have confirmatory tests available but can make public health decisions based on the history and observation in the context of the unfolding epidemic. We seem to have forgotten the cardinal symptoms of continuous cough and fever.

    We have pointed out in earlier Blogs that countries that have been successful so far in controlling C-19 such as South Korea and Taiwan have been ones that have used widespread testing, tracing contacts and quarantining them. Germany has also been an example of a Western European country that has used this traditional communicable disease control methodology to save lives and protect their health service. Such a public health approach is most important in epidemics like this where there is no vaccine and no effective therapeutics other than sophisticated intensive supportive care.

    It is symbolic that the data that is presented at the daily press briefings has in the main used hospital testing data, hospital admissions and until recently exclusively hospital deaths. TV crews have been crawling over ITUs to get extraordinary footage of these wonderful NHS teams doing outstanding and stressful work. The incredible success of building Nightingale Hospitals in record time has been a reminder of the extraordinary efforts made in Wuhan to meet urgent need.

    However outside hospitals we have had the social care sector relatively unprepared, people self isolating in their homes and having to gauge the seriousness of their symptoms with intermittent telephone calls to NHS111. The disease has been spreading across the country from London to other metropolitan centres and then into smaller towns and rural areas. We could and should have shutdown London earlier as this has been our Wuhan. Local surveillance is limited and active contact tracing thought to be irrelevant even when many areas across England, Wales and Scotland had few cases. Environmental Health Officers in Local Government have not been mobilised. An opportunity missed.

    We have also seemed content to keep our airports and seaports open with little if no border health security. Again other countries who have managed to control this pandemic stopped and controlled air traffic, quarantining arrivals from high risk areas and making basic investigation on history (?cough) and taking travellers temperatures. Not difficult to do and look at Australia and New Zealand for actions on this source of new infections of a virus with high levels of transmissibility. In the UK it is estimated that over 190,000 people flew into the UK from China between January and March with no testing/quarantining.

    1. Evidence of unpreparedness

    The UK seems set to be one of the countries in Western Europe with the worst outcome in regards to mortality rates from C-19 despite the effectiveness of the NHS, which has withstood the pressure. We are often said to have an exemplar emergency planning system, the government had a pandemic as No. 1 risk on the national risk register, kept stockpiles and has computer modellers of world class.

    Yet we do not seem to have acted on the emergency planning exercises such as the 2016 Operation Cygnus (‘swan’ flu). We are now aware that in Sept 2017 the National Risk Register of Civil Emergencies reported that “There is a high probability of a flu pandemic occurring with up to 50% of the UK population experiencing symptoms, potentially leading to between 20,000 and 750,000 fatalities and high levels of absence from work’.

    There have been disclosures recently that are worth referring to that set out the timelines which showed the Prime Minister distracted and absent from COBRA meetings in January/February (A comprehensive countdown to how Britain came to have one of the highest COVID-19 per capita death rates – http://www.bylines.com). Also there has been an Insight team report for the Sunday Times on the 19th April 2020 (Coronavirus: 38 days when Britain sleepwalked into disaster). The current Secretary of State is an actor in this drama and the former Secretary of State for Health Jeremy Hunt who has been a critic of some aspects of the Governments response was of course in power during this time. We are told that ‘pandemic planning became a casualty of the austerity years when there were more pressing needs’ and ‘preparations for a no-deal Brexit sucked all the blood out of pandemic planning’

    1. Getting out of lockdown

    There are various scenarios that are being set out about how to get out of lockdown once the number of new cases decline and the first wave is thought to be ‘over’. This is likely to take time as the curve is flat and the proportion of the population with resistance is thought to be quite low. The government are hesitating about setting out the scenario and talking too much about the delivery of an effective, safe and tested vaccine. This usually takes 12-18 months and can never be guaranteed. They also are talking up the possibility of an effective drug therapy but we all know that viral illness do not lend themselves to highly effective drug treatments as we know with the Tamiflu debate after the 2009 H1N1 pandemic. So really we should again consider more immediate and classic public health control measures that have been shown to work in this pandemic.

    This will need health scrutiny and effective border controls that New Zealand and Australia have used successfully. There will within the country need to be effective systems of testing, contact tracing and quarantining with every day life respecting physical distancing and the use of facemasks. South Korea has shown the way that this can be enhanced and made more bearable by using mobile phones loaded with new technologies. These will warn people if at risk and disclose red, amber or green status. This will allow the economy to restart and people begin to get out and about again. The very vulnerable will in the early phases of this need to be protected.

    Prof Pollock in a recent BMJ editorial (Covid-19: why is the UK government ignoring WHO’s advice) states that ‘this means instituting a massive, centrally co-ordinated, locally based programme of case finding, tracing, clinical observation, and testing. It requires large teams of people, including volunteers, using tried and tested methods updated with social media and mobile phones and adapting the guidance published from China’ and other countries who are implementing such systems.

    This will require a change of mindset in government and from their medical and scientific advisers but as J.M.Keynes said:

    When the facts change, I change my mind. What do you do?”

    20th April 2020

    Published by Jean Smith on behalf of the SHA Officers and Vice Chair’s

    2 Comments

    SHA COVID-19

    Blog 5  

    12th April

    The Socialist Health Association (SHA) has published its weekly Blogs on the COVID-19 pandemic since the 17thMarch 2020. This provides a narrative of political and health issues over the past 5 weeks.

    A lot has happened over the past week and we will address some of these developments from our socialist health perspective.

    1. Situation update

    So far in our Blogs we have drawn attention to how the UK has been to slow to respond to the pandemic threat since the warnings from Wuhan started at the end of December 2019 and were confirmed in mid January 2020. This was despite the fact that an infectious disease pandemic ranks No 1 in the UK government risk register and we knew that this was a Sars like virus.

    The Tory government had not paid attention to the various simulation exercises that have been done over the past few years most notably Exercise Cygnus in 2016, during Jeremy Hunt’s time as SoS for Health. The exercise simulated ‘swan flu’ and showed that there was a serious risk that the NHS would be overwhelmed with lack of PPE and insufficient ITU beds. Recommendations to increase stockpiles were ignored in a time of austerity and PPE equipment such as face visors were evidently deemed too difficult to store. It is interesting to note that many of the facemasks have a use by date from before that time. Even as far back as the Swine flu pandemic in 2009 the relatively small number of ITU beds has not been addressed and we have seen how relatively low the NHS acute bed numbers, as well as the ITU beds/1000 population are comparatively. The government have it seems been more interested in preparing for Brexit at the end of January than for a real pandemic threat. Instead of building up stockpiles of ventilators and other equipment the government have had to turn in emergency to their friends such as Dyson and JCB but it is no surprise that delivery takes time as medical equipment needs testing and tough quality assurance.

    We have also pointed to the laisser faire approach to this pandemic even after it became a global threat. The scientific advisory group ‘modellers’ had by late February warned the government that the country faced the possibility of suffering 500,000 deaths from Covid-19. So at this time we knew that this was a virulent virus that was easily transmitted person to person and if not suppressed would spread within communities rapidly and seek to move out to new areas. The religious community in South Korea was a clear case of transmission from Wuhan and rapid spread within a religious community in Daegu. In mid February this was traced back to Patient 31 by their effective contact tracing and testing protocol. South Korea, to their credit, stamped on the virus and did not allow it to spread and has only had just over 200 deaths within its population of 52m who continue to enjoy freedoms outside lockdown.

    As the virus began to spread we saw countries closing their borders and screening people arriving from air or sea. New Zealand and Australia are examples of this tough policy and they have managed to keep the virus from penetrating the country at scale. New Zealand has had four deaths and Australia 60 by 12th April. The UK note is also surrounded by sea and with Ireland is a separate landmass from Europe but we have not introduced any significant border health checks at any time.

    In Europe we all watched with mouths open when health services in Lombardy were overwhelmed and people who had been on skiing holidays had already returned to the UK and started to spread the virus here. What actions did the Border Forces take? How actively did we follow up reports of fever and cough in returning travellers? Do we even now check peoples travel history and report symptoms on return to the UK? Our death rates now are moving to exceed Italian and Spanish rates and compete to be the worse in Europe.

    Some of the success of countries such as Germany and Denmark has been closing their borders and undertaking health checks, testing and advising quarantining/isolation if needed. Denmark closed the border on 13th March (final day of the UK Cheltenham Gold Cup meeting in the UK) and a few days later closed schools, universities and banned gatherings of more than 10 people. Denmark which, is a small country of only 5.6m, has had 273 deaths by the 11th April. Scotland in comparison with a population of 5.5m has already had 566 deaths. Denmark is now considering loosening the lockdown requirements whereas Scotland still fears new spread.

    However frightening Covid-19 virus is in terms of its effects on people it is a virus, susceptible to soap and water and unable to spread between human beings unless spread by aerosol or droplets by coughs and sneezes or hand to face contamination. Basic communicable disease methodologies work – hence the WHO advice to test, trace and treat by isolation. No need to rely exclusively on mathematical models but tried and tested methods of infectious disease control measures. We hear very little of the most basic ‘tests’ namely asking people about their contact history and what symptoms they have. In the early days of this pandemic we had all heard about the cardinal symptoms and signs of Dry Cough and Fever. In the current situation that is enough for classification as a possible if not probable case. This then needs follow up with an antigen PCR test to confirm. Tracing other contacts and testing them and all contacts need to be isolated/quarantined. We realise that we have missed the boat now but should acknowledge that this is basic public health methodology in use for decades but not used here even at the start of the epidemic spread in the UK. Public Health trainees were often told – use more shoe leather than computer software when involved in outbreak management. The UK seems to be bemused by other countries testing temperatures with thermal imaging meters or checking if people have stayed in isolation as advised. God forbid people wearing face masks either!

    In earlier blogs we have also referred to the reluctance to learn from policies in countries that have been successful in suppressing the pandemic. Take facemasks, which are used widely in Asian countries, who have had success in controlling spread. It just seems to make sense (have face validity) that a virus transmitted from nose and throat to others would be hindered in person to person spread if everyone was wearing a face mask. A recent review by the respected evidence based group in Oxford recommends the precautionary principle in a time like this. The CDC in the US is recommending the use of facemask too especially as we look to reducing lockdown rules. Rather than say we need a randomised control trial – just do it! Of course in the UK it is almost impossible to buy quality facemasks, hand sanitiser gel or often latex gloves!

    The situation we find ourselves in is that PPE seems to be rationed and sadly there remain reports from NHS and social care clinical staff that they cannot get proper PPE supplies. Again we see TV reports of other countries in the world where many essential workers –non health care providers have access to PPE equipment which reassures them and is symbolic to others about the risk of cross contamination. Our bus drivers and other public facing non-NHS public servants have been exposed to risk.

    The government has struggled with scaling up the logistics and thanks to the Armed Forces supplies are getting through. However Public Health England (PHE) who were fast off the blocks once the Chinese Government shared the genome of Covid-19 have been unable to seriously scale up the PCR testing capacity. It remains to be seen whether the 100,000 tests by the end of April will be delivered. It is said by management consultants – ‘Never promise more than you can deliver’. It is also recommended; ‘don’t stretch the truth’. We have sadly seen this transgressed by Matt Hancock promising the ramping up of testing, supply of PPE. His boast of purchasing 3.5m antibody tests before they have been shown to be valid is embarassing. Reminds us of the Brexit Ferry contract from a company that had never managed a Cross Channel Ferry service.

    The vaccine is of course much more important than the antibody test and we applaud the progress that researchers have made but do caution that we should not promise more than can be delivered. A safe and effective vaccine requires safety and effectiveness trials and this all takes time.

    1. Inequalities and risk factors

    One of the striking findings of this pandemic is the susceptibility of Black and Minority Ethnic (BAME) groups to the virus. It has been striking that the first group of doctors who have given their lives to the virus have been Black or South Asian heritage. Some of the areas where the NHS has had pressures are also areas with relatively high Asian populations (Brent, Luton, West Midlands). This risk factor will of course have social, economic and cultural determinants alongside some biological factors such as a higher risk of diabetes and cardiovascular disease. There are very few health conditions where socio-economic factors do not affect incidence and prevalence. The two hospital porters from Oxford who died recently of Covid-19, were out sourced workers, both of Filipino heritage and like doctors and nurses exposed to risk at work. Their NHS fellow workers allegedly offered to share PPE in the early stages of the pandemic!

    We are familiar with the social gradient of disease and death. So it is no surprise that in the USA we are also seeing African American citizens are losing their lives disproportionately. For example in Michigan 15% of the population is black, but account for 40% of the deaths. Chicago has a 30%  African American population and this group have a 70% death rate. These ratios are also reflected in Louisiana in the deepsouth, especially New Orleans, where the Mardi Gras celebrations continued regardless of the pandemic.

    These global health inequalities will also be mirrored in Africa when the virus moves down that continent. Think of our discourse about the dearth of PPE and medical equipment such as ventilators. In the Central African Republic of the Congo (CARC) with its 5m population it is estimated that they have 3 ventilators. On the international market prices have responded to demand. Costs of a ventilator on the market have jumped from $9000 to $20,000 over the past few weeks. The CARC‘s GDP/capita is $1.3 per day with very poor health infrastructure.

    It is good to hear that the British Government has donated Aid to the UN and WHO to support Low and Middle Income Countries combat the pandemic. It is in all our interest that these countries and their people weather the storm. One World and Planetary Health – we are all mutually dependent.

    1. 3. Political Leadership

    One of the issues that has emerged through the experience so far with this public health emergency is the quality of political leaders. We have already drawn attention to Denmark with Mette Frederiksen who is a woman and the country’s youngest–ever PM. Last week we referred to Angele Merkel’s clear leadership in Germany, which is doing extremely well so far in controlling Covid-19. Think too of Jacinda Ardern the Labour Prime Minister in New Zealand who in her short time as PM has had to deal with three different emergencies – the Mosque massacre, the Whakaari/White Island volcanic eruption and now the Covid-19 pandemic.  She has provided exemplary leadership by going hard and going early. She placed the country in total lockdown on the 25th March and softened the blow by using a slogan – ‘be kind’. Epidemiologists have praised her ‘brilliant, decisive and humane leadership which has seen New Zealand achieve a remarkably efficient implementation of the elimination strategy. Of course the country will still be susceptible to Covid-19 but the health protection measures have worked so far and unlike the UK will not have such high death rates/population.

    1. A great science policy failure?

    Richard Horton, Editor of the Lancet, has said that the global response to Sars-CoV-2 is the greatest scientific policy failure in a generation. The signals were clear. Hendra in 1994, Nipah in 1998, Sars in 2003, Mers in 2012 and Ebola in 2014; were all caused by viruses that originated in animal hosts and crossed over into humans. Covid-19 is caused by a variant of the same coronavirus that caused Sars. The US Institute of Medicine (IOM) in 2004 concluded that; “the rapid containment of Sars is a success in public health, but also a warning. If Sars recurs health systems worldwide will be put under extreme pressure and continued vigilance is vital”

    The IOM report quoted Goethe:

    Knowing is not enough; we must apply.

    Willing is not enough; we must do”

    Sadly we have known about this threat since Sars emerged in 2003 and we have undertaken simulation/emergency planning exercises as recently as 2016 which tested resilience for ‘swan flu’. However it looks like we did know but we did not act.

    13.4.2020

    Posted by Jean Smith on behalf of the SHA Officers and Vice Chairs.

    2 Comments

    The Socialist Health Association (SHA) published its first three Blogs on the COVID-19 pandemic weekly since the 17thMarch 2020. A lot has happened over the past week and we will address some of these developments from our ‘politics and health’ perspective.

    1. The global crisis

    The pandemic continues to spread around the world and we are seeing that while Europe remains a global hotspot the new epicentre has now shifted to North America.

    New York Governor Cuomo is showing some visible leadership and filling some of the space that the President should be in. It was always the case that the private health system in the USA would not be able to present a joined up emergency response and primary care has never been strong either in the States. The CDC in Atlanta has, like the UK public health system, been starved of funds during Trump’s Presidency but more alarmingly their advice has been ridiculed and ignored. Compare this to when the USA public health system, under President Obama, supported the international effort to control the Ebola outbreak in West Africa?

    President Trumps best friend Mr Modi has declared a 3 week lockdown across India and in the process condemned millions of migrant workers to walk without adequate food or water hundreds of kilometres back to their rural villages. These dreadful scenes include police spraying them with disinfectant and stories of pushing wheelchair bound people 25 miles each day. Such news reports are matched only by the sealing off of ghettos areas in big cities such as Mumbai and Kolkata. Looking at how these people in dire poverty live without adequate housing, drinking water, food and sanitation is heartrending. Consider our government’s guidance on staying at home, washing hands and social distancing makes the prospect of widespread community spread, illness and death in these slums an absolute certainty. Let us hope that Modi’s BNP party do not further  fuel anti Muslim feeling in these poor and excluded communities.

    So Africa will be next and looking at Lagos with a population of 21 million with a large shanty town and Kinshasa in DRC at 11 million there will be vulnerable populations with inadequate sanitation and housing for the virus to spread exponentially. African economies are characterised by local markets which like India are very crowded, in narrow streets where people struggle against various motor and animal vehicles as well as packed buses and taxis. The WHO and UN as well as the IMF/World Bank need to urgently do what they can to help African governments mitigate the worst consequences of the pandemic, which includes harmful longterm economic impacts. Many African countries remember have over the last 5-10 years enjoyed solid growth in their GDPs.

    The pandemic will harm the poor more than the rich and although as Michael Marmot noted recently – at the beginning of a pandemic both prince and pauper are infected but over time the social conditions that the poorer populations are living and working in will mean that they suffer most. Securing income to live on for the many and somewhere to shelter for the homeless will be an urgent part of our pandemic response.

    1. The European picture

    So what can we learn about how the pandemic is affecting Europe? The first thing to note is of course that Italy and Spain are and have been suffering badly with high numbers of confirmed cases and deaths reported. In parts of the country both their hospital systems have been overwhelmed with health care staff succumbing to the infections and overall death rates being high. The pictures of patients on corridor floors and overcrowded trolleys is distressing as are the reports of nursing homes left to their own devices exposing staff and residents to mortal danger. We do need to ensure that mutual aid is respected in the UK to avoid NHS hospitals becoming overwhelmed as this is dangerous and hugely demoralising.

    Why is Germany apparently riding the storm better than their southern neighbours? The simple answer seems to be that they were better prepared than we are and have sufficient testing capability across the country, have a sound public health system at a national and federal level, sufficient numbers of hospital beds and ITU capacity, and supplies of PPE/ventilators to handle the load. There seems to be a better link between the national government and the federal institutions able to undertake public health action locally. There have been criticisms in the UK of the lack of coherent leadership at regional public health in England who are linked into the NHS and local authorities. The devolved system of national governments gets more coherence via the CMO roles at UK level and their links to First Ministers of devolved government.

    Recent reports show that Germany with 97,000 confirmed cases has had 1,478 deaths compared to the UK’s 48,000 confirmed cases and 4,932 deaths (18 deaths/million population compared to the UK 65 deaths/million at this point in the pandemic). Compare these rates to Italy and Spain who have been ahead of us in terms of epidemic spread at 259 deaths/million and France at 117 deaths per million.

    We have raised questions in earlier Blogs about the preparedness of the UK for a pandemic and the constraints on testing capacity, the shortage of adequate PPE for frontline staff and the inadequate supply of acute hospital beds (Germany 601 beds/100,000 and UK 211 beds/100,000) never mind ITU staffing and beds. We obviously commend the rapid building of the Nightingale Hospitals, which will be able to receive ventilated patients thus relieving local hospitals. We are pleased to hear too that the Abu Dhabi based owners of the Excel centre are withdrawing their charge of £2-3m per month for the venue, which would have been empty during the pandemic. We also commend the NHS for its preparation by increasing ITU capacity and redirecting staff usually working in other specialties. Let us investigate how the private hospitals are charging the NHS for access to their beds and facilities – our position has always been – requisitioned in a national emergency.

    The private hospital sector in the UK will be protected through the pandemic unlike other businesses. Large players such as Circle Health and BMI have been making a loss in 2018/9 amounting to £12m for BMI and Circle’s £14m. During the pandemic they faced economic disaster as their Middle East customers and the NHS elective care referrals ceased. These private health care companies are controlled by US health insurance companies and private equity funds. Another large group, Spire hospitals, lost £24m in 2018. Spire’s share price jumped 15% on Matt Hancock’s announcement! The Wellington and Portland Hospital, owned by US group HCA, lost £74m last year and will also be pleased to have access to taxpayers’ money. It remains to be seen under ‘open book accounting’ how the expenditure will be audited. Note that the best paid executives at Circle, BMI, Spire and HCA earned £377,000, £452,000, £615,000 and £711,000 respectively according to Private Eye sources!

    1. The UK

    The NHS has been making huge efforts to be as prepared as possible for the potential tsunami of COVID-19 cases. With the lockdown A&E departments have been relatively quiet and with elective care suspended and no visiting for inpatients many hospitals outside of London/Birmingham/Newport have been eerily quiet. Healthcare staff have been trained up to undertake different roles in anticipation of patients being admitted who require respiratory support – this seems to be the main serious impact of Covid-19. Let’s not forget however that heart attacks, strokes and childbirth will continue to occur, as will the treatment requirements of cancer patients.

    In previous blogs we have referred to the care sector and how important they are in managing the pandemic. The recent guidance on PPE has clarified some of the queries and enabled more staff to feel more protected than before. However the supply of PPE to front line staff remains patchy and with the death toll rising of healthcare workers the government must ensure that supplies are readily available for community nurses and care workers as well as social care staff in the residential and care home sector.

    While it is absolutely necessary to be transparent about the evidence of benefit from ventilation we do not think it humane or ethical to have strict age-based criteria for decisions to admit to acute hospitals for assessment. Frailty criteria published by NICE, for suitability for ventilation are of course necessary but the reports of people being coerced to sign Do Not Resuscitate (DNR) advanced directives is very dangerous and will lead to the perception that older and disabled people are being denied hospital treatment. Residential and Nursing Homes will also feel that they are being left to manage very ill residents who are on an end of life pathway without adequate resources and safeguards for staff. The same feeling will apply if domiciliary patients are transferred to nursing homes with a Covid diagnosis in large numbers. This is a very sensitive policy area, which needs careful consideration and an investment in resources to mirror that provided to NHS hospitals and the new Nightingales. There have already been examples of nursing homes having to deal with a relatively large number of residents with Covid-19.

    1. Looking forward

    The pandemic will sadly spread across the UK from its hot spots in London, the West Midlands and Gwent. The government is being held to account for its failures in preparation – perhaps more attention to Brexit than Pandemic planning! The slow response has been noted, the lack of scaling up of testing and the poor logistics on PPE stand out in the story so far.

    We still sense a racial/culture hostility to widespread use of masks yet many Asian countries that have controlled the spread have used them widely. We look forward to the WHO reviewing the evidence. The virus is transmitted from and to the nose and throat, so it does seem that there is a case that face masks have a role to play. However facemasks have not been available in the UK for weeks and have in a sense been rationed to health and social care staff!

    As we have pointed out even without the widespread use of facemasks Germany has shown us the benefit of sound preparation, supplies and capacity in their health system and we need to learn that lesson from our European partner. Austria is already planning its exit from lockdown. There has also been clear political leadership in Germany without chopping and changing with promises announced almost daily as we have seen here.

    The exit plan needs to be addressed and in the same way that we have not treated London as our Wuhan we do need to nuance our policies to match regional/metropolitan differences in where the pandemic has occurred and the readiness to relax the lockdown based on testing evidence of community immunity, protected populations and overall resilience.

    Posted by Jean Smith on behalf of the Officers and the Vice Chairs of the SHA.

    Comments Off on SHA COVID-19 Blog 4

    The Socialist Health Association (SHA) published its first two Blogs on the COVID-19 pandemic on the 17th March and 24th March 2020. A lot has happened over the past week and we will address some of these developments from our political perspective.

    1. A global crisis

    The pandemic continues to spread around the world and we are seeing that while Europe remains a global hotspot the epicentre is now shifting to North America. It remains to be seen how the Trump administration ‘handles’ the situation but global leadership and best practice will not emanate from the White House and we will need to look to those progressive State and City level leaders in New York City and California for examples of political leadership in a crisis.

    The astonishing successes in tackling the pandemic seen in the Far East should still be sources of practical evidence of good practice. Despite the concerns about transparency in the Chinese system it remains an extraordinary achievement to have controlled the spread from the centre of Wuhan (population 11m) to be contained within Hubei Province (population 58m). A bit like London and the rest of the UK! The 1.4bn population of China have so far been exposed to relatively minimal spread. Some of the urban populations in China are huge such as Shanghai’s 24m people and the density and housing would be vulnerable to the spread of C-19. Our government talk of ‘contain’ and ‘delay’ and ‘suppress’ the coronavirus – well there is much to learn from Asia.

    Whenever we see TV footage of the Chinese control measures, staff in public places are gowned, have masks and/or goggles and gloves. Clearly there is no shortage of PPE in China! Frequently you see officials challenging people in the streets and checking temperatures with the thermal imaging meters. Of course these screening measures are imprecise and the scientific evidence to support them is thin but we were told in the UK that the two key questions were – have you got a fever or a dry cough? We know that many people are symptomless when they first contract the virus and can be infectious but this does not rule out basic questions such as these delivered by lay workers to protect others in the streets/shops/surgeries/workplaces? People who have symptoms of a cough or fever are referred to diagnostic pods for advice and further testing. This does seem to be good public health control and is also used at airports and seaports, which have been pretty absent in the UK.

    Test, test, test was the refrain from WHO leader Dr Tedros A. G. and one of the countries that has shown success in controlling the spread of C-19 is democratic capitalist South Korea where the population of 52m has had 9,583 confirmed cases with only 152 deaths by the 29th March. They have led the world in PCR testing for the presence of the virus with an estimated 316,000 tests done by 20th March. Germany is close behind with 167,000 tests done and the UK trails behind at 64,000 by the 19th March. It is basic communicable disease control methodology to identify probable cases by the history (symptoms/signs) and then have a test to confirm the case. If positive then there is contact tracing and cases are quarantined. It is still not clear why the PCR testing capacity was not scaled up in the UK during the time between the middle of January when the RNA code of COVID-19 was shared worldwide and March when demand for testing and containment accelerated. This is one of the key questions for the enquiry after the pandemic is over.  The relative lack of testing capacity has made the control measures here more difficult. The cases recorded here have, since abandoning the contain phase, been those presenting to hospitals rather than measuring the incidence in the community.

    Attention is now moving towards rolling out the second test – the ‘have you had it?’ antibody test. This will not help in the early stages of the illness but will help confirm that people have actually had C-19 and will in most cases have immunity to the virus. This will give more confidence for NHS and Social Care and other essential workers to return confidently to their workplaces. This is in the evaluation stage but should be available soon and hopefully will not be held up. Getting scarce NHS and Social care workers, and other essential workers back to work is extremely important as is protecting them at work from contracting infections.

    The pandemic is gradually spreading to India and down the African continent too. This will expose more at risk populations living on the edge economically, often in poor and unsanitary housing. We know that infection control measures will be difficult to undertake and the health services remain relatively weak in LMICs. As ever, social determinants of health and wellbeing will emerge as factors and the mortality will reflect the global inequalities we already know about.

    So it was good to learn on the 25th March that the G7 countries have stated their support for the UN and WHO and committed some resources to help tackle the pandemic. The UK has offered £240m which if mirrored by other G7 countries will not get very far towards the WHO target of £71 billion for the immediate public health response and priority research. Lets hope that sufficient resources will flow but sadly the richest country in the world (USA) has had a recent track record of disinvesting from global organisations such as the UN and WHO.

    As in the previous Blogs we support the research into novel treatments and the development of a vaccine but not to let that divert us from trying to delay the spread of the virus across our country by enforcing the stay at home and lockdown measures. We should continue to apply basic public health control measures, even within households, of isolating symptomatic people, strengthening hand washing and hygiene measures.

    We also welcome the action that has been taken by some Local Authorities to provide accommodation for the homeless and rootless and also providing them with food and places to stay during the day, which reduces spread amongst this very vulnerable population. Lets make some of these initiatives set the pattern for tackling this issue in the post pandemic age.

     

    1. 2. The NHS and Social Care

    The NHS has been ramping up their preparedness and we welcome the use of private facilities as part of the national response although we prefer that this is seen as requisitioning and not a favourable commercial contract for the private sector. We also welcome the creation of the emergency Nightingale Hospitals built in Conference centres and sports stadia in London, Birmingham, Manchester, Glasgow, Belfast and Cardiff . These new beds will be purpose built for COVID-19 caseloads but we note that they will need to be staffed by trained nurses and doctors. These new beds must be seen alongside the closure of an estimated 33,000 beds since 2008/9, which has weakened the NHS resilience and made the UK one of the European countries with the lowest beds/1000 population. For example Eurostat data for 2017 identifies ‘curative beds/100K population’ and shows that Germany had 601, France 309, Italy 262, Spain 242 and the UK 211. It is no surprise then that we see intensive care patients being airlifted from Italy and France to Germany. Germany’s testing control measures and its hospital bed capacity is part of the explanation for them appearing more in control of the situation with currently a comparatively low death rate.

    We have seen a massive shift in the way that GP services are provided and how GPs and patients are adapting to telephone and videoconferencing. GPs are also playing a vital role in advising and supporting those receiving community care and have long term conditions. These vulnerable patients will be well known to their primary care teams and reliant on being able to get advice. It goes without saying that out of hospital care will be vital during the time when local acute hospitals are stressed with redesigning services to deal with acutely ill COVID-19 patients.

    In terms of overall preparedness one does wonder whether the NHS was more prepared for Brexit than a pandemic!

    The social and residential care sector in the UK will be a vital player as the pandemic rolls out with its particular risk for older people. The dynamic between social care and the NHS will be important as the NHS struggles and the transfer/admitting/discharge criteria change. Already the NICE guidance on criteria for intensive care has identified frailty explicitly as an issue to assess suitability to admit a patient.

    As with other key services social and residential care staffing will be a challenge as recruitment and retention issues increase and staff stay off work to self isolate. The guidance on personal protective equipment (PPE) is being actively reviewed and both NHS and Social Care staff in the Community must be provided with appropriate protective equipment to match the cases that they are assessing in the community or actually caring for. This will become more important for primary care clinicians as well as social care staff asked to look after acute COVID-19 patients or those discharged for hospitals.

     

    1. Jobs and income

    Clearly the pandemic has driven a coach and horses through the economy. The Chancellor’s proposals have been helpful and the proposals for the self -employed has moved a long way toward providing some security for this sector. The gig economy however is more difficult and the benefit system has been shown to be inadequate as a place to go for this group of workers. The SHA still feels that there is an opportunity to trial universal basic income as a mechanism to provide all citizens with assurance of having enough income for their health and wellbeing.

    There are also concerns that without close Parliamentary scrutiny there are risks that the Tory government will award contracts to their people and the State revenues will be subject to fraudulent claims from off shore companies and global players who have been able over the years to duck paying tax. The SHA has always viewed a progressive tax system to be the route to funding necessary services and that tax dodging should be rooted out.

    There may be a case now for a form of  Parliamentary scrutiny so Labour Shadow Ministers have sight of the details around awarding such huge amounts of public money to companies run by the Bransons and Dysons of this world. There is a positive movement underway shown by the selfless work of health and social care services and other essential workers. It is also exhibited by the clapping applause last Thursday and the 750,000 volunteers.

    There should be an opportunity as we come out of this crisis to lay the foundations for a different type of society in the same way that after WW2 the incoming Labour party brought in such great reforms as creating the NHS and introducing State Education.

     

    On behalf of the Officers and the Vice-Chairs of the SHA.

    2 Comments

    The Socialist Health Association (SHA) published its first Blog on the COVID-19 pandemic last week (Blog 1 – 17th March 2020). A lot has happened over the past week and we will address some of these developments using the lens of socialism and health.

    1. Global crisis

    This is a pandemic, which first showed its potential in Wuhan in China in early December 2019. The Chinese government were reluctant to disclose the SARS- like virus to the WHO and wider world to start with and we heard about the courageous whistle blower Dr Li Wenliang, an ophthalmologist in Wuhan, who was denounced and subsequently died from the virus. The Chinese government recognised the risk of a new SARS like virus and called in the WHO and announced the situation to the wider world on the 31st December 2019.

    The starter pistols went off in China and their neighbouring countries and the risk of a global pandemic was communicated worldwide. The WHO embedded expert staff in China to train staff, guide the control measures and validate findings. Dr Li Wenliang who had contracted the virus, sadly died in early February and has now been exonerated by the State. Thanks to the Chinese authorities and their clinical and public health staff we have been able to learn about their control measures and the clinical findings and outcomes in scientific publications. This is a major achievement for science and evidence for public health control measures but….

    Countries in the Far East had been sensitised by the original SARS-CoV outbreak, which originated in China in November 2002. The Chinese government at that time had been defensive and had not involved the WHO early enough or with sufficient openness. The virus spread to Hong Kong and then to many countries showing the ease of transmission particularly via air travel. The SARS pandemic was thankfully relatively limited leading to global spread but ‘only’ 8,000 confirmed cases and 774 deaths. This new Coronavirus COVID-19 has been met by robust public health control measures in South Korea, Taiwan, Hong Kong, Japan and Singapore. They have all shown that with early and extensive controls on travel, testing, isolating and quarantining that you can limit the spread and the subsequent toll on health services and fatalities. You will notice the widespread use of checkpoints where people are asked about contact with cases, any symptoms eg dry cough and then testing their temperature at arms length. All this is undertaken by non healthcare staff. Likely cases are referred on to diagnostic pods. In the West we do not seem to have put much focus on this at a population level – identifying possible cases, testing them and isolating positives.

    To look at the global data the WHO and the John Hopkins University websites are good. For a coherent analysis globally the Tomas Peoyu’s review  ‘Coronavirus: The Hammer and the dance’ is a good independent source as is the game changing Imperial College groups review paper for the UK Scientific Advisory Group for Emergencies (SAGE). This was published in full by the Observer newspaper on the 23rd March. That China, with a population of 1.4bn people, have controlled the epidemic with 81,000 cases and 3,260 deaths is an extraordinary achievement. Deaths from COVID-19 in Italy now exceed this total.

    The take away message is that we should have acted sooner following the New Year’s Eve news from Wuhan and learned and acted on the lessons of the successful public health control measures undertaken in China and the Far East countries, who are not all authoritarian Communist countries! Public Health is global and instead of Trump referring to the ‘Chinese’ virus he and our government should have acted earlier and more systematically than we have seen.

    Europe is the new epicentre of the spread and Italy, Spain and France particularly badly affected at this point in time. The health services in Italy have been better staffed than the NHS in terms of doctors/1000 population (Italy 4 v UK 2.8) as well as ITU hospital beds/100,000 (Italy 12.5 v UK 6.6). As we said in Blog 1 governments cannot conjure up medical specialists and nurses at whim so we will suffer from historically low medical staffing. The limited investment in ITU capacity, despite the 2009 H1N1 pandemic which showed the weakness in our system, is going to harm us. It was great to see NHS Wales stopping elective surgical admissions early on and getting on with training staff and creating new high dependency beds in their hospitals. In England elective surgery is due to cease in mid April! We need to ramp up our surge capacity as we have maybe 2 weeks at best before the big wave hits us. The UK government must lift their heads from the computer model and take note of best practice from other countries and implement lockdown and ramp up HDU/ITU capacity.

    In Blog 1 we mentioned that global health inequalities will continue to manifest themselves as the pandemic plays out and spare a thought for the Syrian refugee camps, people in Gaza, war torn Yemen and Sub Saharan Africa as the virus spreads down the African continent. Use gloves, wash your hands and self isolate in a shanty town? So let us not forget the Low Middle Income Countries (LMICs) with their weak health systems, low economic level, weak infrastructure and poor governance. International banking organisations, UNHCR, UNICEF, WHO and national government aid organisations such as DFID need to be resourced and activated to reach out to these countries and their people.

    1. The public health system

    We are lucky to have an established public health system in the UK and it is responding well to this crisis. However we can detect the impact of the last 10 years of Tory Party austerity which has underfunded the public health specialist services such as Public Health England (PHE) and the equivalents in the devolved nations, public health in local government and public health embedded in laboratories and the NHS. PHE has been a world leader in developing the PCR test on nasal and throat samples as well as developing/testing the novel antibody blood test to demonstrate an immune response to the virus. The jury is out as to what has led to the lack of capacity for testing for C-19 as the UK, while undertaking a moderate number of tests, has not been able to sustain community based testing to help guide decisions about quarantining key workers and get intelligence about the level of community spread. Compare our rates of testing with South Korea!

    We are lucky to have an infectious disease public health trained CMO leading the UK wide response who has had experience working in Africa. Decisions made at COBRA and announced by the Prime Minister are not simply based ‘on the science’ and no doubt there have been arguments on both sides. The CSO reports that SAGE has been subject to heated debate as you would expect but the message about herd immunity and stating to the Select Committee that 20,000 excess deaths was at this stage thought to be a good result was misjudged. The hand of Dominic Cummings is also emerging as an influencer on how Downing Street responds. Remember at present China with its 1.4bn population has reported 3,260 deaths. They used classic public health methods of identifying cases and isolating them and stopping community transmission as much as possible. Herd immunity and precision timing of control measures has not been used.

    The public must remain focused on basic hygiene measures – self isolating, washing of hands, social distancing and not be misled about how fast a vaccine can be developed, clinically tested and manufactured at scale. Similarly hopes/expectations should not be placed on novel treatments although research and trials do need supporting. The CSO, who comes from a background in Big Pharma research, must be seen to reflect the advice of SAGE in an objective way and resist the many difficult political and business pressures that surround the process. His experience with GSK should mean that he knows about the timescales for bringing a novel vaccine or new drugs safely to market.

    1. Local government and social care

    Local government (LAs) has been subject to year on year cuts and cost constraints since 2010, which have undermined their capability for the role now expected of them. The budget did not address this fundamental issue and we fully expect that in the crisis, central government will pass on the majority of local actions agreed at COBRA to them. During the national and international crisis LAs must be provided with the financial resources they need to build community hubs to support care in the community during this difficult time. The government need to support social care.

    COVID-19 is particularly dangerous to our older population and those with underlying health conditions. This means that the government needs to work energetically with the social care sector to ensure that the public health control measures are applied effectively but sensitively to this vulnerable population. The health protection measures which have been announced is an understandable attempt to protect vulnerable people but it will require community mobilisation to support these folk.

    Contingency plans need to be in place to support care and nursing homes when cases are identified and to ensure that they can call on medical and specialist nursing advice to manage cases who are judged not to require hospitalisation. They will also need to be prepared to take back people able to be discharged from acute hospital care to maintain capacity in the acute sector.

    Apart from older people in need there are also many people with long term conditions needing home based support services, which will become stressed during this crisis. There will be nursing and care staff sickness and already fragile support systems are at risk. As the retail sector starts to shut down and there is competition for scarce resources we need to be building in supply pathways for community based people with health and social care needs. Primary health care will need to find smart ways of providing medical and nursing support.

    1. The NHS

    In January and February when the gravity of the COVID pandemic was manifesting itself many of us were struck by the confident assertion that the NHS was well prepared. We know that the emergency plans will have been dusted down and the stockpile warehouses checked out. However, it now seems that there have not been the stress tests that you might have expected such as the supply and distribution of PPE equipment to both hospitals and community settings. The planning for COVID-19 testing also seems to have badly underestimated the need and we have been denied more accurate measures of community spread as well as the confirmation or otherwise of a definite case of COVID-19. This deficiency risks scarce NHS staff being quarantined at home for non COVID-19 symptoms.

    The 2009 H1N1 flu pandemic highlighted the need for critical care networks and more capacity in ITU provision with clear plans for surge capacity creating High Dependency Units (HDUs) including ability to use ventilators. The step-up and step-down facilities need bed capacity and adequate staffing. In addition, there is a need for clarity on referral pathways and ambulance transfer capability for those requiring even more specialised care such as Extracorporeal Membrane Oxygenation (ECMO). The short window we now have needs to be used to sort some of these systems out and sadly the supply of critical equipment such as ventilators has not been addressed over the past 2 months. The Prime Minister at this point calls on F1 manufacturers to step in – we wasted 2 months.

    News of the private sector being drawn into the whole system is obviously good for adding beds, staff and equipment. The contracts need to be scrutinised in a more competent way than the Brexit cross channel ferries due diligence was, to ensure that the State and financially starved NHS is not disadvantaged. We prefer to see these changes as requisitioning private hospitals and contractors into the NHS. 

    1. Maintaining people’s standard of living

    We consider that the Chancellor has made some major steps toward ensuring that workers have some guarantees of sufficient income to maintain their health and wellbeing during this crisis. Clearly more work needs to be done to demonstrate that the self-employed and those on zero hours contracts are not more disadvantaged. The spotlight has shown that the levels of universal credit are quite inadequate to meet needs so now is the time to either introduce universal basic income or beef up the social security packages to provide a living wage. We also need to ensure that the homeless and rootless, those on the streets with chronic mental illness or substance misuse are catered for and we welcome the news that Sadiq Khan has requisitioned some hotels to provide hostel space. It has been good to see that the Trade Unions and TUC have been drawn into negotiations rather than ignored.

    In political terms we saw in 2008 that the State could nationalise high street banks. Now we see that the State can go much further and take over the commanding heights of the economy! Imagine if these announcements had been made, not by Rishi Sunak, but by John McDonnell! The media would have been in meltdown about the socialist take over!

    1. Conclusion

    At this stage of the pandemic we note with regret that the UK government did not act sooner to prepare for what is coming both in terms of public health measures as well as preparing the NHS and Local Government. It seems to the SHA that the government is playing catch up rather than being on the front foot. Many of the decisions have been rather late but we welcome the commitment to support the public health system, listen to independent voices in the scientific world through SAGE and to invest in the NHS. The country as a whole recognises the serious danger we are in and will help orchestrate the support and solidarity in the NHS and wider community. Perhaps a government of national unity should be created as we hear much of the WW2 experience. We need to have trust in the government to ensure that the people themselves benefit from these huge investment decisions.

    24th March 2020

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    COVID-19 Pandemic

    The SHA wants to contribute to the tremendous national and international debate about controlling and mitigating the worst effects of the COVID-19 pandemic. We will base these thoughts through the lens of a socialist society, which advocated politically in the 1930s to create the NHS in the UK and for other socialist policies, which see the social determinants of health being as important as the provision of health and social care services as we strive for a healthier and fairer society.

    This blog will be the first of a series and will cover

     

    1. A global crisis
    2. The Public Health system
    3. The NHS, Local Government and Social Care
    4. Funding for staff and facilities
    5. Staff training, welfare and support
    6. Vulnerable populations
    7. Assuring Universal Basic Income

     

    1. A global crisis

    This COVID-19 pandemic has already been cited as the greatest public health crisis for at least a generation. The HIV/AIDS pandemic starting in the 1980s had a much slower spread between countries and is estimated to have caused an estimated 25-30m excess deaths so far.  The potential scale of this type of respiratory viral infection pandemic with a faster spread means we should probably look back to the 1957 Asian flu pandemic and indeed the 1918 post war ‘Spanish flu’. The 1918 pandemic led to an estimated 40-50m global deaths and was when there was also no effective vaccine or treatment for the new variant of flu. So basic public health hygiene (hand washing), identifying cases and quarantining (self isolation) are still important. We recognise this as a global challenge, which requires global solidarity and the sharing of knowledge/expertise and advice.

    The WHO, which is part of the United Nations, needs our support and is performing a very beneficial role.  This will be especially important for those Low Middle Income Countries (LMICs) who often have unstable political environments and weak public health and health systems. Remember the Democratic Republic of the Congo who have only just seen off their Ebola epidemic, war torn Syria and the Yemen.

    The USA and other high-income countries should be unambiguous about recognising this as a fundamental global pandemic requiring collaboration between countries along the principles of mutual aid. The UN and WHO need our support and funding and we look to international financial organisations such as the IMF/World Bank to rally around in the way that the world banking system showed they could in their own self inflicted 2008 financial crash. The WHO has recently referred to Europe as the epicentre of the pandemic and we urge the Government to put aside their ideological objections and co-operate fully with the EU and our European partners.

     

    1. The public health system

    The UK itself is in a relatively strong position with a national public health service, which has focus at a UK level (CMO/PHE), scientific advisory structures (SAGE), devolved governments, municipalities and local government. The NHS too still has national lines of control from NHSE to the NHS in England and the equivalents in devolved countries. The Tory ‘Lansley’ reforms in England destroyed the health authority structure below national levels (remember the former Strategic and District Health Authorities) but at least PHE has a regional organisation and Local Government have Directors of Public Health. We regret the fact that the 10 years of Tory austerity has depleted the resources in PHE and Local Government through not funding the PHE budget adequately and not honouring the public health grant for local authorities. We hope that the recent budget will mean that the public health service and local government does receive the financial and other resources required to help lead the pandemic response. Pandemics have always been high up in the UK risk register.

     

    1. The NHS, Local Government and Social Care

    We are grateful that despite the privatisation of many parts of the NHS in England we still have a recognisable system and a culture of service rather than profit within our one million or so staff and their NHS organisations. We were pleased to hear the open ended funding commitment from the Chancellor at the last budget and urge that leaders within the NHS in England and the devolved countries use this opportunity to try to mitigate the underfunding over the last 10 years and implement the emergency plans that exist and calibrate them to deal most effectively with this particular viral threat. Any debates about further privatisation of the NHS needs to be taken off the agenda and let’s not use the budget money to prop up the private sector but requisition capacity if that is what is needed and compensate usage on an NHS cost basis. We want to protect the NHS from the risk that the NHS Long Term Plan proposals for 44 Integrated Care Schemes opens up the risk of US styled private insurance schemes.

     

    1. Funding for staff and facilities.

    It will of course be difficult as a result of the staffing crisis that has been allowed to drift over the past 10 years with shortages of NHS workforce of 100,000 of which 40,000 are nurse vacancies but also includes doctors and other key staff. We and our Labour Party colleagues have been reminding Tory Ministers  that it takes 10 years to train a medical specialist so you cannot whistle them up or poach them from other poorer countries. The government needs to abolish their proposed points based immigration regime and indeed the compulsory NHS insurance of £650 per adult which is a huge disincentive to come here and work in the health and social care system.

    Hospitals and other health facilities in the UK take time to plan, build and commission. We can of course learn from Wuhan in China where they built a 1000 bedded hospital in weeks! Our own war preparation in the late 1930s when industry shifted production rapidly from civilian to military supplies is another exemplar. Despite the negative impact of 10 years of Tory austerity we urge the NHS to embrace this opportunity to invest in staff, supplies and facilities needed to manage the effects of the pandemic. Creating strategic regional NHS bodies will ensure that capital and revenue resources committed from the centre are used optimally and equitable to meet population needs in collaboration with local authorities.

     

    1. Staff training, welfare and support

    Front line NHS and social care staff will need our support over this time. We must ensure that working practices protect staff as much as possible from the risks in the workplace. Training and provision of Personal Protective Equipment (PPE) is vital and employment practices will need to adapt to the changing situation. Lets not forget social care workers, dentists, optometrists and district nurses who are part of our front line. Staff will need retraining if doctors and nurses are to be diverted to unfamiliar roles as we will need A&E, pandemic pods and intensive care unit capacity to be enhanced. Sadly, we now have a significant workforce who work for private contractors as part of the Tory privatisation of the NHS. We need to ensure that they have the same employment safeguards, minimum pay levels, sick pay and the health and safety entitlements as NHS staff. This is the time to renationalise such services back into the fold.

     Patients with existing long-term conditions remain in need of continuing care as will patients presenting with new life-threatening conditions such as cancers, diabetes and circulatory diseases. NHS managers will need support to organise these different services and decisions to postpone non-urgent elective surgery to free up resources. What also makes sense is testing novel ways of supporting people digitally and by teleconferencing to reduce attendance at NHS premises. This can be rolled out for Out Patient provision as well as GP surgeries. The NHS 111 service, and other online services  and the equivalents in the devolved nations can easily be overwhelmed so pushing out good health information and advice is being done and needs to continue. The public and patient engagement has always been at the heart of our policies and can be rolled out in this emergency utilising the third sector more imaginatively.

     

    1. Vulnerable populations.

    In our assessment of what needs to be done we must not bypass the urgent needs of some of our most vulnerable populations. The homeless and rootless populations, many of whom have longstanding mental health conditions and/or substance dependency, are particularly at risk. They need urgent attention working closely with the extensive voluntary sector. Also those populations with long term conditions who will feel at risk if services are withdrawn due to staff redeployment or staff sickness need planning for. Primary care needs to be the service we support to flag up those in need and ensure that their medications and personal care needs continue to be met even if we need to involve volunteers and good neighbours to help out with daily needs such as shopping/providing meals and other tasks.

    Undocumented workers such as migrants and refugees are often frightened to use health services for fear of police intrusion. The government needs to make it clear that there will be no barriers to care for this population during this crisis and beyond.

    Social care is in need of particular attention. It was virtually ignored in the budget. This sector is at risk in terms of problems with recruiting and retaining staff as well as the needs of the recipients of care and support.. While business continuity plans may be in place there is no question that this sector needs investment and generous support at the time of such an emergency. They will be a vital cog in the wheel alongside home-based carers in supporting the NHS and wider social care system. Those most at risk seem to be the most neglected. Disabled people with care needs have received little advice and no support. Already carers are going off sick and can be replaced only with great difficulty. Those paying for their own care with Direct Payments seem to get no support at all.

    With the COVID-19 virus we are seeing that the older population and those with so called ‘underlying conditions’ are at particular risk. We must ensure that this large population do not feel stigmatised and become isolated. Rapid assembly of local support groups should be encouraged which has been referred to as ‘local COBRA groups’. Local government can play a key role in establishing local neighbourhood centres for information and advice on accessing support as we move toward increasing quarantining and isolated households. Again wherever possible the use of IT and telephone connectivity to share information and provide remote support will make this more manageable.

     

    1. Assuring universal basic income.

    Finally the SHA recognises that the economy will be damaged by the pandemic, organisations will go to the wall and staff will lose their jobs and income stream. We have always recognised that the fundamental inequalities arise from the lack of income, adequate housing and the means to provide for everyday life. This pandemic will last for months and we think that the Government needs to ensure that we have systems in place to ensure that every citizen has access to an adequate income through this crisis. We pay particular attention to the 2m part time workers and those on zero hours contracts as well as the 5m self-employed. There have been welcome changes in the timely access to the insufficient Statutory Sick Pay but this is not going to be the answer. People will be losing their jobs as different parts of the economy go under as we are already seeing with aviation, the retail sector and café/restaurants. The government needs to reassure those fearful of losing their jobs that they will stand by them during the pandemic. It may be the time to test the Universal Basic Income concept to give all citizens a guarantee that they will have enough income for healthy living. We already have unacceptable health inequalities so we must not allow this to get worse.

     

    1. Conclusion

    The SHA stands ready to support the national and international efforts to tackle this pandemic. We assert our belief that a socialist approach sees universal health and social care as an essential part of society. That these systems should be funded by all according to a progressive taxation system and meet peoples needs being free at the point of use.  We believe that a thriving state owned and operated NHS and a complimentary not for profit care sector is essential to achieve a situation where rich and poor, young and old and citizens in towns, cities and in rural areas have equal access to the best care.

    We recognise that the social determinants of health underpin our health. We agree with Marmot who reminds us that health and wellbeing is reflected by ‘the conditions that people are born, grow, live, work and age and by the inequities in power, money and resources that influence these conditions’.

    The pandemic is global and is a major threat to people’s health and wellbeing. Universal health and public health services offer the best means of meeting this challenge nationally and globally. Populism and inward looking nationalism needs to be challenged as we work to reduce the human suffering that is unfolding and direct resources to meet the needs of the people at this time.

    On behalf of officers and vice chairs

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