As we pass two years from the beginnings of the pandemic, many commentators are scrambling to distance themselves from their initial responses, especially where these promoted approaches like Zero-Covid. This is an interview that I gave to an online magazine aimed at older people and carers on 7 April 2020… Would I change anything, given that pressing thoughts like these ultimately led to my exclusion from the science advice networks? I now think that I exaggerated the risks of going to outdoor sporting events and we have been lucky to get a reasonably effective vaccine delivered more quickly than anyone expected in April 2020. Otherwise, I would be happy to stand behind anything here and my concern for the collateral damage from chasing the moonbeams of eradication or elimination.
‘Government coronavirus advice – where is it going wrong?’:
An Interview with Dr Robert Dingwall
Robert Dingwall is a Professor at Nottingham Trent University and one of the UK’s leading sociologists, having advised on government policy for pandemics since the Blair government of the early 2000s. He is currently part of two advisory groups supporting the UK Government on their response to the COVD-19 pandemic. We spoke to him about why the UK should have been better prepared for Coronavirus, why older people are being neglected in government decisions and the potential serious dangers of prolonged social distancing.
Robert, how did the UK Government formulate their approach to stopping the spread of COVID-19, and how much was learned from how other nations responded to the pandemic?
That’s a very interesting question, because the UK was better prepared than almost any other country in Europe for this pandemic.
We’d identified the risk of pandemic influenza in around 2001 as one of the greatest threats to national security. The UK Government at the time invested significant time and expertise during the first decade of the 2000s in drawing up and testing robust plans. I was particularly involved in this process between 2005 and 2007. These plans were reviewed after the swine flu epidemic of 2009, a revised plan was published in 2011, which was reviewed again in 2016.
However, the UK process missed two key points. One of which was the growth of precarious employment in the past ten years (like self-employment or contract work), which has greatly magnified the economic impact of COVID-19. The other was the rise of social media and the 24/7 news agenda, where celebrity political journalists hijacked the information sharing process at the expense of knowledgeable science and health journalists.
Self-isolation could put people at greater risk of harm than a ‘common sense’ approach to personal contact, which would carry a very small risk of infection.
As a result, a lot of the work that had gone into understanding strategy and cost was lost amid media and public demands for Boris Johnson to copy what other nations were doing (lockdown, self-isolation etc). The frustration for me was that there was so little discussion around whether the UK had good reasons for doing things differently because we had thought more deeply about things to start with.
School closures, for example, were never strongly justified in the case of the Coronavirus. You would get a Downing Street press conference, or a BBC Newsnight report latch on to this one simple thing that we can all demand. We had this with masks, we’re seeing it now with testing. I think a lot of the journalists who are demanding testing don’t understand how and why it would be useful.
What examples are there of misappropriated advice or guidance around how to stop the spread of COVID-19, particularly relating to older people?
Well, I think in relation to older people, what I would probably highlight is the so-called ‘two-metre rule’. Obviously, there are the people who have underlying conditions that put them at very high risk, and we should encourage these people to stay at home as much as possible, but as I’ve written elsewhere, we shouldn’t treat self-isolation as self-imprisonment. I don’t think we should be telling people: “Stay in your house, lock your door, do not ever think of venturing out.”
Over a three-month period, a lack of any kind of break from the four walls around you may cause serious long-term health damage, both physically and mentally. Therefore, this strategy of self-isolation could put people at greater risk of harm than a ‘common sense’ approach to personal contact, which would carry a very small risk of infection.
It’s also important to note that the two-metre rule in its current form has no strong scientific evidence behind it.
From discussions with people in public health and infection control, my understanding is that indoor experiments were done to establish where the distance at which people, health workers, needed to wear PPE. It was concluded that if you were running procedures on patients that would generate droplets from the chest (coughing, sneezing, heavy breathing etc.) and were within a metre of those people for more than 15 minutes, you should definitely wear PPE.
However, this conclusion was then translated into: “well, if we’re saying a metre for health professionals wearing PPE, we should double that for the general public”. The 15-minute time dimension fell by the wayside and we were left with a very shaky conclusion from a useful body of medical research, which has been turned into a rule for the population at large.
My problem with this rule, and what affects me, is seeing the terror in the eyes of an older person who has been hearing this message as: “it’s instant death if a jogger goes past.” In that scenario, the risk of a virus transfer is effectively zero. You have to take quite a lot of the virus on board in order to get infected, and that means being in the presence of somebody who is actually shedding the virus for a lot more than a few seconds.
Distancing is a sensible idea in a football stadium, where you might be sitting next to the same people for a couple of hours to watch a match, and you might be going through a very crowded space to get there. It is nowhere near such a big deal when you’re walking past a children’s playground or in a park on a Sunday afternoon. We need a scientifically rational set of rules that have some scope for adjustment or interpretation to fit the everyday lives of the people subjected to them.
That’s what I mean by bringing a bit of common sense to bear, rather than having the public believe: “Somebody has encroached on this space, and it means that I’m going to get infected and die.”
In your experience, socially and psychologically, do older people respond differently between being given advice to follow as opposed to laws or orders to obey?
The word ‘advice’ is very interesting in this context. The police have been giving a lot of ‘advice’ recently, but it’s not at all clear what happens if you decline to accept this advice. So, what happens when a PC comes over and shouts at you for sitting on a park bench?
It’s important to note that the two-metre rule in its current form has no strong evidence behind it
Say you’re asthmatic, you’ve been for a walk and you need to sit down for ten minutes and recover before you can go any further. If you say: “Well, I’ve heard what you have to say, and I decline to accept your advice.” Where do we go from there? Many older people want to venture out, but society is insisting they stay put. Generally we are seeing a lot of bullying of the elderly into doing things by their middle-aged children.
To me, these different perspectives reflect a very different attitude toward death, and a very different understanding of it. As you get to a certain age, you appreciate the inevitability of dying, and you trade that off against the quality of the life that you have. Now, any sensible person would rather die later than sooner, but they might not value the infinite extension of life in quite the same way as somebody in their 30s, 40s or 50s. This is particularly true of people living with a long-term or progressive health condition.
I will be 70 in August. I suspect many of my contemporaries are most concerned about whether we will end up with two or three years in a care home with some form of dementia, or do we have a more peaceful exit at some point? As we get older, we understand the idea of quality of life and quality of death in a way that our children don’t yet.
It seems to be one of the differences, for example, between the approaches to COVID-19 taken by the UK and Italy. The Italians have been throwing everything at keeping people alive for as long as possible. As a rule, British doctors and their patients have a much more nuanced approach to analysing what we will achieve by using aggressive interventions on frail people and those with severe underlying conditions.
It’s not a ‘devaluing programme’, it’s a question about the appropriate action to take when all things are considered. Is it kind to move somebody with advanced COPD into an intensive care unit, when their prospects of surviving that traumatic experience are actually quite small? Are we better giving them palliative care and a comfortable exit?
British doctors ask themselves these questions every day of the year. They may just have to ask them more often in the course of this pandemic. In the UK, we’re good at asking those questions. We reflect on the limits of medicine to a much greater extent than our European counterparts do.
Ministers have previously mentioned ‘four months’, ‘the end of May’ or ‘early summer’ as possible end points for self-isolation. Could give us some insight into how these estimates are being calculated, and your take on these inconsistent messages?
All of these predictions come from running the statistical models forward through time. Clearly, self-isolation is not going to last forever, but it isn’t scientifically responsible to start projecting a specific end date, because it won’t work like that.
All of the language we are hearing about a ‘war’ on coronavirus implies that there will be a day when we can declare victory and we can all go out and have a big party with banners in the streets. In reality, there will be a gradual process of dismantling the least effective controls. It will take a considerable number of months to unwind measures that have been put in place very quickly.
The other thing I think that people are not getting their head around is that, in the absence of a vaccine, the only thing that is going to bring the pandemic under control is the rising level of population immunity. The choice that governments have is how we get there.
One option is the strategy of ‘boom and bust’. You lock everything down, then unlock everything very quickly, and if infections rise again, you repeat the lockdown process until it abates. The other option is the approach the UK and Sweden have taken, which is more of a ‘slow burn’. In this case, you accept that infections are going to run through the population quite slowly until the virus runs out of people to infect, which could last for a considerable period of time. As the level of immunity builds up in the population, the progress of the disease will slow up, if there are re-infections, they’re likely to be milder. In the end, you’re potentially left with something similar to seasonal influenza.
In this scenario, in the long run, we have to learn to live with it, at least until we have a safe, effective and affordable vaccine. But this is not necessarily going to come anywhere near as quickly as the politicians have made out. It is more likely to be two to five years rather than 12-18 months.
It’s not an easy thing to hear, but we can’t hope to accurately predict an endpoint to this outbreak based on what we know today. It could be that we still have a long way to go. That is why we need to take a long hard look at the policies we are enacting and make considered, informed and interdisciplinary decisions about how best to protect the population, both physically and mentally.
Interview with Joe Newman for The Elder https://www.elder.org/the-elder/an-interview-with-robert-dingwall/