The UK government has regularly been denounced by many in the public health community for its absence of strategy in responding to the COVID-19 pandemic. Much of this criticism, however, reflects a simple dislike of the strategy or of the government that has authored it. On closer inspection, the UK government does have an intellectually coherent position – just one that is different from that preferred by many public health specialists and activists, and, to some extent, the biomedical community in general. This position is not secret. It is plainly set out in Our Plan to Rebuild: The UK Government’s Covid-19 Recovery Strategy, published in May 2020.
The starting assumption, repeated several times, is that the SARS-Cov-2 virus will become endemic: ‘eradication of the virus from the UK (and globally) is very unlikely’ (p.19). That may or may not be a correct assumption but it is a mainstream scientific view. It might be possible for small island nations to eradicate the virus within their territory by aggressive quarantining of travellers. This is not a credible option for a large country with a major transit hub and global trading connections.
If we accept that assumption, the policy question is not ‘how do we eliminate this infection’ but ‘how do we keep it at a tolerable level?’ What strategy do we choose to achieve this goal? The UK government take the view that they cannot dictate what is tolerable. This has to be discovered as the aggregate of the risk preferences of the population. Their strategy reflects the thinking of Hayek and other Austrian economists. Governments can never have sufficient information to micro-manage the lives of individual citizens. At best, they can give advice and ‘ensure that everyone has the information and education needed to take responsible risk judgements and operate in a way that is safe for themselves and for others’ (p.45). This involves a ‘more differentiated approach to risk’ (p.23) where individuals are able to assess for themselves, or with the assistance of GPs, the likely impact of contracting the infection and the degree to which they might choose to arrange their lives to avoid this: ‘to be able to take more risk…[or]…wish to be more cautious’ (p. 23). The intention is to avoid the blanket measures of March 2020. If fit 80-year-olds choose to accept the risk of going out and about, the government will not try to stop them, while continuing to support frail 80-year-olds with needs for health and social care.
Of course, critics of the Austrian School have pointed to various problems with the model. Information rarely flows as freely as it assumes. Secondary institutions may intervene by constraining choices – insurers may refuse cover to universities that do not gold plate social distancing or retailers may refuse entry to citizens who choose not wear face coverings. Individual decisions may have negative collective implications for shared spaces or resources – the tragedy of the commons. Nevertheless, we cannot say there is no coherent basis for UK government policy.
It is, however, very different from the traditions of the public health world: ‘The medical officers of health brought in the ideas of searching out cases, of insisting on treatment at the incipient stage, of regarding even one ‘missed case’ as an evil and a public danger’. The words are those of Sidney Webb, speaking in 1909 about the Minority Report of the Royal Commission on the Poor Law. However, they might equally have been written about the present pandemic. They reflect a starting position that populations can be micro-managed in the interests of health outcomes. If people will not choose to do the right thing, their lives must be searched, interventions must be insisted upon and any deviation represents an evil. Citizens’ lives must be aligned with the prescriptions of public health and biomedical science, with their goals of promoting health, combatting disease, and preserving and prolonging life. If citizens choose to do otherwise, then the power of the state can justifiably be mobilized in support of those objectives, and the rational means by which they might be achieved.
In a modern society, however, the goal of ultimate health is not necessarily shared by all citizens, and its undiluted pursuit may lack democratic legitimacy. As the UK government’s plan recognizes, for example, the management of COVID-19 is not sustainable for any length of time without a robust and functioning economy. The population cannot sit unproductively at home while the government prints money. There are also other desirable ends for a society, in terms of education, order, national defence and well-being. The latter is different from health in that it encompasses opportunities for leisure, sport, culture and recreation as desirable in their own right, as much as for their contribution to physical and, especially, mental health. It is also important to protect spheres of privacy, not least because they are sources of diversity, dynamism and innovation in societies.
The tensions between these approaches are long-standing: Ibsen’s 1882 play Enemy of the People explores them in ways that might still feel familiar. The protagonist is a physician who exposes the bacterial contamination of a spa development, intended to bring trade and employment to a small Norwegian town. Although the physician is usually played as a hero, Ibsen was more ambivalent about the character and his obsession with public confrontation rather than a quieter and more diplomatic resolution of the problem. Do we need to regulate social distancing or just recognize that humans do not like to get much closer than 1 metre to anyone who is not a close friend or family? Should we compel face covering in the absence of evidence for individual or collective benefit – or leave it to individual choice in the light of different appetites for risk?
Many of our current policy problems stem from the failure to recognize that there are two long-established and legitimate views of government and the state that are in conflict here. The scientific advisory process has been largely colonized by the public health tradition of single-minded planning and direction, while the government side reflects a more libertarian belief that the state cannot impose a good society but simply provide the space for citizens to achieve their own goals. The public health and biomedical communities may not like this position, but it is equally respectable. Like most conflicts, it is unlikely that a resolution will be achieved by denunciation and abuse.