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Back in April 2020, I wrote of my despair that so many people were desperately ill and dying because politicians had “refused to listen and act on advice”. It is barely believable that I find myself with similar feelings a full nine months later. Once again, the central government has delayed decisions and not followed the advice of scientists. It failed to follow Sage advice on an England-wide “circuit-breaker” in early autumn, and went on to relax controls in December, despite high case numbers. Predictions of an inevitable rise in cases did not deter ministers from trying, unsuccessfully, to “save Christmas”. The utterly predictable result is now happening, with pressure on hospitals and more than a thousand deaths most days, a toll even worse than the first wave. The emergence of the new, more transmissible variant has doubtless made control even more difficult, but we still seem to have been on the back foot at every stage.
There is a stark contrast between the poor control measures and the outstanding scientific progress. We know so much more than we did back in April. We have a better understanding of transmission and the natural history of the infection, the immunology, and the variation in risks within the population. These advances have led to a growing number of tools that can be used to tackle the epidemic, adding to the basic early interventions of social distancing, hygiene, protective equipment, testing and isolation. We can now add to them rapid tests, contact-tracing apps, vaccines and better treatment. So why are we not in a better place?
The answer is that these innovations are simply tools, and tools have to be used skilfully as part of a clear strategy in order to be effective. Underpinning this has to be engagement with ordinary people to make sure that the proposed interventions are understood, feasible and acceptable. Take the chaotic interventions in education in England, where the government has imposed decisions on exams, masks, mass testing and closures without sufficiently engaging teachers, schools and parents, thereby losing credibility. The response in the UK has been particularly centralised and top-down, with little attention paid to working at local level and with different groups.
We can learn here from other public health strategies. Most of my research and public health practice has been in the prevention and control of HIV. Since the early days of that pandemic in the 1980s, we have learned a lot and now have a wide range of effective tools, from home-testing programmes to antiviral drugs. Yet, despite all this, the burden of HIV remains high, and very unequal, and the problem is worse in low- and middle-income countries and more deprived populations. The challenge is not the lack of effective technologies, but how to use them.
I worked with colleagues around the world on how to maximise the impact of HIV prevention technologies, and the consensus was the need for a strategy with “local ownership, community engagement and acceptability, good evidence and data to guide planning and implementation”. It’s time for the government to seriously apply these insights to Covid-19.
When it comes to contact-tracing for sexually transmitted infections, for example, we know that people will not disclose their contacts if they fear the consequences. This mirrors what we are seeing in Covid-19, with some people avoiding testing because if they test positive they will have to stop work and lose income, and will be asked to inform colleagues, who may also have to isolate and lose money. Introducing a hugely expensive test-and-trace scheme without investment in isolation and income protection shows that these are seen as technological solutions without consideration of the real-life context.
With each new technology, politicians often respond with over-eager optimism and promises that this will be the answer if only we do it bigger and better. The UK government has promised more tests, more ventilators, world-beating apps and faster vaccination. But, in the absence of a joined-up strategy, this Stakhanovite approach has led to a lot of money wasted and inadequate public health gain.
So what is the UK strategy for Covid-19 control? Boris Johnson has talked of a “race against time” to get vaccines into people’s arms, implying that this will turn round the growth in hospitalisations, deaths and the overwhelming of the NHS. Sadly, this is not a race that is going to be won in the short term. Vaccination is a critical long-term strategy, and the rapid roll-out is welcome. But it will take time to have an impact, and has to be used carefully alongside other tools.
Science and technology are of little use from a public health perspective unless we take into account the actual societies – with all their granular details, inequalities and differentiations – in which they exist. I think we need a clear strategy, developed rapidly with all key stakeholders (such as key workers, pupils and their parents, trade unions, minority-ethnic communities) and covering the appropriate use of all tools, many of which need to be used in tandem: travel controls, such as those belatedly introduced last weekend, social distancing, masks, ventilation, hygiene, testing (together with tracing, isolation and support), vaccination and healthcare.
This will allow us to drive down infections to zero. Herd immunity, achieved through vaccination and previous infection, will hopefully lead to the point where we can relax many of these controls. But it will not last for ever, and may not protect us from new variants, so we will need continued vigilance to detect and respond quickly.
Source: The Guardian
Keyword: The UK has record death tolls, yet still the government has no clear Covid strategy | Coronavirus