The Sound of Sirens

Posted by John Mooney FFPH, Consultant in Public Health, NHS Grampian @StandupforPHlth

Easily my most notable memory from the first Covid-induced lockdown was the unmistakable and disconcerting shriek of ambulance siren calls, regularly piercing the ‘lockdown’ silence of largely empty streets. Prompted by the memory of the mythical origins of the word ‘siren’, in which enchanting songstresses lured sailors and their ships to a rocky destruction, it struck me that the lure and temptation of ‘freedom day’ on which all Covid-19 constraints on social and other gatherings are no longer mandatory might yet similarly have an unfortunate aftermath. While I expect that risks placing me firmly in the ‘doomster’ camp, it seems I am in good company after the letter in last week’s Observer from some of our most eminent public health leaders who were at pains to point out that “living with Covid is not the same thing as letting it rip”.

   

Watch 'Sound of Sirens' by John Mooney and Dr Clare Pettinger (AKA the Singing Dietitian) inspired by this blog post

This is now my third Fuse blog about Covid, in what is sadly proving to be a rather prescient series of posts about the pandemic. I set out in the first (published in February 2020), that as a newly emergent single stranded RNA virus, Covid-19 would be genetically unstable and undergo mutations which could influence its epidemiological characteristics including virulence and transmissibility. To say therefore that the present situation was not foreseeable (given my rudimentary grasp of evolutionary genetics), is clearly not that convincing. It’s probably even more self-evident that the more transmissible variants will be the same variants that are most transmitted, because this is the essence of viral survival strategy. Even with that knowledge however, the speed with which the Delta variant became the dominant strain (from under 10% to over 90% in a matter of weeks and now accounting for 99% of identified cases), was fairly breath-taking even by viral standards. 

A particular concern just now of course must be that the UK’s success in achieving a high vaccination uptake creates a new ‘selection pressure’ of its own, in that any newly emergent strain with the capacity to evade vaccine induced immunity will have an enormous selection ‘advantage’ in a population which has the combined characteristics of a high vaccination rate plus a high level of circulating virus. It’s easy to appreciate then how such a new variant could assume a ‘delta-style’ trajectory towards dominance, leaving even the fully vaccinated vulnerable once more. This is of course not a reason for reducing vaccination efforts which have been critical in protecting vaccinated age groups, thereby reducing the proportion of the population susceptible to new infections. If I could squeeze in one final take-home vaccine basics key message: the more infectious a particular variant, the higher proportion of a population needs to be vaccinated to mitigate transmission. This has prompted some commentators to expect that the holy grail of ‘herd immunity’ will always prove elusive for Covid.

The very real challenge for those of us in practice settings (having recently returned to NHS public health myself), is how best to advise local populations and relevant agencies in order to keep reducing the levels of circulating virus. The mechanisms that work here are very much those that are already in place combined with ongoing vaccination and access to local testing. The extent to which people might be willing to submit to testing that could sacrifice a long-coveted holiday, versus their readiness to isolate away from work, might begin to explain a divergence in the surveillance data in some health-board areas between declining numbers of cases and relatively stable hospital admissions (even allowing for the two week lag). The latter of which has already led to cancelled elective procedures in ours and other regions. We also know that infections in younger age groups are more likely to be mild / asymptomatic taking away the ‘illness prompting’ rationale for seeking a test.

Receiving supplemental oxygen in A&E
 6 months after initial Covid symptoms
 (mask displaced to drink)

At this point it would be useful to highlight the relevance of the second blog in this series as then it all looks impressively planned! (Spoiler alert: it wasn’t!). In that article, I described my experience with Long-covid which I was unfortunate enough to develop very early in the first wave and which included an unscheduled hospital stay and fast track angiogram (think X-ray to check heart blood vessels) thanks to a “dangerous ECG”. Thankfully 18 months on I am much recovered, but remain very conscious that there was more than one false dawn over the course of the illness, although later episodes were milder. The inescapable parallel from a population standpoint is that Covid-19 can prove a truly mercurial adversary, lulling you into a sense of comfort and security, just like the mythological Sirens, before dashing you against the rocks of reality once again. The attached illustration above: ‘Ulysses and the Sirens’ is an 1891 painting by Pre-Raphaelite artist John William Waterhouse. In the words of the Wikipedia description:

"The work depicts a scene from the ancient Greek epic the Odyssey, in which the Sirens attempt to use their enchanting song to lure the titular hero Odysseus and his crew towards deadly waters. As per the Odyssey, Odysseus' crew had already blocked their ears to protect themselves from the Sirens' singing, but Odysseus, wanting to hear the Sirens, had ordered his crew to tie him to the mast so that he may have the pleasure of listening without risking himself or his ship."

In other words, the measures clearly employed were distancing and personal protective equipment! [Note the bound ears of the crew]. Perhaps the fact that the new variants are being ascribed Greek lettering might help persuade us to take a leaf from these mythological mariners and maintain some of our protective measures just a little longer while vaccine roll-out continues. In keeping with worrying reports from our clinical colleagues and as anecdotal as this could certainly be described, I have increasingly of late been hearing much more of the sound of sirens… 

John is currently employed as a consultant in public health with NHS Grampian and has a background in respiratory infectious disease epidemiology. 

Image:

1. John William Waterhouse, Public domain, via Wikimedia Commons

The views expressed in posts are those of the authors and do not necessarily reflect those of Fuse (the Centre for Translational Research in Public Health) or the author's employer or organisation.

Find the gap: where is the healthy, enjoyable human body in policy?

Posted by Rachel Kurtz, PhD researcher at Durham University

Balancing varied and sometimes conflicting priorities within a large geographical area and between multiple departments is not a job to be envied. Ensuring the detail is suitably deliberated while also holding in mind how a policy affects other interests must be attempted but cannot possibly be achieved to perfection. My role on behalf of County Durham Sport was much easier. Over three weeks in June, I reviewed Durham County Council documents and the priorities of the Area Action Partnerships (AAPs) to identify areas of local strategy that did (or did not) address the issues of physical inactivity and the climate emergency. As an environmentally-informed, lifelong dancer-turned-researcher, I simply had to view the documents from two perspectives in which I am already personally invested and consider possible changes. Some interesting things emerged.

As you might expect, topics are viewed through whatever lens highlights policy concerns in that area. For example, the County Durham Plan understands physical activity functionally, through land use, waste, and movement of people, advocating for active travel (walking, cycling etc.) and providing and improving recreational areas. Meanwhile, the Joint Health and Wellbeing Strategy considers the environment as either beneficial or detrimental to public health, e.g. air quality. Thinking that is limited by departmental divisions can make it difficult to link overlapping policy areas. Consequently, councils are attempting to increase communication and collaboration by forming multi-disciplinary teams to create joint policy and consider issues from multiple perspectives. The County Durham Health and Wellbeing Board (author of the previously mentioned strategy) is one such team. This ongoing shift towards a collaborative approach is already countering siloed thinking and Durham County Council is taking a systems perspective through its work in Mental Health, from its strategic partnership both within and outside the council to delivery vehicles like the AAPs (which give local people and organisations a say on how services are provided). Nonetheless, a change of perspective inevitably exposes assumptions and raises new challenges, and this was no exception.

Encouragingly, some of the documents reviewed, such as the 2018 Open Space Needs Assessment, comprehensively address both focus areas, however in most cases the environment features more prominently than physical activity. A Physical Activity Strategy is still being developed, therefore gaps in this area might be expected and indeed in many cases the human body was entirely absent from policy. However, what was most noticeable was the underlying attitude where physicality was mentioned. Almost none of the policy documents feature the healthy, enjoyable human body. To cite a specific example: while addressing a rising mental health crisis, the Health and Wellbeing Strategy implicitly regards bodies as problems to be solved. This is particularly noticeable in the section on older people who are seen as frail and in need of preventative and remedial support. The framing of the strategy is already being addressed in this case but overall, any focus on the impact of health and wealth inequalities on the body tends to see physical inactivity as a problem rather than an opportunity. There were exceptions at delivery level (e.g. the Healthy Weight Action Plan and some AAP interventions, both of which are very much about enrichment) but at the strategic level, bodies are overwhelmingly framed as problematic. This is true even where you might expect an enrichment perspective such as the Children and Young People’s Strategy and Strategic Walking and Cycling Delivery Plan.

As a dancer and embodiment researcher this outlook is all too familiar, and I understand it as cultural rather than a failing of the council. In the main bodies are accommodated, objectified and treated as problems to be solved, while the sensual, experiencing body is largely ignored. Unfortunately, when we take this deficit perspective, we lose important, humanising opportunities for productive fun. Policy could be very influential in this respect. If we choose instead the underpinning belief that bodies are an incredible gift through which we explore and enjoy an endlessly engaging world, we automatically find more playful and interesting solutions. Suddenly new possibilities abound, like generating power from playground equipment or a dancefloor made with kinetic tiles. When we remember our sense of fun, urban environments become play spaces for curious bodies. Street furniture is for parkour, roller blading or skateboarding as well as resting. Outdoor games and gyms spill out of parks and line the route of our walking commute. Community growing spaces (already a popular solution to poor diet, food miles, climate change preparedness, physical inactivity, social isolation and low income) are no longer confined to small allotment plots but proliferate around the city alongside the begonias, encouraging healthy eating and a pedestrian habit.

Negotiating such varied needs and uses does of course require extensive consultation and consideration, which again highlights the importance of a partnership approach through which all voices are heard, but as I said at the outset, policy making is inevitably a difficult job. The bonus of reframing in this way is that by using strategies that are intentionally enjoyable rather than those that feel worthy or obligatory, uptake is likely to be far higher and as a result there is a better chance of achieving positive outcomes. Surrounded by the richness of creative human expression and snacking on free, community-grown fruit as we walk, jog, cycle or even dance our way to work and school, why would we choose to drive? 

Images:

1. Photo by Anthony Fomin on Unsplash

2. Photograph 'Exercise Machines' (2103264189_e26de7ba22_z) by Catherine via Flickr © 2007: https://www.flickr.com/photos/30325243@N00/2103264189 (CC BY 2.0) Adapted (cropped)

3. Photo by markusspiske on Pixabay

(Re)taking liberties: Reclaiming positive freedom as a public health argument

Posted by Jack Nicholls, Lecturer in Social Work at Northumbria University

At the time of writing, the government intends to lift most remaining Covid restrictions still in place in England on July 19, widely touted as 'Freedom Day'. 

I recently passed my PhD viva defending a thesis that was concerned with the diverse ways a contested value concept is understood by human welfare professionals (in my case, 'social justice' and newly-qualified social workers). As a result of that undertaking, I am now habitually critical of the ways in which ethical and moral language is used and claimed for particular agendas. In the looming shadow of so-called 'Freedom Day', I have been thinking about how caring professions and health and wellbeing researchers might reclaim the word 'freedom' for ourselves.

Possibly in contrast to many of my wonderful colleagues in the caring professions and their associated research wings, I am in broad terms a libertarian rather than a collectivist*. Individual rights and freedoms - the ability to live as one chooses unfettered without just cause, to be different, to not fit or conform - are close to sacred to me. While I can be persuaded by arguments advanced by those of a more communitarian mindset, it is always despite, rather than because, they are communitarian. When, as I will here, express concern about the speed and totality of the easing of Covid restrictions, I do so from a liberty-minded philosophical position.

The 'Freedom Day' discourse draws almost entirely on the concept of negative liberty and is emblematic of a long-established idiolect that frames freedom (with personal responsibility) in a zero-sum game against statutory entitlement to and provision of help. Negative liberty refers to the absence of constraint and control. As an idea, it is of profound importance for those of us who believe rights and freedoms are inherent to personhood, and that it is for the state to uphold them, not hand them down as bounties and favours.

Sir Isaiah Berlin 

Alongside negative liberty however sits the concept of positive liberty (both liberty concepts were set out by Sir Isaiah Berlin (pictured right) in his 1958 lecture and subsequent written works). Positive liberty refers to the idea of freedom being enabled by active action and the provision of resources, facilities and support. The two work in tandem and, for the kind of libertarian I am, they are equally important and necessary for one another. Covid restrictions have impacted both our negative and positive liberties - the former by restricting our movement, travel and association, the latter, at least for many people, by restricting our incomes, our ability to access welfare, social security, safe transport, childcare and informal support networks.

The rationale for these actions, a rationale that was broadly accepted by the majority, can be understood as a trade-off with other positive freedoms, most notably seeking to keep as many people as possible, and particularly those at most risk of developing serious or fatal Covid symptoms, free from infection. It is a trade-off I would make again in a heartbeat under similar circumstances. That is part of why the present language about 'Freedom Day' is so galling, because for many, particularly those with high-risk health conditions, their families, and those who have not yet been able to be vaccinated, July 19 will not signal any kind of freedom. I can't tell you how much I'm looking forward to my first liberated Guinness, enjoyed in the hostelry and company I choose, with all the health risks confined to the pint glass. I can't do that on July 19, because the decision has been made to prioritise the negative liberty of those of us who can enjoy it over the positive liberty of those still at particularly serious risk. We aren’t choosing freedom; we are choosing some people’s freedom over that of others.

This situation behoves health and social service practitioners and researchers to consider whether we can reclaim the concept of freedom, particularly positive freedom, as a full and proper part of our value base and lexicon. I argue that we both can and should, for what are we if not participants in endeavours for more positive freedom through greater knowledge and better health and wellbeing. Freedom 'from' is fairly hollow and useless without meaningful freedom 'to', and though many who share my philosophical persuasion see an overbearing state as a legitimate risk to freedom of all kinds, no less important is freedom from preventable illness, pain, anxiety, suffering, burden, loss of control, and the wider contributors to health inequities, not least poverty and postcode.

Our professional fields, with the best of intentions, often couch our arguments in terms of the community or public good. Without besmirching the place and value of those arguments, it is my view that were we to speak also in terms of freedom, including individual freedom, we would do so with complete intellectual coherence and legitimacy. Rather than being unjustly tagged as over-cautious and dictatorial, we could put our criticism of the end of restrictions in pro-positive freedom language. Beyond that, we could reframe and bridge the unfounded but perceived gap between individual choice and public wellbeing, all while avoiding the former being reduced to callous responsibilisation, and the latter being unfairly painted as nannying control. We might even unlock a new set of tools for persuading individuals and institutions who are rarely engaged by welfarist, collectivist or even duty of care arguments about public health concerns. We've done it before; we rarely talk about the smoking ban nowadays, rather we refer to pubs and train stations being smoke-free. Likewise fat-free, alcohol-free - it's a nice word, and an effective one.

At this moment, whatever their diverse feelings about the end of restrictions (I should caveat, the end for some) freedom is high in the public consciousness. Let us who are concerned for public wellbeing liberate our arguments and reclaim the concept of freedom, particularly positive freedom, for ourselves.

*Collectivism: a social pattern in which individuals construe themselves as parts of collectives and are primarily motivated by duties to those collectives. More here: https://plato.stanford.edu/entries/culture-cogsci

Images:

1. Courtesy of Pixabay: https://pixabay.com/illustrations/bird-cage-aviary-freedom-flying-730478

2. Sir Isaiah Berlin by Rob C. Croes (ANEFO), CC0, via Wikimedia Commons

The views expressed in posts are those of the authors and do not necessarily reflect those of Fuse (the Centre for Translational Research in Public Health) or the author's employer or organisation.

Intersectionality: buzzword or key to tackling health inequalities?

Posted by Dr Daniel Holman, Professor Sarah Salway, Dr Andrew Bell, University of Sheffield

Intersectionality – the idea that multiple axes of inequality overlap and interact – arguably holds great potential to understand and tackle health inequalities. But what do researchers and those working in policy and practice in this area actually think about the approach? What do they see as the key challenges and opportunities? We held a professional stakeholder workshop and consultation survey to find out. Our findings indicated a ‘cautiously optimistic’ view of an intersectional health perspective.

A growing interest in intersectionality and health

Intersectionality is currently something of a buzzword. A search of the scientific literature reveals an explosion in interest, with an eight-fold increase in papers mentioning the term in the last ten years, and a twenty-fold increase for those mentioning both ‘intersectionality’ and ‘health’:

Figure 1 - SCOPUS documents mentioning both 'intersectionality' and 'health' in title, abstract or keywords

The interest in applying intersectionality to health research, and specifically health inequalities research, has now also been fuelled by the pandemic. Ethnicity, deprivation, and age strongly influence Covid-19 outcomes. Calls for intersectional analysis of Covid-19 have now been published in BMJ Global Health and The Lancet.

Yet recent events have indicated significant political barriers. The Sewell Report essentially explained away ethnic health inequalities with reference to socioeconomic factors – anathema to intersectionality – and last year the UK Government declared itself ‘unequivocally against’ Critical Race Theory (within which intersectionality is rooted).

Further, policy-making is a process of dialogue, negotiation and ‘knowledge interaction’, with power relationships, varied sources of ‘evidence’ and competing drivers clearly at play. So, we should not expect the concept to straightforwardly impact how health inequalities are understood and addressed.

Theory vs. practice

In theory, intersectionality offers a critical, innovative approach for understanding and tackling diverse health inequalities. It essentially concerns the power structures and processes that drive these inequalities, and seeks to highlight how unjust systems of discrimination such as racism, sexism and classism operate in tandem to result in unequal, unfair life chances. The animation video below gives an overview of the approach:

 

Putting intersectionality to work entails a number of practical challenges. Many of our participants thought the term sounded like just another buzzword, questioning what it adds. Concerns were raised about the complexity of intersectionality both as a conceptual and methodological framework. For resource-strapped public health teams this was felt to be a particular barrier. Complexity can sometimes inhibit action because policy making processes support simplicity and certainty.

Methodologically, intersectionality includes a danger of over-disaggregation. Working with finer and finer categories to produce a granular picture of inequalities risks losing sight of the processes of disadvantage that impact across groups of people. Questions were also raised over how we can reveal mechanisms including discrimination, use mixed methods and participatory approaches, include marginalised populations, and access large, high quality datasets that intersectional analyses might require.

How might intersectionality actually be implemented? We asked respondents to consider two suggestions

First was the idea of using intersectionality to target and tailor interventions and policies. This raised numerous concerns that it potentially takes focus away from structural changes; assumes that all those in a particular intersection are the same; excludes those who do not fall into the targeted category, and; reinforces deficit and stigmatising narratives. Nonetheless, respondents thought that targeting could have value if marginalised groups were included in the process. They also suggested that geography should be considered when targeting as it is a key aspect of social context.

Second was the idea of monitoring and evaluating the impact of policies and programmes on different sub-groups. This approach was more popular, with participants keen to be able to demonstrate differential and unanticipated outcomes of initiatives. Again, the importance of meaningful engagement of marginalised groups and careful attention to understanding mechanisms, were highlighted.

What is the way forward? Our participants emphasised some key principles and points of action:

• Ensure a clear focus on systems of social discrimination and how they structure access to power, resources and life chances, especially via social institutions (such as schools).
• Wherever appropriate, participatory and co-productive approaches - entailing more equitable knowledge-production – should be used.
• Carefully consider complexity; arguably intersectionality’s biggest asset and challenge. What constitutes the right level of complexity and in which context? Trade-offs are inevitable.
• Develop clear methodological guidelines, possibly in the form of a toolkit, to help with implementing intersectionality, especially for non-academics with limited research resources.
• Big datasets with well measured social variables are essential.

Intersectionality holds much promise. It has the potential to help ensure that those experiencing multiple discrimination are not further disadvantaged by the Covid recovery phase. Acknowledging and addressing potential pitfalls and limitations of the approach is therefore crucial. Marginalised populations, researchers, policy and practice professionals all need to be part of the conversation.

To read more about the project from which this research originated, please take a look at the project website: http://intersectionalhealth.org