A little over five weeks ago COVID-19 started to take over my every working moment. Calls and emails started flooding in, and the rest is history. An explosion of activity even more exponential in its curve than the number of people infected has been the experience that we directors of public health have had since then.
I know I bang on about this being my fourth pandemic - HIV, Sars and H1N1 Swine Flu having gone before - but while they are all very different, there are lessons you can learn from each of them.
Among these key lessons are that pandemics are unlike any other kind of major incident. They are driven above all by the levels of infection, illness, recovery and sadly death. The virus, and our response to it, drives us. And that means you need to be guided by levels of infection which, if we are getting anything right, will change and fluctuate. So anything you do, any timescale you give, is provisional.
Another key lesson is that pandemics have a rhythm. As the number of people recovering or dying rise, so the numbers susceptible reduce. And not everyone gets infected. So you have to understand that rhythm. You have to understand what that means for a second wave, for recovery, and you have to try to map that.
A further key lesson is that directors of public health (DPHs) in a pandemic go through a cycle too. And the watchwords here are resilience, adaptability and, ironically, consistency. The resilience is about being able to have the public health system stay the course as you work along. The adaptability is about being able to flex and change advice and tactics as the cycle of infection and recovery changes, and to be able to articulate this. And the third watchword is to have a consistent eye on the science, and a consistent eye on the road to get out of this.
A final crucial lesson is pandemics never come with just a pathogen – the virus. They bring in parallel epidemics of anxiety, mental ill-health, deprivation of service because of system stress, financial distress and the stacking up of ‘low priority’ health issues. So after we have had the first and possible second waves of infection from SARS-CoV-2, we will have a wave of mental ill-health. Particularly in this epidemic, because of the nature of social distancing, there will be many whose grieving for loved ones is interrupted and made harder by what may well feel like the cruel circumstances of being unable to touch and be close to those we have lost. But there will also be an epidemic of physical ill-health backed up from this. A backlog of diabetes complications, dental ill-health, pain and lack of mobility from routine operations and treatment postponed or cancelled, and some otherwise avoidable deaths from this will come too.
A key task for DPHs will be to chart the way out of this, identify the milestones and identify the tasks to come.
To do all this your average DPH will be looking in multiple directions at any one time. This is certainly true of what I have been up to, and I share it with you as my ‘go to guide’ for what I have been doing and will keep doing.
One key thing that runs all through this is that everything in here is done with other agencies. This is when it gets hard to monitor. I have 23 COVID related workstreams. Not one of them is completely self-contained in my team. We went through the following steps:
1. Getting the system ready
This was my first cycle of activity, and sometimes resulted in very long hour days until we got our team structures and on-call arrangements sorted. Ensuring guidance was produced, information available, science translated into England and briefings provided to schools, elected members, faith communities, higher and further education institutions, funeral directors, and employers. Feeding regular and quality checked information to elected members so they can do their job was a key part of this.
We had a schools helpline launched a week before the Department for Education launched theirs. In a little over three weeks my team and I fielded thousands of emails, phone calls, meetings, briefings and activity on this, ranging from school travel advice to video presentations for care homes and advice on cleaning surfaces for offices. Identifying what we needed to do, so others could play their essential roles, was probably the first and most important thing for our team to do. I built a rota and a command structure, so we have a public health on call function and our schools response function jointly with our children’s services.
Working with our 10 district and borough partners we worked on one toolkit for enabling councils, police and partners to use the new and existing public health powers, sharing lawyers and paperwork to enable any orders needed to be processed quickly.
2.Prevention
We worked with communications to field press and media queries but also to get a range of prevention messages out there. We had posters on buses and train stations and a series of messages and resources from a public facing set of resources to information to prevent spread in workplaces. Pressed with shortages of Personal Protective Equipment (PPE), not only did we line up a system to buy and source it working across agencies, but we got our university manufacturing hand sanitiser for social care and schools making masks and visors for carers.
3. Ensuring public health services are doing their bit
This is one of the most complex parts of the work I and my team have been doing. We have to make sure we divert our significant clinical muscle into the COVID effort. That means I had to prioritise which services could be switched online, and what became urgent only. Switch all drug treatment or health visiting to COVID and people die, and safeguarding crises happen. Switch off immunisations and vaccinations and we have epidemics of measles and meningitis at the same time as COVID. Pressure from some to shift everything to COVID is not something I was minded to bow to.
I’ve actually done more of some things. As evidence grows that smokers who are at high risk of severe COVID disease fare even worse if they smoke, we’ve ramped up smoking cessation for people at high risk.
4. Capacity and support for others
What might be obvious here is providing staff help to Public Health England to help with contact tracing. What won’t be is the fact I fielded PRINCE2 qualified project managers into setting up a range of cells and programmes across other parts of the council and wider, including helping devise arrangements for the programme to get food to people being shielded. My team leads the PPE, data and analytics and some other work.
5. Providing the beacon in the storm
This is probably the single most important thing a public health team do at this point. Articulating when the peak is, what beds we will need, how many spaces for storage of the deceased we will need, when will recovery start and more are questions in a pandemic that must be answered carefully. My team produce a series of analytical products into the multi-agency work to inform response and planning. I am already thinking about the road to recovery, because a failure to plan for recovery will cost lives and jobs.
6. Public mental health, coping, anxiety and trauma
Finally, I brought together a range of agencies to look at public mental health impacts both short and longer term. From voluntary agencies working on bereavement to crisis mental health, guides to how to stay resilient and tools for staff welfare, my team have been involved in co-ordinating the work to ensure we minimise the harm to people’s mental health.
The job of a DPH is complex. There’s more we have done that I can cover here. But with the right mindset and the right team, it makes a crucial contribution. I have a job, a council, a system and a team I am proud to serve.
Jim McManus is director of public health at Hertfordshire CC and vice president of the Association of Directors of Public Health