COVID-19: Which way now?

Director of Public Health for Liverpool, Matt Ashton, outlines his thoughts on how we should respond to the coronavirus pandemic, as the rules around what we can and cannot do become more restrictive.

• A whole population approach
• Herd immunity is a non-starter
• Health and the economy go hand in hand
• We should be as proactive and preventative as possible
• Focus on effective measures
• Do things with people – not to people!
• Protect other health and care services
• Education is an important priority
• Good mental health and wellbeing is crucial
• Accept it is complicated
• Honest and transparent communications is essential

Last week, the government announced a series of enhanced public health measures specifically for Merseyside, Warrington, and Halton, along with most of Lancashire.

This followed a similar move in the North East earlier in the week, and was on the back of rapid increases in positive cases in these areas, to the point where our latest data shows a rolling total of over 800 cases a week, giving us a 7 day rate of around 165 per 100,000. For context, in the middle of July we were having around 14 cases a week, and in the middle of August we were having around 50 cases a week.

In addition, earlier this week, the Prime Minister announced a series of additional measures for England.

This shows how serious our current Covid situation is. Covid hasn’t gone away, and it looks like we will be living with this virus for some time to come. Ultimately we may either have to wait until a vaccine is developed (but timescales for that to be done at a large scale currently look like spring next year at the earliest), or change the way society behaves, in order to mitigate the ongoing impact of what has become an endemic disease.

Right now however, we have to go with what we have got, and where the evidence points us, and make really pragmatic decisions based on a fine balancing act of:

• Protecting the most vulnerable members of the community

• Preventing wider spread of the virus in our communities, and stopping further outbreaks in all settings, especially high risk settings

• Bringing levels of Covid infections back at least in line with the national average, if not better, as quickly as possible

• Ensuring the economy in Liverpool and Liverpool city region continues to function as best as possible, which will equally support jobs, income, and wellbeing.

It is worth stating that Covid-19 also appears to be highly divisive. Lots of people totally understand the seriousness of the situation, and respond accordingly. Lots of people do understand how serious Covid-19 is, but also worry about whether the impact of the solutions are worse than the disease itself. And of course, some people don’t think Covid-19 is really an issue at all. And all of us, probably without exception, are totally fed up, and wish it would go away pretty damn fast.

Having given this a great deal of thought (my life since January has pretty much been Covid-focused, which is remarkable if you think that when I applied to be Liverpool’s Director of Public Health in November 2019, Covid hadn’t even become an issue yet!), I have come up with a list of considerations and hopefully some conclusions and a way forward:

So how should we all be responding right now?

These are my thoughts:

1: It is clear to me that we need to take a whole population approach to preventing the spread of Covid-19 further. We cannot do this just by protecting the most vulnerable members of our society. Although Covid definitely affects some people worse than others, actually Covid can and does affect everybody. The youngest person to die in the UK from Covid was just 5-years-old. Otherwise healthy individuals have died from Covid, and some are living with the after effects of Covid (Long Covid) for months afterwards. There is also emerging evidence about the longer term developmental impact on lungs, kidneys, heart and brain in the young.

2: You cannot segment whole populations that easily. People don’t just exist in their own bubble, we all have friends, family, loved ones and work responsibilities that very easily cross into vulnerable groups. For example that would mean grandkids couldn’t see grandparents, people would need to choose between social lives and working lives (you can’t work in a care home and still see your friends, etc) So saying to ‘vulnerable groups’ you just need to bunker down for the next 6 – 12 months simply won’t work.

3: The Herd Immunity theory. I am not aware of a single disease for which herd immunity was reached without a vaccine. There is also some evidence that whatever antibodies are produced after Covid, they reduce after a couple of months, and there is also some evidence that some people have now had Covid twice. Some people seem to be suggesting we should just take the breaks off, and let the virus run though our communities. But this is an incredibly high risk strategy due to the potential numbers of deaths that could happen as a result (current worst case scenario prediction is approx. 200,000 people, 200,000 people who will be lost to their families and loved ones. In addition, these deaths would be unlikely to be spread evenly – they would affect the poor, and BAME communities and key workers to a greater extent and would deepen inequalities. Sounds like a big price to pay to me.)

4: Health and the economy go hand in hand. If people are fit and healthy, the economy can be fit and healthy. If the economy is broken, people will be broken. One is not more important than the other, both drive each other. In fact, I would say they are not really different things, just two sides of the same coin. And if we are to truly make a difference, we must take a wellbeing economics approach, putting wellbeing at the heart of our decision making, in order that we end up with a fair, inclusive economy that looks after everybody and results in improved health and wealth for everyone.

5: We should be as proactive and preventative in our approach as possible. Not wait for infections to rise further, hospitalisations to increase, outbreaks to occur. We should be putting in place measures right now to stop the situation escalating and getting worse. The good news is, that this is the approach we have been taking in Liverpool all along, albeit in very difficult circumstances

6: We should focus on the measures that we absolutely know will be effective, and make sure everybody is following them. Simple things like good hand hygiene, social distancing and frequent appropriate use of face coverings, will all contribute towards suppressing the levels of the virus. However, they will be most effective if everybody is doing them, not just the people who choose to, because of the way we come into contact with people during our everyday lives. We should also be local by design. Do the things that work for us, for our context and for our communities. That doesn’t mean we should deliberately undermine national direction, but we should not wait for the national direction to catch up.

7: We should absolutely be using the power of our communities in our approach, working incredibly closely with our brilliant community champions, faith leaders, local businesses, volunteers, and residents to make a difference right in the heart of the communities they live in and love. This should never be about doing things TO people, it should always be about doing things WITH people.

8: We need to make sure our critical services are still operating to the best of their ability, things like our health and care services, not just in relation to Covid, but also in relation to other health and wellbeing priorities. One of the big impacts of the first lockdown was massive disruption to these services. We cannot allow this to happen, as it impacts badly on individual lives and will only widen our existing health inequalities. Of course, suppressing the virus as much as possible through everybody taking the steps above will actually help services run as normally as possible

9: Similarly, education is an important priority for all of us. Education equals life chances for our brilliant young people. It motivates, develops and inspires. Without education, people will not achieve their potential. We must allow our schools, colleges, and universities to continue to operate as best as possible, and in the safest way possible.

10: Mental health and wellbeing. I have written about this before. The impact on our collective mental health and wellbeing throughout the pandemic has been significant, and we still have a long journey ahead of us. We must make sure we give people the support they need to be mentally healthy, and must encourage all of us to take control of our individual wellbeing, through things like 5 ways to wellbeing and bekindtoyourmind.

11: We need to acknowledge that we live in a complex system, so not one policy intervention will make all the difference, it has to be a combination of measures, pragmatically applied, and tweaked according to the evidence as new evidence emerges.

12: Communications and the narrative are essential. We need to be honest and transparent in our approach, speak to people individually – and collectively – in ways that matter to them and their lives. This definitely isn’t a one size fits all approach. We also need to listen to what our communities tell us. Communication is very much a two-way street, continuous gathering of insight into how people understand official messages, interpret them and discuss them with friends and workmates and family will help us refine our approaches further. Again I think this is an area where Liverpool has done really well, a strong comms strategy speaking honestly with knowledge and insight to the people that matter in this city, and empowering us all to do the right thing.

Sometimes in life it is as much about the ‘how’ as it is about the ‘what’. We are at a critical point in our Covid pandemic, so it is essential that we hold people to high standards, but don’t let that move into judgement, division and hatred. We should apply kindness, understanding and patience in all our approaches, ask why people may be behaving in a certain way – are they scared, worried, anxious? If they are, we need to respond accordingly.

It is really hard right now. Hard for everyone. We must acknowledge that, but that doesn’t change the size of the task. We need to ask ourselves – are we all playing our part? We must work together to truly make a difference, to protect individuals, communities, the city and the economy. And we can do this. My experience in Liverpool over the last six months has shown me exactly what is possible. We just need more of it, as soon as possible.