COVID-19, An Unfinished Tale... by Dr Henry Dowlen

COVID-19, AN UNFINISHED TALE...

Dr Henry Dowlen OG 1997 MBE

Dr Dowlen trained in the military, in medicine and in public health. He has worked for the Government, humanitarian organisations, military and the UN in complex emergencies globally, ran the build of one of the Nightingale hospitals and is currently involved in the national COVID-19 response. T here are clear reasons why this pandemic is causing such enormous global shockwaves. In comparison to other infectious diseases it occupies a relatively unusual set of behaviours that make it successful in propagating far and wide without being so devastating that it burns out. However, there are many who believe that COVID-19 could be a test-run for something worse; for example, a disease which causes more fatalities or spreads more easily from one person to another.

The lessons we learn from this outbreak will shape every aspect of society for generations. Getting on top of an infectious disease outbreak is a collective responsibility, and we must ensure that those lessons are applied by all of us, but we should also not forget the lessons of the past. There exists standard guidance for how to respond to public health threats of national concern, and they work, they have been developed based on evidence and applied in multiple geographic settings over many years. The standard wisdom about this guidance has been that it mainly applies to lower income countries with fragile socioeconomic systems, but the year 2020 has challenged that assertion.

For instance, there have been huge efforts applied to testing and tracing, but contact tracing is a difficult art form, it requires trust at an individual and societal level. It is also vastly time consuming, with even small outbreaks of disease requiring hours of patient investigation to identify a source and those at risk.

Command, control, coordination, collaboration and communication are all vital. These are not aspirational throwaway buzzwords but relate clearly to different parts of an infectious disease outbreak response of international concern. Clear structures for rapid communication and decision making are vital, as is cross-border coordination. Borders are often the source of persistent disease transmission towards the end of an outbreak.

Earlier this year a highly ambitious project was launched to build numerous new ‘Nightingale’ hospitals across the country... Running one of these builds was an extraordinary personal experience

Especially important is the role of social science in conducting rapid anthropological research into what is driving behaviours, rumours and fears in communities, and then connecting that into insightful clear communications that help people understand their part in the community’s efforts to reduce disease transmission.

The infrastructure to support the machinery of large-scale outbreak response is also vast, consisting of laboratories to process tests, supply chains to ensure scarce resources are deployed where they are most needed, infection prevention and control teams are trained and deployed to deal with multiple and variable hazards, and finally health care facilities are prepared to deal with the ill.

Earlier this year a highly ambitious project was launched to build numerous new ‘Nightingale’ hospitals across the country in record-breaking time, to provide additional capacity in case hospitals could not cope with the burden of caring for those unwell with COVID. Running one of these builds was an extraordinary personal experience, with hundreds of people committed 24 hours per day to achieve something together that often felt impossible. The whole community around the site offered support of every kind, construction crews worked around the clock, volunteers stepped forward and NHS workers trained to work in the new facility in record time.

At that point it was believed that COVID was a single-organ disease affecting the lungs, but we quickly learned that it is in fact a multiple-organ affecting disease requiring much greater levels of intensive care. This has huge implications for the Nightingale hospitals, should they be required again, in that they need to be much more capable than first envisaged. Nevertheless, the Nightingale work was the embodiment of the type of no-regrets national decision making and collective community action required to tackle this, and any future crisis of a similar scale.

At the time of writing, the country is facing another difficult set of decisions about how to approach the pandemic. With new infection numbers rising fast and outstripping the capacity to test people with symptoms, decision makers are looking to the number of people admitted to hospital as one of the few key indicators that can guide what should happen next. What seems certain is that the restrictions on social interaction, as the only evidencebased intervention proven to interrupt transmission, will continue to tighten. Anything more that could be written in this article about what might happen next will be just one more prediction to add to the plethora already circulating.

The underlying tension that has been at the heart of difficult decision-making is between those who want to prevent excess deaths, and those who want to protect the economy from significant damage. The morbidity and mortality associated with a long-term severe impact on the economy is one factor that should, from an objective point of view, perhaps be part of the national dialogue. In reality, however, it is hard enough to gain traction with the public about behavioural change against an invisible disease, let alone have a discourse about the trade-off between short and long term health economic damage, i.e., notwithstanding the capacity of the health system to care for those infected, the morbidity and mortality associated with allowing COVID to spread relatively unchecked and therefore minimising economic damage, versus the longer term morbidity and mortality associated with restrictions which cause economic damage that impacts on quality of life indicators.

There is a sense that this is all unprecedented, and for most people in the UK that is true, but globally and historically it is arguably not.

In the Ebola crisis in West Africa only six years ago, there was a national lockdown for an extraordinarily long period of time, with enormous resilience demanded of the populations there. In the Zika virus pandemic four years ago, the socio-economic and mental health effects were profound.

Prior to vaccines and better health care, population attrition from infectious disease was an accepted norm to be endured. Not only are the World Health Organization (and yes, it’s with a ‘z’, the UN have their own dictionary), and national public health bodies constantly combatting infectious disease outbreaks which could have global impact, but diseases of all types cause health, social and economic distress which we – to a large extent – accept as natural or at least tolerable.