Most of us are fed up with Covid-19, some because the economy is in tatters, some because of the never-ending restrictions and some because of the failure to control transmission despite our sacrifices. It is intensely frustrating to see us flounder while some countries particularly in the far east are enjoying near normal life. All western countries have had a hard time but why have Anglo-Saxon countries fared so badly? Could it be a mixture of scientific arrogance and the belief that the private sector can provide a public service better than the public sector?
A failure to learn from Asia
It is a common belief that our scientific expertise in infection epidemiology is top class and with justification. Our modellers are probably the best in the world and have taught many scientists who now practice abroad. There was misplaced belief that we did not need to seek help from others who had recent experience of SARS-CoV1 and MERS-CoV and who were battling with SARS-CoV2. We knew it all; we understood everything about epidemics. How wrong we were. We would have stopped the virus in its track if we had followed their advice. Our scientists would have learnt that this was not influenza and our politicians would have learnt from Ying Yong, the Party Chief of Hubei Province, how decisive action works. This is what he could have told 10 Downing Street in February.
|Wuhan case study of Population-scale Tracing, Testing and Isolation. Written by Lily Guiqing Yao, Professor of health economics, University of Leicester and Prof. Dr. Ouyang, Kang, President of Institute of State Governance, Director of Institute of Philosophy, Huazhong, University of Science and Technology, Wuhan, Hubei|
Wuhan is a city of 11 million people, London 9 million.
Wuhan has experienced several stages of trial and error approaches from understanding the virus, strategically planning to combat the virus and putting the knowledge into practice. On the 23rd of Jan, the city was quarantined. However, the outbreak was still unmanageable due to the lack of testing kits; hospitals reaching their full capabilities and treatment of different diseases were mixed together, which led to a kind of chaos.
On the 1st Feb, Prof Ouyang and his group proposed to increase the accuracy of the testing and isolating patients according to different categories. The strategy was implemented on the 2nd Feb, it was known as “those who should be tested must have the tests done and those who need to be isolated must be isolated”. However, at that time, it only targeted those with higher temperature and those confirmed cases. Later they proposed to isolate all such cases collectively upon identification at initial screening. The isolation with susceptible were placed locally (district level). It had little impact on the spreading of the virus.
On 13th Feb, Ying Yong took his place as Party chief of Hubei province. His view was that you could only win the battle if you know what is going on. They employed 30,000 personal and used 3 days to check every household in Wuhan. The slogan was: “not even one household or one person is left behind”.
Between 17th -19th Feb, Wuhan launched whole population mass screening. It screened all households in Wuhan i.e. the whole population of Wuhan. Its objective was to identify four groups of people: infected cases, suspected cases, close contacts and those with fever. It declared that all confirmed cases would be accepted in hospital, all suspected cases would be tested, all those with fever would be clinically diagnosed, and all close contacts of confirmed cases would be isolated. During this period, all districts under screening had been closed down for 24 hours. No one was allowed to be out of their doors.
A health worker visited every family and checked the temperature of every single person in the family. Anyone with high temperature was referred to get tested. If confirmed, they sent them to hospitals. For confirmed infected cases, their family members were considered as close contacts and were sent to isolation in a central location (families stayed together in hotels). They were provided food and their temperatures were checked every other day. They were isolated for 14 days and if they developed new symptoms, they were transferred to another group. If no new symptom and no temperature after 14 days, they were sent back home. For the 3 days of massive screening 3502 people were identified with 559 confirmed cases, 820 suspected case, 283 fever and 1840 close contacts.
After this measure was implement for a month, the spread of the infection within families and communities was brought under control.
Please note that from a public health point of view they could do this without a Covid-19 test and did so to start with as quarantine and isolation can be based on symptoms. All you need is a case definition and that was available. Our leaders could have read the WHO/China Joint Mission Report which was published on 24th February if Ying Yong was too busy to tell us what to do. The report set out what had happened in China and what to do at home. The differences between this guidance and the WHO guidance for Influenza are stark[i]. The yellow cells highlight the main differences between the two sets of guidelines. The coloured red text identifies those interventions recommended in the Joint Mission Report which spells out this advice “Achieving the high quality of implementation needed to be successful with such measures requires an unusual and unprecedented speed of decision-making by top leaders, operational thoroughness by public health systems, and engagement of society”.
Singing from the wrong hymn sheet
It is easy to forget just how badly we sang! We did not close borders, we did not help cases isolate, we stopped tracing and isolating contacts and we ignored masks. On 30th April the Chief Medical Officer gave a masterly lecture at Gresham College describing the epidemic and what was needed except for one thing. He failed to mention contact tracing. So even at that late stage he was singing the flu tune.
The scientific arrogance was widespread. Richard Horton, editor of the Lancet, was in despair when he appeared before the Science & Technology Select Committee in March[ii]. He had published top quality papers from China and clearly no one was reading them!
Belief in the private sector
It is understandable that Ministers who do not trust the public sector run in a crisis to the private sector which is seen as agile, flexible and outcome driven. But it is unsurprising that the private sector model does not work delivering public health interventions. After all the epidemic is made up of a myriad of local outbreaks. Public trust is crucial if quarantine is to be obeyed. Who do people trust in a health crisis? – their GP. Who knows the local problems? – the NHS and local councils. Public health works best with GPs organising the tests, the local hospital laboratories doing the tests and the local authority doing the contact tracing and quarantine. Instead we had Serco, Sitel and Health Professionals in impersonal car parks and call centres doing their best in impossible circumstances, engendering mistrust and non-compliance. £12 billion has been spent on Test & Trace. Could it have been better spent building up the local capacity used in Wuhan?
Unlike Germany, what limited public health structures we have are centrally based and controlled, without the agility to respond rapidly or locally. Once public health measures failed to halt the epidemic in April the public health approach was side-lined. Why should 10 Downing Street bother to demand a public health strategy – an exit strategy – if public health cannot even trace a few contacts!
What is to be done?
The attempt of the private sector to Test & Trace is failing. Testing without isolation is useless. Lockdowns seem to be the only way to control the epidemic which means the economy will continue to be hammered. Public trust is eroding. Vaccines will help but will not eliminate the virus which will be around for years. Failure needs to be turned to success and to do that we need a public health strategy – a Ying Yong strategy – bold, coherent and based on public health principles.
A public health strategy
Such a strategy can
- Provide an exit strategy to be shared, discussed, debated and agreed by everyone
- Show how and when transmission will be controlled
- Describe with targets how successful test, trace and isolate needs to be and how each individual can play their part
- Explain how the economy will not need to suffer further lockdowns if we all commit ourselves to this approach
- Delegate to local government full responsibility for public health control in all its aspects
- Provide an open purse to give local authorities no excuse to fail for whatever it costs will be many times less expensive than further lockdowns[iii]
- Separate scientific advice from political messages to mend the loss of trust in the public health measures
- Give us confidence of the robustness of the strategy by asking Ying Pong and his team to peer review and help launch it.
Are we too arrogant to admit our failings and seek advice from those who have succeeded? Is it a pie worth eating?
Cam Bowie – 10th December 2020. Retired Director of Public Health, Somerset and retired Professor of Community Health, Malawi.
[i] https://www.who.int/influenza/publications/public_health_measures/publication/en/, WHO. covid-strategy-update-
[iii] Modelling the health and economic impacts of different testing and tracing strategies for COVID-19 in the UK. Published 11 Dec 2020. F1000.