The early warnings
In early January 2020, we first learnt of the arrival of a new virus in Wuhan. It was a relative of the highly fatal SARS virus that has caused epidemic pneumonia in the Far East. At first there was discussion as to how infectious this new one might be, but this was quickly resolved when person to person cases were reported, and we saw the desperate measures being taken by the Chinese authorities. Unfortunately, Chinese New Year and the associated travel had already allowed it to escape from Wuhan and cases were being reported more widely in East Asia and on a cruise liner. However, SARS had been controlled and it still seemed far away and on 24 January we were advised by the English Chief Medical Officer that risks to us were low. One week later, the first two cases of the new viral infection were reported in England.
In early February, we were advised to wash our hands but that there was no need to avoid crowded places. On 21 February, a careful Chinese study showed that this virus, now called SARS-CoV-2, was transmissible by asymptomatic people. I said to my wife: ‘This is the big one’. The one we had all feared and that would be extremely difficult to control. A friend and I decided to watch the Scotland rugby international on TV rather than use the tickets he had bought.
On 23 February, the UK Government’s Scientific Advisory Committee for Emergencies (SAGE) advised that school closures and social distancing could reduce infections by at least 50%. By then, my wife and I had decided on self-isolation, knowing the mortality risk in our age group to be 20%. That week, I submitted my first Covid article to Scottish Review advising readers to take the same approach ( 4 March 2020 ). By 20 March, 177 deaths had been reported in UK and on 23 March 23, the government announced a national lockdown. Despite three notorious episodes of breach of these instructions by people responsible for them in both England and Scotland, the public response was extremely compliant.
The toll so far
Now, 19 months after COVID-19 reached us, over nine million people have been diagnosed in the UK and 163,500 COVID-19 associated deaths have been reported. Of these, over 643,000 cases and 11,500 deaths have occurred in Scotland. Almost 87% of the over-12 population has now been vaccinated. The virus has been most fatal among the oldest, poorest and those suffering from obesity and diabetes. As with many diseases, those in the poorest social circumstances have suffered disproportionately.
Five waves of increased rates of infection have swept over us in Scotland, associated with viral mutations and failures of national management. Now as winter approaches, we are seeing a stable but high rate of infection, an endemic phase when local outbreaks occur, partially controlled by vaccination and local public health measures. The modellers, on whom so much attention has been focused, are now finding it hard to predict what will happen as much now depends on public behaviour and the risks from new variants. It is time to assess how we got here and where we should go.
What has gone wrong?
In May ( 19 May 2021 ) I identified some things that seemed to have gone badly wrong:
• Lack of preparedness.
• Erratic control of borders.
• Waste of money on private sector.
• Failure of trace, track and isolate.
• Poor timing of lockdowns.
• Failure to protect those in the NHS, care sector and schools.
In October 2021, two Commons Select Committees published their report. This is a devastating catalogue of government incompetence, scientific indecisiveness, and chaotic, secretive advisory structures: Coronavirus: lessons learned to date by the Health and Social Care, and Science and Technology Committees ( parliament.uk ). In its own words, it was ‘one of the most important failures of public health the United Kingdom has ever experienced’. The whole process was considered to have suffered from what the committees called British exceptionalism and group think.
The report is particularly critical of Public Health England and of the contact tracing failure, singling out Baroness Harding and over-reliance on expensive private sector management companies, and waste of public money on management consultants. The Health Secretary at the time, Mr Hancock, is however commended for his efforts to increase the rate of testing, and of course the positive roles of the NHS and vaccine procurement are praised.
The roots of this disaster went very deep, reaching into the policies of most recent governments. It is the business model: the ideology that public services are essentially businesses selling items of consumables to their customers, the public, dating back to Mrs Thatcher and the Griffiths report on NHS management on 1983. This means that they require to be both efficient and effective, to give people what they need or even want. This can work well in good times but unlike businesses, public services cannot be allowed to fail in bad times. As anyone who has worked in business knows, efficiency often means employing the smallest number of the people best able to sustain competitiveness, and when times are hard, the least suitable are shed. Certain functions that seem only peripheral to the main objective, which in business is usually making profit, may be discarded. One such function to fall victim of this efficiency drive in the NHS in the UK was to be public health.
Public health lessons
Historically, the British tradition of public health was world-renowned, built up initially in the Victorian era and celebrated for its successes in tackling childhood infections, tuberculosis, cholera, typhoid, smallpox and, more recently, HIV, legionnaire’s disease, meningitis and E.coli. Now, a generation of politicians has grown up who have never had any illness worse than a cold or influenza, and who probably wondered what public health was for. Even some clinical doctors rather patronise their professional colleagues in the specialty. Universities, needing to prioritise their research functions over the development of practical teaching skills and looking for their research priorities of international excellence, may find preventive health teaching and research uncompetitive with drug development.
This attitude has allowed governments to initiate the process of death by a thousand cuts. Despite the HIV pandemic and the rise of antibiotic resistance in common pathogenic bacteria, public health action to control infectious diseases became less visible as public health practitioners drew attention to smoking, obesity, and other non-communicable disease factors. It seemed reasonable to tackle these centrally rather than locally, and much of this effort did not require expert medical input. Local control of public health waned, jobs were lost, and many key posts were occupied by people with no experience in infectious disease.
Importantly, while all Scottish health boards retained expertise in infection control, key laboratory services were centralised in the south of England. Yet, 40 years ago I was teaching students that the future of medicine would lie in managing infectious diseases, something I understood from my own teachers. Infections are the major killer of the young worldwide. Indeed, the last great pandemic in 1918, fortunately unlike the present one, targeted young people particularly.
The natural instinct when things go wrong is to seek to attribute blame, and it is apparent that many individuals, from the Prime Minister and leading scientific advisors down, on occasions have performed at a level they will come to regret. We can leave this to what will be a prolonged and contentious public enquiry. More important is to consider the lessons learned, and the Commons report is not very clear on this.
To me, the most important responses to this disaster are to work towards:
• Ensuring that the NHS is, at all times, adequately resourced to meet changing demographic needs.
• Robust planning for worst possibilities, in terms of staff, equipment and facilities. The report cited above failed to mention that the recommendations of the last epidemic preparedness exercise were ignored by government.
• Ensuring proper recognition of the vulnerability of the care sector.
• Ensuring decisive and clearly enunciated action early – delays cost lives.
• Having simpler but balanced advisory structures which include those on the front line, medical, scientific and adminstrative, and include international liaison.
• Devolution of responsibility for case finding, laboratory testing and contact tracing to local public health with overall support from a central organisation.
At present, it appears that some moves are being made in this direction and I am heartened to see mayors and directors of public health appearing on television occasionally talking about their areas. However, radical change is necessary, and this requires leadership of the calibre of Lloyd George, Churchill or Attlee (to be politically neutral). Sadly, the UK has not had this, but has instead developed a culture of policy based on pleasing potential political supporters and winning more (witness the recent budget). This does not fill one with hope.
Four things undoubtedly have gone well. Two, the development, approval and distribution of vaccines, and the discovery of cheap life-saving treatments, were indeed world-leading and owed much to the NHS and the pharmaceutical industry. The third was the compliance of the public, who did respond well when advice was clear. The fourth, less noted but commended in the report, was the use of the military when required in logistics and provision of trained personnel. When you think of this, you will realise that the military is always in the position of having to respond to unexpected and often overwhelming demands and, to do this, has a trained reserve.
Interestingly, in the USA they go even further. When I worked there in a government public health facility, I was surprised when some of my colleagues turned up in smart officers’ uniforms. They were in the US Public Health Corps, a branch of the military, working mainly in State or military hospitals but ready for deployment in emergencies.
Where now?
The immediate problem is endemic disease. There is a great deal of immunity from infection and vaccination in the population, and this with newly developed treatments and better understood management of ill patients mean that the mortality risk has been reduced dramatically. However, substantial numbers are still falling ill and hospitals and care homes are under intense pressure, worsened by staff absences and recruitment issues.
This is likely to have an adverse effect on all-cause mortality over several years; if it occurs, it will be a permanent marker of bad government – something that happened in Eastern Europe during the era of Soviet control. This points to the importance of much better local control of the infection by efficient case finding, contact tracing and isolation. It also indicates the need for continuing cautious behaviour by all of us, including obtaining vaccinations, wearing face coverings in public places, prudent social distancing, and hand hygiene. This should become a mark of personal good behaviour into the indefinite future. The advice given by government on this should be clear and unequivocal, and individual politicians should set an example.
The other issue is preparation for future major infective outbreaks. We have discovered that we can erect emergency hospitals remarkably quickly, and that clearing beds in acute hospitals is not only difficult but dangerous, by transferring infections and preventing routine care. The problem is staffing the new beds made available. There are two alternatives in a crisis: requisition of private hospitals which largely deal with non-acute conditions to take such patients from the NHS as wards are filled with infectious patients, or to have a reserve body of staff for the emergency hospitals if the NHS is likely to be overwhelmed.
We have also discovered that test, trace and isolate is a failure as currently designed, but we know that it is essential to take control of an epidemic. This should be organised locally by public health on military lines and again have a reserve corps of trained contact tracers with local knowledge, since effective contact tracing becomes impossible if numbers of cases are allowed to increase exponentially.
When the acute sector of the NHS is overwhelmed, there are many patients who are not ill enough for acute care but not well enough to go home unaided and some of whom may be incubating the disease. At one time, the NHS had spare capacity in its geriatric hospitals to accommodate and rehabilitate such patients, but this was a soft target for the supermarket model (the Griffiths report was the work of a Sainsbury’s director). The loss of NHS geriatric facilities owes everything to an executive letter from Mrs Thatcher’s Government that determined that no patient should remain in an NHS bed for more than six weeks beyond the end of their active treatment – unless they were expected to die shortly.
This led to rapid growth of the private care home sector and the need for patients or relatives to pay for nursing home care. Even the enlarged private care sector is now in no position to accommodate such a surge. This bottleneck must be attended to urgently by our governments. It would be nice to think that it would again become part of an NHS intended to look after us from cradle to grave. Incidentally, three hospitals that I worked in as a consultant, previously TB sanatoria, would have been perfect for this. They are all now converted into luxury flats, as is Edinburgh Royal Infirmary.
We have discovered that the private sector has limited value in a pandemic other than, in combination with universities, the development and production of vaccines. Effective control of an epidemic requires rapid identification of cases and tracing of contacts. In the present pandemic, we had developed a test for the virus but did not have a comprehensive system to use it effectively and appeared to have insufficient capacity to carry out the necessary population surveillance. We already had a network of experts in universities, the NHS, the armed services and public health to help but they were not used until much too late, and money was wasted on untested methods and private and foreign companies. One of these, Immensa, has recently and scandalously been found incapable of detecting the virus in positive swabs. Few, if any, have been able to demonstrate either efficiency or effectiveness.
Preparedness for future waves of this and other infective epidemics should be based on the expertise we already have in place. In the pandemic, it has operated as an informal network but needs to be built into a structure. I suspect that the only world-beating aspect of our response to the pandemic other than treatments and vaccine deployment has been the amount of public money wasted on the private sector, on equipment, services and consultancies. The publication this week of Test and Trace update , the Committee of Public Accounts’ devastating critique ( parliament.uk ) of the waste of billions of pounds on Test and Trace on thousands of expensive consultants and profit-making private companies, gives us some guidance on what could be available for investment in the NHS and university laboratories in the UK for the next time we confront a pandemic.
Perhaps we should now invest in preparedness measures, including forming a trained volunteer corps, ready to support local directors of public health and the local NHS and care sector. If doing this in the UK is too difficult, let’s demonstrate what could be done in Scotland.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own
By Anthony Seaton | 3 November 2021