One of the hard lessons we've learnt over the past four years is that public health is a balancing act. As the recent COVID inquiry reminded us, in reducing the impact of a disease, we have to closely weigh the benefits of any actions against the harm they could cause.
But what exactly were these benefits and harms during the pandemic? Getting a clearer understanding of this – basically, what worked and what didn't in fighting COVID – was one of the aims of the inquiry. So, what did we find out? This is my assessment...
Was the spread of COVID in care homes inevitable?
In the early weeks of the pandemic, being a resident or member of staff in a care home carried some of the highest risks of death from COVID.
The virus spread into care homes as elderly patients were discharged from hospitals to free up beds for COVID admissions. But before the pandemic, we knew it was almost impossible to stop the spread of infections like norovirus and influenza once they were introduced into care homes.
Even if we had been able to test all patients before transfer, we wouldn’t have prevented the care home epidemic. This is because tests done while someone is incubating COVID are often negative until they become infectious.
Did personal protective equipment really work?
The importance of personal protective equipment (PPE) in reducing infection risk in hospitals and care homes was well accepted before COVID. That the UK didn’t maintain its stocks of PPE was one of the main drivers of the high mortality rates of health and social care workers – one study showed that availability of PPE was one of the main factors affecting transmission of COVID in care homes.
More uncertain at the start of the pandemic were the benefits and risks of community non-pharmaceutical interventions (NPIs). These refer to those control measures that don’t include vaccines or drugs, such as closing schools, banning meetings and wearing face coverings.
At the start of the pandemic, we knew that NPIs would be effective at reducing the spread of the virus, though we didn’t know by how much. Several groups showed, early on, that different NPIs had differing impacts on the spread of the infection.
For instance, banning indoor gatherings and closing non-essential businesses, such as pubs and restaurants, were most effective. But stopping people meeting up outdoors? Not so much.
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Did wearing masks help defend against COVID?
The value of masks was a hotly debated issue. Early in the pandemic, many experts doubted their value outside of hospitals. But the evidence shows that wearing masks did reduce transmission of COVID in the community, at least until the emergence of the Omicron variant.
There have been conflicting studies on the value of masks in school, hoperswever. Using US data, one study showed that mask mandates in schools reduced infections, at least in the first couple of weeks. But over a full term there was no difference in infection rates between schools where masks were required and schools where they were not.
Did isolating help?
The value of self-isolation is another area where the overall effect is unclear. In theory, testing and self-isolation should have reduced the transmission of COVID.
But studies found that a substantial proportion of infectious people would need to self-isolate for this to work. As we never actually identified more than about half of all infections, it’s doubtful that self-isolation rates would have made much difference.
Arguably, by January 2022, staff having to self-isolate put more stress on the NHS than treating the increased wave of COVID admissions.
How effective were lockdowns?
Initially, we didn’t know what impact lockdowns could have on people’s health. Since then, we know that lockdowns were associated with mental and musculoskeletal health problems, and developmental problems in children.
Whether the benefits of NPIs outweighed their harms is not just a scientific issue but a wider debate across society as a whole. My personal view is that those early controls were more beneficial until most people had received two doses of vaccine. Then the harm probably outweighed the benefits.
How effective was the vaccine rollout?
The real success during the pandemic was the fast development of effective vaccines, without which we would have seen many more deaths. But, as my group’s work showed in January 2021, these vaccines were never going to generate herd immunity and eradicate the virus. Vaccines do prevent infections, but only for a few months.
Adverse effects were seen with vaccines, of most concern were blood clotting and heart inflamtion. However, these outcomes were even more common in people who had a COVID infection.
Claims that COVID vaccines have contributed to the excess mortality we’re still seeing are not supported by the evidence – vaccinated people are not more likely to die than the unvaccinated, after adjusting for age.
Also, the advancements in vaccine science during the pandemic are likely to have benefits for other infectious diseases for decades to come.
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