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Friday, January 8, 2021

January 08, 2021

(The Guardian) - By Alex Crozier - The millions of people who cannot afford to self-isolate face a choice between Covid compliance and financial devastation.

Lockdowns only work if they reduce transmission. And transmission only reduces if those who are sick self-isolate. But what if that comes at too great a cost? The millions of people who cannot afford to self-isolate face a choice between financial devastation and compliance. By not providing proper support, the government is forcing people to decide between their families and their communities. This choice is cruel. And it is avoidable.

The evidence is clear that Covid-19 disparities are driven by differences in exposure both at home and at work. Those of lower socioeconomic status are hit hardest by both the virus and the collateral damage of restrictions. In lockdown, almost all risk is shifted on to the 10 million key workers who cannot work from home, as well as those living in deprived areas and overcrowded houses – two groups that often overlap.

Given that the new variant of Covid-19 is significantly more infectious, transmission within households and among key workers, who spend extended time in close proximity to others, will increase. As always with deprivation, one problem amplifies another – being an essential worker and living in dense housing with multiple generations is not just associated with Covid-19 risk: it is the mechanism that creates the risk.

Like lockdowns, testing and tracing will only reduce transmission if infectious cases are able to isolate effectively. Yet possibly fewer than 20% of those who should isolate do so fully. The data shows that, while most people intend to adhere to government advice, only 12% get a test, 18% isolate, and 11% of contacts isolate properly. Crucially, self-reported ability to self-isolate is three times lower in those who earn less than £20,000 per year or have less than £100 saved.

An OECD review showed that, because it permits workers to self-isolate, paid sick leave can contain and mitigate the spread of the virus. Therefore, it plays an important role in protecting workers and their communities during a pandemic. Yet the UK has one of the lowest proportions of income covered by statutory sick pay in Europe, and millions don’t even qualify. The government calls it a war on Covid, but they have left a key weapon at home.

This failure to provide proper self-isolation support has meant that the country is split in two: those who have the means to stay at home and protect the NHS, and those who cannot, no matter how much they want to. Affluent communities with adequate housing and sick pay provisions are given socioeconomic immunity, while the burden is shifted on to the networks of the working class. It is protection for some, and pandemic for others.

Nowhere has this been more obvious than in Leicester. Most of the country at least had some sort of break from Covid-19 over the summer, but Leicester has been on the highest level of restrictions since June due to a surge in cases in the city. Public Health England evidence showed that workers in the city’s garment factories and food-processing plants were a significant driver of transmission. Many of these workers felt they could not stay off to self-isolate when sick. Transmission was likely amplified further by poor working conditions and networks of people living in over-crowded, multi-generational housing. These outbreaks then spilled over into the community, contributing to a surge in cases and restrictions being applied.

This is the untold story of the pandemic. The focus on personal compliance has taken attention away from the structural inequities that preclude compliance and drive transmission risks in communities.

And yet, with all of this evidence, with school, university, and business closures, local economies in freefall and the NHS near breaking point, the government has still failed to implement the most basic of public health principles. By not enabling the financially vulnerable to self-isolate, we have repeatedly exacerbated social inequities and the disasters of the pandemic.

Now we desperately need action from the government. Key workers must be guaranteed social and income protection. Additional support must be provided to ensure low-paid, non-salaried and zero-hours contract workers can afford to follow isolation rules. In addition to employment protection, Sage states that for individuals to be able to self-isolate properly, support should include a daily text or phone call and provision of food supplies and essential goods. Sage also stresses a need for solidarity and togetherness rather than divisive messaging. Workplaces can also be made safer by reinstating the 2-metre rule, provision of PPE and sanitiser and, importantly, ensuring ventilation wherever possible. Like in New Zealand, South Korea and New York, the government should use the thousands of empty hotel rooms to provide accommodation so that people, particularly those in crowded and multi-generational households, are able to self-isolate properly.

By directly addressing the barriers faced by socioeconomically vulnerable populations, self-isolation support to patients and their households can also increase test uptake and the number of contacts given. In Liverpool, a pilot of mass testing was rolled out with hundreds of thousands of rapid tests and large numbers of army personnel to implement it, but the government ignored requests from local public health leaders for additional funds to support isolation. The pilot report concluded that the impact of mass testing was reduced due to low test uptake in deprived communities. The reason most often given? A fear of not having adequate support to self-isolate. It’s one of countless examples of the government shooting for the moon without bothering with fuel for the rockets.

Isolation of infectious individuals is the single most important measure in terms of controlling transmission. If we don’t pull these basic public health brake levers to slow the spread, the virus will simply continue to transmit among key workers and their families. Therefore, the effect of lockdown will be limited. Given the emergence of the new variant, providing income protection and support for self-isolation may be the deciding factor in whether we reduce R below 1.

The disproportionate impact of Covid-19 on households living in poverty emphasises the need to urgently update our definition of “vulnerable” populations and address these inequities. Many (rightly) take issue with the Great Barrington declaration and its policy of focused protection. But this current blanket lockdown approach fails to address what is really driving the pandemic, and is merely the focused protection of the middle classes. Even the strongest of wills cannot overcome hard economic realities. We need targeted and sustainable solutions, based on evidence and core public health principles. To make this lockdown a smart lockdown, the government must support key workers and self-isolation. This tale of two pandemics has gone on far too long.

Alex Crozier is a Covid-19 research scientist, also involved in science communication


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