SOM (The Society of Occupational Medicine), The Faculty of Occupational Medicine (FOM) and the University of Glasgow held a summit in November to discuss the issue of how reducing one risk to control Covid-19 may cause risk elsewhere. Nick Pahl and Ann Caluori outline what it concluded.
Our event, ‘Perspectives on Covid-19 and risk’ was opened by Professor Ewan Macdonald, consultant occupational physician and head of the Healthy Working Lives Group at the University of Glasgow.
About the authors
Nick Pahl is chief executive and Ann Caluori is communications and events manager at SOM
He said: “In 1957, US Surgeon General Burney wrote of a future pandemic: ‘I am sure that what any of us do we will be criticised either for doing too much or for doing too little. If it does occur, I hope we can say that we have done everything and made every preparation possible to do the best job within the limits of available scientific knowledge and administrative procedure.’
“Our world of occupational medicine and health and safety is based on risk assessment: is the pilot fit to fly the plane? Is the train driver fit to drive? Is the surgeon with early parkinsonism fit to operate? What are the risks of occupational exposures? And, in a Covid pandemic, is it safe for the worker with a high ‘Covid age’ to return to their job?”
Advising workers and workplaces requires competence in risk assessment and control, he pointed out, adding that he had been “shocked” by initial guidance on PPE issued to the health service “which demonstrated either incompetence or a lack of preparedness and made me realise that healthcare workers were going to die because of preventable occupational exposures”.
Workers, he emphasised, should never die because of their occupations. It also needs to be recognised that the mental health consequences of Covid are significant, along with the interruption of ‘normal’ NHS care.
As Professor Macdonald put it: “It is likely that the deaths due to the interruption of the process of general healthcare will kill more than Covid. The interruption of care has also prolonged sickness absence and caused job loss and the medical profession in general has a blind spot about employment and unemployment.”
The event brought together a range of global experts – academic, public health and scientific leaders. It sought to address four key questions:
- Does unemployment create a bigger societal risk to health than Covid-19?
- Are scientific approaches to individual and societal risk to Covid-19 challengeable?
- What long-term approach to risk should medical leaders take to the public?
- Do people understand risk and what level of risk can we afford?
Balancing health, economic and societal risk
The first speaker (introduced by Dr Anne de Bono, president of FOM) was Dr Oliver Morgan, director of the World Health Organization’s Health Emergency & Risk Assessment Unit, who discussed how we should be better trying to balance the health, economic and societal risks we face.
With over 50 million Covid-19 cases recorded, more than 1.25 million lives lost, and many more lives lost indirectly, he said we are now living in a world where everyone is trying to manage risk.
He suggested we therefore need to balance the public health response to control against considerations of the impact to society and balancing economic concerns.
He offered the example of the recently concluded two-year-long Ebola outbreak in the Democratic Republic of Congo, where there had been debate about travel restrictions, with concerns that no travel to Rwanda and Uganda would cut off important communication routes for the population. The lesson learned from that was that pandemic risks can be split into three levels:
- Emergence – including exploitation of ecosystems, and climate variability and change;
- Amplification – including poor living conditions and unsafe health care settings; and
- Propagation – including domestic and international travel.
Managing pandemic risk is therefore dynamic, and we must balance changes as epidemiology changes. Dr Morgan finished with a reminder that every day we balance risks and, for the most part, we are good at it. However, we can also become overwhelmed with information, a challenge for all.
The role of health inequalities
The next speaker was Professor Sir Michael Marmot, professor of epidemiology at University College, London and author of the seminal ‘Marmot Review’ into health inequalities.
He focused on the inequalities seen in Covid and explained how the pandemic has revealed underlying problems in society and amplified them.
While the initial consensus had been that Covid-19 was a great leveller, we were soon disabused of this notion. If anything, its impact has been exaggerated the persisting inequalities within society.
Professor Marmot drew a clear link between how the UK is faring during Covid-19 to how we were faring prior. For example, 2010-11 saw life expectancy slow dramatically, yet that improvement was slower in the UK than other rich countries in Europe.
Regionally, if you were rich your life expectancy was the same regardless of where you lived; if you were poor, life expectancy was declining everywhere, except in London.
Now, with Covid-19, numbers of excess deaths from the virus in the UK are the worst in Europe. Importantly, Covid-19 mortality in the UK is following a similar social gradient to non-Covid mortality.
High Covid-19 mortality rates are likely to be found in those living in overcrowded multi-generation households and working in public-facing roles.
Black British women score high for Covid-19 mortality, but when we adjust for geography and deprivation most of this is accounted for.
Professor Marmot referenced a question he had posed before: why treat people and send them back to the conditions that make them sick? What had happened between 2010-20 left the UK in a poor position for the pandemic; for example, the rolling back of the state. Local councils, too, had seen large cuts in spending with, ironically, the greater deprivation the area had, the greater the reduction in spending.
The UK had managed the pandemic badly and had one of the greatest reductions in GDP. Figures show that the lower a country’s excess mortality, the lower the reduction in GDP.
What this suggested was that the idea there is a supposed trade-off between managing the pandemic and managing the country is a fallacy. Manage the pandemic well and you do not have the same economic hit.
When it came to the UK ‘building back better’ post pandemic, Professor Marmot suggested we learn from New Zealand, whose wellbeing approach has sought to enable citizens to live lives of purpose, balance, and individual meaning. As he put it: “We need to put wellbeing at the heart of what we are trying to achieve”.
The BP perspective
Next to speak was Dr Richard Heron, vice president health and chief medical officer at BP, who talked about Covid-19 and risk from the perspective of his industry.
He highlighted that there is currently great change and uncertainty within the industry, including BP, as not only does it work to work to respond to the effects of the pandemic but tries to transition to a carbon neutral business model across.
With BP operating in 79 countries, risk management needed to be different depending on the environment. With the pandemic, there was a sense that we do not know when it might end, and we must balance what people want versus how we can help, he argued.
It was helpful to try to keep advice as constant as possible but, inevitably, it will change. One of the problems with new diseases was the lack of evidence, he highlighted, meaning we are seeing a lot of pre-publication studies, which then get amplified on social media.
Dr Heron suggested that every three years since 2010 there has been an infectious disease outbreak: Sars, Ebola, Zika and so on. So, is this time for a new chief medical/public health officer role within organisations, one grounded in occupational health?
Corporations must not only do risk management, they must do it in absence of complete evidence, in a way that is humble, and be prepared to change their minds if needed.
Clinical risk stratification
The next speaker was Professor Julia Hippisley-Cox, professor of clinical epidemiology and advanced general practice at Oxford University.
She discussed the ‘QCOVID’ clinical risk stratification tool, its development and value. The tool is a ‘living prediction’ algorithm funded by the National Institute for Health Researc and recently published in BMJ. Based on the premise behind it that, with the virus likely to change, knowledge is also likely to need to change, it is a dynamic model that uses the data of 10 million currently registered patients in UK.
Professor Hippisley-Cox suggested there needed to be caution in its predictions, as some patients had already started to shield before national guidance came in, so there will be some underestimate of risk.
Nevertheless, results of its validation showed that the model is robust and results were likely to be generalisable to the UK.
It was also efficient at risk stratifying the population and will identify different groups at risk. There are plans to make this available more widely for doctors and patients in the NHS.
‘Covid age’ risk assessment
Professor David Coggon, professor of occupational and environmental medicine at Southampton University, and Dr Tony Williams, medical director of OH provider Working Fit, discussed the development of the ALAMA (Association of Local Authority Medical Advisors) Covid-age medical risk assessment tool, which is now the tool of choice for Scotland and Ireland.
Dr Williams emphasised that we need to focus on the most vulnerable, particularly those in caring roles who often work outside the NHS.
They may well have limited or no occupational health support and, if they cannot work, they do not get sick pay. Lockdowns are immensely damaging to the most vulnerable in society.
Shielding those of working age is immensely damaging to them and their families, in most cases for no good reason. Organisations can make themselves ‘Covid secure’ and, if they are, they should be allowed to continue to function, he highlighted.
Professor Coggon described how Covid age provides estimates of relative and absolute vulnerability to Covid-19 according to demographic characteristics and health-related variables in people of working age.
Vulnerability is assessed in terms of infection-fatality rate, and risk estimates are derived through regularly updated critical review of published epidemiological studies. The main sources of data have been large cohort studies in which data on potential risk factors, ascertained from general practice and hospital records, were linked to data on mortality from Covid-19 obtained from death certificates or hospital records.
“Allowance is made for the possibility of bias from differences in exposure to infection (for example, because of regional and socioeconomic variation or selective shielding), and where possible, risk estimates have been triangulated between more than one source,” he said.
The challenge of ‘long Covid’
Professor Trish Greenhalgh, professor of primary care health sciences at Oxford University, talked about the risks and ‘lived experience’ of ‘long Covid’.
She explained how long Covid is Covid symptoms persisting for longer than a month (‘post-acute’) or three months (‘chronic’).
Its incidence is contested: some say 10% for post-acute and 1% for chronic – but it is likely to be higher.
The symptoms of long Covid are many and varied but fatigue, breathlessness, and cognitive impairment (‘brain fog’) dominate.
Patients with long Covid describe difficulties accessing services, difficulty being taken seriously, and variable standards of care, she highlighted. Patient-generated quality principles for long Covid therefore needed to include:
- Access (for everyone with long Covid, not just hospitalised people).
- The burden on the patient (reduce).
- Clinical responsibility and continuity of care (a named clinician should be available).
- Multi-disciplinary rehabilitation is needed for many but not all cases.
- Evidence based standards and guidance will help reduce variation in care.
- Further research is needed, with a priority on acknowledging the condition
- A recognition that, for patients with long Covid, there is a risk of losing or becoming unsafe in their job.
Health versus economy
Professor Maggie Rae, president of the Faculty of Public Health, echoed Professor Marmot in highlighting that we need to recognise health and economy are not a choice; they are inextricably related.
As she said: “There has been so much talk about trying to protect the NHS but what we have not heard enough of is one of the best ways to protect the NHS is to maintain a healthy workforce”.
Workers in public health had been in ‘major incident’ mode since January, and this would inevitably lead to an increase in mental health problems, such as anxiety.
Professor Rae said test and trace was not performing well. However, the fact local and regional response had been 95% effective meant it was likely to be a better option, especially if integrated with the current system.
The faculty had been advocating for proper testing in the workplace, she highlighted. Professor Rae emphasised importance of occupational health within this context – protecting the lives of those on frontline, supporting mental trauma, supporting long-Covid, caring duties and many other reasons.
OH was the link between healthcare and the workplace, and specialised OH expertise was essential to tackling Covid-19.
Professor Rae emphasised the importance of access to OH for everyone who is in work. Even more intense services would be required to support people. Public Health and OH therefore needed to together, and this collaboration needed to extend into training, she recommended.
Variables around understanding risk
Sir David Spiegelhalter, Winton Professor of the Public Understanding of Risk at Cambridge University, discussed the challenges associated with communicating risks.
A key message in this context needed to be that age is the dominant risk factor for Covid morbidity and mortality, and this needed to be made explicit in all guidance.
Sir David spoke of the incredible challenge for risk communication that Covid had posed. For example, he had said the chance of dying if you catch Covid closely matched the normal risks that we face each year, but his words were misinterpreted by the media, giving the wrong impression of Covid-19 risk of dying.
He identified some challenges of communicating risk. Are we trying to just inform or to persuade? Who are we communicating to? Which risk are we talking about; risk of catching, dying, hospitalisation? Risk in first or second wave? What does ‘high risk’ mean to people when talking about risk of death from Covid-19? People hugely overestimate the risk of dying from it, but does this matter?
If we gave the right numbers, would it solve it? No, we must give some context. He concluded that people want this information and that, when presenting it, “colour with care”, including using percentages that seem clearest and tools such as age comparators.
Misconceptions around herd immunity
Professor David Heymann, professor of infectious disease epidemiology at London School of Tropical Hygiene and Medicine, talked about “Living with the Covid-19 pandemic: using the tools we have”.
He highlighted that there had been a misunderstanding about the concept of herd immunity. We do not have enough information yet to know if it will be possible with Covid-19, for example if protective immunity is possible or how long immunity lasts.
There may be an unacceptable level of mortality with herd immunity, and that will be in the elderly. Vaccination with long-lasting immunity in all populations was the surest way of attaining herd immunity, he argued, though he also cautioned that herd immunity can still be difficult to obtain even with a vaccine.
Effect of interruption of routine NHS care
The event was then brought to a conclusion by Dr de Bono, Professor Macdonald, and SOM president Professor Anne Harriss. They highlighted that one of the key risks for occupational health from Covid-19 (beyond the ramifications of individual risk from infection) was the interruption to routine NHS care.
This poses a risk to the health of the nation and prevents people staying in work. Moreover, the outcome of this was yet to be seen.
Another key risk was from unemployment. Studies have shown there is a clear link between unemployment and shortened life expectancy, significantly elevated risk of suicide and non-fatal self-harm.
Of the 33 million UK citizens who were working before the Covid-19 outbreak, 9.4 million had been furloughed, and 2.6 million self-employed are claiming financial support. Almost 700,000 jobs have disappeared in the UK, and many are facing long-term unemployment and financial difficulties.
Therefore, had the medical community articulated well enough the significant health risks (including vastly increased mortality) of unemployment?
There needed to be better links between research and policy, which could have prevented mistakes, they suggested. Indeed, could aspects of the pandemic have been handled better if institutions such as SOM’s proposed multi-disciplinary Centre for Work and Health think-tank had been in place?
References
“Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: national derivation and validation cohort study”, BMJ 2020; 371:m3731. Available online at: https://doi.org/10.1136/bmj.m3731
Covid-19 Medical Risk Assessment, https://alama.org.uk/covid-19-medical-risk-assessment/
Clemens T et al (2015). “What is the effect of unemployment on all-cause mortality? A cohort study using propensity score matching”, European Journal of Public Health, volume 25, Issue 1, February 2015, pp.115–121. Available online at: https://academic.oup.com/eurpub/article/25/1/115/2837443
Van Lenthe F J et al (2005). “Neighbourhood unemployment and all cause mortality: a comparison of six countries”, Journal of Epidemiology and Community Health, vol 59, issue 3. Available online at: https://jech.bmj.com/content/59/3/231
Möller H et al (2013). “Rising unemployment and increasing spatial health inequalities in England: further extension of the North-South divide”, Journal of Public Health, vol 35, issue 2, pp.313-321. Available online at: https://academic.oup.com/jpubhealth/article/35/2/313/1544364
Nordt C et al (2015). “Modelling suicide and unemployment: a longitudinal analysis covering 63 countries, 2000-11”, Lancet Psychiatry, 2015 Mar;2(3): pp.239-45. Available online at: https://pubmed.ncbi.nlm.nih.gov/26359902/
Hawton K et al (2015). “Impact of the recent recession on self-harm: Longitudinal ecological and patient-level investigation from the Multicentre Study of Self-harm in England”, Journal of Affective Disorders, vol 191, pp.132-138. Available online at: https://www.sciencedirect.com/science/article/abs/pii/S0165032715309940?via%3Dihub
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Macdonald E (2020). “Safely returning clinically vulnerable people to work”, BMJ 2020;370:m3600. Available online at https://www.bmj.com/content/370/bmj.m3600
“SOM calls for a Centre for Work and Health to lead OH research”, Occupational Health & Wellbeing, July 2019, https://www.personneltoday.com/hr/centre-for-work-and-health-occupational-health-research/
