key: cord-256717-bnzbhetc
authors: Paton, Calum
title: Insouciance and inexperience: A deadly combination when dealing with COVID‐19
date: 2020-06-03
journal: Int J Health Plann Manage
DOI: 10.1002/hpm.2991
sha: 
doc_id: 256717
cord_uid: bnzbhetc

This article gives key reasons for the UK's tardy and confused attempts to react to the COVID‐19 pandemic. It explains very poor outcomes in the UK (in terms of the spread of the virus and high mortality, already striking at the time of writing), in terms of an initial lack of political will to prioritise public health, itself a product of a strong Prime Minister who made the “wrong call”. It also highlights a failure to “follow the science”, except in so far as the “science” had already accepted some dubious political judgements and the lack of capacity to test as the starting‐point.

The Johnson administration quickly became noteworthy for the preeminent position of its leader when he was elected in summer 2019. Working with his chief advisor Dominic Cummings, Boris Johnson showed early ruthlessness in dealing with Brexit. As well as seeking to suspend Parliament to get his way, he purged the Conservative Party of many of its most senior "grandees" prior to a convincing, indeed overwhelming, election victory in 2019.

The post-election Cabinet is composed mostly of loyal, inexperienced young Tories without an independent power base. Even after his December 2019 general election victory, Johnson accepted the resignation of his new Chancellor of the Exchequer (Finance Minister), Sajid Javid, rather than see an unprecedented centralisation of power in his own office thwarted.

Thus Johnson was ideally placed to use strong and unchallenged leadership to take early decisive action against COVID-19. The Prime Minister had both the clout and the temperament to take decisive, even ruthless, action to prevent COVID-19 taking root in the UK.

Instead he put his pseudo-Churchillian rhetoric at the disposal of pooh-poohing prioritisation of public health in meeting the threat of a pandemic. In a notorious speech, he said the world needed the UK to "take off its Clark Kent spectacles" (to become Superman) to battle to prevent "new diseases such as Coronavirus triggering a panic and a desire for market segregation that go beyond what is medically rational". 1 In another insouciant speech, this time only 4 days before a striking U-turn in the form of a lockdown, attempting to evoke the doughty British bulldog, Johnson promised "to turn the tide in 12 weeks" and send COVID-19 "packing". 2 Johnson was not asleep at the wheel: he was driving in the wrong direction, recklessly at that.

Johnson did not resist immediate action to limit inward flights to the UK and quarantine passengers and, later, control movement within the country because he is a theoretical libertarian as alleged by some on the Left or imbued with a mistrust of government in the style of some U.S. far-right activists. He is in many respects a populist, and also a believer in an active state if it suits: by instinct, he is more the Romanesque provider of bread-and-circuses to the populus than a "minimal-state" man. Yet his initial reaction to the novel coronavirus was as if he had been a libertarian in denial.

The UK knew, as did the rest of the world, by January 22nd at the very latest, not only that the novel coronavirus was transmittable from human to human and seemingly quite easily, but also that the resulting illness was serious and capable of causing death in individuals other than those very elderly and infirm usually at risk from influenza.

Meanwhile the UK's top scientific officers knew that, in terms of capacity to test for cases and treat patients, the UK was ill-prepared for a pandemic. The years of so-called austerity after the banking crash of 2008-2009 had led to many items of public expenditure being deemed unaffordable. Testing capacity and also personal protective equipment (PPE) for health and other front-line workers in the event of a pandemic were not exempt. (Hospital capacity too was threadbare, although the post-COVID-19 mobilisation of new intensive care capacity was now arguably the government's only partial success.) The government's own pandemic simulation exercise in 2016 3 had identified gaping needs in the country's preparedness which were deemed unaffordable, and remained unaddressed right up to the present.

The science of COVID-19, a novel Coronavirus, was unclear, as pointed out by Correia. 4 What follows from this is that governments around the world had to take life-or-death decisions under conditions of significant uncertainty. Two things follow from this. First, attitude to risk and overall priorities come to the fore in influencing, indeed determining, policy. Second, any claim that the British government's COVID-19 policy was wholly determined by "following the science" was dissembling. In the case of the British government, "science" has had to follow policy both past and present: both ill-preparedness for a pandemic and the unwillingness of government to take drastic action (until it was too late)

were the backdrop to the UK's Chief Scientific Adviser Sir Patrick Vallance's alarming admission that "herd immunity" was the aim, 5 illustrating the extent to which the UK was an outlier in terms of its response to the threat.

With a novel virus and a new pandemic, there is no unequivocal "science" based on evidence at the time key decisions are needed. Sometimes common sense is indeed a guide, if by common sense we mean sound judgement when evidence does not mandate a clear approach. Not only the island and peninsula states of South East Asia but also Australia and New Zealand showed the way. As an island state, Britain had more opportunity than its European neighbours to limit inward travel before the virus had taken root. Pointing to Italy, Spain and France as countries with high mortality and serious case ratios is at least in part a cop-out.

Knowing that timely "test, test and test" was going to be beyond the capacity of the UK, a responsible government would have acted quickly to: suspend flights from hotspots; quarantine whichever other travellers it needed to; and trace any returning citizens or visitors who had arrived without quarantine. Here it is likely that the inexperience of some of the key expert bureaucrats limited their confidence or clout (or both) in "speaking truth to power." In any event, the need for urgent action was not a message the government wished to hear until it was too late.

In the early days, the UK policy was allegedly to contain the virus by isolating those few arrivals known to have the virus and quarantine others known to have had direct contact with infected individuals. But the continuation of multiple daily flights from Wuhan, the rest of China, Italy and elsewhere made a nonsense of this approach. The only reason it was unknown that virus carriers were entering the country was that checking and testing were absent. A The UK's Chief Medical Advisor Chris Whitty has repeatedly claimed 7 that testing was difficult in the early days, partly because the virus often caused minor symptoms difficult to identify and test, let alone trace contacts with equally minor symptoms. This however assumes that testing of those with symptoms was the only game in town even in theory. It is no more than a less-than-forthright restatement of the harsh reality that testing on a large enough scale, of asymptomatic arrivals, contacts and populations, was ruled out both by overt political decisions and also a lack ofnot expertise and skill, but capacity. Such apologia came as the UK moved from its soi-disant first phase, containment, to the second phase, "delay," geared to "flattening the curve" of infection in order to allow the NHS to cope.

What the abandonment of containment also involved was the temporary but disastrous dalliance with the approach of seeking "herd immunity." This seemed, furthermore, to involve accepting, if not publicly, that the third phase was going to be the so-called "mitigation" of the spread rather than its suppression. It was when containment was formally abandoned, on March 12, that Johnson's alarming reference to "many more families….losing loved ones" was made. 8 But abandoning containment also led to Imperial College's modelling 9 of a more laissez-faire approach to manage the now-endemic COVID-19, without lockdown, as possibly leading to more than 500,000 deaths, and likely to lead to at least 250,000. The government then semi-panicked, calling for social distancing and exhorting people not to make unnecessary visits, for example, to pubs and restaurants. This led inter alia to a farcical discussion as to when a pub visit could be deemed necessary, involving Stanley Johnson the Prime Minister's father.

This semi-panic became full panic only days later, when voluntary restraint Swedish-style was shown to be a pipedream. The fact that mandatory social distancing and a (very British, partial) lockdown ensued only days after a voluntary version of social distancing had been announced did not inspire confidence that the government was following a stable strategy, let alone "following the science," a mantra still being repeated ad nauseam by both politicians and advisors. Glib words, as were the Education Secretary's, urging schools and universities not to close only days before the lockdown was announced. 10 Some harsh questions for the British government include the following. If, as it was claimed by Ministers as well as Chris Whitty, testing was abandoned due to there being too many cases and COVID-19 becoming embedded, why was lockdown still rejected, after the abandonment of containment, on the grounds that it was not justified by the evidence? Too many cases, yet not enough cases, it seems.

Why were there 15,000 inward passengers a day throughout the peak of the epidemic? It was eventually teased out of the Health Secretary that the number of possible virus carriers was allegedly statistically insignificant, given the endemic nature of the virus in the population. 11 Later, the Transport Secretary, in response to questioning, 12 said that it would make sense to "review" the issue of screening flights once the numbers infected within the UK were under control and the issue would matter more. How ironic was this? Presumably he hoped that the public would not notice the backhanded acknowledgement that screening flights could have worked much earlier, before the numbers had grown too large.

We may note that government spokesmen reject international comparisons of the UK's record, particularly on mortality from COVID-19, as premature yet were happy to boast that their belatedly increased testing numbers, by the end of April, bore international comparison. Hardly following the science: Germany's exhaustive testing worked as it was done on time. Facts out of context are hardly scientific. Normal "low politics" at an abnormal time leaves a bad taste.

In an international context, at the time of writing the UK, with 32,000 deaths of people in hospitals and care homes with COVID-19, and indeed 55,000 excess deaths above the expected value, may well end up as the worst performer in combating COVID-19 in the world, whether one uses age-adjusted COVID-19 mortality per population or the increase above the expected value of the age-adjusted all-cause mortality ratio. In terms of the actual number of deaths, the UK is second in the world to the USA (which has more than five times the population), having overtaken Europe's otherwise worst performer, Italy. Alongside these depressing facts, the UK has treated its public not only as children but as rather dull and over-trusting children at that, hoping for self-restraint by media, opposition and commentators in order to get away with this.

If one is referring to international evidence on preventing such a virus taking hold, then the British government was conspicuous by its failure to follow the science. The WHO's mantra of "test, test, test" is not just a slogan but a conclusion based on what has been learned in the past. Regarding COVID-19, not only South Korea and other South East Asian states but also Germany followed this approach, and reaped the rewards. The UK abandoned containment through testing before it had meaningfully begun.

If however one is referring to national evidence, then as the COVID-19 story unfolded, the claim to be following the science is fatuous. A failure to test on time led to the "science" telling us that there were not enough extant cases to justify a "lockdown"-until it was too late, that is. Add in that we are an island state more able to police its borders-unlike France, Italy and Spain, the other "poor performers" in Europe-and our performance is even more dismal. Hardly science to claim that there were not enough cases identified in the UK to justify an earlier lockdown when we were not finding them-because of a lack of testing! It is quite staggering now to recall Ministers' complacency as recently as mid-March, claiming to be following the science in keeping not only educational institutions but also pubs, restaurants and entertainment venues open, as well as allowing the now notorious large sporting events right up to mid-March including a race meeting with 50,000 people in attendance and a football match in Liverpool with a similar number and 3000 fans also visiting from Spain, at the time one of the worst-affected countries.

The evidence creates the science, and by definition the evidence is available only after the event. Judgement is by contrast required at the outset. A series of poor judgement calls, buttressed by a dubious belief that the doughty (or is that spoiled?) British public would not tolerate precipitate restrictions, condemned the country to far worse outcomes from this public health crisis than were necessary. Yes, China's irresponsible market practices seem to have been the root cause. And we need to strengthen, not curtail, the WHO, in order to cure its inability to make the technical political when necessary, so that governments can receive compelling recommendations in such times. But as soon as it was "over to us" here in Britain, we failed.

https://orcid.org/0000-0002-5476-1126

Presentation at UK government's daily 5pm briefing

See also The Telegraph (UK), online

SARS-CoV-2 pandemics: the lack of critical reflection addressing short-term and long-term challenges

BBC Radio 4 Today programme

BBC 1 TV

Testimony to UK House of Commons Health and Social Care Committee

Statement After COBRA (Cabinet Office Briefing Rooms) Meeting

Impact of Non-pharmaceutical Interventions (NPIs) to Reduce COVID-19 Mortality and Healthcare Demand

The Education Secretary, Speech to Conference of Association of School and College Leaders

How to cite this article: Paton C. Insouciance and inexperience: A deadly combination when dealing with COVID-19