Doctors and community health campaigners are working out how to start local testing and tracing projects, as building blocks of the public health strategy needed to combat Covid-19.
The local initiatives come in response to the government’s disastrous failure to organise testing and tracing, seen by public health specialists as one cause of the UK’s high rate of infections and deaths.
In Sheffield, a group of doctors including retired public health specialists, directors of public health and GPs have set up a pilot project, aimed at working out how volunteers without medical training could do contact tracing.
The Sheffield Community Contact Tracers work with the World Health Organisation guidelines on
Covid-19, which recommend that “cases are identified, advised to isolate, and that contacts are traced, advised to quarantine, and then followed up to identify new cases”.
The organisation points out: “Contact tracing is not currently part of UK guidelines, but there is a groundswell of opinion that it should be.”
Local authority and NHS staff have contact tracing skills, but there are not enough of them, the group says. Volunteers can be recruited and trained to do contact tracing, and to support people who need to isolate: the pilot project will determine exactly how.
In Oxfordshire, the Keep Our NHS Public group published a briefing this week urging that the Sheffield initiative be “supported and replicated”.
The Oxfordshire group call for the local authorities’ public health teams, and the Directors of Public Health who manage them, to implement testing and tracing, working together with GPs, Local Medical Committees, Clinical Commissioning Groups and heads of hospitals.
It is these local health structures that have been undermined and weakened by the Health and Social Care Act 2012, and the years of austerity policies that followed it. The Act gave public health responsibilities to local government bodies, who were then starved of funding.
Testing, tracing, isolating and supporting “is most safely done under the public health team’s direction, by publicly recruited, trained and employed staff, using publicly owned equipment”, Oxfordshire KONP argues.
In this way we can keep a grip on what is done, make certain it is carried out with all possible speed, in a way which is integral to local services and carried out in full knowledge of local circumstance.
The local public health teams will know where best to carry out tests, where the care homes are, and how to ensure maximum compliance. […] Above all, they will be working for us, their population – accountable to us for what they do.
The alternative, Oxfordshire KONP warns, is the government approach that has – last week, instead of three months ago – given directors of public health responsibility for testing in care homes, while at the same time contracting-out testing, tracing, data collection and analysis to the private sector. This “guarantees delays and fragmentation” – and “may be the largest handover of NHS patient data to private firms in history”.
The Save Our NHS group in Newham, east London, the borough with the UK’s highest death rate from Covid-19, on 7 May called for a locally-based “test and trace” scheme.
Locally-recruited contact tracers “will have case loads based on local knowledge of Newham’s rich and diverse community structures, ethnicities and languages”, the group stated. Newham residents and Newham care workers “will be reassured and empowered” by such a scheme.
In Hackney, the council’s head of health and the Mayor wrote to the government on 7 May, calling for its tracing and tracking system – a pilot for which is being tested on the Isle of Wight – to be further piloted in the borough. They wrote:
There is in-house capability and credibility in the council’s public health team, as well as resources in environmental health, sexual health and the local health system. […] We have also been overwhelmed with local volunteers who could be trained as additional contact tracers.
At a meeting of public health experts in Hackney a week later, the limitations of the government’s phone-app-based contact tracing system were discussed. There had apparently been no response from Whitehall to the previous week’s letter. Surprise surprise.
Such examples show that Covid-19 is opening new fronts in long- and hard-fought battles over public health that have pitted health workers and weakened local government structures against Tory (and before that, New Labour) strategies of centralising, privatising and wrecking local infrastructure.
Significantly, academic specialists in public health have spoken out vociferously against the government (in the context of a wider rift between health experts and government: see Research Resources below).
Cicely Marston, Alicia Renedo and Sam Miles of the London School of Hygiene and Tropical Medicine, writing in The Lancet, criticised pandemic responses that “have largely involved governments telling communities what to do, seemingly with minimal community input. Yet communities, including vulnerable and marginalised groups, can identify solutions.”
Sir Chris Ham and Robin Tuddenham, writing in the Health Service Journal, denounced the government’s approach as “top down”. Current policies
lack an effective role for regional coordination through the Integrated Care Systems/ Sustainability and Transformation Partnerships and Local Resilience Forums, and risk marginalising the essential skills of local authorities, GPs and the voluntary and community sector in place.
Health campaigners have resisted Integrated Care Systems, which they see as unaccountable. Nevertheless, the critique of the government’s destructive approach to local bodies is telling.
Ham and Tuddenham recalled that local government in its present form began in Victorian England, with the 1848 Public Health Act, “to rid the population of disease, to ensure clean sanitation and food that was safe to eat”. This partnership of medicine and state “seems to have been forgotten” at the time of Covid-19.
All this is part of a gigantic shake-up of relations between the state and society, provoked by Covid-19, in my view. I can not get my head around all the implications, but here are two thoughts:
■ Across the world, there are a huge range of class battles being fought over coronavirus – about personal protective equipment in hospitals and other workplaces; about health provision for migrants, prisoners and other vulnerable groups; about the economic hardship caused to working people by lockdowns. In the UK, there is an immediate fight coming up over reopening schools, with the Tories and their press on one side, and teaching unions and millions of parents on the other. Organising local testing and tracing – like repurposing production to make e.g. health equipment, hand cleaner or food parcels – takes one step further: it seeks not only to protect society from the government’s management of the crisis, but implicitly challenges its right to manage. It is about us taking matters into our own hands.
■ In making that challenge, we are fighting on the terrain of the state – alongside local health directors, councillors and so on, and bodies such as local Health Overview and Scrutiny Committees, who are trying to claw back control from central government. This is in some respects alien territory for those (including me) who believe that fundamental change depends on powerful movements outside and against the state. This not a new contradiction – and in the 1980s was the subject of a pamphlet, In and Against the State, which is worth re-reading – but it is one we need to live with, and think about.
As background, I summarise below (1) Criminal Catastrophe (the government strategy that, unresisted, will produce more disasters); and (2) Research Resources (work by medical researchers on alternatives).
On 12 March, just as Covid-19 was taking hold in the UK, the government stopped all community testing and tracing. The chief scientific officer, Sir Patrick Vallance, said the next day that the government aimed to “try and reduce the peak, broaden the peak” and “build up some
kind of herd immunity”. This triggered a horrified reaction from health specialists. Some of them have gone on to suggest that thousands of extra deaths have been caused by the combination of testing and tracing being junked, care homes being left unprotected, and the government’s unexplained refusal rapidly to impose lockdown and border controls.
If you’re in the UK you have probably been following this unfolding catastrophe. But let’s remind ourselves of the highlights.
The restart of testing – described by one veteran health researcher as “long overdue” on 25 March – began in April, but the focus was on “Lighthouse” super-labs, set up in conjunction with private companies, with no transparency and no attempt to consult health workers’ unions. The NHS’s 44 labs remained underused. Chaos ensued, with health and care workers unable to access tests, tests being sent to the USA after problems at one lab, and other results going down a “black hole”. The farce of the government setting and missing its target of 100,000 tests by the end of April would be funny if it was not so serious. And if testing in care homes had not been a “complete system failure”. And if the target had not distracted from the need for a joined-up public health strategy including testing, tracing and isolating.
Meanwhile, while local public health structures were ignored, efforts to crank up contact tracing were focused on mobile phone apps. Giant questions have been raised about the privacy implications, about the contracts handed out to tech giants to supply the apps, and about whether the apps can even be effective, given the large numbers of people who either don’t have a smartphone or wouldn’t use the apps if they do.
On 12 May the Department of Health & Social Care, apparently backtracking, said local government would play a bigger part in testing and tracing. But the next day the government brought in Serco – which has previously been fined for cheating on NHS contract arrangements – to manage call centres for contact tracing.
The government behaves like this, in my view, for a combination of reasons: the Tory obsession with privatising health care; hatred of local government and the welfare state; pressure from the
extreme Tory right who wanted to end the lockdown fast; and simple incompetence on a scale that would have been inconceivable in the Thatcher era. This is the next chapter in the meltdown of British conservatism, itself a sub-plot of British post-imperialism’s geopolitical decline. All of which is no comfort to us who are on the receiving end of their vicious actions.
I would suggest not stewing in anger – which is easy to do under lockdown.
Contact your friends locally, your local Covid-19 mutual aid group, your GP, local councillor, or whoever, and talk about following Sheffield’s example and get testing and tracing going locally.
Since the start, this crisis has featured forceful opposition to the government’s combination of heartless calculation and chaotic indifference from medical researchers. Some of them have completely abandoned the pretence that research exists separate from politics: for example, Devi Sridhar suggested in a recent article “what you should be demanding from your government”. Allyson Pollock and Anthony Costello are equally outspoken.
In response to government attempts to bury the proceedings of its own Scientific Advisory Group for Emergencies (SAGE) – and Dominic Cummings’s ham-fisted attempt to impose himself on it – an independent SAGE has been set up by Sir David King, an insider of the political establishment par excellence and former chief scientific adviser.
The independent SAGE report on Covid-19, released this week, is an important resource for social and labour movements. On test-trace-isolate-support-integrate, it not only critiques the government’s actions so far, but lays out strategies.
On lab capacities:
There is an urgent need to plan for migration of testing back from the emergency Lighthouse laboratories into a more integrated future “normalisation” of such increased capacity across our existing Public Health England/NHS laboratories. […] Even more local use of forthcoming point-of-care PCR tests based, for instance in primary care / community settings may play an important role. […]
On quarantining, the report says the current seven-day isolation standard is “untenable” and points to the WHO recommendation of 14 days.
On integrated public health care:
We argue that a future sustainable system is based locally, making full use of existing primary and secondary care networks, including local laboratory capacity as well as local authority-based public health and social care.
On the likely scenario 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” [i.e. constantly maintained in the population]:
The country will be subject to recurrent local outbreaks requiring rapid intervention. It follows that exit from the current lockdown must encompass a strategy of searching for the virus wherever it appears, understanding and intervening in transmission networks, as well as protecting those with disease. This requires a virus control system which has long term sustainability. It must be built into an enhanced public health protection system, taking advantage of the primary and secondary health care system, but also incorporating locality-based integration (integrated Care Systems) including local government and social care, and crucially with community participation.
We do not have to treat specialists’ opinions as god-given. But, while these opinions are formally presented as advice to the government, they have been made transparent as a matter of principle – and are a resource for social and labour movements. The group’s press conference is worth watching on youtube, if you don’t want to read the whole report. GL, 18 May 2020.