COVID-19: public health, public trust and public support

The novel Coronavirus COVID-19 has understandably generated increased anxiety in the UK and Europe, as elsewhere, as its spread continues. The protection of public health is a key function of Government, and measures to contain and respond to COVID-19 are and will remain essential. But they should also be ethical, proportionate, and subject to robust democratic accountability.

Co-authored by Hugh Whittall and Sophia Griffiths

The UK Government has already taken measures to prepare for the spread of COVID-19 (see DHSC information and advice, and our guide to the ethics of surveillance and quarantine for novel coronavirus), but as the number of cases in Europe continue to rise, UK authorities will be preparing further prevention and control strategies to deal with a potential outbreak in the UK.

Already we have seen the quarantining of UK citizens returning from Wuhan; the ‘lock-down’ of towns in Italy; enforced quarantine of people in a hotel in Tenerife; and the closure of a number of schools in the UK (despite advice from Matt Hancock that closure should not be necessary).

Such measures have serious implications for the freedom, privacy and well-being of UK citizens, and measures that are restrictive or coercive need to be proportionate and evidence-based – and adequately explained and justified – if they are to be effective and to receive the trust and support of the population.

In our 2007 Public health report we examined the ethics of public health interventions in the context of infectious diseases. We’ve set out below a brief analysis of what the Government is doing now, the possible restrictive measures that they might take to prevent and control the spread of COVID-19, why these might be justified, and why it is important that the Government sets out publicly – and early – the case for implementing such restrictive approaches.

Surveillance

Information about rates of infection and the emergence of new diseases is crucial for planning public health interventions. The outbreak of COVID-19 has had global implications, with several countries already severely affected.

Measures the Government is currently taking

Public Health England has introduced monitoring at airports with direct flights to China, with a team of public health experts working at Heathrow to offer on hand support to anyone coming from China who feels unwell. They are also undertaking ‘contact tracing’ – if a person tests positive for COVID-19, authorities speak to the patient to identify anyone who has had close contact with them during the time they are considered to be infectious, and will contact them. These people are then categorised into high or low risk and monitored if necessary.

Medical practitioners must report cases of suspected coronavirus to authorities. Where medical professionals pass on details of cases of notifiable diseases for the purposes of control, consent from the affected individual is not required and the data passed on necessarily include information that identifies the individual.

Further possible measures and ethical issues

To assess and predict trends in infectious disease it is acceptable for anonymised data on individuals to be collected and used without consent, as long as any invasion of privacy is reduced as far as possible. It may be ethically justified to collect non-anonymised data about individuals without consent if this means that significant harm to others will be avoided.

The avoidance of significant harm to others who are at risk from COVID-19 may outweigh the consideration of personal privacy or confidentiality, and on this basis it can be ethically justified to collect non-anonymised data about individuals for the purpose of implementing control measures. However, any overriding of privacy or confidentiality must be to the minimum extent possible to achieve the desired aim, such as the case in contact tracing.

So far, the quick and transparent sharing of information about COVID-19 has been lauded by relevant global health authorities. As COVID-19 begins to reach more countries, the sharing of information may become more challenging, but remains essential. At a global level, countries have an ethical obligation to reduce the risk of ill health that people might impose on each other across borders, therefore, countries should notify other relevant countries and bodies about outbreaks of COVID-19 at the earliest stage.

Quarantine and isolation

‘Quarantine’ refers to restrictions on the activities of a healthy person or group of people suspected of having been exposed to an infectious disease – in this case, COVID-19 – and who therefore might go on to develop it. ‘Isolation’ refers to restrictions on the activities of a person who is known to be infected, typically at a treatment centre where they can also receive appropriate medical attention. The aim of both these measures is to prevent or limit the transmission of disease. These measures can be an effective part of the control of a serious disease, but have costs in terms of individual liberty.

Measures the Government is currently taking

At the moment, the Government is advising people who have travelled to Wuhan and Hubei Province and other specific areas to self-isolate – stay indoors and avoid contact with others, and call NHS 111 to inform them of their recent travel. This advice applies to all people who have travelled to these specific areas, whether or not they have symptoms of the virus.

The Government has also issued advice to people who have travelled to other parts of China and other specified areas that are still impacted by the virus but to a lesser degree, to self-isolate only if they develop symptoms of cough or fever or shortness of breath.

The UK Chief Medical Officers have raised the risk level to the UK from low to moderate, which allows authorities to forcibly quarantine or isolate someone infected with COVID-19 if they pose a threat to public health.

Further possible measures and ethical issues

The Government could forcibly quarantine or isolate someone who is infected with COVID-19 if they pose a threat to public health. Quarantining is potentially the more coercive than isolation, as it restricts the liberty of more individuals, and can place those not infected at a higher risk of becoming infected if groups of people are quarantined together. Isolation and quarantine greatly restricts individual liberties, but can be justified if the risk of harm to others can be significantly reduced. Policy-makers should demonstrate that by forcibly isolating or quarantining individuals, it is a proportionate intervention that significantly reduces the harm or threat of COVID-19 to others.

Social distancing and travel restrictions

This measure involves closing facilities that bring a large amount of people together, for example, schools and workplaces, and avoiding large gatherings such as conferences and public events. Employees may encourage staff to work from home. The Government could, for example, also restrict travel to and from certain areas, restrict the use of public transport, or include screening measures such as temperature checks.

Measures the Government and others are currently taking

The Government is advising against all travel to Hubei Province, and against all but essential travel to the rest of mainland China, Daegu and Cheongdu in South Korea, and ten small towns in Northern Italy. British Airways have cancelled all flights to and from Beijing and Shanghai until 17 April 2020.

Some schools in the UK have sent home students and teachers who went on skiing trips in the Italian Alps during half-term to self-isolate for 14 days. The Department for Education and Public Health England have advised that schools should stay open, though some have chosen to voluntarily close.

Further possible measures and ethical issues

Social distancing measures may disrupt the lives of individuals within the population, but they do not have the same restrictions on individual liberty as isolation and quarantine. If there are more cases of COVID-19 in the UK, especially in populous areas, employers might encourage their staff to work from home. If relevant authorities were to close down schools or other places, they would have to demonstrate that the measure(s) would prevent infections. In addition, authorities should neither downplay or overstate the risks through the provision of information or through the implementation (or lack of implementation) of restrictive measures.

Travel restrictions could be quite restrictive in terms of people’s freedoms, depending on what they are. If the Government decides to go ahead with mandatory travel restrictions, they will need to be proportionate to the effect they’re intending to achieve. For example, restricting travel to and from Wuhan or other hotspots would likely be justifiable. It may impact a group of people’s individual freedoms, but the proportionality of limiting the risk of harm to others by restricting the individual liberties of fewer people needs to be considered and demonstrated.

The time is now

As the Government prepares for the possibility of further restrictive interventions, it’s crucial that they begin communicating what these might be and why they might impose them. The COVID-19 outbreak is fast-moving and it’s likely that if the UK government needs to put more restrictive measures in place, it will happen quickly. Such measures could be vital to the containment of the spread of the virus and for the protection of the public. Trust and support of the public will also be vital, but we have rarely, if ever in the UK, experienced measures of this kind. Now is the time to start informing the public in a measured way about the possible implications of the COVID-19 outbreak, the interventions that might need to be implemented and the rationale for their use. At the same time, they must ensure that messaging is clear and consistent. We have seen advice from local service providers that creates more unnecessary anxiety and is more burdensome for individuals (in terms of self-isolation) than current national public health measures require.

People can be reassured about the limited risk that the outbreak currently poses for most of us, and about the sensible measures that they can take to protect themselves. But they can also be reassured that if further steps are needed, they will be appropriate, proportionate, and in the public interest.

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