From barriers to behaviour

On Saturday the UK recorded 24,885 COVID cases and 18 further deaths within 28 days of a positive tests . Over the last few days figures in Scotland have shown significant increases too. Possibly more proportionately than the other side of the border.  The numbers needing hospital treatment has risen 55% in a week in England . 

Against this we have the Government in England saying that the majority if not all restrictions including the wearing of face masks will be removed on 19th of July  of  which the BMA Council chairman Dr Chaand Nagpaul said “ it makes no sense to remove restrictions in their entirety in just over two weeks time .” 

The Government in England believes that people should be allowed to exercise personal responsibility, Dr Nagpaul seems to think differently . So who is right ? 

Probably both, and neither,  which in itself is a neat descriptive of the state of confusion that has exemplified the  handling of C19 thus far . 

Meanwhile the Scottish Government has been quite quiet. Of course they have extended their period of restrictions to early August so there is no immediate pressure for a statement from them . In a sense that is good news because they can reflect upon the thinking of their colleagues down South and come to their own conclusions . 

I have said for some time that there will be a time when we will have to move to a different place in terms of managing this disease. We surround ourselves and comfort ourselves with a  appropriate appreciation  of the brilliance of science but in health there is an uncomfortable reality that we also have to deal with  and which is not being adequately explained. Taking political capital from the provision of vaccines is a dangerous place to be when vaccines alone cannot eradicate a disease. 

As a species, with all the science that we have,  with all the resources at our disposal thus far we have successfully eradicated just two infectious disease;  small pox in humans and rinderpest in ruminants . There are other,  human diseases we are working towards and they include; Polio, Yaws, Guinea Worm and Malaria. TB isn’t on that list,  yet it is  a treatable and preventable  disease – 1.4 million people died of TB in 2019 most in Africa and the East. 

There is a discussion to be had here about how the colour  our skin and the geography of our diseases affects the way we as a species determine how we invest in science , but that is for another time. 

Except it isn’t really. 

The saying “ this isn’t over for any of us until it is over for all of us “ is actually quite relevant. If there is a reservoir of a disease anywhere in the world then there is a potential for reinfection across the world. That reality feeds the current analysis, COVID 19 is here to stay, science right now can’t affect that analysis so the management of this disease going forward cannot just be about science, it is about how we as a species,  behave . 

I have no issues  per se with the notion of removing legal restrictions on how we live our lives. 

If you accept the notion I have put above that we cannot ( at least in the short to medium term ) eradicate this disease, then we either live with restrictions for ever or we vaccinate and then  manage our behaviour to adapt to the disease.  To be blunt about this, restrictions  were not there to protect us individually, they were there to protect the NHS ….which  in turn protects us . 

Restrictions created a barrier to the disease multiplying itself. Concluding that we have to live with the disease but manage its impact through vaccination is a totally legitimate strategy but the public needs to be very aware that this does  not mean the disease  is “ done .” All we are doing is moving from a barrier to an exposure model of diseases management . ( Herd immunity seems to have been dropped from the vocabulary.)

The issues I have are three fold  , timing, variants and behaviour adaptation . 

As of this weekend 50% of the UK population have the full set of jabs , it follows , at least to me that 50% do not and are therefore vulnerable . Some of these will be the very young for whom the vast majority, but not all,  are unlikely to be come very ill with the disease. But there are other concerns  . First,  being double jabbed does not completely protect against getting C19 although it could/ should protect against very severe illness. But we are dealing with large numbers here and some will be uniquely vulnerable . Double jabbed people are also being hospitalised and some are dying with the disease. People need to know this,  it is an actuarial view of disease management, vaccines reducing deaths not eliminating them . 

We also do not now how long the vaccines protect for . Listen very carefully to scientists comments and you will hear words like “ fading immunity “ being used  now because frankly we don’t know and neither have scientists ever suggested that they know, how long the vaccines will protect . Hence we we have a “ top up.” The restrictions were the  barrier to the disease, my concerns about timing is “does it make sense to remove all restrictions while half the population is vaccinated and before the top up? “

Variants -more disease burden in a host population will lead to more variants and we cannot predict the course of those variants. It is a virus’s behaviour not to kill off its host ( humanity) entirely but to adapt to replicate itself more successfully. There is a risk that we will see vaccine resistant variants emerging . But there is a question politicians have failed to answer  – is this a scientifically calculated risk or a political gamble? If it is the former, publish the evidence . 

If you are to trust the public , give them the facts .

So to behaviour management  . In England on the 19th of July we will see a seismic shift in responsibility from the barrier aspects of disease management being the responsibility of Government to it being the individual responsibility  of each person .

In a sense it replicates Conservative political thinking on the primacy  of individual choice  but it is quite remarkable to see it applied to collective approaches to health . 

To quote Professor  Stephen Reicher ( Bishop Wardlaw Professor of Social Psychology at  the University of St Andrews and a member of the SAGE subcommittee on behaviour science ) “ My freedom affects your freedom “ he went on in a quite extraordinarily impactful twitter statement to say the following :- 

“It is frightening to have a ‘Health’ Secretary who still thinks Covid is flu

Who is unconcerned at levels of infection

Who doesn’t realise that those who do best for health also do best for the economy

Who wants to ditch all protections while only half of us are vaccinated.

Above all, it is frightening to have a ‘Health’ Secretary who wants to make all protections a matter of personal choice when the key message of the pandemic is “this isn’t an ‘I’ thing, it’s a ‘we’ thing. Your behaviour affects my health. Get your head around the ‘we’ concept”.

So much for scientific reserve !

He used the analogy of driving – we all have the right to drive but we have rules because if we all drove exactly as we wanted there would be negative consequences . The same exactly applies to turning all “ restrictions” into “ advice” in terms of  COVID . This sounds great until one person exercises their choice to cough  all over you and the food in a supermarket without a mask. Do we say to smokers “ hey do what you like where you like , your choice ! It’s my responsibility  to avoid secondary cancer.” How is this different ? 

What if the supermarket insists on masks ? Without a law who resolves that ? Has Government legislated for that ? Will there be By- laws?

All governments are careful to say that they trust the public to do the right thing. Politically it benefits them – but do you? Do you really believe that we can avoid irresponsible behaviour of others without consequences? 

I am a football fan so I am allowed to say this …ok I am a fan of Stranraer and the prospect of us winning  the Scottish Premiership is marginally  less than others but the premise remains valid . I wont be partial here . Fans joy at the Euros has been wonderful  but joy and reserve are not good bed fellows .  The impact of disease transfer in those events is now obvious. And predictable.

Measure that against the largely successful experiments in large gatherings at music festivals. 

This will be as successful as the level of communication put into it. So what communications  are being put into it ? Can you see any ? ( An appeal to Scot Gov – please put some in and legislate for the right for those managing public places to have enforceable rules that override individual choices . )

We have a society where for decades personal choice has been a political mantra not collective action . To expect a behavioural volte face is the height of naivety , to promote it for political gain is crass while taking political capital out of headlines like “FREEDOM DAY!!!!”  and  is to abdicate responsibility

Please let me be clear, we have grounds for optimism but now is not  the time put barrier management of  disease entirely in the hand of individuals .  It should be a partnership. It should be measured. It should be proportionate to risk. It is also a great time to promote collective action and the notion of “ We.” 

Surely we have all worked so hard that we should not throw away the gains we have made? 

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