Robert, how did the UK Government formulate their approach to stopping the spread of COVID-19, and how much was learned from how other nations responded to the pandemic?
We’d identified the risk of pandemic influenza in around 2001 as one of the greatest threats to national security. The UK Government at the time invested significant time and expertise during the first decade of the 2000s in drawing up and testing robust plans. I was particularly involved in this process between 2005 and 2007. These plans were reviewed after the swine flu epidemic of 2009, a revised plan was published in 2011, which was reviewed again in 2016.
However, the UK process missed two key points. One of which was the growth of precarious employment in the past ten years (like self-employment or contract work), which has greatly magnified the economic impact of COVID-19. The other was the rise of social media and the 24/7 news agenda, where celebrity political journalists hijacked the information sharing process at the expense of knowledgeable science and health journalists.
As a result, a lot of the work that had gone into understanding strategy and cost was lost amid media and public demands for Boris Johnson to copy what other nations were doing (lockdown, self-isolation etc). The frustration for me was that there was so little discussion around whether the UK had good reasons for doing things differently because we had thought more deeply about things to start with.
School closures, for example, were never strongly justified in the case of the Coronavirus. You would get a Downing Street press conference, or a BBC Newsnight report latch on to this one simple thing that we can all demand. We had this with masks, we’re seeing it now with testing. I think a lot of the journalists who are demanding testing don’t understand how and why it would be useful.
What examples are there of misappropriated advice or guidance around how to stop the spread of COVID-19, particularly relating to older people?
Well, I think in relation to older people, what I would probably highlight is the so-called ‘two-metre rule’. Obviously, there are the people who have underlying conditions that put them at very high risk, and we should encourage these people to stay at home as much as possible, but as I’ve written elsewhere, we shouldn’t treat self-isolation as self-imprisonment. I don’t think we should be telling people: “Stay in your house, lock your door, do not ever think of venturing out.”
Over a three-month period, a lack of any kind of break from the four walls around you may cause serious long-term health damage, both physically and mentally. Therefore, this strategy of self-isolation could put people at greater risk of harm than a ‘common sense’ approach to personal contact, which would carry a very small risk of infection.
It’s also important to note that the two-metre rule in its current form has no strong scientific evidence behind it.
From discussions with people in public health and infection control, my understanding is that indoor experiments were done to establish where the distance at which people, health workers, needed to wear PPE. It was concluded that if you were running procedures on patients that would generate droplets from the chest (coughing, sneezing, heavy breathing etc.) and were within a metre of those people for more than 15 minutes, you should definitely wear PPE.
However, this conclusion was then translated into: “well, if we’re saying a metre for health professionals wearing PPE, we should double that for the general public”. The 15-minute time dimension fell by the wayside and we were left with a very shaky conclusion from a useful body of medical research, which has been turned into a rule for the population at large.
My problem with this rule, and what affects me, is seeing the terror in the eyes of an older person who has been hearing this message as: “it’s instant death if a jogger goes past.” In that scenario, the risk of a virus transfer is effectively zero. You have to take quite a lot of the virus on board in order to get infected, and that means being in the presence of somebody who is actually shedding the virus for a lot more than a few seconds.
Distancing is a sensible idea in a football stadium, where you might be sitting next to the same people for a couple of hours to watch a match, and you might be going through a very crowded space to get there. It is nowhere near such a big deal when you’re walking past a children’s playground or in a park on a Sunday afternoon. We need a scientifically rational set of rules that have some scope for adjustment or interpretation to fit the everyday lives of the people subjected to them.
That’s what I mean by bringing a bit of common sense to bear, rather than having the public believe: “Somebody has encroached on this space, and it means that I’m going to get infected and die.”
In your experience, socially and psychologically, do older people respond differently between being given advice to follow as opposed to laws or orders to obey?
The word ‘advice’ is very interesting in this context. The police have been giving a lot of ‘advice’ recently, but it’s not at all clear what happens if you decline to accept this advice. So, what happens when a PC comes over and shouts at you for sitting on a park bench?
Say you’re asthmatic, you’ve been for a walk and you need to sit down for ten minutes and recover before you can go any further. If you say: “Well, I’ve heard what you have to say, and I decline to accept your advice.” Where do we go from there? Many older people want to venture out, but society is insisting they stay put. Generally we are seeing a lot of bullying of the elderly into doing things by their middle-aged children.
To me, these different perspectives reflect a very different attitude toward death, and a very different understanding of it. As you get to a certain age, you appreciate the inevitability of dying, and you trade that off against the quality of the life that you have. Now, any sensible person would rather die later than sooner, but they might not value the infinite extension of life in quite the same way as somebody in their 30s, 40s or 50s. This is particularly true of people living with a long-term or progressive health condition.
I will be 70 in August. I suspect many of my contemporaries are most concerned about whether we will end up with two or three years in a care home with some form of dementia, or do we have a more peaceful exit at some point? As we get older, we understand the idea of quality of life and quality of death in a way that our children don’t yet.
It seems to be one of the differences, for example, between the approaches to COVID-19 taken by the UK and Italy. The Italians have been throwing everything at keeping people alive for as long as possible. As a rule, British doctors and their patients have a much more nuanced approach to analysing what we will achieve by using aggressive interventions on frail people and those with severe underlying conditions.
It’s not a ‘devaluing programme’, it’s a question about the appropriate action to take when all things are considered. Is it kind to move somebody with advanced COPD into an intensive care unit, when their prospects of surviving that traumatic experience are actually quite small? Are we better giving them palliative care and a comfortable exit?
British doctors ask themselves these questions every day of the year. They may just have to ask them more often in the course of this pandemic. In the UK, we’re good at asking those questions. We reflect on the limits of medicine to a much greater extent than our European counterparts do.
How much consultation with experts has been done to influence the government’s response to mental health, particularly to the elderly population?
This is a dimension of the response that has been neglected. I’ve had conversations and Twitter exchanges with some of the most eminent psychiatrists in the field, who have expressed their concern about the price that the elderly are being asked to pay in terms of their mental health.
There’s a reason why we try to avoid putting criminals into solitary confinement, because it does so much damage to them mentally. Even in the relatively liberal environment that I find myself in, I recognise the disruption to my sleep patterns, the difficulties in sustaining concentration and the small degree of disorientation that sets in.
I can imagine this being seriously heightened for somebody who is 20 years older and a lot frailer. They may be a lot less confident about going outside or feeling intimidated by the messages coming out from the Government. All of this together pushes them to a level of pain and distress that policy makers should weigh very carefully against the potential benefits of self-isolation.
I don’t see a lot of evidence, from where I sit, that this is being taken seriously in government circles and that the eminent psychiatrists are being heard. We need to think much more carefully about the social context of isolated older people.
One of the questions raised by a colleague very early on was: “what do we do about elderly lunch clubs?” My response would be: why would you stop having lunch clubs for isolated older people if they’re not mixing with anybody else? Why wouldn’t you allow the self-isolating to get together?
If you have 20 or 30 people, with appropriate bio-security on their means of transport and at the place where they’re meeting, why would you make them all stay at home? Why wouldn’t you positively try to get them together? Yes, there is a small risk that you will get the infection leaking in, but you have to balance that against the damage that you’re doing by removing these vital psychological supports.
One of the things that sociologists and anthropologists bring to policy consultation is an understanding of wider social effects. We bring more flexibility. We’re not quite as obsessed with saying: “here is the one way to do social distancing”, so much as asking how can we achieve social distancing while also protecting the mental health of older people. We need to look at how we can bring those two objectives together in a way that may or may not be absolutely ideal for each, but which is a reasonable compromise that protects both.
Ministers have previously mentioned ‘four months’, ‘the end of May’ or ‘early summer’ as possible end points for self-isolation. Could give us some insight into how these estimates are being calculated, and your take on these inconsistent messages?
All of these predictions come from running the statistical models forward through time. Clearly, self-isolation is not going to last forever, but it isn’t scientifically responsible to start projecting a specific end date, because it won’t work like that.
All of the language we are hearing about a ‘war’ on coronavirus implies that there will be a day when we can declare victory and we can all go out and have a big party with banners in the streets. In reality, there will be a gradual process of dismantling the least effective controls. It will take a considerable number of months to unwind measures that have been put in place very quickly.
The other thing I think that people are not getting their head around is that, in the absence of a vaccine, the only thing that is going to bring the pandemic under control is the rising level of population immunity. The choice that governments have is how we get there.
One option is the strategy of ‘boom and bust’. You lock everything down, then unlock everything very quickly, and if infections rise again, you repeat the lockdown process until it abates. The other option is the approach the UK and Sweden have taken, which is more of a ‘slow burn’. In this case, you accept that infections are going to run through the population quite slowly until the virus runs out of people to infect, which could last for a considerable period of time. As the level of immunity builds up in the population, the progress of the disease will slow up, if there are re-infections, they’re likely to be milder. In the end, you’re potentially left with something similar to seasonal influenza.
In this scenario, in the long run, we have to learn to live with it, at least until we have a safe, effective and affordable vaccine. But this is not necessarily going to come anywhere near as quickly as the politicians have made out. It is more likely to be two to five years rather than 12-18 months.
It’s not an easy thing to hear, but we can’t hope to accurately predict an endpoint to this outbreak based on what we know today. It could be that we still have a long way to go. That is why we need to take a long hard look at the policies we are enacting and make considered, informed and interdisciplinary decisions about how best to protect the population, both physically and mentally.
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