Abstract
As we move into the latest phase of the COVID-19 pandemic, it is becoming possible to gain perspective on how the latest challenge from nature fits into our place in the natural world as an animal species dwelling in a potentially hostile environment. It should now be clearer to clinicians and public health professionals alike that some basic assumptions about how we respond to both existing and novel infectious diseases must be re-appraised together with the role of pharmacological and vaccine interventions.
At the heart of such a re-appraisal must be a recognition that the traditional medical approach based on the mechanistic sanitary desire to eliminate specific diseases has limitations and that it is time that we adopted a more contemporary ecological frame of reference.
From the beginning of the public health movement in the 1840s, three eras can be recognised as the initial emphasis on environmental action aimed at improving the sanitary conditions of slum dwellers and in which engineers played a crucial role, gave way initially to a focus on hygiene, made possible by the advent of ubiquitous safe water supplies, the bacteriological discoveries of the early researchers including the Pasteurs, and the germ theory of disease, together with the mass production of cheap soap by Lever Brothers at Port Sunlight; this second phase of public health was in turn superseded by the therapeutic era, dating from the 1930 s with the advent of insulin and the sulphonamide group of anti-microbial agents. Until that time there was little of proven efficacy in the therapeutic arsenal. 1
This third era coincided with the apparent conquest of the common infectious diseases of both childhood and adult life, which we now know to have been largely brought about by improvements in living and working conditions and improved growth and development led by the availability of cheap, wholesome food backed up by programmes of free school milk and meals and the beginnings of childhood vaccination.
Unfortunately, this now seems to have led us into a belief that those earlier non-pharmacological interventions, that had proved so valuable in the years before the breakthroughs in laboratory science, could be ignored and bypassed by the quick fixes of pharmacy aimed at the eradication of the agents responsible as a sole objective. The sanitary idea that drove Victorian public health has lingered on together with simplistic notions of mechanical, albeit pharmacological, nostrums.
The consequences of this narrow approach to the practice of medicine, with its neglect of the environmental and social dimensions, can be seen both in the failures of our early responses to the arrival of the novel coronavirus causing the COVID-19 pandemic and the dilemma we now find in trying to ‘live with’ the virus. 2 Furthermore, the emergence of the whole series of new infectious agents over the past 30 years, including HIV/AIDS, Bovine Spongiform Encephalitis, Avian Flu, Swine Flu, SARS, Ebola, COVID-19 itself, and now what appears to be a differently behaving Monkeypox, should cause us to reflect on the limitations of our working assumptions. In this, we could do worse than take on board ideas from ecology and the notion that we live in a series of levels of habitat ranging from the neighbourhood to Planet Earth.
The contemporary view of how we might live in human-built habitats incorporates thinking from the world of ecology underpinning which is the idea that we should live in harmony with the natural environment rather than imposing mechanical solutions on it. At a World Health Organization conference in Liverpool in 1988, four principles of ecological design for town planning were proposed:
Minimum intrusion into the natural state Maximum variety As closed a system as possible An optimal balance between population and resources.
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The failure to adopt these principles in an age of rapid global urbanisation has created the environmental conditions in which the habitats under which humans evolved have been ruptured producing new threats to public health whether biological, social or environmental. The default response so far has been to seek help from laboratory science in efforts to suppress the consequences of our mass behaviours and as an alternative to understanding how the new threats have come about and learning to live in ways that respect and adapt to the natural world.
In this, issues as divergent as high density living, mass personal transport and sedentary lifestyles, the move away from traditional diets to processed foods with mass obesity and reducing physical fitness levels have converged with the emergence of new or rejuvenated infectious disease agents such that we are running up a down escalator in the vain attempt to catch up with problems of our own making.
One of the notable aspects about the early days and weeks of the COVID-19 pandemic was the failure of public health agencies, not least that of Public Health England, to turbo charge efforts at health promotion and improving the dire state of the nation’s fitness.The consequences in terms of the death toll among the physically unfit emerged subsequently and efforts to reinstate traditional public health efforts aimed at primary prevention alongside environmental and hygiene interventions played second fiddle to the pursuit of vaccines by Big Pharma with massive government support.
The underlying assumption seems to have been that vaccines alone would bring salvation, ignoring the available lessons from antibiotics and the emergence of antibiotic resistance, once hailed as wonder drugs, that having amazing pharmaceuticals is one thing but how they are deployed may be entirely a different matter.
Despite the remarkable achievement of producing effective vaccines from a standing start in under 12 months from the appearance of the new coronavirus, ‘living with Covid’ now seems to be more complex than just implementing mass vaccination with regular boosters, keeping one step ahead of a real-life Darwinian experiment, comparisons being made with influenza, which nevertheless annually kills many thousands of people around the world. Ironically, it appears that improved personal hygiene during the pandemic had a knock-on effect in reducing influenza rates, a bonus that has subsequently been thrown away with the abandonment of all personal preventive measures.
What then is the alternative to a single club pharmacological future for living with COVID-19? The first line of defence from any infection is a physically and mentally fit population with good levels of general immunity. In another time and era, when a large proportion of working-class recruits were found to be unfit for military service in the Boer war, the British government implemented a comprehensive programme of public health measures that included a continuing anthropometric survey, day nurseries, free school meals and medical inspection, physical education and instruction in hygiene, along with many other measures. Underlying this was the concern about the rising military power of Germany and our ability to compete in the global economy, something that seems to be equally pressing today.
If we are to learn the lessons from the COVID-19 pandemic and from history before that, we would be wise to re-instate our Public Health Service to the strength it was before the pharmaceutical age and to pay proper attention to the habitats in which we live out our lives. The value of the new vaccines is undoubted but exactly how they should be used, when and for whom, is at this stage an open question. The optimal deployment of these gifts from the gods must strike a balance between a universal population based programme and a more targeted approach based on vulnerability while building resilience for the whole population through a concerted effort of health promotion.