“Selfish asshole”; “inconsiderate”; “spreader”; “poluter”. “Do a runner: Horrific video shows coronavirus particles from runners can infect you even if you’re 2m away”. I’ll be getting my baseball bat when I next see a runner; when I’m in my car I run them off the roads…
I wonder if the authors behind a simulation study (and a well circulated blog post) on release of saliva particles and potential Covid-19 risk considered the potential impact of their work on attitudes towards runners? And yet, above are the sorts of words I’ve seen in discussions about the piece.
As it happens, despite the apparently very technical imaging in the published “white paper”, there is unfortunately no information that can enable an informed judgement about the findings. Methods are not described and no review has been done of the work, ostensibly because it is too important to go through the normal channels : “we decided it would be unethical to keep the results confidential and keep the public waiting months for the peer review process to be completed”. The researchers may or may not have done an excellent job of their simulation. Most of us don’t have the expertise to judge this. But they haven’t yet provided any information that would allow even an expert to assess this.
Appealing as their argument for publishing their headlines is, unfortunately this puts the work in similar territory to Donald Trump’s promotion of hydroxychloroquine treatment: based on partial, unvalidated data. Not a suitable basis for public policy.
There is limited evidence that the team (not public health researchers) correctly understand the modes of transmission of the Covid-19 virus; their footnote citing “intensive debates” on this topic is somewhat at odds with the WHO’s findings on transmission mechanisms – namely that airborne transmission is very limited. One of the WHO’s sources of evidence for this is a study of 75,465 COVID-19 cases in China, with no reports of airborne transmission.
It can’t hurt.
“It can’t hurt”, said Trump when talking about experimenting with untested treatments. Unfortunately it can hurt and has already hurt, with reports of fatal overdoses by people self-medicating with chloroquine, as well as hoarding drugs that patients with other diseases need.
But: the recommendation that runners keep 5m rather than 1.5 or 2m away from others, can that hurt? Very doubtful. And yet, there are still potential harms to this sort of headline. Firstly, the risk of normalising the use of sub-standard information when dealing with very serious problems. It’s not more OK to accept the simulation paper just because the immediate impacts are unlikely to be harmful or just because the authors seem to be scientists (the authors of the hydroxychloroquine papers were scientists too…). This is not to say that informal research in the form of using emerging “real time” data, and learning directly from practice in the field can’t be incredibly useful in developing new hypotheses and responding to emergencies. Along with some colleagues we found excellent examples of exactly this, which we wrote about in a recent article. Research doesn’t have to be published in a journal to be good or useful. But it does have to be published and explained in a clear, transparent way so it can be assessed alongside other evidence.
Are there any other ways it can hurt? A number of runners I know have had insults hurled at them in the past few weeks when out and about. This started long before the paper described above was published. But misguided publications risk compounding existing prejudices. Consider the change in tone between the blog post linked above (“I’m a runner so I’m going to keep a bit further away from people” – fine) to the screaming use of the word Horrific in the Sun newspaper – which has a somewhat higher readership than the Medium blog. Suddenly, runners are the enemy.
As it happens, runners tend to be a pretty robust bunch. Not only that but by and large they are pretty considerate. Though as in any walk of life there are probably a fair few who aren’t. I would say this of course – I am a runner. I want to be able to keep on running (considerately).
But the point isn’t really about runners: it is more about blame. Having worked in HIV responses for over 20 years I’ve heard many times over how specific sub-groups have been blamed for HIV and targeted, stigmatised and excluded as a result. We know that in the era of Covid-19, Asians have been on the receiving end of severe prejudice and hate crime attacks in Europe and the USA. Pandemics have been blamed on “others” – almost always excluded, marginalised others – since time immemorial. While nobody really knows what the next steps in the response to Covid-19 are going to look like it seems likely that the same pattern will emerge. And not only is that tragic for those on the receiving end but will also make it very hard to win against the virus. So this is not about not being mean to runners. It is about looking out for that prejudice and challenging it wherever it emerges, in a positive way and with correct information.
Update 31 March 2020. I’m going to leave the post below up, as well as the previous one. They still tell a bit of a story about who is being tested. However I’m not that happy with the interpretation. There is some confusion between the number of tests carried out and the number of individuals tested (since some may be tested more than once).
Update from this post which explains the importance of yield.
Earlier in the week the UK reported results of over 8,000 tests in a day but this number has fallen. It is hard to say if the number exactly represents the number of tests in a day since the processing time for Covid-19 tests varies. Testing levels are still well short of where they need to be.
I have updated the yield chart to include a second measure of “cumulative yield”, i.e. the average yield of all tests done, on each day. It again indicates that more and more of those being tested are symptomatic. It may also suggest that an increasing proportion of those with those symptoms are Covid-19 patients, with a rapidly increasing burden on the health system.
As ever, the new numbers of positive cases don’t represent all cases – they just represent the cases identified through testing, which as I understand it still primarily takes place in hospital settings.
Questions continue to be asked about the UK’s Covid-19 testing strategy. Are we test, test, testing as the World Health Organisation Director General recommended? Why are health care workers not able to access tests for themselves? Why isn’t everyone with symptoms being tested, or all contacts of known cases?
The government has explained that there has been a transition of the strategy from community testing to testing of suspected cases in hospitals. While this has been perceived as a scale back in testing, it actually comes alongside a significant scale up in the number of tests being done every day. When PHE publishes its daily report on testing it reports the number of tests and the number of negative and positive cases as cumulative figures. I plotted the values for testing on a graph. Data is missing for some days, so in those cases I have input zero – although because the data is cumulative it is smoothed out by the values on the next day that data is available. Here is how the number of tests each day has progressed:
And here is a chart of the number of daily tests:
The good news is that testing is ramping up. We’re currently running at over 8000 tests a day. Two weeks ago we were at 2000 and a month ago we were in the 100s.
It really matters who you test.
What difference has the change of strategy made? For this we have to look at the “yield” – the proportion of tests coming back positive. Good testing programmes have a higher yield since they are targeting those most likely to be infected. The table below shows the yield of testing over the same period:
An important caveat is that the because of the timelag between testing and getting results the two numbers (tests done / positives) do not correspond exactly. It should be assumed that we’re looking at positive results from tests conducted a day or two earlier. But we can still see a broad pattern.
It is worth looking at the left hand side first. The highest yield on any day was very early on. This was when very little testing was happening – fewer than 200 a day. This was likely some form of sentinel surveillance testing but at a very low level. It would be interesting to know where these tests took place but the data is not available.
Then on 31 January a number of cases were detected. Although this was high “yield”, it was also very early in the “contain” phase, so there were still only a handful of cases. Rigorous contact tracing and testing very early on meant a high likelihood of finding and containing additional cases. However, as time went on over the next week or so, new community contact testing yielded few if any new cases. This is because while those who had tested positive had interacted with dozens of people who were tested as contacts, the infection was not passed on to the majority of those contacts. Community testing was effective in terms of containment of the early outbreak (in Brighton and Hove).
The strategy moved to hospitals when it became clear that there was already quite a lot of Covid-19 infection circulating in the community, and too little testing capacity to rigorously trace contacts of each new case. Remember – this can mean testing dozens of contacts for each new case. That is feasible when there are a few cases but not when there are hundreds, and when testing capacity is limited.
As this happened, around the second week of March, it also led to big increases in testing yield. More and more of the “right” people were being tested. As of 19 March the yield was just under 12% of close to 6000 tests, which explains the very high number of new reported cases (in fact the yield may be even higher if the new positives relate to samples taken a day or two earlier). Assuming that those being tested are hospitalised with respiratory complaints it also suggests that for now at least the majority of those cases are still not Covid-19 related. But unfortunately this is changing rapidly. It also means the figures for new cases probably primarily represent people who are ill enough to be in hospital; and we know that most people with Covid-19 don’t fall into this category. However they can still pass on the infection.
As the government scientists have said, testing still needs to be scaled up further, and the Prime Minister has promised to do this. But even better would be the roll out of rapid testing and of an antibody test that would detect whether someone had previously been infected and recovered. The ability to test quickly at home or in communities is going to be vital in future stages of the pandemic, so that it becomes easier to quickly identify and contain any resurgent cases, as happened at the beginning in the UK. This was shown to work in the Italian town of Vo. But given current testing technology and capacity it isn’t possible yet.
I’ve put the numbers in a spreadsheet here: Covid testing.
Since writing yesterday’s post I have started to feel less optimistic. Shortly after the post went up I saw the BBC Newsnight interview with Health Minister Helen Whately in what was, in my view, an incompetent, unclear and ill-informed appearance. I have also read the detailed guidance on self-isolation and shielding vulnerable people. Many people don’t understand how the advice applies to them.
A few days ago I was suggesting that one way to distinguish fake information on Covid-19 from accurate information was that good public health information is generally concise and easy to follow. And yet the guidance above is long, rambling and vague. While I still think it is correct to allow a measure of flexibility, I feel like many people will need an interpreter to get their heads round this advice. We urgently need to translate it into clear, easy to use actions. If the government can’t do this then community groups, local support groups and so on are going to have to do it themselves.
It is also clear that the lack of compulsion under the new measures have left many people worried about their future, in particular small businesses which have not been told to close but who will effectively have no clientele for the foreseeable future.
The latest UK advice on reducing social contacts, household self-isolation, and measures to shield old and vulnerable people represents a significant shift in the effort to combat the virus. But while many countries introduce stringent “lockdowns” and just next door in France President Macron raised the prospect of punishment for anyone not complying, the UK government was keen to portray this as a voluntary or advisory effort.
Asked if laws to force compliance would be introduced, Boris Johnson said that the government already had powers but prefered to rely on peoples’ common sense and good will. People self-isolating in the UK will be able to exercise outdoors – alone – while over in Albania, walks in the park are out of the question. “Hiking is not vital at this time of war“, said the Prime Minister. We heard phrases like “if at all possible” and “largely” – that stopped short of absolute injunctions, recognising that there may be exceptions, but that they really should be exceptional.
Meanwhile the Chief Medical Officer Chris Whitty emphasised more than once the importance of UK citizens understanding how tough these measures were and how long they might last. He also explained that the risk presented by Covid-19 is not just Covid-19 related illness and death, but also the significant indirect impacts such as the inability of an overstretched NHS to treat other health problems, as well as the negative health impact of measures that will isolate and restrict people. The response is not a war against Covid-19 so much as a national effort to protect the ability of the NHS to look after our health.
I believe this approach is based on two related, sensible, insights. Firstly that in public health, even when you know exactly what people should do, it is very hard – perhaps impossible – to force everyone to do it. Especially if you need them to do it for a long period of time. Secondly, people are more likely to stick to something that they have some ownership over – where they have understood the issues and figured out how to adapt their lives. These are not just new-fangled “nudge” theories – they are lessons learned from decades and even centuries of public health.
It’s a big relief to me that the government has stepped back – for now – from the temptation to take a more authoritarian approach. I would not have been at all surprised if this new government had leapt at the chance given the tendencies it has shown in the short time it has been in power. The fact that it hasn’t suggests to me that it is in fact listening to the people who know how to fight epidemics. On the other hand questions are being asked about whether this approach means small businesses – which have not been ordered to close – will be protected, since they will not be in a position to claim on their insurance. We are yet to hear concretely how the government will achieve protection of the thousands of small businesses and “gig economy” workers.
Strangely, after years of Brexit messaging based on the disingenuous catchphrase “take back control” it feels like with Covid-19 we have a chance to do just that. As I said in my first post on this subject, I think local groups, neighbourhoods, and communities have it in their power to act, and support each other, and to react as the situation changes. I hope we all find ways to use this power. But government reassurance and support for those suffering hardship will be vital to this working.
~~~Update 17 March 2020~~~ Since the above post went up I’ve recognised a number of huge failings in the government’s approach. More here.
You have probably seen a lot of information and advice circulating about Covid-19. It is tempting to circulate this, especially if it provides hope in the form of previously unheard advice.
It is important to be careful about scrutinising any new information that appears. I worked through an example with one of my kids earlier. She said it looked legit because it said it “came from a hospital board member”. But: had she heard of that hospital? Was the individual named? Had the hospital actually issued that advice? The answer was no in all of these cases!
So firstly, it is always important to be clear what the source of information is.
Secondly, does it say things that you’ve not heard before? Probably, because this is what makes these bits of information so attractive. However, it also makes it more likely that they are not correct. The WHO and NHS advice is as accurate as it can be based on current knowledge. There are no secret self-tests or solutions that some doctor in Wuhan came up with that somehow escaped everyone else’s attention.
Other warning signs are that misinformative pieces are often poorly written, and often long and rambling, sometimes with a touch of hyperbole or capital letters or exclamation marks. Good health communications are generally brief, precise, and designed to be easy to act on and remember. If in doubt, check where information came from and compare it with official sources.
The BBC has an article about some of the most common fake advice stories.
The World Health Organisation published guidance on Covid-19 and mental health. The link to the full document is here but I thought it would be useful to provide a simpler summary which I have copied below and which is attached as a PDF. In my summary I have not included the elements specifically related to health care workers.
Covid-19: how to look after your mental health
The World Health Organisation (WHO) has recognised that the spread of Covid-19, and the response measures being put in place, are creating a lot of stress among people, and has come up with some advice on how to manage this for both you and those close to you. Exactly how you act on these will depend on your circumstances and your communities, but they should provide a starting point for thinking about what you can do.
The full guide (https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf) is quite long and includes advice for health care workers, so I have summarised some of the main points here.
- The virus is affecting people from many countries – it is not attached to any one ethnicity or nationality. We know that the onset of the virus has led to some people being attacked and insulted because of where they come from. It is important to be empathetic to anyone affected, in and from any country. Nobody affected has done anything wrong.
- Remember that the vast majority of people who are affected go on to make a full recovery, and their life will go on with their jobs, families and loved ones. Once they are recovered they cannot transmit the virus.
- News reports can be very worrying, as can ill-informed information sources. Avoid watching, reading or listening to news that cause you to feel anxious or distressed; focus on getting information that will allow you to take practical steps to prepare your plans and protect yourself – for instance from the WHO (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public) or NHS (https://www.nhs.uk/conditions/coronavirus-covid-19/?fbclid=IwAR20eLC0Y3pGeiYSAXCfGlEpvDS5UgdNsTcPLEHlw-r942_bYzFCeOwHixw) websites. These can help you tell facts from rumours.
- As well as protecting yourself be supportive to others when they need it, either because they are affected by the virus itself or by the control measures that may be introduced.
- Listen to the experiences of those who have been affected or who have supported those affected and who are willing to share their experience.
- Children may be especially anxious. Help them find positive ways to express fear and sadness. Children feel relieved if they can express and communicate their disturbing feelings in a safe and supportive environment.
- Avoid separating children and their caregivers as much as possible. If a child needs to be separated from his/her primary caregiver, make sure they receive appropriate care and that regular contact with parents and caregivers is maintained (e.g., by phone, social media depending on the age of the child).
- Try to keep familiar routines in daily life as much as possible, especially if children are confined to home.
- In times of stress, it is common for children to seek more attachment and be more demanding on parents so discuss this with them. If your children have concerns, addressing those together may ease their anxiety. Children will observe adults’ behaviors and emotions for cues on how to manage their own emotions during difficult times.
Supporting older adults
- Older adults, especially in isolation and those with cognitive decline/dementia, may become more anxious, angry, stressed, agitated, and withdrawn. Provide practical and emotional support through informal networks (families) and health professionals.
- Share simple facts about what is going on and give clear information about how to reduce risk of infection in words older people with/without cognitive impairment can understand. Repeat the information whenever necessary. It may also be helpful for information to be displayed in writing or pictures.
- Encourage older adults with expertise, experiences and strengths to volunteer in community efforts to respond to the COVID-19 outbreak (for example the well/healthy retired older population can provide peer support, neighbour checking, and childcare for medical personnel that are still working).
Supporting people in isolation
- Stay connected and maintain your social networks. Try as much as possible to keep your personal daily routines. If health authorities have recommended limiting your physical social contact to contain the outbreak, you can stay connected via e-mail, social media, video conference and telephone.
- Pay attention to your own needs and feelings. Engage in healthy activities that you enjoy and find relaxing. Exercise regularly, keep regular sleep routines and eat healthy food. Keep things in perspective.
Taking on Covid-19 in different ways
In the past week I’ve been part of four different conversations in four different settings about Covid-19. Not just the gossip about what it is and where it might be heading, but the specifics of what we could do about it within each of these settings – or communities.
The first conversation was in a hotel seminar room in Abidjan where I was running some training for about 20 participants. At the time nobody in Cote d’Ivoire had been diagnosed with Covid-19 but many of the participants (including me) were frequent travellers and so one of the participants asked to take the floor and to suggest a few simple ways to avoid spreading germs. We agreed what you could think of as an informal contract, to be adhered to for the week. Occasionally one person had to remind another that, say, we had agreed not to shake hands. Because all of this had been discussed and agreed no offence was taken.
A few days later, back home in the UK my neighbourhood Facebook group (the only reason I am still on the platform) had a discussion where we agreed to share information from reputable sources; to look out for elderly or other vulnerable neighbours who might in particular be affected by movement restrictions (for instance if they rely on family or social care visits); and to behave positively and supportively to anyone in the area who eventually becomes infected and not engage in gossip or stigmatising behaviours.
Hours later I was discussing with leaders of a local primary school what the contingency plan should be in case anyone in the school community is affected, how to support families who are anxious about the school staying open, and how to provide ongoing learning to pupils in the event schools are shut down. We also talked about the difficulty of schools continuing to provide other essential services such as free meals or safeguarding support if this happens.
And a day after that I was down at a running track, with yet another of my communities or tribes. While it is open air and we don’t run in very close proximity to each other there are normally sweaty handshakes and back-slaps after the workout. We agreed we could give these a miss. We also agreed to avoid spitting on the side of the track. It’s rather unpleasant but it is a reality for a lot of runners and everyone who was there understood and knew exactly what the deal was.
I wanted to write all this down because it reminded me of a couple of things. Firstly that groups, or communities, can work together and come up with practical ideas to deal with anticipated or actual problems. Secondly that the settings or activities that different people are coalescing around have specifities that might require a certain reaction. I don’t remember reading any WHO guidance on spitting; on the other hand if I’d suggested to the Facebook group or my Health financing training participants that we don’t spit I would have got some funny looks. I imagine choirs, dog walkers, HIIT fitness squads and plenty of other groups could all think about what they do and how to do it more safely too.
So: get together with your gangs, tribes, communities. Get informed using reputable sources. Discuss. Identify things you can do, practically, that are in line with sound information on how Covid-19 spreads and what it’s impact (and the impact of control measures) might be. Don’t just wait for the government or public health authorities to spell it out. They can give overall guidance and frameworks but they have limited power to compel people. They’ll play their role but so must people and communities.
Hopefully what I’ve written above will be intuitive and understandable to most people. But the experience of the past few days has a deeper resonance for me and those of a navel-gazing disposition might want to read on. I’ve been working in what people call “community health” for about 21 years. I started off working on HIV, which is another salient example of how people who were affected by a scary, unknown new virus organised themselves and did something about it. The response to HIV was and still is very much driven by those most affected by it.
In my work I spend quite a lot of time designing programmes and assessing, analysing and describing how community practices can and should support health promotion and health care. Something I struggle with is providing specific recommendations of what communities should “do”. My clients – who tend to be international NGOs and funders, but also governments and NGOs mostly in sub-saharan Africa – often ask for very detailed plans for community programmes. When I end up writing about issues and solutions being context-specific, and instead making recommendations about how to support communities to figure stuff out for themselves, I expect people roll their eyes… before asking me to break down each context and give specific recommendations for each.
If I was writing about Covid-19 the expectation would be that I’d write a long list of bullet points like “don’t spit on the side of running tracks” or “find ways to stop your dogs chasing balls or sticks that other dogs or people have touched”. These points would be completely lost on anyone but the runners and the dog walkers who happen to be reading. Either that or I would have to write up a similar but slightly different set of advice for every single group. The ones I listed above but also the scouts, the football clubs, the birdwatchers…
What I tend to look for and talk about in my work, then, is not the specific practices that people adopt to keep themselves healthy and safe – although I have no objection to describing these. But more importantly I also describe the factors that made it possible for those agreements to be arrived at. The reasons we had constructive conversations in my four brief interactions were because we were well-informed, committed and not restricted to just following the five or seven handy tips tweeted out by Public Health England. We had autonomy and confidence. In most cases, someone stood up and took the lead. It didn’t mean they became in charge of Covid-19 – it just took someone to see beyond the awkwardness and suggest their groups discuss what they can do. And so this is the sort of thing I tend to emphasise in my professional life too. While governments, and funders – and in fact many ordinary people – tend to be attracted to the idea of top-down, prescriptive actions these tend to lead to very poor, limited results. They also tend to like fancy, “innovative” approaches when the reality of what can be helpful is a bit more boring and mundane. I’m very inspired and re-energised by the examples I’ve seen recently of people in my immediate spheres thinking about and taking on this huge new challenge. I am also reminded that context is important. And that most people aren’t part of one monolithic community but move in and out of many at the same time, playing different roles in each – something we say a lot in community health without always knowing why it matters.
But most of all I remain convinced that ownership is important. What works – I believe – about the different groups I’ve ended up discussing Covid-19 with, is that we were able to discuss the challenge, and agree pragmatically what to do about it. Because we’re figuring things out in an informed way but among ourselves we’ve got a bit more of a stake in sticking to our plans. And it also means that if and when things change in the next few weeks – a dramatic increase in cases; restrictions on our activities – we will be able to rise to the challenge and to talk about what else we need to change in these new, uncharted times.
There have been a number of very sensible and well-articulated commentaries on the sexual abuse scandal in the aid sector which point out that we should not expect the aid sector to be immune to what is a systemic problem, that there are specificities within the aid sector that make it difficult to address these issues, and that neither of these facts should be used to undermine the importance of aid. Here are a few examples:
There is something important to add, which is that the architecture of the aid sector poses particular challenges to safeguarding. While the Oxfam story focuses on abuse by international and western aid workers, as I pointed out the other day, most people delivering aid are nationals of the countries where the programme is being delivered.
Moreover much actual aid delivery is not done directly by international NGOs but through patnerships with national and local institutions – both governmental and non-governmental. There is sometimes oversight through the country offices of international organisations or NGOs, but a number of projects are also funded directly by donors based in rich countries.
Just as INGOs, banks, parliaments and film producers are not immune to sexual abuse, these national and local entities are not either.
Also, local entities delivering aid are often resourced to do so through a range of sources – different international donors, local funding, government funding and volunteerism – which makes the job of figuring out who is responsible for what somewhat murky. Accountability towards donor agencies is often much stronger than accountabililty to citizens and monitoring tends to focus on financial management risk rather than programme results. Safeguarding and abuse risks are low on the list of priorities.
To cut a long story short, aid is delivered through an intricate web of partnerships and intermediary relationships and deciding who is ultimately responsible for what is difficult – and is often dealt with by simply passing the buck. And to make things harder, aid is often delivered in contexts where there are limited safeguards or safeguarding implementation.
What this all means is that the welcome spotlight on abuse in the aid sector and the need to strengthen efforts to combat it needs to look much further than the roles of INGOs. As welcome as international humanitarian passports and DBS checks are, they are only a small part of the solution. It needs to engage primarily with safeguarding systems at country level and with the need to support them to be effective. Unfortunately this is going to be even more complicated to do but it is essential if the sector is going to get this right.
I also wonder if there is a particular challenge for organisations working in the areas of sexual and reproductive health, HIV, and LGBT rights. One of the biggest challenges to tackle in these areas is stigma. To do this effectively it is important to take a positive and open approach to sexuality. Does this make it harder to identify and call out abuse? Possibly; so it’s important that organisations working on those areas pay particular attention to their systems while not compromising positive, evidence-based approaches.