Richard Horton’s crisply written book was finished in May. So much has happened since then, yet most of it is prefigured in the book, and much is still not getting the urgent attention Horton calls for. His case is that too much – on occasion he even says all – of what has befallen us could and should have been avoided, if policy-makers had responded properly to the accumulating evidence produced by medical scientists. And he is worried that – unlike China, South Korea, Taiwan and Singapore, scarred (and in China’s case, internationally embarrassed) by their experience of SARS – we in the UK will not learn from our experience of COVID-19. Horton fears this failure to learn will mean a missed opportunity to radically reorientate our treatment of public health, medical science, and of health policy-making. The recent announcement that the government is to cobble together its outsourced test and trace system with bits and pieces of Public Health England into a new ‘health protection institute’ has nothing whatever to do with the kind of reorientation that is needed, as Horton has made forcefully clear.
A government looking in the wrong direction
Horton’s most pointed criticisms are of the UK government and UK scientists, but a central theme is the global nature of the new virus, and the need for a global response to the others that we can expect to follow it. The World Health Organisation’s (WHO’s) international intelligence system, and its power to declare health emergencies and deploy crucial expertise where it is needed, is our only significant line of early defence against new viruses. So Horton considers Trump’s decision to cut the WHO’s funding in the middle of the pandemic to meet the definition of a crime against humanity. And the question of how funding is to be made up has been barely discussed in the UK. Instead the UK government – which for its part has massaged and at times withheld the most basic data on the progress of the pandemic in the UK – has come close to endorsing the US government’s unfounded charge that the Chinese state covered up the COVID-19 outbreak.
Horton is not starry-eyed about China, and wants to know more about what happened in Wuhan before the identification of the new coronavirus on 30 December 2019. But he notes the radical investments in medical science that the Chinese made after the 2003 SARS outbreak. These made it possible for Chinese clinicians and researchers to provide the rest of the world, just three weeks after the initial identification of the virus, with the crucial initial information needed for preparing a defence: its genome, the fact of human to human transmission, the progress of the infection, the incidence of severe cases, and the fatality rate, especially high for older patients. And he asks, again and again, why neither the UK government nor the medical establishment paid serious attention to this for the next month and a half, by which time the virus was already spreading rapidly in the UK.
Horton offers a series of rather disparate answers to this crucial question, the most important being, in his view, that political leaders in much of Europe and North America “could not believe that a virus that originated in a Chinese city they had probably never heard of could have such calamitous effects in their own communities… this risk was just not on their horizon of possibilities”. This is all too plausible. The British government was also obsessed with Brexit: Rishi Sunak’s first budget on 11 March was heavily focussed on ‘getting Brexit done’ and made a bare £3bn provision for the expected costs of the pandemic – a figure he had to revise, just weeks later, to £350bn.
On top of this Johnson’s chief policy adviser, Dominic Cummings, had a well-publicised contempt for existing policy-making procedures. He had an independent influence on what was decided, whatever advice was given at the meetings of the government’s scientific advisory group for emergencies, SAGE (which both he and David Halpern, of the Cabinet’s ‘nudge unit’, attended). There was also, as Horton doesn’t say but probably takes for granted, a default aversion to the public sector on the part of all the new cabinet ministers, and most Conservative MPs. Similarly the Conservatives tend to be wary of meaningful discussions of population health, which raise inconvenient issues of inequality that only state interventions can address. The government’s sluggish and reluctant steps when it was finally forced to act have all reflected this mind-set.
The fragmentation of our health system
And underlying all this, as Horton notes, was the damaging effect of the run-down of the UK’s public health resources during the years of austerity, when regional and local level capacities for disease control were particularly hard hit. Horton doesn’t stress, perhaps because it was already obvious, the way the 2012 Health and Social Care Act played a particularly destructive role in abolishing clear lines of responsibility for managing epidemics, as the Centre for Health and the Public Interest warned at the time. The mixed and sometimes conflicting messages from many different sources, ranging from the Prime Minister to the Health Secretary, the Chief Scientific Adviser, the Chief Medical Officer Public Health England and NHS England, have contributed heavily to denting people’s confidence that the government knows what it is doing, and has their interests at heart.
A further consequence of that dispersal of responsibility is that there is no single , easily accessible source of up to date information on the progress of the pandemic in England, equivalent to those available to citizens in other European countries such as France and Germany. In early July SAGE “highlighted the importance of getting the maximum amount of information into the public domain for people to understand the epidemic in totality”, and proposed that the new Joint Biosecurity Centre (JBC) should be charged with “integrating and publishing available data on a single website”.
But what exactly is the JBC? No one really seems to know. On 18 August Matt Hancock announced that Public Health England is to be replaced by a new National Institute for Health Protection, supposedly modelled on Germany’s Robert Koch Institute – except that unlike the Koch Institute the UK version will be chaired by a Conservative place-woman, Baroness Dido Harding, with no qualifications in or experience of health protection. The JBC is to be part of this but all we really know about it so far is that it is being set up by a “senior spy”, Clare Gardiner, seconded from GCHQ, who apparently reports to Baroness Harding. It does not sound as if earning the public’s trust in the government by providing the public with “the maximum amount of information” will be high on the JBC’s priorities. But we must hope so, because detailed local information on the progress of the infection is all-important from now on, and especially for the 8 million or so people in the UK who are at high risk if they get Covid-19, whom the government has stopped shielding and so must judge for themselves how to try to stay safe.
The failings of our medical establishment
Horton’s justified anger is not directed only at the politicians, but also at the failure of the medical establishment in western countries to mount an urgent demand for action as soon as the WHO declared a Public Health Emergency of International Concern on 30 December. ”In the UK”, he notes, “we have the medical Royal Colleges, the Academy of Medical Sciences, the British Medical Association, Public Health England, the Faculty of Public Health and an array of think tanks, such as the Kings Fund and the Nuffield Trust. Yet none reinforced the urgent call to action in early February.”
As editor of the Lancet Horton feels this failure especially keenly, since it was in the Lancet that Chinese researchers published some of the key evidence that was shaping the WHO response, but which the medical establishment failed to respond to. He says, tactfully, that he doesn’t know the reasons for the failure, but anyone who has tried to mobilise support from clinicians or medical academics for the NHS, in face of the relentless pressures to subvert its founding principles over the past 30 years, is familiar with them. The Thatcherite onslaught on professional independence and academic freedom, and the promotion of the ‘new public management’ throughout the NHS and in the Department of Health, have inhibited public criticism of both senior management and government costly, and created a culture of conformism.
One of the few positive effects of the pandemic has been to give a public voice to a wide range of experts from outside the policy-making establishment who have felt they must say what they think. In this respect Sir David King’s formation of Independent SAGE is an unprecedented breaking of ranks, publishing its full membership, doing its work in public, and rehabilitating the idea that professional status carries an obligation to speak out. In contrast the official SAGE, after a short burst of openness about its membership, now lists everyone who has ever attended a SAGE meeting, 86 people in all – plus some who have been allowed to keep their participation secret – but gives no indication of what their individual expertise consists of. One of the 86 is the above-mentioned Baroness Harding.
Harding’s ‘NHS’ Test and Trace system, outsourced via Deloitte to Serco and at least seven other companies plus the British Army, was only put in place at the end of May. By late July its 21,000 phone-call contact tracers were reaching only 80% of the roughly 5,000 positive cases referred to them every week, and reaching only three quarters of these people’s contacts. So in August 6,000 of them were laid off, and Harding stated that the scheme was always supposed to be ‘local by default’. It was widely reported that some of the tracers would be redeployed to work in local authorities, where everyone with experience of epidemics knew they should have been located in the first place. But as openDemocracy has exposed, local authorities are not in fact being provided with contact tracers from the national call centres, at least for now. And a further missing component in the system is becoming obvious: ensuring that contacts comply with the instruction to self-isolate. For many people, especially those doing low-paid work, the disincentive of having to rely on statutory sick pay, or even risk losing their job, by self-isolating when told that they have been in contact with someone infected with Covid-19, is unlikely to be effectively countered by the threat of a fine. This means that compliance is liable to be low, and there is in any case no enforcement capacity. Yet without compliance by contacts the whole purpose of testing and tracing is defeated and the virus spreads again.
Yet in August the established medical bodies which had failed to call for action in February were again failing to call for action. It was left to Independent SAGE to call for full financial and practical support for people who test positive, and their contacts, along the lines adopted in Korea and Germany, adding that “If we don’t take isolation seriously our economy will spiral downwards. We should have had an effective isolation policy in February, with better pandemic planning”. Not to have one six months later, they added, perhaps unhelpfully, “is nothing short of public health malpractice”. All this lay in the future when Horton’s book went to press, but it is consistent with the overall UK response which prompted him to write it: politicians’ persistent failure to respect medical knowledge, and the failure of the medical establishment to lead the call for what is needed to protect the public.
In spite of being short The Covid-19 Catastrophe is wide-ranging and insightful, not just about the urgent practical issues facing us but also about some of the complex ethical and philosophical issues raised by the pandemic. Among the practical issues, this review does not do justice to one which is a recurrent theme of the book – the confused and collusive relation between medical scientists and the government. Probably no country has got this relationship quite right, and it is very hard to prescribe an ideal one, but the UK has undoubtedly got it more wrong than most. While Horton’s deeply-felt views on this deserve a fuller treatment.
As for the larger issues, what exactly is it about SARS-Cov-2, or perhaps about contemporary society and culture, that has made its onset a reason to shut down whole economies and plunge millions into unemployment and loss for years to come? The virus is likely to be with us for ever and COVID-19 could eventually become just another of the causes of pneumonia and other leading causes of death for older people that we – including older people like myself – mostly accept as natural. There are well-informed people, not all of them devoid of empathy, who think the policy reaction to the pandemic has been misguided and excessive.
Horton has no time for this, holding strongly to the view that saving lives is an absolute priority, and that having to choose between saving lives and saving livelihoods, or between saving COVID-19 patients and saving patients with other life-threatening conditions, could have been avoided by a properly prepared and resourced NHS. But his discussion roves over many of these issues, and all of it is rewarding reading.
The COVID-19 Catastrophe: What’s gone wrong and how to stop it happening again is published by Polity.