A pandemic of international cooperation?

A PANDEMIC OF INTERNATIONAL COOPERATION ?
PROFESSOR JOHN MIDDLETON,
UNIVERSITY OF WOLVERHAMPTON
AND
PRESIDENT, ASSOCIATION OF SCHOOLS OF PUBLIC
HEALTH IN THE EUROPEAN REGION
SEMINAR, MAY 22ND 2020

We find the public health community ill-equipped and poorly
connected for the new challenges of ‘ISIS, crop failure and no
antibiotics’; we need to grow our partnerships with international
lawyers, political scientists, climate scientists and ecologists. To those
new challenges we now operate in the era of surveillance capitalism,
fake news and disinformation. We live increasingly in political
systems with little respect for expertise, willing to destroy scientific
capacity, ignore expert advice and promote disinformation.
The ‘merchants of doubt’ have infiltrated all political systems and all
aspects of policy making. The white horse, Conquest has taken on a
new guise – a cadre of elite, super-rich, world leaders who see
ignorance and partial information as virtues, suiting their control of
power and misuse of wealth. And, as in the Australian fires, the UK
floods, and in China in the early stages of coronavirus, these leaders
show themselves to be rabbits in the headlights, incompetent and

Public health systems are
being depleted; prominent
public health figures
removed silenced, or ignored.
Dr Li Wenliang, is only the
most prominent of Chinese
whistle blowers who first
expressed concern about the
new COVID19 to have been
killed by the virus or to have
disappeared. It is timely that
our
intrepid Talkpublichealth team
chose the theme
of whistleblowing for the public
good for their recent podcast.

John Middleton [lecture title]
[date]
My son Rory enjoys
a pizza in the quiet
steets of Milan 3
days before full
lockdown

JOHN
HOPKINS
GLOBAL
COVID
TRACKER,
7TH
MARCH
2020

[date]In the toilet roll
shelves of a local
supermarket
March 2020

[date]
Back in
Berlin’s
Club Isol-8

[date]
British handwashing
instructions - wash
hands in the time it
takes to sign ‘happy
birthday’

[date]
Or for the
actors,
handwashing
to Lady
Macbeth’s ‘out
damn spot’
speech…

[date]

[date]
The warnings
kept
coming…
days behind
Italy in the
confirmed
cases race

WUHAN EPICURVE AND NARRATIVE,
PAN A ET AL , JAMA APRIL 2020

[date]
https://link.springer
.com/article/10.100
7/s00038-020-
01362-x
INTERNATIONAL
JOURNAL OF
PUBLIC HEALTH
MARCH 29TH
2020

ASPHER COVID TASK FORCE PRIORITIES (AS OF 2/4/20)
DE-ESCALATION POLICIES
TESTING CRITERIA AND OPERATIONS
USE OF MASKS BY THE GENERAL PUBLIC
INEQUALITIES AND VULNERABLE GROUPS – IMPACT OF THE
DISEASE AND IMPACTS OF LOCKDOWN
SURVEILLANCE APPS- TECHNICAL EFFECIEICNY AND ETHICS

ASPHER COVID TASK FORCE PRIORITIES (AS OF 21/4/20)
DE-ESCALATION POLICIES LIVE MATERIALS ON WEBSITE TODAY
TESTING CRITERIA AND OPERATIONS- PUBLISHED ON WEBSITE; FURTHER WORK ON CONTACT TRACING
USE OF MASKS BY THE GENERAL PUBLIC- PUBLISHED ON WEBSITE AND NOW INTO VERSION 2
INEQUALITIES AND VULNERABLE GROUPS – IMPACT OF THE DISEASE AND IMPACTS OF LOCKDOWN – TO BE
PUBLISHED ON WEBSITE BY 28/5/20
SURVEIILLANCE APPS- TECHNICAL EFFECIENCY AND ETHICS IN PROGRESS
’THE EROSION OF PUBLIC HEALTH’ - A REPOSITORY OF CUTS AND WEAKENING OF PUBLIC HEALTH AND
PANDEMIC PREAPREDNESS ACROSS COUNTRIES, AND FAILURES TO FOLLOW PUBLIC HEALTH ADVICE - WITH A
VIEW TO REBUILDING PUBLIC HEALTH CAPACITY IN THE POST PANDEMIC PERIOD, AND IN THE SECOND WAVE
GLOBAL HEALTH GOVERNANCE
YOUNG PROFESSIONALS SUPPORT TEAM
WORKING WITH THE EUROPEAN OBSERVATORY /WHO HEALTH SYSTEMS MONITORING PLATFORM

[date]
https://www.aspher.org/d
ownload/413/aspher_stat
ement_on_the_strategic_
use_of_masks.pdf

[date]
Sporting
my new
fashion
statement-
2 layer
snood by
Seasalt

[date]
A case for masks on
public transport
Cases of Covid per
100,000 in
destination local
authorities of the
London
underground
Brent and Barnet,
Northern line
Harrow, Bakerloo
line

[date]
Don’t forget
your face
mask in
public
places

[date]
https://www.aspher
.org/download/421/
aspher_statement_o
n_the_covid-
19_testing.pdf

Testing
Sensitivity - ability of test to find disease - good outcome =true positives
Bad outcome = false negatives
Result: people can spread COVID because they think they are OK
Specificity - ability of test to tell if someone is really clear
Good outcome= true negatives
Bad outcome= false positives
Result: people falsely believe they’ve had it and won’t believe it if they get ill again
People wrongly go into isolation when needed as key workers
Population estimate of disease is higher than it should be, so influence estimates of
prevalence and decisions about coming out of lockdown

Testing
Positive predictive value out of all the positive tests, how many are showing true disease
Depends on the level of disease in population.
Adversely influenced by a lot of false positive results, in the unaffected population eg Sicily-
low prevalence - positive predictive vale 50:50 true to false
NegatIve predictive value
Out of all the negative results, how many are really negative, and therefore, how many are false
negatives.
Less important for population estimates, but
Vital in track and trace. low sensitivity test, or poorly delivered in the field, will liberate large
numbers of false negative people to spread the disease

Testing has been recognised as a key component of national responses to
the COVID-19 pandemic, since the World Health Organisation mantra of
‘test test,test’. However, much of the public debate about the meaning of
test results has been superficial, with political claims focussed soley on
how many tests have been done. Germany, Vietnam, and Taiwan have
been hailed for their decisive use of testing, but in Wuhan, the epicentre of
the first major epidemic, only 11000 tests were done. Lockdown, and
central quarantining were the strongest elements of their response. For
Italy, lockdown was central to the country wide response, and appears to
have protected low prevalence areas.

https://www.aspher.org/recovery-from-the-covid19-pandemic.html

[date]
https://www.covid1
9healthsystem.org/
mainpage.aspx

WHO Europe guidance includes 6 criteria for moving to ease
lockdown restrictions. Countries must ensure:
1.Evidence shows that COVID-19 transmission is controlled.
2.Sufficient public health and health system capacities are in place to
identify, isolate, test and treat all cases, and to trace and quarantine
contacts.
3.Outbreak risks are minimized in high-vulnerability settings, such as
long-term care facilities (i.e. nursing homes, rehabilitative and mental
health centres) and congregate settings.
4.Preventive measures are established in workplaces, with physical
distancing, handwashing facilities and respiratory etiquette in place,
and potentially thermal monitoring.
5.Manage the risk of exporting and importing cases from
communities with high-risks of transmission.
6.Communities have a voice, are informed, engaged and

For the USA, John Hopkins University American Enterprise
Institute has set four criteria for coming out of lockdown:
1.The number of new cases has declined for at least 14 days.
2.Rapid diagnostic testing capacity is sufficient to test, at minimum, all
people with COVID-19 symptoms, as well as close contacts and
those in essential roles.
3.The healthcare system is able to safely care for all patients,
including having appropriate personal protective equipment for
healthcare workers.
4.There is sufficient public health capacity to conduct contact tracing
for all new cases and their close contacts, as described in the
National Plan to Enable Comprehensive COVID-19 Case Finding and
Contact Tracing in the US.

[date]
Governor Cuomo, New York State lockdown dashboard, May 2020

[date]

Our plan to rebuild
The UK government relaxing restrictions depends on five criteria :
• protecting the NHS’s ability to cope;
• a sustained and consistent fall in daily death rates;
• the rate of infection decreasing to manageable levels;
• confidence in our capacity to provide tests and personal protective equipment;
• and confidence that relaxation measures will not risk a second peak of
infections.
Our plan to rebuild May 2020 https://www.gov.uk/government/publications/our-plan-to-rebuild-the-uk-
governments-covid-19-recovery-strategy/our-plan-to-rebuild-the-uk-governments-covid-19-recovery-strategy

Latest public Health England
COVID Dashboard Daily cases
and deaths

[date]
Upsides
of
lockdown
1 :
Decline in
air
pollution

Upsides
in
lockdown
2: interest
in more
active
travel

https://blogs.bmj.com/bmj/2020/05/05/now-is-not-the-time-to-undermine-the-world-health-organization/
Global governance for health

https://epha.org
/public-health-
must-be-
strengthened-
for-a-healthy-
post-covid-
world/
Global governance for health

[date]
Global governance
for health

Global governance for health- European Public Health Week Seminar May 18th
2020 European Public Health Association, World Health Organisation- Europe, American Schools
and Programmes of Public Health, Association of Schools of Public Health European Region

Thank you
John Middleton
John.middleton@aspher.org

A pandemic of international cooperation?

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