The post-mortems on national governments’ management of the COVID-19 pandemic are getting under way. Some European countries have completed theirs, with rapid expert reviews. The United States Congress is still arguing about whether to have one, particularly as the response became so politicized and it is difficult to see how a review could command bipartisan support. The United Kingdom has opted for the ponderous mechanism of a judge-led public inquiry. This is likely to take most of the rest of the decade and cost a vast amount of money – the bill so far is reported to be around £40 million. The British state likes the impartiality of judicial leadership and lawyer-centered processes. However, this tends to marginalize the large body of social science work on disasters and institutional failure, represented in the work of people like Charles Perrow, Diane Vaughan, Kathleen Tierney and Lee Clarke, in the US, or Barry Turner and Nick Pidgeon in the UK.
The first module of the UK Inquiry has looked at pandemic preparedness. The report will be published next spring but the evidence-gathering underlines some of the problems of a lawyer-led approach. The Inquiry team’s questions are building a story about how the government and civil service prepared for the wrong virus and neglected the possibilities for suppressing the pandemic. The first shows that the lawyers have not understood the science. The second that they have not dug deeply enough into the history of UK pandemic planning to discover that suppression had been seriously considered and dismissed.
Both the inquiry team and many of the witnesses seem very confused about the nature of influenza. The influenza virus is one of about 200 respiratory viruses that cause familiar symptoms like fever, coughing, runny nose, and tiredness. As the name implies, they all tend to be passed on through the air, although some can linger on surfaces, get onto hands and be taken in when we touch our faces. We don’t usually bother to distinguish between these viruses but true influenza is capable of having a serious, even fatal, impact on the very young and the very old. This is why the UK vaccinates vulnerable groups every autumn.
Human influenza, however, is a peculiarly unstable virus. Its genetic material changes easily and swaps elements with the influenza viruses that affect birds and pigs. The small changes happening all the time are called genetic drift. Seasonal influenza vaccines are tweaked every year to match.
Every now and then the influenza virus goes through a much more radical change, called a genetic shift. This is when pandemics happen because the virus is so different from what anyone has seen before that few people have any immunity. The consequences can be severe, as in 1918, or relatively mild, as in 2009. No one knows why these shifts occur and they cannot be predicted.
A pandemic influenza virus is just as much a novel virus as COVID-19. It is not a mistake to use it as a model in planning. Planners can look at past experiences and the evidence of what did and did not work previously to design a starting point for responding to an infrequent but serious challenge to societies and their health systems. We do not have to reinvent the wheel every time a new respiratory virus comes along.
This is the source of the second mistake being made by the Inquiry. The possibilities for suppression were considered in the work that went on around 2005/06 and discarded. Either there was no evidence that they would work or the costs of doing so were thought to be unacceptable.
I was a member of a group called CEAPI – Committee on Ethical Aspects of Pandemic Influenza. In practice, our brief was rather wider and we looked at most of the social aspects of the pandemic planning. We had a broad membership – academics, journalists, patient advocates and people with clinical and operational responsibilities in health and social care. The voices that were entirely absent from SAGE, the biomedically-led committee that dominated scientific advice to the UK government during the COVID-19 pandemic. Medics were in the minority and we received papers from epidemic modelers rather than having their voices shout others down.
CEAPI saw most of the working documents produced to support the plan, as well as producing its own statement to guide others in thinking about the ethical implications of their decisions. It was part of a process taken over by the Cabinet Office, which provides personal support to the Prime Minister to deliver a whole-of-government approach to whole-of-society challenges. We did not need a Minister for Resilience, as has been advocated by some witnesses – this was the role of the minister in everyday charge of the Cabinet Office. This approach was widely admired at European conferences I attended, where the structural weakness of assigning lead responsibility to the health ministry was recognized.
Discussions in 2005/06 included considerations of closing borders, internal travel restrictions and school closures. It was soon obvious that closing borders would rapidly cause food shortages, like those that occurred in the early days of Brexit. Internal travel restrictions – checkpoints on the main highways – would be unworkable in a country with a dense road network.
Closing schools provoked more discussion. As soon as you do this, the country’s workforce is decimated by the need to stay at home and look after children. Any improvised alternative puts children at risk of abuse or neglect. They would be safer in school, provided there were enough teachers to supervise them, and oversee any volunteers needed to have an acceptable ratio of adults to children. Children’s interests came first.
As far as I can recall, masks were not even discussed. From my own reading, it was clear that cloth masks had not helped during any previous influenza pandemic. Their use in a few Asian countries had as much to do with urban pollution from power generation and traffic as infection control. An independent review by the influential Cochrane group was published in 2007 which underlined the lack of evidence for any benefit.
Contact tracing was equally pointless beyond the first few hundred cases, to build a more specific picture of the virus. It would be much more cost-effective just to ask people to stay at home if they had any relevant symptoms – these might be caused by other viruses but reducing circulation of these would help manage the bigger problem. There was no great interest in closing bars, clubs, cinemas, theatres or other places where people might mix. Again, there was no evidence from previous pandemics to justify this.
If the Inquiry were interested, they would discover that the planning process had not been negligent. It had considered the evidence available, weighed the costs, harms and benefits and concluded that attempts at suppression were unlikely to be effective and that government resources would be better used to keep society and the economy going rather than shutting it down. Suppression was not ignored but was futile.
No plan can be fixed for all time, of course. It should be reviewed regularly in light of new risks and new evidence. CEAPI met to review its approach after the 2009 influenza pandemic. This had not really been severe enough to test the plan. The documents were so recent that there was no need to repeat the work. Ten years on, a full reconsideration was sensible. This seems to have started in 2016 but been disrupted by Brexit planning. The experts on how to keep supermarket shelves full in a pandemic were needed to plan how to keep the shelves full after Brexit.
Since March 2020, I have reflected on why so much emergency planning work was so lightly discarded. I think there are three main factors.
First, we overestimated the courage of politicians and their readiness to tell the British people that they were facing a crisis and little could be done to prevent significant loss of life. This is obvious in the evidence from former health ministers Jeremy Hunt and Matt Hancock. Both assumed that something could be done and looked for people to tell them that, regardless of the expertise of the advisers.
Second, we did not allow for the fact that a significant body of scientific and medical professionals would seize on the pandemic as an opportunity to attack a government that they disliked. This was partly a consequence of austerity and its pressures on pay and working conditions and partly a clash of values. The pandemic released a streak of elitism and paternalism that had long been present in both biomedical science and public health. There was now an opportunity to use the power of the state to reshape individuals and society without democratic consent or respect for the rule of law.
Third, we underestimated the opportunities for private gain, both in the classic commercial sense and in the more modern sense of funding for biomedical research. The UK is gradually uncovering major scandals in the procurement of personal protective equipment and diagnostic tests. It is less obvious that the pursuit of a technological fix for every problem funneled resources into science without the usual scrutiny. Policy analysts have been concerned about the excessive influence of biomedical interests on UK science funding and investment for the last ten years or so. The pandemic overwrote that in spades.
The inquiry’s obsession with diagnostic testing is a good example. Witnesses hailed its use in South Korea. What value did that country add by mass testing over just advising sick people to stay at home? It is a long-established principle that mass screening is not justified unless there is a positive intervention available. Matt Hancock seemed to think we should have had a stockpile of anti-viral drugs for coronaviruses – this would have been a hill of magic beans. Compared to antibiotics, there are very few anti-viral drugs and none specifically licensed for coronaviruses. If someone is sick enough to consider hospitalization, there is a reason to identify the specific virus because it may help to identify the best way to relieve their symptoms. Otherwise, as was known from February 2020, just take your usual paracetamol or whatever.
Looking back, you could reasonably say that some of us were a little naïve about what would happen in a real pandemic. As rational planners and thinkers, we expected the same level of rationality in others. Perhaps we should not have done, although it was not our job to plan the politics as well as the operational responses. The Inquiry needs to look more deeply into the history of pandemic planning and recognize that the alleged flaws are not the result of neglect but of evidence-based decisions. Otherwise, it will become just another pawn in the political games rather than making a useful contribution to thinking about how to respond to future crises. And that would be a hugely missed opportunity at eye-watering cost to the public purse.
An edited version of this piece was published in the Daily Mail August 4, 2023