Lessons From Tuberculosis Control for COVID-19: Screening Should Be Universal

Introduction

Having had the privilege of working for my doctorate in sociology of health ¹ with many of the important actors in the strategy to fight tuberculosis (TB), I wish to bring to the current pandemic some lessons drawn from their experience. They were pioneers in infectious disease programs in countries where these diseases were endemic. Wallace Fox (died 2010) was the program leader of the Medical Research Council in London ² ; he developed the world’s standard treatment for TB after having led, in India, the first trial of outpatient TB treatment at the end of the 1950s. Pierre Chaulet (died 2012) was a professor of pulmonology at the University of Algiers after the war for the liberation of Algeria ³ ; in collaboration with Wallace Fox, he was a second central player in the fight against TB in Algeria and much more widely in Africa and Asia. Involved with others actors in the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (The Union), they greatly contributed to the implementation of screening and treatment programs, which were accessible to the poorest countries and the most deprived populations.

In this moment of forced lockdown, it is worth contrasting the experience of TB control with the strictly hospital-based strategy deployed and reserved for critical cases of the coronavirus. Although TB is still the leading cause of death from infectious disease, WHO estimates that its policies helped save 58 million lives between 2000 and 2018. The fact that the bacille Calmette-Guerin (BCG) vaccine, which was first produced in 1921, is part of WHO’s TB strategy provides an object lesson to those who believe that a COVID-19 vaccine will bring an end to the pandemic.

Where France Went Wrong

Whereas in Germany, Iceland, Australia, Viet Nam, and South Korea, the strategy chosen was to give the whole population very wide access to COVID-19 tests, France reserved testing for severe cases only and in hospitals. Those delivering the testing included nursing staff who often lacked the necessary means of protection and who are paying a heavy price for the cruel absence of screening and prevention procedures.

The French Minister of Health remains content to count the dead, excluding statistics that could be established if the prescription of tests was decentralized to the level of health centers and general practitioners. In conjunction with municipal laboratories, attending physicians who best know people and their contacts would be able to give a more precise count.

Why wait for patients to deteriorate before doing the tests? What is the best way to ensure follow-up of the contacts of these cases from overcrowded hospitals? Preventive procedures would produce individual and population-level knowledge of the epidemic. The absence of organized screening at the level of primary care encourages a state of general suspicion among people and attacks on certain ethnic groups. Is the reason for the lack of generalized screening economic, given the price of the tests, or the persistence of an elitist medical ideology coupled with a refusal of the administration to appreciate the full measure of the health disaster in progress? Or is this simply another instance of top-down public health policy, distant from the concrete lived realities in health, illness, and death?

Another Strategy Is Possible

Another strategy is possible, one that has proven itself since the post-World War II period. Wallace Fox and Pierre Chaulet were key players in TB control, and WHO drew on their work to develop technical guidelines to manage epidemics of infectious diseases. Relying on the experience and knowledge gained from this fieldwork, in the late 1970s WHO and UNICEF developed the primary health care strategy (the Declaration of Alma Ata), which enshrined the decentralization of public health services as close as possible to populations and a reorganization of relations between the center and the periphery, between hospitals and primary care. ⁴ Had it not been for structural adjustment programs and the commercialization of health services foisted by the International Monetary Fund (IMF) and the World Bank on all the so-called developing countries, primary health care policies would have enabled a substantial reduction in social inequalities in health.^5,6 What was imagined at Alma Ata is pertinent to the pandemic of COVID-19.

Based on TB programs and primary health care strategies, we have learned that the control of infectious diseases, bacterial or viral, is possible by combining:

Early detection based on mild symptoms, at the level of primary care;

In France, general practitioners provide primary care. It is completely incomprehensible that these practitioners, who know their patients and their medical history, as well as their families and their occupational activity, have been marginalized in the management of the epidemic. During the first and most stressing period of the epidemic in France (February to June 2020), the testing monopoly was hospital-based, far from the usual places of primary care. Hence, the overcrowding of hospital services and the refusal of tests represented a form of nonassistance to people in danger.

For Specific Medical Surveillance in Occupational Health

One of the failures of the strategy chosen by the French government is lack of compulsory testing for all workers forced to work at their workplace rather than remotely from home (essential workers), knowing that these workers lacked information about the threats they face. Insufficient research has been conducted to determine the efficacy of workplace exposure prevention measures. Evidence is establishing the potential for aerosol transmission of SARS-CoV-2, the virus that causes COVID-19. ⁸ Consequently, the plexiglass barriers and other measures to distance workers from others are insufficient to guarantee an effective level of safety. ⁹ Due to the very serious shortage of respirators, masks, and tests in the early months of the epidemic, the only preventive measure offered to workers in sectors such as supermarkets was the plexiglass screen. In other sectors, including health care and care for the elderly (especially dependent elderly people), employees had no personal protective equipment.

Anthony Smith, a labor inspector who wanted to impose such equipment in a not-for-profit care assistance company was suspended, during lockdown, for “abusive” intervention not in conformity with the directives of the Ministry of Labor (MOL). ¹⁰ Muriel Pénicaud, Minister of Labor, determined that this inspector had not respected the informal rule established by her Ministry not to exert pressure on employers. This violated the International Labor Organization’s Convention Co 81 that establishes the independence of labor inspectors in the exercise of their supervisory role with reference to employers’ obligation to prevent occupational hazards. As of 15 April 2020, Anthony Smith was still suspended from his position as a labor inspector. A very large support committee, coordinated by the MOL agents’ trade unions has been mobilized. ¹¹ Nearly one hundred fifty thousand people have signed a petition demanding his return to work, for the benefit of the health and safety of employees. ¹²

As this is a serious and potentially lethal hazard, COVID-19 must be subject to reinforced medical surveillance as defined in the French Labor Law. ¹³ Surveillance should be based on the systematic practice of screening tests. This practice could allow people to know whether they are contaminated. If they are, they must stop working immediately, and be quarantined; the same work accident protocol as applied for nursing staff confronted with HIV or hepatitis C contamination must be followed. All persons in contact with the patient must also be given screening tests, which is the way to break the chain of contamination. Surveillance of cases and case-controls must be carried out in order to monitor the consequences of contamination. From a public health perspective, the validity of statistics requires that all cases and case-controls should be listed, with a rigorous record of their fate.

While the French government describes itself as being at “war” with the virus, the “health emergency” law does not include COVID-19 on the list of diseases that gives workers the right to reinforced medical surveillance in the occupational health setting. Knowing that positive but asymptomatic cases are thus left in the dark about their own contamination, the authorities have not created access to systematic screening of all essential workers. The continuation of nonessential economic activities only delays the time when this epidemic will end.

In France, on 30 March 2020, at Vitrolle near Aix-en Provence, employees of Carrefour, a supermarket chain, decided to exercise their right to refuse dangerous work. Two of these workers became infected with COVID-19: one of the security service workers has been hospitalized in intensive care, the other, a butcher, presented symptoms and tested positive. ¹⁴ Despite union demands, the management refused to close nonessential departments like household appliances and Do It Yourself. Given the situation, all employees of this supermarket should have had access to a screening test, as well as customers who could request it, at Carrefour’s expense. But on this too, the ministers of Labor and Health remain completely silent.

After a real decline in the epidemic between April and June, the numbers of COVID-19 cases in France began to increase again after 15th July. Among the clusters identified, workplaces are on the front lines, despite successful legal actions by labor inspectors and the CGT and Solidaires trade unions leading to suspensions of activity in the automobile industry, supermarkets, Amazon platforms, and other care and service sector companies. These actions have made it possible in these places to implement prevention plans with the active participation of workers’ representatives. ¹⁵ But they are isolated actions. No coherent overall strategy, for the prevention of the risks of contamination by COVID-19, has been imposed by the government on employers. There are particular concerns for the lack of overall strategy for addressing the hazards in slaughterhouses, construction, and cleaning and maintenance operations.

The consequences of the lack of a screening and global prevention strategy in the workplace are dramatic on an individual level, since affected workers have died in the last months. The effects are terribly consequential at the population level as well: by not having generalized screening in the workplace since the beginning of the epidemic or even closure of all businesses, the positive outcome of the lockdown, which was implemented to slow the spread of the epidemic, has been denied to workers and the rest of society. It is a political choice that erases traces, since nothing is listed, and the dead cannot tell what killed them. Only the living can memorialize the victims.

A Look at the Experiences of Other Countries

A simple look at some strategies implemented in other countries shows the importance of screening in the fight against the present epidemic. In Iceland, anyone who requests it can be immediately tested. In Australia, the test can be ordered by the local general practitioner or by the hospital emergency department. It is performed in public health laboratories across Australia, not just in a hospital. The Germans took this disease seriously in December 2019. They carried out tests and devoted enormous resources to finding sources of community spread, enabling each chain of contamination to be identified, and those who are linked can be warned, isolated, tested, and treated.

In the small town of Vo, in northern Italy, one of the communities where the epidemic first appeared, the entire population of 3300 was tested and 3 percent of residents tested positive, and of these, the majority had no symptoms, according to the researchers. When the population was retested after two weeks of lockdown and quarantine for positive cases, the researchers found that transmission was reduced by 90 percent. Anyone who was still positive although symptom-free had to stay in quarantine.

Conclusion

In France, seventy-eight offers of public laboratory services were made early in March. According to Mediapart (29 March 2020): “The public animal health laboratories have been alerting the Ministry of Health for almost two weeks about their capacity to produce large numbers of tests. Four province territories presidents have stepped up to the plate.” ¹⁶ Why does the national government refuse?

On 15 April 2020, with a rate of 5.1 tests per 1000 inhabitants, France ranked 27th out of the thirty-five OECD countries, just behind Turkey. France’s COVID-19 testing rate was one-third of the average for OECD countries, and far behind Iceland, the country with the highest test rate of 106/1000. ¹⁷ In an article entitled “Coronavirus screening: the reasons for the French fiasco on testing,” Stéphane Foucart and Stéphane Horel, journalists of the newspaper Le Monde, present the bureaucratic and economic dimensions of such a failure in the strategy implemented in France to fight against the coronavirus. They leave no doubt about the Macron government's deep-rooted reasons, concluding that, “Even the most crucial health issues are also subject to economic choices.” ¹⁸

Since May 11th the lockdown in France has been ended. Gradually “normal” life has restarted. But the pandemic remains very present in daily reality. Wearing a mask is becoming mandatory in many cities. But government attention is still focused on individual prevention behavior, without requiring employers to implement workplace COVID-19 prevention measures. The lessons we could learn from decades of efforts to prevent and control infectious diseases have not been used to organize the prevention and management of the disease with the primary objective of stopping the chains of contamination.

A final comment on what happened to the elderly, who were abandoned in elderly homes, an increasing proportion of which are private for-profit. Deteriorating conditions for the residents and working conditions for the caretakers were not new but have led to a hecatomb for both. How can those who have decided to abandon the elderly who gave us life still look at themselves in the mirror?