Updated: Jun 10, 2020
Sharing our new blog from the British Medical Journal. Solid public health decision making requires engagement of a wide range of disciplines and looking past a "one disease" outcome. Focus only on reducing covid-19 deaths is creating a "generation C" and damage to health for decades to come.
Deaths from covid-19 could be the tip of the iceberg
The public health impact of choices made now will have implications long after the immediate crisis is over
Public health has been defined an “integrative approach to protecting and promoting the health status of both individuals and society.” Made up of different disciplines including epidemiology, environmental and population health, biostatistics and socio-medical sciences and using a range of research and analytical tools, the public health approach has evolved beyond addressing a single health outcome or disease. In this way it takes into account information about specific populations, the health systems with which they interact, and the social and environmental factors that promote health and prevent disease.
Across the world, the driver of the approach taken in the response to covid-19 has been to “flatten the curve”—the strategy is to slow down the spread of the virus to enable health systems to cope better with the high-end intensive care capacity required by severe cases. Countries have therefore implemented a range of lockdown measures aimed at spatial and physical distancing.
While this strategy is proving effective in reducing the spread of covid-19, these measures have also resulted in compromises to a range of other health services, including care for those who may require it for other conditions. Visits for routine preventive care have decreased drastically. Further, there is increasing evidence of excess deaths, meaning people dying of heart attack or stroke because they didn’t access care early enough or at all. There are also reports of increasing family violence, stress and mental health problems, including for children and youth, now coined “generation C” for the lifelong impact this pandemic will confer upon them.
In addition to the direct effects, lockdown measures have also compromised a range of social determinants of health, including educational attainment, food security, employment and income which disproportionately affect those families and populations who are already vulnerable, and further exacerbating health inequities and discrimination within and across countries. Given that many people have underlying conditions associated with both poverty and covid-19, including obesity, heart disease, diabetes, and hypertension, the lockdown may have resulted in putting asymptomatic or mildly symptomatic people shedding the virus in close household contact with people at risk.
The public health impact of choices made now will have implications long after the immediate crisis is over. After decades of work to reduce maternal and child deaths, including through vaccination programmes, the negative impact of placing these services on hold, particularly in countries with high fertility, a large under-5 population and high rates of infectious diseases, is already having serious consequence.
Recognizing that many of the current mitigation strategies are based on limited evidence, we must put in place a global learning agenda so that mistakes are not repeated and secondary population health effects are not overlooked.
It is not too late to re-introduce many of essential services of public health and the principals of population health into the covid-19 response. To do this, hospitals and public health authorities must collect, collate, and share disaggregated clinical, demographic, and socioeconomic data so that public health professionals can better decode both the clinical risks and understand the risks for various population groups. This will also allow for a response which takes into account social determinants, including population density, mobility, poverty and inequalities when assessing health outcomes. Summary tables are not enough to drive evidence-based decision making or precision public health which is required to target efforts to those most at risk.
Context matters and different contexts require different interventions. Lessons from other public health emergencies of international concern, including from Ebola and HIV, provide us with a blueprint on types of strategies and approaches for community engagement that can address the immediate health issue while also reducing stigma, discrimination and fear. Unfortunately, these lessons on community partnerships have largely been absent in the covid-19 response. They could have and still can help improve the design of prevention measures such that communities themselves have agency and voice in deciding how best to protect themselves.
When we are past the immediate crisis, the community and countries themselves must convene independent expert panels, that include a range of voices and actors, to review decisions taken. In the meantime, we must urgently shift our approach and begin learning, evaluating and adapting our strategies in real-time. If not, deaths from covid-19 will be the “tip of the iceberg” of the public health problems created by a single disease-focused response. The hard-won public health gains, as well as the potential to achieve Sustainable Development Goals in health and other areas, will be lost for our generation and generations to come.