The geopolitics of public health in a pandemic

We are more than a year on after the start of the coronavirus pandemic. We have witnessed the disproportionate impact of covid-19 in the UK, Brazil, US and other countries, as well as the ongoing covid-19 situation in India and other parts of South Asia. It seems the right time to reflect on why public health approaches to pandemic management have had so much less traction than medical ones. 

When data started emerging about covid-19 last January, it was clear that it was highly infectious, that communities living and working in densely packed environments were at greater risk, and that it was disproportionately affecting older people and those with underlying conditions. These observations are not new: society’s structural inequalities tend to be mirrored during pandemics.

The UK government’s first Coronavirus action plan adopted a medical approach, focused on “protecting the NHS”, treating those with covid-19, and the future development of vaccines. Although it was an obvious route, there was a distinct lack of focus then on using traditional public health approaches aimed at suppressing the virus.

That would have involved understanding and addressing viral transmission; communicating risk by tailoring messages in culturally competent ways to the diverse communities affected; and providing adequate support for those needing to self  isolate. But that didn’t happen in the UK, or in many other countries.

Most governments across the world favoured the medical, rather than public health, model to tacking the covid-19 pandemic. The latter requires investment in health protection, primary care, mental health, housing and transport, which don’t carry the attraction of “announceable” media opportunities.

Some Government leaders have found it easier than others to implement and role-model public health protection measures, while others have found the appeal of populistic gestures, for example, the “eat out to help out” initiative, or allowing international holidays, too alluring with the vaccine rollout making steady progress.

In the UK, we are potentially coming to the end of the prime minister’s “roadmap” for easing covid-19 restrictions, but we still lack some basic public health measures: salary protection to support self-isolation, universal border controls, strict quarantine for visitors from all countries, and clarity on making schools safer by improving air quality. This is even more important given the trajectory of the delta variant. In the long term, vaccinating adults as quickly as possible is vitally important, but in the short term, we need public health measures to reduce the rate of transmission of the new variant.

The dependency on the vaccine rollout, above these basic public health measures risks the need for future lockdowns, especially in the summer if tourism is left unchecked by a lack of border controls. The resulting covid-19 hotspots will likely mirror areas of highest deprivation, which have disproportionately greater numbers of low-paid workers, high housing density, and a younger population less likely to have been vaccinated. It will be important not to stigmatise those hotspots. Instead they require government support to implement the aforementioned public health measures. 

The blindness of many governments to adopting basic public health principles explains how we’ve ended up in this tragic situation. Covid-19’s impact on the most vulnerable groups is a terrible indictment on our society.

These problems have sadly been compounded by the fact that the public health profession lacks the political sway enjoyed by the medical community. This is the case in most countries. In the UK, the multiple attempts to resolve social care budgets, and the ongoing disinvestments in public health funding exemplify the lack of political influence. The image of a prime minister standing in an empty airport showcasing strict border closures doesn’t have the media caché of holding an arm out for a vaccine dose. Indeed, this is the public health paradox, prevention is better than cure, as other countries have demonstrated—Australia, New Zealand etc—where the implementation of public health measures have led to much lower death rates from covid-19.  

Looking to the future, we need public health leadership at every level—most pressingly at the government’s covid-19 policy top table. Public health impacts on all government departments, and is now more relevant than ever. With the government mantra of ‘Build Back Better’, a Secretary of State for Public Health whose remit straddles all government departments is needed to ensure that protecting the public’s health and tackling inequalities are at the forefront of future policy development. 

Countries around the world are standing in solidarity with India as they grapple with the enormity of the consequences of not adopting public health approaches. We would do well to remember that only by ensuring population health will we build global wealth, but first and foremost it is now the time for compassion, kindness, and unity. 

Gurch Randhawa is Professor of Diversity in Public Health at the University of Bedfordshire. Twitter: @gurchrandhawa

Shaun Griffin has written freelance for the BMJ about covid-19 throughout the pandemic. He is Head of Communications at the UK Pandemic Ethics Accelerator which is funded by the Arts and Humanities Research Council (AHRC) as part of the UK Research and Innovation rapid response to Covid-19. Twitter: @drshaungriffin @PandemicEthics_

Competing interests: GR is a member of the BMA Medical Ethics Committee and a member of Public Health England/Joint Biosecurity Centre/NHS Test and Trace Non-Pharmaceutical Interventions Ethics Group. SG writes freelance for Public Health England.