It came back to me on my walk though the woods. As I listened to the wind and the bird-song, my mind wandered to the first sound I remember hearing – the wail of the air raid siren. I heard again that siren and saw again the barrage balloons, and I remembered; it was the 80th anniversary of the successive defeats in Norway and Dunkirk. A hopelessly unprepared Britain, led by a weak and ailing Prime Minister, had been defeated by a ruthless enemy we had underestimated.
Tens of thousands in the front line died, as did many heroic men and women in rescuing the survivors, who included my uncle and godmother, from the beaches. The Prime Minister resigned and the Government fell, to be replaced by a coalition headed by a leader who did not mince his words. We all know how the story ended, with an impoverished Britain finally having to learn that it no longer ruled the waves but eventually finding a respected place, allied to Germany and France as one of the leaders in Europe, strong in the arts, medicine and the sciences.
There is much truth in the view of those who have suffered in battle that the fault was that the lions at the front line were led by donkeys at the rear; that preparation and strategy are critical and that courage alone does not win wars. Indeed, this is applicable beyond warfare – in business, education, medical care – wherever you look, leadership is what determines success or failure. So, in asking what led to Britain's terrible loss of life in the war declared by the Prime Minister to beat COVID-19, it is reasonable to look first at the top. Who are the commanders whose decisions have led to Britain's people having the highest mortality in the world from the virus? What decisions have put us in the position of being looked on with pity by countries that until recently looked up to us?
In April, the Prime Minister, trying but failing to control his tendency to thump tubs and to flourish metaphors, announced that we had passed the peak, gone through the dark tunnel and could see the sunny prospect ahead. This was at the end of a week in which over 5,000 families had received the news of a death and on a day when a further 674 were receiving that news. Where was the admission that things had gone wrong? Instead, we got a painful grasping at on possible drug treatments and vaccine developments, feeble attempts to discount the strikingly better effects of strong, often female, leadership in other countries by implying that their statistics were somehow less reliable than ours. Finland, Norway, New Zealand, South Korea? Where was his strategy for reaching an end, in his words 'to beat this thing'?
The origins of the pandemic
People often attribute illness to some noteworthy prior episode, perhaps a fall or a shock. Similarly, it is usual for us all to look for one obvious explanation of events beyond our control. Such an explanation, post hoc ergo propter hoc
: after the event and therefore because of the event, is often fallacious and misleading. There is a well-known aphorism: 'For every complex problem, there is a simple explanation that is wrong'. Most illnesses and accidents have multiple causes. The same is true of pandemics, and each of these teaches us new lessons. While we have learnt a good deal in the past from the control of tuberculosis, poliomyelitis, influenza and HIV, somehow COVID-19 has put us in the position of having to explain why the UK and Scotland have suffered so many more deaths per head of population than most other countries of comparable size. And we need to recall that only one virus – smallpox – has ever been beaten. The rest are under partial control.
It is important to think of these points as we look for explanations of the current COVID-19 pandemic and its effects in these islands. The simple-minded belief, for example, that it is all the fault of the Chinese gives rise to absurd conspiracy theories and can lead to trade wars, cold wars, and even physical conflict. The fundamental truth is a biological one, that this is a conflict for reproductive advantage between a newly discovered virus and Homo sapiens, in which the virus SARS-CoV-2 has a huge evolutionary and genetic advantage and Homo has to rely on inherent sapientia, the wisdom he has attributed to himself but which is far from universal in the species.
I think of wisdom as more than just the detailed understanding by experts of specific matters; it includes a much broader appreciation of the wider environment in which these matters have developed and which in turn they may influence. Wisdom is not confined to the highly intelligent. It is generally understood to increase with experience and thus age. It does not flourish among the self-satisfied surrounded by their sycophants and appears to be largely absent in some notable national leaders.
The first obvious error occurred in early January when the Chinese leadership tried unsuccessfully and tragically to conceal the arrival of a new virus. Someone quickly realised the mistake and thereafter China collaborated closely with WHO. The Chinese doctors and scientists were heroic in dealing with the crisis and quickly published extremely useful research which explained the main features of the disease and its serious consequences. They rapidly worked out and published the viral genome, allowing other scientists throughout the world to work on possible treatments and vaccines.
The origin of the novel virus was traced to a live food market and was probably derived originally from a bat virus. While this remains under investigation, the lesson from this and from other coronavirus and influenza epidemics is that such markets need to be tightly regulated. This was a lesson that the Chinese rulers had not learned from previous epidemics such as SARS and Ebola, and this, with their early attempts at concealment, demonstrates a failure of leadership.
The spread of the pandemic
The Chinese authorities responded by introducing a lockdown of the city of Wuhan and Hubei province, measures thought at the time to be drastic, indeed draconian, and only possible in a very authoritarian regime, but which ultimately proved very effective. China is now reporting a death rate of only 3.3 per million. Nevertheless, the disease leaked out, particularly from the coincidence of Chinese New Year and associated travel. Other parts of China and local Asian countries announced cases of COVID-19. All introduced case-finding and contact tracing, isolation of contacts (and support for those isolated), plus general hygiene measures including the production and use of face coverings, and lockdown measures, as advised by WHO.
Illustrating the dangers of viral spread in the modern world, cases were soon found in cruise ships, and study of one such led to it becoming apparent that the virus could be spread by asymptomatic carriers as well as by infected individuals before developing symptoms. These two observations immediately showed that its control was going to require rigorous contact tracing and isolation, even of asymptomatic individuals.
The early Far Eastern experience provided the rest of the world with adequate warning. By late January 2020, we knew that the virus was highly infective, that it was fatal in a small proportion of those infected, primarily the elderly, the obese, and those with prior chronic ill health. It was known that this would place unprecedented demands on the health and care services of all countries affected.
On the more positive side, by February it was becoming apparent that its effects could be controlled by stringent public health measures. Such measures were being used in countries such as South Korea, Singapore and Taiwan, and their efficacy is now apparent; their crude mortality attributed to COVID-19 to date is respectively 47, 4 and 0.3 per million population. Singapore and South Korea have similar populations to Scotland, whereas Taiwan has five times more people.
In contrast, the same figures for the UK and Scotland are now 569 (an acknowledged underestimate) and 693 per million. We share the highest rates in the world with France, Spain, and Italy, though not with Germany, Greece, Norway, Finland and Denmark, the worst of which is 102 per million. These figures, though unadjusted for differences in counting, and demographic and social factors, nevertheless show that something has gone radically wrong with our response.
The UK response
The most obvious conclusion is that we were woefully unprepared despite plenty of advanced warning, we had to do everything in a rush, and had completely neglected our supply lines – exactly what caused Chamberlain's resignation in May 1940. For at least two decades, our Civil Service and associated organisations such as the Health and Safety Executive and Government laboratory services had suffered huge cuts in staffing and expertise. Ideological obsessions with privatisation and pursuing austerity had led to the fragmented and under-equipped NHS, particularly in laboratory services and social services; both are suffering terribly as COVID-19 has struck.
Local organisation of public health was destroyed in England when its communicable disease function was centralised to Public Health England, the rest being dependent on local authority funding during a long period of financial stress. At least 330 people working in the NHS and social care have been reported to have died so far as a consequence of this work-related disease. This is something that happened in the pre-antibiotic era; it is both tragic and scandalous and no amount of clapping can make up for it. As Jim Callaghan said in another context, 'the sky has turned black with the flapping wings of chickens coming home to roost'.
This unpreparedness was not due to an absence of advice: in 2016 a detailed review, named Exercise Cygnus (referring to risks of bird flu) had produced a report concluding that the NHS and social care were unprepared for a pandemic and indicating the measures that needed to be taken when one occurs. The report in July 2017 was, extraordinarily, kept secret and the recommendations appear largely to have been ignored. Among them were reported to have been advice on ventilators, personal protective equipment for staff, and the need to fund extra capacity for social care and disposal of bodies. This failure of UK Government was equivalent to the original failure of the Chinese.
This seems to have been a fundamental political failure, but it only added to other past political mistakes going back to the Thatcher-driven introduction of competition into the NHS and to the separation of social care from the health services. The ideologies have differed in the devolved administrations, but the effects seem to have been the same. Health and care have been viewed as commodities subject to market rules rather than as services provided by the taxpayer for the well-being of the population. The fact is that we were all inadequately prepared for a pandemic and the fears anticipated by the Cygnus exercise were realised.
The role of scientific advice
Medicine and healthcare are not strictly sciences but depend on the application of science. The branch of medicine involved in epidemic disease is public health and relies inter alia on epidemiology and microbiology. Britain and Europe were responsible for the development of both these disciplines and have strong records of their application in public health. It is possible that this has led to some complacency. The British record dates to John Snow's investigations of cholera in the 1850s through Professor Archie Cochrane's studies of coal mining diseases in the 1950s, both dependent on shoe-leather epidemiology: visiting and quizzing individuals. All the countries that overcame the worst effects of COVID-19 used this tried and tested method. Those like us that failed appear to have abandoned it in favour of a wait-and-see approach based on mathematical models of the intensity of the epidemic as it approached our borders.
These theoretical models were originally used to test the probable effectiveness of different preventive interventions in endemic disease like malaria, then in epidemic diseases like influenza, but their use as the primary method while a pandemic is sweeping across the globe seems to have been in retrospect rather adventurous. This is particularly so when the progress of the pandemic was visible in the countries first hit; we had plenty of real evidence without making models.
Nevertheless, the UK relied on the scientific advice of a large committee called SAGE (Scientific Advisory Group on Emergencies), the membership, deliberations, and recommendations of which were kept secret for reasons still unexplained. It turned out to comprise mainly senior scientists in government employment and was chaired by the Chief Scientific Adviser, a clinical pharmacologist and including six from Public Health England. In these respects, it differed from the usual independent scientific committees commissioned to advise governments. It did not apparently include people familiar with the day-to-day problems of public health or infectious diseases in the NHS and social care at local level, whom one would expect to be heavily involved in implementing any preventive actions recommended. It was heavily influenced by mathematical modellers.
Where things went wrong
It seems that the original plan was to detect cases early and trace and isolate their contacts, but this was stopped almost as soon as it started. No attempt seems to have been made to restrict migration from affected countries into this 'island built by nature… against infection and the hand of war'. The reasons have not been revealed, but it is apparent that we had started too late and that tracing and testing facilities were insufficient. This would have been related to the decision that the actions should be run centrally by Public Health England which had neither adequate human and laboratory resources nor sufficient regional representation, and actively prevented a regional testing approach. It appears that local public health authorities and university and NHS laboratories, which might have been expected to have better knowledge of the epidemic in their areas, were not involved.
Following the decision to stop tracing contacts, the Chief Scientific Adviser briefly proposed the view that we should aim for herd immunity until the modellers, in a dramatic report, explained that this could lead to half a million deaths in the UK. In that they were almost certainly right: waiting for herd immunity to develop would have been catastrophic.
The scientific advice has been controversial, in part because it differed so much from that applied in the Far East and in part because being secret it was not tested as science usually requires. It is obvious that the SAGE committee could easily be subject to bias when confronted with political expression of difficulties if their conclusions were unwelcome. This became explicit when the Chief Scientist of the Department of Transport, a member of SAGE, was later questioned about the reasons for a change of advice and admitted that it was because of lack of the availability of testing facilities.
The mantra of the politicians that 'we are following the science' would only have been true had it been qualified by 'if we have the resources to do so'; the 'science' took that into account. Nothing is very wrong with that, so long as it is admitted and explained. Science and politics are unhappy bedfellows. For example, the question arises as to whether the objective science included calculations that undervalued the lives of those in care homes by application of estimates of quality of life-adjusted years. Did SAGE use these and is that why their deliberations have been kept secret?
The role of ideology
The COVID-19 pandemic will prove an interesting study for philosophers and students of politics. If, as Cicero averred, the health or well-being of the people ought to be the supreme law, there is little doubt that our Governments' political ideologies should come under intense scrutiny. Could it be that a long period of neo-liberalism with an emphasis on reducing government and selling off core public assets to profit-making consortia has led to our lack of preparedness?
In some countries, friends of politicians do very well out of such policies; in ours they may get to sit in the House of Lords and head important committees. It is not quite the time to make firm international comparisons but, in our case, we have seen the spectacle of an independence-minded Scottish Government following without question the lead of an economically laissez faire English nationalist UK Government. Nationalism has not played a role, but both have agreed on a de haut en bas
command policy, with the central theme of following the science and the belief that we have the best scientists. Fortunately, whether we used them or not is now testable in the way scientists like; by measuring the consequences.
If we did indeed follow the best science, why have so many died? I believe it is because the advice was tempered by practical considerations in the light of political failure across UK to prepare for the onslaught. The modelling at least prevented a much worse disaster. One thing is clear, that the Far Eastern countries, whatever their ideologies, have performed far better than most European nations. Has our version of capitalism led to decadence? I think it has, and we have got the leadership we deserve.
The UK and Scotland
The ways in which the UK was unprepared are numerous and shameful for a prosperous country. The blasé approach of Johnson with his ignorance of the importance of hand hygiene, later emphasised by the disgraceful arrogance of his advisor Cummings in breaking lockdown and dishonestly attempting to justify it, show why we were so late to appreciate the gravity of the situation.
Our greatest assets were the NHS, our public health system, and the wisdom of the population. The NHS responded magnificently because it had rehearsed regularly for emergencies and because doctors and senior nurses took control. Nevertheless, its success was a consequence of effectively ceasing any hospital activity other than care of COVID-19 patients. Hospital control of infection and occupational health services proved incapable of dealing with the emergency and there has been a terrible toll on the employees.
Local public health teams in England, who have detailed knowledge of their local communities but no longer include experts in Communicable Disease Control, appear to have been ignored by the implementation of Public Health England's centralised policy. The local public health services were completely cut out by central policy. Only they could have run the contact tracing which proved beyond the capacity of Public Health England and its devolved analogues. Only now, as the numbers of new cases decline, is it being recognised that local public health services have the main role in helping us get out; their neglect during years of austerity-based funding of local government will make this a severe test for them.
Scotland appears to have decided to follow England and its advisory bodies throughout the emergency. This was probably a sensible decision since a unified approach has advantages and we do not have a defensible border. But here the question of leadership must have been a consideration and the contrast between Johnson and Sturgeon could not have been starker. As it was, we were led by a notoriously unreliable man whose rhetorical style and tendency to trivialisation were ill-suited to the occasion, supported by a Cabinet selected primarily for their enthusiasm for cutting us off from our largest export market.
Sturgeon, who had been a good Health Minister, must have been aware of the problems confronting the Scottish NHS and the funding difficulties of the social care sector. That may have played a part in her thinking when, as First Minister of a Scandinavian-sized country, she could have resisted the cessation of contact-tracing and emulated Denmark, Finland, and New Zealand. I am pleased that the message of a need for a distinctive local approach is now being heeded.
Whatever the reasons, the fact is that we in Scotland were slow fully to appreciate the risks and delayed our response until it was too late to prevent the epidemic at a time when it could have been stopped. This was illustrated by the inability of our then Chief Medical Officer, a gynaecologist, on whose advice Sturgeon presumably depended, to appreciate the importance of taking it herself on social isolation. We were unprepared in terms of equipment and intensive care beds and seemed unaware of the risks to old and disabled people in care homes. Worse, we compounded those risks by carelessly discharging COVID-19 patients from hospital directly to care homes. We shared with the rest of the UK the inability to provide sufficient antigen testing capability, and this must have frustrated the ability of our better organised public health system to maintain effective tracking and tracing.
The pandemic is now coming under partial control here while continuing to devastate the poor world. However, in Scotland the current levels of infection (between 40 and 60 new cases daily) should be manageable by traditional public health measures. In England (c2,000 new cases daily), an untested new centralised system of contact tracing combined with rather hazardous partial release from lockdown make the prospects of control worrying.
This pandemic has demonstrated the resilience and altruism of our population but displayed a fatal weakness of our governance over years and especially in response to crisis. It has wrecked the economies of most of the richer countries and we can expect a long period of a less comfortable life. I believe this is not entirely attributable to the disease, but rather is a consequence of our style of life and our abuse of the planet that sustains us.
The times we live in now are reminiscent of those when I was a young child, the consequence of an era of self-satisfaction and British exceptionalism, of arrogant and self-interested government, of inability to perceive the looming threats, now climate change, epidemics and social divisions.
As we look towards a continuing battle with COVID-19, an economic recession, and a no-deal Brexit, we need radical reforming governance. From different perspectives, Cromwell first said it to the Long Parliament and Leo Amery repeated it to Chamberlain in 1940. Does anyone have the courage to stand up and say to these people: 'In the name of God, go'? We need better leaders, ones who put the welfare of all the people first and understand how to achieve it.
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.