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Raj Bhopal: Blaming, petrifying, and punishing the population are not viable, long term public health strategies

We must cultivate trust, argues Raj Bhopal

The covid-19 pandemic shows no signs of being suppressed worldwide, despite the deployment of exceptional and sustained political, scientific, public health, and financial resources. Controlling the pandemic may take several years and will rely on us having a safe and effective vaccine. [1, 2] Our strategies need to be envisioned in the long term and be balanced, thoughtful, and create trust in all sectors of population—young and old, men and women, rich and poor, and in all ethnic and migrant groups.

Trust is vital and it goes two ways. The public must trust our leaders and our leaders must trust the public. The public should give due credit to the government and its clinical advisers for dealing with an unusually difficult situation. However, the UK, as elsewhere, was slow to respond to the initial outbreak early in 2020, and the government has come under considerable criticism for not using the time since the pandemic started to build up a robust and coherent strategy to manage it. 

The recent rhetoric of blaming the public for the renewed rise in cases, and vilifying and punishing individuals and organisations who breach what are often illogical, unworkable, and confusing guidelines is not appropriate. Examples of the police enforcing illogical rules and regulations, only serves to undermine the public’s confidence in policy advice. Repeated government u-turns and contradictory advice also undermine confidence. Only a few weeks ago, people in the UK were encouraged to use the “Eat Out to Help Out” scheme and return to work in offices. Now as cases are rising—as was inevitable—the government has adopted a tone of blaming people for not sticking to the rules. If the public do not trust the governments’ approach, or understand the rules, then they will be much less likely to adhere to them. 

The public needs to have a correct understanding of the scale and effects of this pandemic. Data need to be examined and communicated objectively, and the most important factor, given the epidemiology, is for all data (including the reproduction number R0) to be presented in 10-year age groups and disaggregated by sex. [3]

The level of fear about the pandemic needs to be proportionate to its dangers. Some people have become too scared to leave their houses. Others have died in hospitals or care homes without the comfort of saying goodbye to their friends and family, due to blanket bans on visitors for fear of infection. The risk to children and young people is extremely low and even in older age groups many people infected survive and return to normal or near normal health. [4-6] Long periods of convalescence and healing are common with all infections not just covid-19 e.g. influenza, viral hepatitis, and glandular fever. With improvements in clinical management and better understanding of the need for physical distancing and personal protection equipment, we are in a better situation than we were in the first half of this year. 

This pandemic must be put into the context of other pandemics that we have successfully worked through. My training in public health coincided with the start of the AIDS pandemic, and I recall the fear and bewilderment in 1983. Compared with the pandemic of HIV/AIDS (32.7 million deaths, with 690,000 in 2019), or the Spanish flu (estimated 50-100 million deaths in a world population of 2 billion) the effect of this pandemic are still modest, although we have now reached 1 million cases (and rising) and the disruption to our daily lives and the economy is enormous, which in itself has a negative impact. [7, 8]

Public health interventions and strategies should not include striking fear into the minds of the people or punishing them. [1] This is not advocated in any public health strategy or international approaches to controlling the pandemic. [1,9] They must be steeled to the long-term nature and difficulties of the task ahead. This is better than false hopes that are quickly dashed.

The current situation reminds me of the chess metaphor, zugzwang, where every move is bad. [1] Fear, panic and punitive measures will not get you out of zugzwang. Equally, self-delusion or over-optimism will lead to loss. The ideas that we will have a safe and effective vaccine by the Autumn, or that we will have everything under control by Christmas, with zero-Covid or zero Covid deaths, are misleading the public. For any infection that is transmitted asymptomatically, and there are many, eradication is not practicable without a vaccine. Extreme lockdowns would be required to last years, probably doing more damage than the virus. We may already have passed the tipping point when the costs of our efforts to contain the pandemic exceed the benefits, at least for some groups. [8, 10]

The way out of zugzwang is dispassionate and careful analysis. The risks need to be set into context, compared to the risks of everyday life. [4, 5, 6, 11] For example, there are about 12,000 deaths in the UK every week, many of them from causes easier to prevent than covid-19. We need to strike a better balance. We must counter fear by providing objective, quantitative data that sets this pandemic into context. 

Raj Bhopal, Emeritus Professor of Public Health, Edinburgh Migration, Ethnicity and Health Research Group, Usher Institute, Medical School, University of Edinburgh.

Competing interests: None declared.

References:

  1. Bhopal RS. COVID-19 zugzwang: Potential public health moves towards population (herd) immunity. Public Health in Practice. 2020;1:100031.
  2. Bhopal RS. To achieve “zero covid” we need to include the controlled, careful acquisition of population (herd) immunity. 2020;370:m3487.
  3. Bhopal R. Covid-19 worldwide: we need precise data by age group and sex urgently. 2020;369:m1366.
  4. Bhopal S, Bagaria J, Bhopal R. Children’s mortality from COVID-19 compared with all-deaths and other relevant causes of death: epidemiological information for decision-making by parents, teachers, clinicians and policymakers. Public Health. 2020;185:19-20.
  5. Olabi B, Bagaria J, Bhopal S, Curry G, Villarroel N, Bhopal R. Population perspective comparing COVID-19 to all and common causes of death in seven European countries. Preprint. Medrxiv. 2020:2020.08.07.20170225.
  6. Bhopal SS, Bagaria J, Olabi B, Bhopal R. COVID-19 deaths in children: comparison with all- and other causes and trends in incidence of mortality. Public Health. 2020. In press: https://doi.org/10.1016/j.puhe.2020.08.022
  7. Johnson NPAS, Mueller J. Updating the Accounts: Global Mortality of the 1918-1920 “Spanish” Influenza Pandemic. Bulletin of the History of Medicine. 2002;76(1):105-15.
  8. Miles D, Stedman M, Heald A. Living with covid-19: balancing costs against benefits in the face of the virus. National Institute Economic Review. 2020;253:R60-R76.
  9. Sheikh A, Sheikh A, Sheikh Z, Dhami S, Sridhar D. What’s the way out? Potential exit strategies from the COVID-19 lockdown. J Glob Health. 2020;10(1):010370-.
  10. Crawley E, Loades M, Feder G, Logan S, Redwood S, Macleod J. Wider collateral damage to children in the UK because of the social distancing measures designed to reduce the impact of COVID-19 in adults. 2020;4(1):e000701.
  11. Spiegelhalter D. Use of “normal” risk to improve understanding of dangers of covid-19. 2020;370:m3259.