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.
- 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.
- 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.
- 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.
- 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.