COVID19 - Why open and honest public dialogue is needed.

In war, truth is the first casualty. [Aeschylus, 523 BC - 456 BC].

In this war against the COVID19 pandemic, that has proven to be the case. Early on, some claimed it was no worse than the flu. In truth, this appears to be only true for children and young people. In the older age groups, it is much worse than flu. , There has been a profusion of myths and misinformation. There have been political endorsements of unproven treatments, from hydroxychloroquine to oral ingestion of disinfectants. There has been COVID-denial and blame-shifting, including stigmatisation of populations. And there has been an emergence of the anti-mask movement that echo the anti-vaccination movement. Equally, there has been misunderstanding of the scale, even the potential harms, of the pandemic with fear and anxiety disproportionate to the actual risks at both ends of the spectrum.

Public health has also become a casualty. In the US, more than two dozen public health officials have resigned because of personal threats or been sacked following criticism of their handling of the pandemic. In the UK, the government has axed Public Health England (PHE), the national public health institution whose remit included communicable disease control, over perceived failures. PHE has been chronically underfunded for years and many of the errors attributed to it were not of its making. Health leaders have accused ministers of scapegoating PHE to deflect blame for the government's own failings. Ironically, in the 1980s, a predecessor to PHE, the Health Education Authority of England, was also axed at the height of the HIV pandemic.

Some may argue public health decision-making should be driven more by the science, free from political interference. But science has no mechanisms for decision-making except through contesting hypotheses and theories, usually over decades and sometimes lifetimes, which underpins its success. Public health by its very nature is political. It needs to be to influence national policy that has an impact on health and the wider determinants of health. , That also means public health is vulnerable to criticism when political decisions go wrong.

Whilst some political, scientific, and public health decisions may have aggravated the impact of the virus, this pandemic has tested every government. It is so far unclear which of the multiplicity of national strategies will prove to be correct in the long term. Consequently, do we need to challenge what “correct” is? The UK looked to “flatten the curve” to allow the health system to continue functioning, but not every country is taking that approach. Is the right approach to save all lives at any cost? And how does that balance with the maintenance of routine care for other non-COVID19 conditions? Many of the consequences were not easily predictable and difficult decisions have had to be made, balancing a multiplicity of factors. Countries that have so far avoided the worst of COVID19 should not rest on their laurels – this looks like a long battle and there are ample opportunities to trip up.

What does the future look like and what are the policy options? In one analysis of the public health options, Raj Bhopal has likened our position in this pandemic to zugzwang, a position in chess where every move is bad but nonetheless plans need to be made and actions taken. Passivity and inaction are not options. Every possible option must be thought through in detail to avoid defeat and stay in the game while awaiting new opportunities. Allowing the pandemic to unfold uncontrolled or hoping it will go away are not public health strategies. Most options including lockdowns, test, trace and isolate initiatives, or quarantine, buy us time. However, it may not be feasible to sustain these over years and decades. Treatments will improve but will not reduce the incidence of the disease. Whilst a vaccine is desperately needed, balancing the potential benefits and harms, especially in young people for whom the disease is not severe, could be problematic.

The only other route towards population immunity is natural infection, possibly through relaxing controls for low-risk young people. It has been estimated that 40–50% population immunity may be enough and some scientists have suggested the number needed may be even lower. This topic needs a nuanced and careful analysis. Discussion of this topic has, unfortunately, been prematurely closed and the subject is seemingly taboo. Indeed, recent economic analysis indicates the harms of lockdowns and related measures already exceed the health benefits. This is out-of-step with normal social policy decision-making. A public health disaster internationally, especially in low and middle income countries, many times greater than the direct effects of COVID19 may unfold before current strategies are judged to be incorrect.

The truth must be told in an honest way - as much as we want it there is no escape. There has been too much obfuscation and expression of strong evidence-free opinion, much of it based upon fear and emotions. We call for a rethink and an honest and open dialogue with the public, that involves all members of society including children and young people, as well as those at high risk.

Competing interests

AL and JRM have both previously worked for PHE. RSB was previously a non-executive director with the Health Education Authority of England.