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.

(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.