The Health Secretary, Matt Hancock, has commented that plans for self isolation for over 70s may be implemented in the UK in the coming weeks.
Prof Robert Dingwall, Professor of Sociology at Nottingham Trent University, said:
“The UK media have been buzzing this weekend with rumours about a government plan to require people over the age of 70 to self-isolate for a period of at least four months as part of their response to the Covid-19 pandemic. For a few days previously, there has also been a controversy about the alleged influence of social and behavioural scientists on the government’s approach, relative to virologists, modellers and epidemiologists. This is a pointless argument about what counts as ‘real science’ and valid knowledge. However, the self-isolation proposal is a nice indicator of how limited the social science influence actually is – and why it needs to be greater.
“To declare an interest, I am a member of two of the expert groups that are advising the UK government – NERVTAG and MEAG, which does not yet have a website. I am not breaching any confidences by saying that the first I knew of these proposals was the media leak. This response is not based on any special knowledge of the details. These are, however, some of the critical points I would, as a sociologist, have made, had I been asked.
“In a democratic society, we should be very cautious about allowing the state to encroach on the space for individual decision-making and voluntary actions. This does not mean that states cannot signal preferred choices but that citizens have some freedom to interpret them in the light of their unique knowledge of their own circumstances. Even in a public health crisis, one size does not fit all – and a degree of flexibility may mean better outcomes for everyone. The issues around self-isolation are, for example, quite different in an urban area with a dense availability of public services and a rural community where the 70-somethings are looking after the 90-somethings. Nudge theory has been a focus for media criticism: there are issues about its operationalization but it is founded in a wider historic debate about how best to align individual actions with collective goals.
“If the collective goal is to slow disease transmission and divert it from the most vulnerable members of the population, intervention measures must be practical and not fraught with unintended negative consequences. In this case, the ambition informed by modelling work, of eliminating contacts between over 70s and other citizens may not be the best thing to do, compared with encouraging people to make their own risk assessments that minimize contacts – and collateral damage.
“There is, though, a first question: who says it is desirable to prevent every death regardless of the cost? My impression is that the loudest voices are coming from young or middle-aged people who have yet to accept that death is a normal part of life. It comes to all of us in good time. A wise person would, of course, prefer to die later rather than sooner, but they might also consider that some deaths are easier to bear than others. It is not for nothing that pneumonia was described as ‘the old man’s friend’ in the days before antibiotics. Contrary to some media coverage, no-one is advocating that any old person is abandoned to die without professional nursing care. However, we should acknowledge that many frail old people might see Covid-19 infection as a relatively peaceful end compared with, say, several years of dementia or some cancers. Government encouragement to discuss this question within families would not be a plan to cull the elderly but respect for their autonomy and their right to make such decisions rather than have others make them on their behalf.
“The encouragement of self-isolation also needs to be considered against its negative consequences. Studies from the SARS outbreak point to significant impacts on mental health after quite a short period. Some people become depressed to the point where suicide becomes conceivable. Do not ask people to ban visitors but to consider whether they might come less often for shorter periods of time.
“Much of the thinking here reflects the privileged lives of its authors. Advice to use a separate bathroom or sleep in a separate bedroom does not connect with the realities of many poorer people’s lives, especially among the elderly. I could go into a large back garden – a lot of people could not. Activity levels among older people are already considered a serious physical health challenge. How much physical damage will be done by four months incarceration?
“The message needs an injection of common sense. If you have a dog, take it out for walks – but don’t stop to hang out with other dog walkers. If you usually walk down to the local convenience store, keep doing that – just pick a quiet time to do it. Maybe the supermarkets could be asked to set aside a morning each week – or a couple of hours every day – when their shelves will be fully stocked and entrance restricted to over 70s and necessary companions. Could the hospitality trade do something similar – seniors’ lunchtimes, for example, which might help with their cashflow while contributing to the mental health and activity levels of the self-isolating?
“Many of the frailest elderly are in care homes. It is too easy for a care home just to ban all visitors without thinking of the impact on residents. Care homes must come up with positive alternatives to maintain social contacts. Where residents have capacity, this needs to be discussed with them, not just imposed. Care homes are not prisons and residents have rights. Can homes do more to promote video links – residents may lack technological capacity rather than cognitive capacity? Could outside locations be developed as visitor points, rather like smoking shelters? There is still a risk of transmission in the open air but it is much reduced compared with confined spaces.
“We do not need draconian and potentially inhumane interventions to achieve most of the collective goals here, just to consider some fairly basic social and behavioural science questions. Trusting individuals to make their own risk assessments and devise their own solutions is likely to achieve much more than arbitrary and confrontational exercises of state power. Self-isolation must not turn into self-imprisonment.”
Prof William Keevil, Professor of Environmental Healthcare, University of Southampton, said:
“This new virus causes minor problems for 80% of infected people but appears to be easily transmissible and causes serious health problems and mortality for some of those who are more vulnerable. Public officials and governments must therefore take this threat seriously – we have already seen very intensive measures implemented in other countries and the lockdown measures, while slow to implement, appear to be quite effective in China.
“We are now into the community transmission phase (i.e. we cannot trace possible contacts easily) and the lack of symptoms in some people is not unexpected but worrying in terms of being able to isolate them. So yes, as of now, avoid visiting vulnerable people (very old or with serious heart disease and other morbidities e.g. diabetes) unless you are absolutely convinced about your health (no coughs or fever) and personal hygiene (washed hands, clean clothes and shoes etc) being good enough; wash your hands immediately on arrival and avoid touching the person and your own face during the visit. Remember that your outer garments might be contaminated so remove coats with care before washing hands. The longer the stay the greater the potential risk to your host. Importantly, stay in contact with them by telephone, Skype etc to avoid them becoming lonely or depressed; perhaps treat them to a simple iPad type of device or similar and show them how to use it for Facetime or Skype visual calls with you. Make sure they are feeling well and receiving food and any medication they usually take. If the person receives regular visits from support workers, ensure they are able to continue attending regularly or if the health visitors become ill then be prepared to bring the food and medicines yourself. These can be left on the doorstep or open the door and have a friendly chat without going in or, if you are convinced your health and hygiene are perfect, enter for a short stay – taking the hygiene precautions described earlier.
“It is difficult to know whether 4 months isolation is going to be sufficient because this depends on whether the numbers of infections drop significantly during this period. If the outbreak continues then the vulnerable may need to isolate for much longer. This is not ideal from a social and psychological viewpoint for single people but necessary for the person’s physical health. If resources permit, vulnerable people should be grouped into a “day centre” or “care home” environment administered by staff trained in hygiene and infection control to maintain people contact and reduce loneliness and depression. This would be a huge undertaking given the number of single vulnerable people in the country but must be considered long term. Good neighbours are essential but must take the necessary hygiene precautions before they visit.”
Prof Paul, Hunter, Professor in Medicine, University of East Anglia, said:
“The Health Secretary, Matt Hancock, has today flagged that the government is considering advising all people over 70 years old to self-isolate. This is a very big step, but one which I consider to be absolutely the right thing to do. We know that the chance of someone dying if they get the infection is higher in older people and increases steeply over age 70.
“It is important to understand that unlike the self-isolation of cases and their contacts which has been the main stay of UK policy to date, this measure is not aimed at preventing the spread of infection by the self-isolating individual. It will not effectively stop the spread of the infection in the community, nor is it designed to do so. What it hopefully will do is reduce the risk that those people over 70 will pick up the infection from others. But this means that the period of isolation will last a lot longer.
“If we can reduce the number of elderly getting the infection this year then even if the infection spreads widely in other age groups we should be able to stop a substantial number of deaths and so reduce the mortality rate this year. If we can delay infections in the most vulnerable people till next year then hopefully a vaccine will have become available.
“But this advice is not without its risks. The elderly are doubly vulnerable from the COVID-19 epidemic. They are at vulnerable from the infection itself, but they are also vulnerable from the isolation that they may have to experience.
“Many of our elderly people live alone and suffer from loneliness and a range of medical conditions. Prolonged isolation can be bad for elderly people’s mental health and if they are unable to access medical care they may have deteriorating general health. If they cannot go shopping then they may run short of food.
It is essential that whilst we ask our elderly and other vulnerable individuals to isolate themselves we do not leave them alone to fend for themselves but make sure that someone is looking after them and do what we can to help them survive the next few months whilst retaining their physical and mental health and their dignity.”
Prof Janet Lord FMedSci, Director of the Institute of Inflammation and Ageing, University of Birmingham, said:
“Self isolation for over 70’s is a sensible course of action as the weakened immune system of the older adult means that they are more susceptible to viruses in the first place and almost more importantly they are sicker when they do become infected. The reason for this is multifactorial, part of it is exaggerated inflammation caused by the response of the immune system and also the aged lung which is less resilient to damage induced by infections.
“This measure is likely to be effective as it would reduce the transmission of the virus from infected individuals, who may not be showing symptoms, to the vulnerable older adult. It may be achievable for a short time but there could be unintended consequences: if the older adult remains indoors they will take less exercise and we know this makes the immune system worse. So just keeping a good social distance may be best.
“Unless the older adult has a good support network it could be difficult to be in isolation for 4 months, for example for getting their regular prescriptions, food etc. Also if they lose their social networks this is also not good for health.”
Prof Keith Neal, Emeritus Professor in the Epidemiology of Infectious Diseases, University of Nottingham, said:
“Any strategy that reduces the number of contacts someone has, will reduce their risk of acquiring any infection. You can only acquire COVID-19 with contact with an infectious person, either directly or from a surface they have touched. How effective it would be depends on the level of self isolation and the level of infection in the community. It will not be easy as many people have carers and may need routine healthcare. People who live on their own will particularly have increased feelings of loneliness. Four months of isolation will have a psychological impact. Having to keep any social distancing action for many months, rather a few weeks, is a reflection of the difficulties in the decision making required to best control COVID-19.”
Prof Alan McNally, Professor in Microbial Evolutionary Genomics at the University of Birmingham, says:
“Self isolation of those over 70 is of course a sensible move as it minimises the risk of exposure for our most vulnerable population group. Alongside wider social distancing measures, and combined with frequent hand washing this is still our best level of protection against the epidemic. Of course it is not easy and will require an active role from the wider community, volunteering to shop and so on for those who are self-isolated. But in unprecedented times one hopes that communities will rally together. It also requires the wider public to show restraint in purchasing habits to ensure most vulnerable members of society still have access to purchasing essentials.
“The time scale is really an unknown. Clearly the virus won’t disappear if we isolate over 70s for a couple of weeks. Indeed even everyone in the country self-isolating for a couple of weeks won’t make it go away. But it will reduce transmission events and this is our best chance of controlling the epidemic curve. What needs to be made clear, and I think has been, is that such a measure will not be a short term event. The key thing is that wider social distancing measures are going to be needed in all population demographics in the very near future, if not now”.
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