Public Health medicine is the speciality that manages diseases in a population, where a “population” can be the inhabitants of a hamlet, a town or city, or of a country, an island, or a continent. Management includes prevention and treatment strategies. It’s a multi-disciplinary speciality today and includes, amongst others, epidemiologists who study the spread of disease, statisticians and modellers, and those responsible for policy and education. The World Health Organisation (WHO) is an agency of the United Nations and is the responsible global body.
The classic model for pandemic management has these steps: Recognition, Containment, Mitigation, and Vaccine Development.
The appearance of a new disease in China at the end of 2019 was communicated to the WHO who named the specific virus as severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2, and the disease it caused as coronavirus disease 2019 or COVID-19. An epidemic is an outbreak of disease in a localised geographical area; a pandemic is at least country-wide and often involves continents. If a disease persists in an area, it is said to be endemic.
The WHO declared the outbreak a Public Health Emergency of International Concern in January 2020, and as a pandemic in March 2020. The virus has now spread to all continents, with approaching 100 million confirmed cases and over 2 million deaths.
The earliest stage of management is the recognition of the disease and its potential severity. Implementation of strategies is then a matter of coordination between government and public health agencies. It’s clear that some in the UK government did not initially take the threat seriously. There is a continuing political tension between those whose aim is to keep the economy open and functioning, and thus peoples’ livelihoods and finances; and those whose aim is primarily disease management, and the preservation of life.
The initial approach is an attempt to contain the virus within a specific geographic area. In Wuhan where the outbreak first occurred, the area was locked down drastically with considerable local success. Such severe measures, including curfews, are an attempt at suppression. However, the virus had already escaped from there and had spread to Europe, with Italy badly affected.
When containment is no longer possible, the next stage is mitigation. The aim of this is to reduce the number of people to whom the virus is spread while simultaneously reinforcing health resources. The spread of the virus is based on mathematical modelling of the infectivity or basic reproduction number of the virus, that is, how many people can be expected to be infected from one individual. We call this measurement R₀; for Covid-19 it is probably between 2 and 6 in the unsuppressed state. For measles, R₀ is between 12 and 18, though may be higher.
This mathematical modelling is very complex and daunting, and in the early stages of an epidemic or pandemic must by necessity include assumptions. Nevertheless, reasonable worst-case scenarios of the future development of the disease can be developed, with a range of possibilities. The political problem is getting governments to accept such figures and to act on them. Later, when more data is available, the models can be expected to be more accurate.
It was initially thought that Covid-19 was spread by droplets and contaminated surfaces or fomites, hence the idea of Hands Face Space. It’s now clear that aerosol transmission is also important; such aerosols can remain in the air for several hours if ventilation is poor.
A significant local political problem is the presence of two jurisdictions on a small island. It would be very appropriate if both governments worked as one in their efforts at Covid-19 management. The contrast between all of Ireland and Taiwan or New Zealand is very stark.
Mitigation allows time for lacking facilities to be developed. Covid-19 is a respiratory and systemic disease, and seriously ill patients are treated in Intensive Care Units (ICUs). In the UK, a decade of politically dogmatic austerity has reduced the ability of the NHS to respond to normal pressures, let alone extraordinary ones. While a series of Nightingale Hospitals were constructed to give extra capacity, they were to be staffed by the same people already working in the NHS. Likewise, stocks of personal protective equipment (PPE) were run down, and there was a “scramble” to secure stocks. Many health care workers had inadequate protection in the early stages of the pandemic.
Local public health agencies are responsible for implementing the test, track, trace, isolate strategy in people suspected of being infected. In England, this has been largely outsourced to Serco with uncertain results.
Mitigation also buys time for vaccine development. This process is often slow; with Covid-19, there has been an imperative to rapid development; funding was provided, and there were volunteers available during the phased testing periods. Vaccination has already begun in a staged approach with the old and vulnerable, and health care workers being vaccinated first. The worldwide demand for vaccines may reduce available supplies. It should be possible for all adults in the UK to be vaccinated within nine months to a year. Kids are less prone to the severe effects of Covid-19 — though not completely immune.
While herd immunity was first described after disease epidemics, the idea today is usually of immunity provided through vaccination. Some people, because of allergies or immunosuppression, cannot be vaccinated, and must rely on herd immunity for protection; they are perhaps 5% of the population. While measles has a very effective vaccine, its highly contagious nature means that at least 90% to 95% of the susceptible population — mostly children — must be vaccinated for herd immunity to be effective. Covid-19 is less contagious; some vaccines are more effective than others, and it may be that a coverage of 65% of the population will be adequate. These calculations are again part of biostatistical mathematical modelling. Vaccination does not provide immediate immunity; this takes several weeks, and often a second or booster injection is given. It’s not yet clear whether Covid-19 vaccination will be required annually.
The desired effect of mitigation is clear from this illustration from Wikipedia:
And the effect of inadequate mitigation, a second wave which swamps healthcare resources, is also very clear:
At present, in parts of England and N Ireland where the numbers of patients threaten to overwhelm the system, advanced triage may be introduced. Normally, the most severely ill are identified and managed first. If there are too many such patients so that they cannot all be treated, attention turns to doing the greatest good for the greatest number. In these circumstances, severely ill patients who could have survived had they presented in less stressed periods are likely to die. This is a most difficult and distressing time for health care workers, for patients and their relatives.
Lockdowns and isolation are not consequence-free strategies. Apart from personal financial stress, they are associated with significant deleterious effects on mental and physical health. Health care workers, in addition to the physical risk of infection with Covid-19, also suffer from excessive and difficult workloads, with increasing numbers having stress-related mental health problems.
Evolution was described, not entirely correctly, as “the survival of the fittest”; it’s unsurprising that variants of the virus have emerged; the “UK variant” seems to have a higher R₀ number than the original.
The sudden appearance of Covid-19 as a previously unknown threat has generated a plethora of Conspiracy Theories (CTs), fake news, alternative facts, and misrepresentations; and straightforward denial. Wikipedia is an on-line encyclopaedia largely written by volunteers. At times, the information hasn’t always been very reliable. The WHO joined with Wikipedia in November 2020 in a joint effort to provide reliable information and statistics in an attempt to counteract CTs and other misinformation. Facebook, Twitter, and Google are also working with the WHO.
Wikipedia has a page devoted to a list of Covid-19 misinformation; this is arranged by category; it has over 400 references. The article also describes efforts taken to counter misinformation.
Some of the CTs have been recycled; thus, while 5G networks are alleged as a cause of Covid-19, 4G networks were previously alleged to cause or transmit swine flu, and 3G networks did the same for the original SARS. This would be comical, but for the effect: at least 20 5G masts in the UK have been attacked, and others in Ireland and elsewhere. Unsurprisingly, there are multiple anti-Semitic CTs.
It’s also alleged that the vaccine will be used (by Bill Gates) as a way to implant microchips in people. Such microchips measure 2mm in diameter, and are about 10mm long; they are implanted subcutaneously after anaesthetising the skin. Vaccines use needles which are much too fine for this; but, such is the “logic” of Conspiracy Theories, that this only “proves” just how clever “they” are.
Other CTs include quack remedies, herbal treatments, chloroquine, and spiritualism. These are non-effective and in themselves can be dangerous or fatal. Amazon has removed over a million such products. Wikipedia has a listing of unproven methods.
A read through, or even a skim of the misinformation Wikipedia page is recommended to get an idea of just how much dangerous nonsense about Covid-19 has been pedalled to the unsuspecting, the unwary, the time-poor, and to those who are concerned, uncertain, fearful, and seeking information.
Denial of the seriousness of Covid is a serious and dangerous problem. It’s an extreme version of the political economy versus life tension, and is propagated by right-wing free-marketeers.
Comparisons of the lethality of Covid-19 with the Spanish Flu pandemic are not helpful. None of the medical armamentarium available today, including ICUs, existed a century ago.
Conspiracy Theories around vaccines and “anti-vaxx” supporters have been another “growth area”. These are mostly based on historical themes; that vaccination is unnatural and that natural infection gives a superior immune response; individual liberties and rights and the role of the state; the introduction of foreign matter into people. Such “foreign matter” now includes adjuvants and preservatives; there is no scientific evidence that they do harm. Some vaccines use a viral vector as a genetic container; such vectors include viruses that cause colds in chimpanzees. They cannot turn us into chimps. One of the Covid-19 vaccines uses cells during production which are derived from an aborted human foetus. The Catholic Church is quite clear that it is not sinful for a communicant to receive such a vaccine.
Andrew Wakefield published a paper in the Lancet in 1998 in which he claimed that the combined MMR (measles, mumps, rubella) vaccine was associated with a form of regressive autism. The investigative journalist Brian Deer researched Wakefield’s findings and background. He found an undisclosed financial incentive, and that the research findings were fraudulent. Wakefield was subsequently removed from the register of the General Medical Council, meaning he could no longer practice in the UK. He went to America where he propagates anti-vaxx Conspiracy Theories. His work undoubtedly caused anxiety about the side-effects of MMR, and led to a decrease in MMR uptake, though this has now reversed. His “theory” has been extensively investigated; there is no scientific evidence to support it.
Religious objection to vaccination is common in the US. However, all the leaders of the world’s major religions maintain either a neutral stance about vaccination, or actively promote it. Such religious-based objection is found either in cults, or in repressive cultures. At least thirty vaccinators have been killed over the years, many in Pakistan or Nigeria; they were often young women who in the belief of such cultures ought not to be educated. There was, most unhappily, a real CIA conspiracy involving a fake vaccination programme (against hepatitis B) in Pakistan; the aim was to get a sample of Osama bin Laden’s DNA. Unsurprisingly, this severely damaged worldwide attempts to eradicate polio.
The First Amendment to the US Constitution is about the Right to free expression. This Amendment is taken by some to mean that they should be free from the obligation to wear masks, and that they can opt out of vaccination. The freedom from mask wearing is not associated with any responsibility to prevent others being infected; the freedom from vaccination means that such people are free-riders who rely on others for herd immunity.
Confidence and trust are not easily achieved, but can be easily lost. Trust and confidence in the government was severely damaged by Mr Dominic Cummings not only driving to Durham from London with his family, but then going for a drive to Barnard Castle to “test his eyesight”. He later gave a press conference in the rose garden of 10 Downing Street. He was not censured or dismissed from his post. There was a very understandable feeling that the elite thought that the rules and regulations did not apply to them.
The population needs people in whom they can rely for accurate information. Unhappily, the UK’s government does seem to have initially approached the Covid-19 pandemic with a very cavalier attitude; we were told by the prime minister that the pandemic would be over by Easter, then by the summer. We were later to have a decent Christmas, being able to socialise with family members, until in one of so many U-turns there was a sudden clamp down on that. It’s clear now that the lifting of restrictions in August with the “eat out to help out” scheme directly led to a resurgence in the autumn. Indeed, many see the government’s handling of the present emergency as a mixture of complacent incompetence and financial chumocracy in relation to the purchase of PPE etc.
It’s not easy to discern what is accurate in the blizzard of information and misrepresentation around Covid-19, and it does take time to research this, time which many people simply do not have. Many are more concerned with making ends meet, with financial security, and simply working — even to the extent of working when potentially infected — to be able to research properly. Social media is often a source of bad information and CTs, yet one frequently used by concerned people in search of information.
A useful antidote to Conspiracy Theories is available here as a pdf booklet. It includes a rather contrived, clunky acronym which is nevertheless very useful. CONSPIR is derived from these characteristics of a CT:
O Overriding suspicion
N Nefarious intent
S Something must be wrong
P Persecuted victim
I Immune to evidence
R Re-interpreting Randomness.
Many of us get our information from social media, newspapers, and particularly television. The UK government has presented a series of press conferences, usually fronted by a senior politician often accompanied by the Chief Scientific Adviser (CSA) or the Chief Medical Officer (CMO) or his deputy. It’s hard to escape the feeling of tension between the politicians and these advisers, with the latter seemingly not wanting to contradict the politicians. Further, the prime minister seems more intent on delivering an up-beat, über-optimistic message with his characteristic boosterism than a sober assessment of the significant problems and difficulties. Perhaps if the CSA or the CMO were to appear alone, or with an experienced media presenter, someone who isn’t an apparatchik, messages would be more coherent, reliable, believable, consistent, and trusted so that we could have confidence in them.
My thanks to SeaanUiNeill for his help in drafting this blogpost.
Larson, Heidi J; Stuck: How Vaccine Rumors Start — and Why They Don’t Go Away, Oxford University Press, Oxford, 2020
Berman, Jonathan M; Anti-Vaxxers: How to Challenge a Misinformed Movement, MIT Press, London, 2020
Robert Campbell is a retired surgeon.