It’s time to deploy the Army and call a Public Health Emergency

Population-based triage may not immediately be the most enticing sounding of concepts. But PBT, as it’s known for short, may be the key to how the UK manages the next stages of the coronavirus quagmire.

Under the PBT plan, the population as a whole is treated to the triage technique familiar in accident and emergency and in battlefield medicine. Medical and rescue teams concentrate on the most treatable in preference to those most likely to die.

Frederick “Skip” Burkle, Emeritus Professor of Public Health at Harvard, says: “Traditional health care systems care systems care for patients individually, while public health is caring for an entire population.”

Burkle published his plan for a population-based approach to pandemics in 2006. It was used in the desktop exercise by Public Health England for tackling a major influenza pandemic, Operation Cygnus, in 2016.

The report partly adopted the professor’s approach to running a pandemic operation, but left many questions open. If they had been addressed in the present Covid crisis, thousands of lives may well have bene saved.

Much the same goes for Exercise Isis, carried out by National Health Scotland in 2018, which focused on an outbreak of MERS (Middle East Respiratory Syndrome). The lessons of both exercises have been taken on board, according to Health Secretary Matt Hancock, but as they say in Scottish law, it looks like a case of not proven.

Both the Cygnus and Isis reports of 2017 and 2018 cannot conceal the serious shortcomings in preparing against a major public health emergency. The Cygnus exercise concentrates on the role of the Local Resilience Forums in coordinating emergency services – yet the representatives of the eight LRFs were explicit about their lack of resources.

The LRFs have proved vital since March, but they have no statutory powers and no funding. More ominously, the Isis report for Scottish Health flags up the lack of availability of protective equipment – PPE – for a nationwide viral outbreak.

The problem of managing a workable Public Health Emergency strategy for this coronavirus crisis is brilliantly illustrated in the BBC One documentary drama, The Salisbury Poisonings. Public health officer Tracy Daszkiewicz, played brilliantly by Anne-Marie Duff, must manage a public health threat to a population of 60,000. By closing off central Salisbury and assembling a track and trace regime in two days, she achieves this with the loss of only one life.

Today Dazkiewicz is a Deputy Director at Public Health England, responsible for Covid mitigation operations across the South West of England – which , coincidentally or not, has been relatively free of the virus. Health and Environmental officers like her are the key to managing what has been, like the Salisbury incident, an unforeseeable crisis.

The local government health and environmental teams have been one of the success stories in the crisis. Liaison officers at Local Resilience have been plugging the gaps, as have key volunteers running “Tac”, or “Tactical”, cells coordinating the efforts of charities and volunteer teams. The local health authorities have experience in running tracking and tracing operations for serious human and animal diseases including e coli , legionnaire’s and Weil’s.

Barry Rees, a corporate director at Ceredeggion Council, recently set up a do-it-yourself track and trace team for north west Wales. The result is that only 45 positive cases of Covid have been reported and isolated, out of a population of 75,000.

In contrast, the Whitehall operation appears to have been over-centralized and bureaucratic. Ministries have bickered and clashed over powers and budgets, procrastinated and delayed – with fatal results. The decision was taken on 12 March – Dithering Thursday – to put things off, since tracing facilities and PPE were not sufficiently available.

Locking down was put off for 11 days – potentially costing thousands of lives. This was the opposite of Professor Burkle’s recommendation in his 2006 blueprint for tackling what his profession calls a “BioEvent.”

I caught up with the professor in a midnight call – morning for him – to Hawaii where he is undergoing therapy for leukemia. At 80 he is still writing and debating public health with colleagues across the world. His experience stretches from a serious plague epidemic in Vietnam in 1968, where he served as a Navy doctor (hence the nickname “Skip”), to the SARS and Ebola outbreaks of this century.

“The approach has to be multi-disciplinary, especially at the local level,” he told me. “Public health emergency is a specific science, and you require different scientists for it. The biggest point is that while medicine traditionally focuses on the individual – here you have to realise the entire population is at risk.”

This is where population-based triage applies – a plan to save the greatest possible number possible. It does not go against the Hippocratic principle of “do no harm”, he explains: “Population-based management saves more people in the end.”

Burkle’s blueprint for a Health Emergency follows the precept of Jacinda Ardern, New Zealand’s astute prime minister: “Go early, go hard.” Once it is clear a pandemic is looming (in the UK’s case, February), the government should declare an emergency.

It should then have set up a central operational command and information collection hub. In American parlance, the 2006 paper calls this an “Emergency Operations Centre” and an “Incident Command System”. This means one command system running top to bottom, one strategy and one line of public communication.

On this basis, instead of Dithering Thursday, 12 March should have been the day for Boris Johnson to have declared a Covid Public Health Emergency, with one ministry, one directorate and spokesperson.

In the next phase, according to Burkle’s 2006 paper, the government should have operated the population-based triage system in two phases.

The population of patients is divided into five categories of those likely to survive, requiring only isolation and little intervention, to those who have to be admitted to hospital. Burkle lays out the blueprint of the combination of public health personnel, charities and volunteers needed to manage the crisis.

Despite the previous exercises and warnings in Cygnus and Isis, the UK government did not take a holistic approach. Even the slogan “save the NHS” had a sting. The fear was that the hospitals would be overwhelmed in the first wave of Covid, and would have to leave acute patients in corridors, as happened in Italy. Another persistent Downing Street fear was over whether the NHS could survive a second wave of the virus in late summer.

But saving the NHS had another cost. Sources close to the front line confirm that thousands of patients were pushed out of the hospitals, untested, to free up beds. Many going into the care homes carried the virus with them.

The neglect of the poorer care homes, public and private, starved of supplies, testing and protective apparatus is a scandal that needs to be addressed.

So, too the manner in which funds were distributed to the bigger charities, and an array of agencies and consultants – such as Deloitte and Serco – to build infrastructure and provide aid, from building Nightingale hospitals to distributing PPE.

More than two to three billion pounds have been dispensed on these projects, mostly on non-compete contracts, some worth many millions.

A contractor made such a mess of a Nightingale hospital in Wales that the Army had to be called in to do the job properly. A group of volunteers were stopped from packing and distributing 45,000 boxes of PPE because in the PHE rubric they “weren’t legally accountable.”

Nearly a week late, sources confirm that the Army asked them to do the job after all, under MACA (military assistance to the civil authority) – because “Deloitte couldn’t find anyone to do the job.”

Similar misfortunes occurred in the charitable sector where government funds were distributed to a group of brand leaders, who were to pass them on when where they were needed. This was beyond the experience and capability of most. “It’s like teaching elephants to dance on ice,” one highly experienced volunteer coordinator told me.

Another reported that funds were being withheld on legal grounds from a small street charity that feeds undocumented street folk and rough sleepers, refugees and asylum seekers – the truly hopeless, stateless and penniless.

There is a glaring gap in the Cygnus and Isis recommendations, echoed in the crisis conduct of the government. In neither exercise was the military represented or used. Journalists weren’t consulted or considered.

The Army has crucial capabilities in setting up command and control systems. They did it successfully in the 2012 Olympics and the 2001 foot and mouth outbreak. Instead we have another blue chip City consultant setting up a command system for the Cabinet Office, doubtless at great expense.

Some things really are working today, such as local health officers and volunteer organisers. But now surely is the time for a raincheck, to work out a Public Health Emergency strategy and template to see us out of this pandemic, which could be anything up to 18 months away, and to prepare us for the next.

There is no point in a public inquiry, as on recent form these tend to be an exercise in ploughing sand. There is little use in holding our breath for the “second spike.”  If China, South Korea, Singapore and Israel are anything to go by, we are likely to face spasms of sudden and random outbreaks across the country for months to come.

We shouldn’t bank on the arrival of an effective medicine or vaccine in the short term. Equally, there seems little profit in reckoning on the miraculous “world beating” tracking app promised by the prime minister.

So far the apps have been much less successful than advertised. Dr Lynn Kuock reported to the International Institute for Strategic Studies last week that in Singapore the app has been found to be “only a small, and not very important, part of the trace  and track system.” Instead, putting conscripts on the streets to conduct tracing has been “much more effective”.

Covid strategy needs tightening up. Parliamentary committees should look at three areas: where the money went in the non-compete contracts; how fit for purpose is Public Health England in tackling pandemics; how decisions were taken, funded, and traded between government departments.

According to Professor Burkle over 70% of new viruses identified in the past fifteen years are zoonotic, meaning transmittable from animals to humans. More “reservoir animals” carrying the pathogens are moving from the wild to densely built up human habitations, in India and China, Africa and Latin America.

A global system of public health intelligence is needed, to provide information and guide best practice. This means we should hang on to and improve the World Health Organisation, while we have still got it.

With the enormous changes in human and animal habitats and behaviour across the world, we have entered the new age of the pandemics. And we’re not going back.