This piece was first published on BMJ Opinion
In a much discussed Editorial in The BMJ, Kamran Abbasi focused on the need to make governments accountable for failing to protect citizens from the covid-19 pandemic, but saw no immediately convincing way of doing so. “What’s left,” he wrote, “is for citizens to lobby . . . for a rapid public inquiry,” and for professionals of all kinds “to be active in their calls for justice.”
The wish for accountability is wholly justified, but if the ultimate aim is to change governments’ policies around pandemic preparedness and response, a different approach seems needed. We know that significant policy changes occur only when there is a significant shift in public opinion. If we follow this line of thought, then the best way to improve our response to outbreaks of infectious diseases and the resilience of our healthcare system is by engaging in public debates. I’d argue that now, with the discourse that has emerged in the UK about “learning to live with the virus” and “how many deaths are acceptable,” health professionals have a distinct opportunity to influence opinion.
As July 19 and the lifting of restrictions in England approached, politicians and cabinet ministers (including the new health secretary), supported by business leaders and even some health professionals, began to declare that it was time for us to decide for ourselves what risks we want to run. In this formulation, which has now become received wisdom in the media, the living with the virus discourse is presented as a question of who may die and how much personal inconvenience we are prepared to put up with. Omitted from the calculation is the fact that the current level of risk has been strongly influenced by the government’s decision making, and also that the risk of dying, from whatever cause during a pandemic, is shaped by the level of spending on the NHS.
As many analysts have shown, government spending since 2010 has been kept too low to allow the NHS to maintain the provision of good comprehensive care for all, even before the arrival of the pandemic. (When this is pointed out, the response is that even in February and March this year the NHS didn’t “fall over.” This, however, is patently false. In order to care for patients with covid 19 during the worst peaks, the NHS had to suspend its mission to provide comprehensive healthcare for all.)
Framing the next stage of the pandemic as a matter of “learning to live with” the virus suits those who do not want to be held accountable for what has happened so far. It tacitly assumes that no change needs to occur in either the implementation of infectious disease control measures, or the level of funding of the NHS. The ensuing risks, which we are now being urged to assess for ourselves, are to be taken as given, an inevitable hazard of our freely chosen lifestyles. The idea is being gradually normalised that if we experience a wave of covid-19, or any other future pandemic infection, the NHS can care for those who are infected but it will always have to be at the cost of access to good comprehensive healthcare for everyone else.
Health scientists and professionals have earned an unprecedented level of public respect during the pandemic, and those who are ready to respond to Abbasi’s call to speak out have an unusual opportunity to influence public opinion by demonstrating in simple terms the difference that government action or inaction can make.
Modellers could model the different rates of infection and excess death that may be expected from continuing not to implement several basic public health measures, compared with implementing them, and make the results public in an accessible form. Models could show, for example, the impact of responding early to exponential increases of infection rates, as opposed to delaying; of removing versus ignoring the financial disincentives to take a test or to self-isolate; of sufficiently resourcing local tracing and isolation support teams; of providing free and acceptable quarantine accommodation for arrivals from other countries; and so on.
No doubt some of this is involved in the modelling done for SAGE. But to allow public opinion to influence policy we need modelling that is designed to allow us, the public, to judge the extent to which the level of risk is higher than it might be, and the costs involved.
Health economists could likewise calculate and publicise the cost of maintaining good pandemic preparedness and control capacity, plus the cost of providing good non-pandemic healthcare, benchmarked against what is spent in comparable countries with comparably funded health systems. They could compare the results with current and planned spending in the UK, and both GPs and hospital doctors could reinforce the resulting message. They are best placed of all to point out the impact of the government’s chronic underfunding of the NHS and how the reckless “opening up” has led to covid-19 infections now being 25 times higher, and admissions to hospital 10 times higher, than at the same time last year. Some hospitals are already unable to cope—and the return of children to schools and cold weather are still to come.
What is at stake are different levels of “epidemic equilibrium,” posing different levels of risk to us for the foreseeable future, as well as different degrees of access to healthcare for non-epidemic conditions. Before we accept the need to assess the risks for ourselves, the fact that they depend heavily on government action or inaction needs to be forcibly imprinted on public thinking. If the public is to hold the government to account for what has happened to date, and ensure our risks from covid-19 and access to healthcare are not jeopardised further, then we need to ensure that this truth is not supplanted by narratives of personal responsibility.
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