Coronavirus has taken the world by storm. It is very contagious and produces high fatality rates for a sizeable segment of the population. Crucially, it also produces mild and asymptomatic illnesses, and can be transmitted by asymptomatic and pre-symptomatic individuals. This makes it a difficult disease to control and the government has rightly sought scientific, medical and public health expertise, establishing a Scientific Advisory Group for Emergencies (SAGE) to advise.
However, some public health experts and scientists are unclear about what exactly the government’s strategy is, making it difficult to have a coherent scientific and moral debate about current plans. There are three separate but connected strategies to consider, related to: i) the disease; ii) the health system; and iii) the social and economic impacts.
When it comes to the disease, released SAGE documents and interviews given by the Chief Scientific Adviser and others indicate that the government accepted the inevitability of an epidemic. The strategy thereby consisted of mitigating the impact of COVID-19 by ‘flattening the epidemic curve’ and hoping for the emergence of some population-level ‘herd immunity’, while seeking to protect high-risk groups and working towards the development of a vaccine and effective treatments.
Two other aspects of reasoning informed the government’s strategy. Firstly, the view that the draconian disease control measures required to suppress the epidemic would not be sustainable or tolerable for long periods of time. Secondly, concern that a second epidemic wave would occur once draconian measures were relaxed or stopped being effective, especially if there was insufficient herd immunity. In giving evidence to the Science and Technology Committee (STC) of parliament on March 25th, Sir Patrick Vallance noted that the second wave of the 1918 Spanish flu epidemic caused more deaths than the first wave.
The imposition of ‘lockdown’ measures on March 23rd, which brought the UK in line with the approach in other countries, has been seen by some as a change in strategy or a belated response. Indeed, the Imperial College modelling report produced in mid-March for SAGE stated that “suppression is the only viable strategy” due to the realisation that mitigation would be insufficient to prevent the health system from being overwhelmed.
While there is no longer explicit mention of ‘herd immunity’, there are reasons to think that this is still part of the government’s thinking. The current plans to suppress community transmission have gaps, which suggests a willingness to accept some continued transmission, albeit at a lower rate. Ongoing concerns about a second-wave epidemic and emphasis on expanding antibody tests (not viral or antigenic tests) also suggest an interest in building up herd immunity. In giving evidence to parliament’s STC, Vallance also indicated no significant change in government strategy.
When it comes to the NHS, the government’s strategy is more unclear. Even though the government appeared to have accepted the inevitability of a COVID-19 epidemic, there are no indications that the NHS was adequately prepared. The Imperial modelling report also suggests that the key issue of insufficient ICU bad capacity was only fully grasped in March, when action to increase ICU capacity, provide PPE for frontline staff, and expand testing capacity was thankfully accelerated. The government is now growing capacity in the NHS as quickly as it can, while also contracting the private hospital sector to boost capacity (though there are concerns about the price being paid by the state to do this).
It’s hard to understand the reasons for such belated planning, given the various reports and studies about pandemic preparedness that followed the swine flu and Ebola epidemics. But undoubtedly, structural weaknesses within the health system – produced by austerity, marketization and constant restructuring – have diminished the capacity for rapid and effective planning and mobilisation, especially in England.
This has been compounded by three changes that have weakened public health capacity: first, the abolition of the Health Protection Agency (a parastatal organisation with a dedicated health protection mandate) and its replacement with Public Health England (an agency with a broader remit, less independence from government, and greater distance from the NHS); second, the shift of several public health functions into local government at a time when it was experiencing huge budget cuts, resulting in public health workforce reductions; and third, the weakening of the health system’s area-based structures, which hinders the ability to coordinate and plan services according to clearly demarcated areas – a problem made more acute by the increasingly fragmented and competitive nature of the health provider landscape.
The government’s social and economic strategy for COVID-19 is even harder to discern. The SAGE documents provide a limited social and economic analysis: concerns about the willingness and ability of the population to adhere to disease control measures were fed into the disease control strategy; and subsequent to the ‘lockdown’ being implemented, the government has taken important measures to cushion the effects of a partial economic shut-down on households and businesses, and is making efforts to address food supply issues, especially for those deemed vulnerable and at-risk.
But a comprehensive and bold social and economic strategy is now important, and needs to address multiple and complex challenges. Mass quarantine, travel restrictions, school and university closures, unemployment, and economic recession can also cost lives. How do we weigh this up against the harms caused by the virus, and make choices between competing calls on limited resources?
It is also unclear who is going to pay for the government’s fiscal interventions. Will we see, for example, another round of austerity imposed on the population and public services? Will COVID-19 contribute to the further widening of social inequalities, and provide the financial sector with another opportunity to exploit the chaos and damage of a crisis? Or will the costs of COVID-19 be paid by redistributing the extreme levels of concentrated private wealth towards public budgets and the rest of society?
So, what should be done now that we are where we are?
When it comes to COVID-19, it’s important to recognise that we are still in relatively uncharted waters with many uncertainties and unknowns. We don’t know if we can eliminate or control this virus to an acceptable level, without it costing too much. Presently, a stringent and population-wide lockdown is necessary to reduce transmission and prevent the health system from collapse. However, this cannot be sustained for long. Experience from elsewhere suggests that we could find less damaging ways to control the epidemic by focusing on two new directions of travel.
First, the government has adopted a UK-wide approach to the epidemic (albeit with some significant variance across the home nations), ignoring the critical spatial dimension present in all epidemics. Area-specific socio-cultural, demographic, economic and geographic factors that influence the pattern of transmission means that there are really multiple outbreaks and mini-epidemics occurring across the country. This calls for more of a decentralised and regionalised approach to COVID-19 control with explicit regional leadership and area-based plans that can ensure a more tailored and sophisticated approach to COVID-19 control, especially if supported by a network of local data collection points and a strategic and expanded community testing policy. A decentralised and local approach would also help mitigate the social and economic effects of COVID-19, by among other things, building social capital and ensuring better coordination across the NHS, social care services, and community and voluntary sector.
Second, thus far, the government has not prioritised testing, individual case detection and contact tracing as a control measure, mainly because COVID-19 can be transmitted by asymptomatic and pre-symptomatic cases (which makes case detection and contact tracing less effective than would otherwise be the case). However, when combined with some continued physical distancing, measured travel restrictions and improved hygiene measures (including use of facemasks), case detection and contact tracing can and should be part of the government’s strategy going forward.
These two approaches will help us achieve the optimal balance between effective communicable disease control and minimising the serious and damaging impacts of full lockdown. But for this to happen, the government’s strategy must not only include appropriate decentralisation of roles and responsibilities to local government and public health teams, but also plans to bolster their capacity.
When it comes to the NHS, it is right to focus on protecting frontline staff with PPE and on expanding ICU capacity. But we must also begin to consider the kind of health system we want for the future. COVID-19 is not a black swan event. It was waiting to happen. The failure to prepare the NHS for COVID-19 signals how it has not been led, financed or organised as a public service to work in the public interest to fulfil its national health protection function adequately.
Similarly, we must question the government’s medium and long-term social and economic strategy. We cannot risk allowing this crisis to make society even more unequal, nor allow public services to become even more denuded than they already are. Indeed, COVID-19 offers an opportunity to transform a political and economic system that has been failing both people and the planet for decades, and we should not delay thinking beyond this immediate crisis.