Monthly Archives: April 2020

Virus reads from around the web

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Intriguing looks at the Swedish approach to pandemic response from Vanity Fair and Nature

An argument that the pandemic is revealing varieties of ‘structural violence’ by government including the UK’s neglect of its health services under austerity, by two professors at Queen Mary University London (this is from Counterpunch, which has provided numerous valuable commentaries on the politics of the pandemic)

A debunking of the idea that UK government is ‘following the science’, pointing out that this claim doesn’t even make sense in the uncertain world of public health policy

And a fine, plain-language guide to the wonderful world of World Health Organization decision-making and finance

From tragedy to farce

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The Telegraph, whose coverage of the coronavirus pandemic has been consistently excellent, reports today (21 April) that UK firms are shipping millions of pieces of personal protective equipment (PPE) to Europe, while frontline NHS personnel do without; UK firms cannot get a reply to their offers of supplies; individual hospitals are ‘sidestepping the government’s procurement process’ (thank heavens); and central government longingly awaits imports from Turkey.

If accurate, the report confirms that the UK’s response to the pandemic has descended past tragedy into homicidal farce.  Sadly, having now observed British universities for seven years, I can understand what’s probably going on within the similar bureaucracy of NHS procurement: quality is a byproduct, although it may be achieved (and in universities, as on the NHS frontlines, it often is); the real concern is ticking boxes, Following Procedures and not annoying superiors.  Those managing the process have little stake in the outcome.

With a brief hiatus after the initial shock of panic buying and lockdown, within days the shelves at Tesco and Sainsburys were filling up again: these and other companies, unlike the NHS, have experience with doing logistics on the fly.  As hard as it is for a committed social democrat to say this, it is hard to avoid the conclusion that turning PPE procurement over to private sector logistics contractors, with RAF aircraft at their disposal if necessary, would have produced a superior outcome and saved lives.*  The government will have to try this route if it is to have any hope of protecting professionals and the public as a step towards a lockdown exit strategy, before the economy collapses beyond hope of repair. 

And on that note Prof. Carl Heneghan of Oxford, one of British medicine’s most conspicuous overachievers, was quoted yesterday as having told BBC Radio 4 that ‘the damaging effect now of lockdown is going to outweigh the damaging effect of coronavirus’.  Indeed, the social science tells us precisely that.  The question now is who will listen.

* Update: The Times reported on 22 April, unfortunately behind a paywall, that the NHS has in fact simplified its PPE supply chain to involve both the armed forces ‘and Clipper Logistics, a private contractor’, but that the military are ‘appalled’ by continuing inability to procure PPE and deliver it where it is needed. Clearly managers cannot get even the simplified logistics right … the fatal farce continues.

Testing and tracing – not here

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So, here we are into week four of a lockdown that threatens to turn the UK into a Third World economy.  There is widespread agreement among those knowledgeable about public health that intensive testing and contact tracing are the least unsafe routes out of the lockdown.  In its 18 April issue, The Economist reports that to carry this out effectively in the US, more than 260,000 people would need to be trained and hired to do a job that is not especially demanding – “anyone with a secondary-school education can be trained in a day”.  It further reports an estimate that paying the first 100,000 hires paid for a year, after the costs of training, would cost US$3.6 billion – ‘a rounding error on the cost of shutting down the American economy’.

I’ve done a simple transposition of these numbers to the UK context.  The UK’s population is about one-fifth that of the United States, so the need is for 52,000 contact tracers, with an initial tranche of 10,000 – a small fraction of the number of people with requisite qualifications who have been idled by the mandated economic shutdown.  Assuming comparable wage costs, after training this first tranche would cost less than £600 million – again, a rounding error in the costs lockdown is now inflicting on the UK economy.

There is no indication whatsoever that the UK government is contemplating the basic measures that, on the best available evidence, would provide a safe route out of lockdown.  Instead, we get reports that: ‘A Department of Health spokesman said the UK was “one of the most prepared countries in the world for pandemics”’ – meaning only that anyone with an official connection to central government is lying, which we already knew. 

The lack of any semblance of preparation lends itself to one of three explanations:

1.  The government is incompetent and has no idea of what it is doing – troubling, since constitutionally it is almost impossible to replace for four years.

2.  The government is well aware of what it should be doing, but also aware that despite the sweeping powers it has granted itself, it lacks the administrative and logistics capacity in Whitehall and perhaps the basic intelligence at senior levels to organise tasks such as repurposing idled industrial capacity to produce protective equipment and setting up training programmes using existing educational institutions.  A government run by normally intelligent grownups would have started on these tasks weeks ago, bringing in private sector expertise as needed.

3.  The government’s objective is to create conditions under which current lockdown conditions will be extended for many months, using public health as a justification – meanwhile, distracting attention from all its earlier failures to take measures that would avoided the continuing crisis.

Take your choice – and if you are fortunate enough to have the choice, organise your own ‘exit strategy’ from what may become an unlivable jurisdiction if and when the lockdown ends.

No exit? The United Kingdom’s probable Russian Future

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As many governments are announcing strategies for ending lockdowns, we have the curious situation in which the leader of the Labour Party and the Adam Smith Institute agree that the UK government needs to set out such a strategy, but the government refuses to do so.  It says only that five tests must first be met, but gives no evidence of being able to meet any one of them.

This is dangerously irresponsible, and is likely to have long-term negative consequences for public health and health inequalities – consequences that most public health researchers and practitioners seem determined to ignore.  Look ahead, for example, to next January when new border controls (the UK imports 30 percent of its food from the European Union) create food shortages whilst economic collapse worsens fuel poverty that was already a substantial public health issue before the pandemic.

In the absence of a clear, credible and rigorously implemented exit strategy, the future may well resemble the situation in Russia after the collapse of the former Soviet Union.  The economy contracted by close to 50 percent, existing social provision mechanisms and large portions of the health care system crumbled, and life expectancy – especially for men, who now are hit harder by the coronavirus – plunged by several years.  Conventional wisdom attributes a substantial part of this transition to alcohol consumption, but from a social determinants of health perspective this is explanandum rather than explanans: that is, it demands explanation rather than providing one.  Twenty-five years on, Russian life expectancy still did not reflect the country’s economic recovery.  That recovery was accompanied by rising economic inequality, massive capital flight, and the emergence of a new stratum of politically connected billionaire oligarchs.

All this could be avoided, but there is no sign that either the UK government or the public health community are even taking these risks seriously. 

Additional sources on the Russian experience: 

Field MG and Twigg JL, eds. Russia’s Torn Safety Nets: Health and Social Welfare during the Transition. New York: St. Martin’s Press; 2000.

Field MG, Kotz DM, Bukhman G. Neoliberal Economic Policy, “State Desertion,” and the Russian Health Crisis. In: Kim JY, Millen JV, Irwin A, Gershman J, eds. Dying for Growth: Global Inequality and the Health of the Poor. Monroe, Maine: Common Courage Press; 2000: pp. 155-73.

Unemployment and the dark future of the post-pandemic world

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I have previously mentioned Andrew Sorkin’s DealBook blog, which I regard as indispensable.  Here’s an example: The first paragraphs of today’s (16 April) update about the situation in the United States:

Think about the short- and long-term health implications of that last figure, and the situation in many other countries, which will no doubt be comparable.  If you take the social determinants of health inequalities at all seriously, you can’t ignore them, even though too many of my colleagues would prefer to do so.

Against Covid-19 fetishism, and other musings

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Herewith a few equity- and policy-oriented musings about the latest state of the pandemic world.

1.  Media, and many researchers who should know better, seem obsessed with the number of deaths from Covid-19, or associated with Covid-19.  Good reasons exist to want to know this over the short term, for purposes of tracking the spread of the virus, but apart from the fact that in most countries the current chaos makes it impossible accurately to determine this number, it is largely irrelevant in terms of the overall health impacts of the pandemic.

The most basic indicator that matters is the all-cause mortality rate (age-adjusted or not, and both figures should be presented), and the inequalities in this indicator amongst various age, class, gender, race/ethnicity and regional demographics. Over time, all-cause mortality rates will reflect not only the short-term health system dislocations and dysfunctions associated with the pandemic, but also the longer-term impacts on social determinants of health of the depression that will follow the lockdown. In a few years, those of us still alive will be able to compare the effectiveness of various national responses … and to restate a point it is all-cause mortality, and not the number of deaths directly attributable to Covid-19 or among people tested positive, that matters. Dead is dead, whatever the cause.

2.  In the UK, I continue to be baffled by the utter lack of comprehension among people professing a concern for equity of what economic downturns of the magnitude now apparently envisioned by Treasury – and of course these anticipations are all dependent on the assumed length of the lockdown, the nature of the exit strategy, and the economy’s subsequent response – will mean for everyday life and for the economic substrates of health inequalities.  The cynical me suspects that most people in a position to prognosticate with anyone paying attention have gardens and can comfortably work from home, unlike much of the rest of the population.

Let me suggest just one example of probable impacts:

Concern about the fate of high street commerce has long been unmatched by meaningful policy response.  Mr. and Mrs. Range Rover, who matter most in political terms, usually shop online or in the suburbs.   Post-pandemic, for hard financial reasons, it is likely that local authorities will simply cease providing services to low-occupancy commercial high streets, and utilities will be released from whatever obligations they have to provide services in those areas.  There will be few users, and fewer still who are able to pay their bills or council taxes. 

A fantasy?  Not at all.  A variant of this policy was partially adopted as “planned shrinkage” in New York City in the 1980s, and much more recently in post-bankruptcy Detroit.  There will be no-go high street wastelands of abandonment, at least until some far distant future when they will become attractive for reinvestment (beyond the lifetimes of many of us).

Alternatives can be imagined, in abundance (and will be the topic of a future post), but it is hard to think that any UK government will pursue them in the near future, especially as the country’s post-pandemic economic policy may well be managed jointly by the International Monetary Fund, as gatekeeper, and China, as the only external actor with the resources necessary to provide direct investment on the scale necessary.

3.  Even if the UK’s post-Brexit departure from the single market and customs union is delayed, as it should be, the full scope of the dislocations will become clear at the start of next winter, when it becomes clear how many Britons simply cannot afford to heat their homes.  Watch the all-cause mortality rate carefully as that happens. 

This post was updated on 15 April.

The Sounds of Silence: Lack of concern for post-pandemic economic and equity impacts

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Like many colleagues, I have spent the past decade and a half mainly investigating the way in which macro-scale economic and social conditions and policies affect health by way of the unequal distribution of exposures, vulnerabilities and opportunities – the social determinants of health.  The way in which authorities in the UK and elsewhere have responded to the coronavirus pandemic cries out for analysis from this perspective.  Yet most colleagues’ silence has been deafening.  Why?

After all, to stay with the UK situation for the moment, the best post-pandemic outcome that can be anticipated is a prolonged recession, the consequences of which will be distributed unequally.  Despite temporary assistance, many small businesses will not reopen, and many workers will exhaust temporary supports as their employers fail.  After a decade of austerity local authorities are, to put it mildly, ill situated to provide necessary assistance.  Such predictions are necessarily cast in general terms.  Modelling the behaviour of economies is even more difficult than modelling epidemics of communicable disease, not least because external influences outside the control of even the best intentioned national policy-makers are more significant.  Yet the population health community in the UK has been almost completely silent on these issues. 

I suspect that part of the answer has to do with apprehensions about being identified with arguments for cautiously restarting the economy that mainly originate from the political right, like Gerard Lyons’ piece in The Telegraph or President Trump’s (in)famous statement that the cure cannot be worse than the disease – which, taken at face value without regard for its deranged originator, is unexceptionable.  In the political arena, such an apprehension may be behind newly anointed Labour leader Sir Keir Starmer’s inexplicable and seemingly reflexive support for the Health Secretary’s threat on 5 April to ban all outdoor exercise if lockdown rules are not followed – a threat that probably has no basis in statute, and if carried out certainly could undermine the rule of law and citizens’ faith in it.  There are sound arguments and important research questions here, about who will bear the financial costs of a prolonged lockdown and their health consequences, which have not been taken seriously enough by colleagues.

Quite apart from the material deprivation that can be anticipated as a consequence of potential economic collapse, there is the ‘loss of control over destiny’ about which Dame Margaret Whitehead and colleagues have convincingly written.  Their important analysis operates on multiple scales, with the paradigmatic example of ‘pathways from traumatic social transition to poorer population health’ being the implosion of the former Soviet Union.  An implosion of comparable severity, with oligarchs the primary beneficiaries, can be envisioned in the UK if both the pandemic and the retreat from lockdown are mismanaged.  ‘Save lives at any cost’ is an emotionally appealing mantra, but no society anywhere, ever, has operationalised this at a population level. Destroying an economy itself has health consequences, the distribution of which will be highly unequal. An Institute for Fiscal Studies briefing shows that the lockdown will hit young workers, low-income workers and women the hardest. Impacts will also be spatially differentiated: Important research by Elena Magrini at the Centre for Cities identifies dramatic differences among cities in how many workers can adapt to work-from-home routines – or, alternatively, are vulnerable to job loss or disease exposure if they work in the essential sectors that are the unsung heroes of the pandemic. The credibility of all researchers concerned with health inequality will be defined in the coming months and years by how seriously we took these differences, and their implications for equity-oriented health, social, and economic policy – in the first instance, the design of exit strategies from the lockdown that is today in place. Those of us who did not take them seriously will no longer deserve an audience.

This post was updated on 6 April 2020.