Independent Experts: Covid-19 needs a more local response

A few hours before the First and Deputy First Ministers unveiled Northern Ireland’s plan for exiting lockdown they were sent an important report which has scarcely been covered by the media.

This was maybe because Tuesday was a very busy day for journalists – digesting the five stage strategy and also covering the new furlough scheme announced by Chancellor Rishi Sunak.

That’s a pity because The Independent SAGE Report Covid-19: what are the options for the UK? has recommendations of enormous significance for Northern Ireland.

The group was set up by the UK’s former Chief Scientific Advisor, Sir David King because of what he and others see as a lack of transparency by the British government on what advice it is receiving, what it is acting on, and what it might even be ignoring.

He said: “When the government says that it is following the advice of the scientific community, but that scientific advice is not known to the public, we, the public, cannot judge whether or not they are.”

Revelations that political advisers Dominic Cummings and Ben Warner joined SAGE meetings have also  fuelled speculation as to whether the government is following the science or acting on political instincts.

Sir David wanted to demonstrate how he felt independent scientific advice should operate and so therefore the deliberations that led to the report were live-streamed on YouTube and the recording is still accessible. It is a fascinating watch.

The subsequent report is not focused on what has happened so far – government failings are seen as a given – but more on what should be done from this point on. It is addressed to the Northern Ireland, Scottish and Welsh governments as well as the UK government. This is significant because much of what it proposes involves devolved solutions, reaching right into individual communities.

And the reason for that approach is very clearly laid out. “The COVID-19 pandemic is not just one large homogenous epidemic. It is made up of hundreds, if not thousands, of outbreaks, each at a different stage, in progress throughout the country.”

So whilst England had its first confirmed case on 30 January and its first death in early March , Northern Ireland had its first case on 27 February and its first death on March 19.

Within Northern Ireland Belfast City Council has had, at the time of writing, 136 deaths, whereas the total for Fermanagh and Omagh is just 10.

The implication is clear. Tackling Covid-19 cannot be the top-down approach  from Downing Street we have seen to date. It also calls for localised, community responses, which will vary according to the spread of the virus. The fact that the Northern Ireland government has not followed the approach laid out by Prime Minister Johnson is therefore welcome.

The report goes further. It argues that Great Britain and the island of Ireland should be treated as “distinct health territories”.  Per the report: “The government has decided that everyone coming to the UK, except those travelling from the Republic of Ireland or transport workers such as lorry drivers, should be required to self-isolate for a period of 14 days. However, we note that there is a serious loophole in it. It will be perfectly possible for someone to fly from somewhere where the level of infection is extremely high, such as New York, to Dublin and then change planes to travel to London. For this, and for other reasons related to the extent of movement across the Irish border, it makes much more sense either to treat the two main islands of Britain and Ireland as separate entities for human health purposes, as is already the case for animal health, or for the UK and Republic of Ireland to agree a common approach.”

This part of the report is interesting because it provides the sort of unredacted scientific advice we can assume governments receive before the political implications are considered and is then ignored.

There’s much in the report, including a coruscating attack on how statistics are currently being used. However the report’s most significant overall recommendation is that the virus needs to be suppressed rather than controlled.

There has been much talk of “flattening the curve” – ie that the strategy is essentially about ensuring that the health service is not overwhelmed. This is the control strategy. The report calls this approach: “counter-productive and potentially dangerous”.

“Without suppression, we shall inevitably see a more rapid return of local epidemics resulting in more deaths and potentially further partial or national lockdowns, with the economic costs that will incur.”

What it means by suppression is for every case to be identified, tested, treated and isolated with all contacts traced and quarantined – for 14 days. Current government advice is for seven days, a period described in the report as “untenable.”

What this would mean for Northern Ireland would be to set up “scores of locally-led, nationally-coordinated and funded teams to trace, find and test contacts.”

This solution different from the much-touted app-based system that the UK government has planned. Quite apart from the human rights issues as identified by NI’s Chief Human Rights Commissioner Les Allamby in Scope last week there are other issues.

“We note that symptom-based (as compared to positive test-based) identification of cases will severely over-estimate the number of cases, and that it remains unclear whether a sufficient proportion of the population will agree to use these.”

In contrast aggressive tracing teams can be very accurate and effective. The report states: “In Wuhan, the lockdown and travel restrictions were accompanied by local intelligence gathering and local, on-the-ground contact tracing and medical observation. Even without mass testing capacity (it appears there were only 10,000 RT-PCR tests conducted in a population of 11m) the Chinese authorities controlled the infection, combining contact tracing with house-to-house symptom checking and quarantining and isolation, travel restrictions, and lock down.”

If the authorities in NI were to adopt the approach recommended that would see GPs and primary care workers taking a leading role, working with public health officials to track, trace and eliminate the virus. Contrast this with the initial response which saw GPs playing a limited role, directing patients to special Covid centres.

A new local response would also involve engaging with and working with local communities promoting understanding of and support for the new system.

The  report is very clear about the role of communities, the third sector and civil society in general. “The Communities and civil society organisations should have a voice, be informed, engaged and participatory in the exit from lockdown. This pandemic starts and ends within communities. Full participation and engagement of those communities on issues such as childcare and public transport will assist with enabling control measures. Conversely, a top-down approach risks losing their support and trust. We are deeply concerned about the effects of the infection and the lockdown on BAME, marginalised, and low-income groups. There is an urgent need for government to demonstrate such active participation from communities from around the country.”

Sadly, as the week has unfolded there has been very little evidence of this from the UK government.

In recent days the government, and the media have been spending a lot of time stressing the importance of the R rate and reducing it below 1 in order to reduce the spread of the infection.

Whilst this is sound, the report points out two important issues. The first is that the R rate will vary from place to place – both in terms of geography and settings. We know that the R rate is higher in care homes, but it will also vary in different regions. So we need to be very careful about using an overall figure to determine policy. To compound this, changes in the R rate are not currently estimated in real time – they are estimates based on retrospective data with a time lag of several days. It states that this will only be useful when a model is developed which can estimate the R rate in real time and then go further to issue warnings a bit like a weather forecast.

Perhaps most important of all the scientists behind the report stress that it would be foolish for anyone to base plans for the future on assumptions that a safe vaccine will be developed in the next few months, or even ever.

“It is likely that the virus will persist in the UK for at least a year, and in the absence of the optimal vaccine, will possibly become endemic within the population.”

From this we can sadly conclude that there will be further outbreaks – and these will need a rapid response. That means we need a proper virus control system in place for Covid-19 and any other dangerous infections.

The report points out that “it is important to appreciate how the UK have come to a situation where “lack of testing and infection control capacity”, has been used to justify the suboptimal UK government response to the pandemic.”

Clearly this cannot be repeated and the report suggests that what is now required is building the required capacity from the ground up, in every local area and that one of the UK government’s biggest mistakes of all has been adopting a centralised approach which has excluded civil society, entire communities and even devolved governments.