Pearls and Irritations

The UK response to COVID-19 has been marred by bad decisions in the face of an impending crisis, built on a decade of inadequate resources, planning and organisational preparedness to make the UK second only to the USA in terms of deaths from the virus.

Month five of the COVID-19 pandemic in the United Kingdom and it is now becoming clear that a country, renowned for its contributions to the Victorian public health movement, has been an abysmal failure when faced with this ruthless modern pandemic. Consumed with a hubristic little England mentality after three years of Brexit-inspired jingoism, the UK government and its advisers took their eye off the ball, leading to the unnecessary deaths of tens of thousands of people in hospitals, care-homes and family residences across the country; undeclared numbers of prisoners and prison officers have also perished in the nation’s gaols. How can this have been allowed to happen and what are the implications for the future of public health and democracy?

Emergency planners describe major incidents as falling into one of three types: the Slow Burn, the Rising Tide or the Big Bang. Whilst each incident is unique in its own way, and has its own ‘battle rhythm’, common themes can usually be identified. One of these is the convergence of several contributory factors underpinning a whole system failure. It may be possible to escape disaster if only one or two factors are in play but the accumulation of four, five, or more brings with it a sense of the inevitable. Historians will find that in the case of COVID-19 in the UK in 2020, not only was there a full house of factors but a convergence of a Slow Burn, Rising Tide and a number of Improvised Explosive Devices seeding a series of domestic outbreaks contributing to the national epidemic.

The search for roots takes us first to the international decline of public health after the Second World War in the face of the fading of  infectious diseases as a public health priority, the increasing importance of non-communicable disease associated with an ageing population and the ascendancy of hospital medicine with its bedfellows of laboratory science and pharmacology. The UK was not alone in allowing public health to be relegated to a second order activity and its practitioners to subordinate status.

Partial salvation came in the form of the World Health Organisation push towards Primary Health Care and prevention through its Alma Ata Declaration in 1978 and its Strategy of Health For all by the Year 2000, published in 1981. These led to a plethora of initiatives and a momentum around the world, not least through WHO’s Healthy Cities Project which tapped into the growing awareness of sustainability issues and the need to rediscover the links between public health and urbanism.

Further support for public health came after the terrorist attacks on the World Trade Centre in New York in 2001 which brought health emergency planning out of the shadows and gave a boost to emergency preparedness, not least with regard to bio-terrorism and increasing awareness of the dangers posed by epidemics of novel infections such as Bovine Spongeiform Encephalitis and viruses such as Avian flu, SARS and Swine flu. In the United Kingdom that decade now seems to have been a high-water mark which came to an abrupt halt following the world financial crisis of 2008.

The support of the Blair government for public health included the appointment of the country’s first Minister for Public Health, significant financial investment, the creation of a multi-disciplinary workforce and new opportunities for local public health leadership together with imaginative initiatives such as Health Action Zones, Healthy Living Centres and a  SureStart programme. This was largely abandoned with the incoming Conservative administration in 2010 and the ten years of austerity that were to follow. A chaotic reorganisation of both the National Health Service and the arrangements for public health, in 2013, moved public health back into local government from which it had been removed to the NHS in 1974 and created a national agency, Public Health England, that has since centralised to the detriment of local capacity. At a stroke this fractured  the functional relationships that had previously been developed with the clinical world, downgraded the status and autonomy of local Directors of Public Health, and over time led to significant reductions in their resources and staffing. This would be thrown into relief during the COVID emergency when the lack of capacity for testing and contact tracing would be exposed. And then came Brexit!

The referendum that led to the narrow majority for the UK leaving the European Union coincided with a large-scale emergency planning exercise for pandemic influenza at a national level, ‘Operation Cygnus’. This revealed major inadequacies in emergency planning, including the capacity and capability of the  equipment needed to mount an effective emergency response. For whatever reasons the report from this exercise was never published and its recommendations were never acted on during the next three years when government and national life were totally preoccupied with Brexit.

On 30th January 2020 the World Health Organisation declared the epidemic of Corona virus, later to be named ‘COVID-19’, a Public Health Emergency of International Concern (PHEIC) and the following day parliament finally passed its legislation to leave the European Union. It seems likely that the combination of the government’s exuberance at ‘taking back control’ (from the European Union), together with the prime minister’s preoccupation with his personal life, (separation, divorce, and arrival of a new child), contributed to the complete failure of what followed. Five meetings of the government national emergency committee, COBR (Cabinet Office Briefing Room), took place before Boris Johnson took the chair of his first meeting on March 2nd.

February was essentially a lost month during which no grip was taken on the rapidly accelerating emergency. If it had been, the need for urgent boosting of COVID testing capacity and Personal Protective Equipment for frontline staff could have been identified and steps taken to remedy the parlous state of local public health departments whose lack of pairs of hands for contact tracing would imminently be exposed. By the time these issues were in the public eye it was too late, community spread of the virus was accelerating and COVID-related deaths were doubling every two to three days. The Slow Burn of the austerity years had created the conditions for a rapidly Rising Tide of the new epidemic.

The series of Improvised Explosive Devices came in the form of a failure to take decisive action to prevent the entry of the virus into the country and its extensive seeding leading to local outbreaks that would converge into a national epidemic. The first few cases  entered the country at the end of January through contacts in China and the Far East and these were rapidly identified, quarantined and contacts traced. At the same time some dozens of returning travellers from Wuhan in China, the apparent source of the pandemic, were carefully sequestered and quarantined for 14 days in secure settings. However it rapidly became apparent that extensive contact tracing would be a task too far should the numbers of cases continue to rise and in mid-March government together with Public Health England abandoned this approach and for a few days promoted the notion of letting the virus run its course in search of a spurious ‘herd immunity’.

The first major seeding event probably occurred as a result of allowing thousands of skiers and their families to return unchecked from the high viral incidence ski resorts of Austria and Northern Italy after the school half term holidays in February. This was followed by a series of inexplicable failures to prevent large scale events in the week beginning 9th March when the biggest horse race meeting in the calendar, lasting four days, took place in Cheltenham, two large stadium pop concerts took place in Bristol, and 3000 Madrid football supporters travelled from their own heavily infected city, where matches were being played behind closed doors, for a major European match at the Anfield stadium in Liverpool. Early analysis of data supports the contention that excess deaths have resulted from such negligence. Later, the desire to avoid the political embarrassment of running out of hospital beds led to the reckless discharge of large numbers of infected and untested elderly patients from hospitals to care homes, kick starting a second epidemic that resulted in many thousands of additional deaths.

An examination of government and WHO planning guidance for dealing with pandemics reveals that openness and transparency, together with full public engagement and mobilisation, are essential in their effective management. In contrast to this the UK government approach was grounded in paternalistic news management, largely in the hands of the same advisers who had led the successful Conservative Party general election campaign at the end of 2019. One of the saddest features has been the shameless use of the government’s medical and scientific advisers as a political shield in the daily Whitehall press briefings with government ministers hiding behind a mantra of ‘following the science’ whilst whatever scientific advice was being proffered and acted on was kept from public scrutiny. It will take years for independent advisers to be taken seriously again.

It is now June. In defiance of much informed opinion the UK government has now, to all intents and purposes, ended the lockdown that has lasted for two months whilst thousands of new infections are occurring daily. Death rates have been falling but not as sharply as in other countries that are now emerging from the greatest public health threat for 100 years. The UK has experienced the most COVID deaths in Europe and is second in number only to the USA. We have no idea what the next few weeks and months will bring but the ramifications for public health and for democracy are likely to be profound.

Dr John Ashton CBE was formerly England’s North West Regional Director of Public Health and President of the UK Faculty of Public Health. He has been critical of the UK government’s actions to tackle COVID since the beginning.

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