Читать книгу The Challenge of Controlling COVID-19 - Lewis Jane - Страница 7



COVID-​19¹ has proved an altogether more threatening and deadly disease than the new strain of influenza that had been expected at some point and for which plans, if not adequate preparations, had been made. Better understanding of the way in which COVID-​19 behaves has rapidly emerged, but many questions have been difficult to answer: for example, why the virus is so highly transmissible, how far being infected will give immunity, and why some individuals are more vulnerable to infection and death. This makes control difficult. But public health structures and expertise are longstanding in the UK and the control of epidemics has long been recognised to come within the purview of government, requiring a coordinated response between central and local government, and between public health and clinical doctors, healthcare managers and government officials.

The pandemic has laid bare socioeconomic fault lines and exposed major divisions in western societies. In the UK, it became clear early on that older people, those on low incomes and black and minority ethnic communities suffered the highest rates of sickness and death, while young people have suffered major disruption to their education and many of those of working age, especially the self-​employed, face high levels of unemployment and/​or debt.

The interests of different groups as to how the virus should be controlled –​ by strict rules about individual behaviour or a more laissez-​faire approach –​ have often been perceived to be in conflict by commentators and politicians, many of whom also tend to take a strong position on the vexed issue of freedom versus responsibility. Attitudinal surveys of opinion and of personal behaviour show that there are also fault lines in the wider population on this issue.² There are therefore real problems for the state in attempting to control the pandemic. Setting rules and telling people what they must and must not do (for example, get tested for the virus and self-​isolate if they test positive); how they should behave (for example, not visiting elderly relatives in a care home); and how far to enforce such behaviours are not necessarily straightforward for liberal western democracies. It is particularly difficult for the Conservative Party in the UK, which has long been committed to individual freedom and choice and would wish to avoid any charge that it is behaving as a ‘nanny state’.

It is also difficult for governments to make well-​founded decisions in a timely fashion during a fast-​moving pandemic, and this has proved particularly problematic for western countries. Decisions about how to deal with a new virus like COVID-​19 –​ whether to try to suppress it, eliminate it or ignore it as much as possible (which effectively means ‘letting it rip’) –​ have to be made, and much depends on the nature and quality of advice that is sought and offered. Carrying on in ‘as normal’ a way as possible has been justified as the best strategy for keeping the economy open, but the infectiousness of the virus meant that this risked high death rates and healthcare systems being overwhelmed by COVID-​19 patients. Nevertheless, this was the route chosen by the US Federal Government and was also supported by a significant proportion of the US population, who explicitly insisted upon personal freedom and rejected government interference. To a lesser extent it also characterised the Swedish approach, which relied mainly on advising citizens on the best way to avoid contracting the virus and, unlike the US, on people’s longstanding trust in government. Some countries in East and Southeast Asia –​ for example, Taiwan, Vietnam and South Korea –​ as well as New Zealand opted for the very different strategy of strict measures, including testing for COVID-​19, tracing contacts (which in East Asia often used technology in ways that would likely be considered to impinge on the privacy of the individual in European countries) and quarantining, all with the aim of eliminating the virus. Most Western European countries have tried to suppress it, with more or less steady application of these same longstanding public health instruments. Governments have also had to decide how to operationalise their decisions, for example how far to decentralise and how to ensure coordination of their policy responses.³

In the UK, major policy issues have often been presented by many politicians and commentators as dichotomous choices between freedom and responsibility, and whether to prioritise health or the economy, but they are not necessarily so. It became clear in 2020 that countries adopting a rapid and decisive response to controlling the virus also ended up with the least economic disruption. At every turn, controlling the virus was essential to economic functioning, and getting people back to work after the cessations of social and economic activity in the form of ‘lockdowns’ that many European countries had to adopt continued to depend on successful control of the virus.

The COVID-​19 death rate in the UK was the highest in Europe during the first wave. Patrick Vallance, the Chief Scientific Officer (CSO), told MPs on 17 March that limiting deaths to 20,000 would be a ‘good outcome’ (HoC (House of Commons) Health and Social Care Committee, 17 March 2020). By late September, the number of excess deaths⁴ from COVID-​19 reached close to 60,000 in the UK, of which at least 40 per cent were accounted for by deaths in care homes for older people⁵ (Bell et al, 2020). Neither the certification nor measurement of deaths from COVID-​19 is straightforward (Beaney et al, 2020; Spiegelhalter, 30 April 2020; West et al, 2020). Indeed, on 12 August a new UK-​wide standard was announced for recording the official death toll, resulting in 5,377 deaths being cut from the official total, a reduction of 11.5 per cent. Nevertheless, by 23 June the UK had recorded about four times as many deaths as Germany. The Office for National Statistics (ONS) published its first comparative study of excess mortality in European countries at the end of July. It reported that England had experienced the longest continuous period of excess mortality of any of the countries compared between 21 February and 12 June, and the highest levels of excess mortality for the period as a whole (ONS, 2020a). By any measure of mortality –​ deaths registered, deaths per 100,000 population, or excess deaths –​ the UK has not performed well. Yet in 2019, the Global Health Security Index ranked the US first overall in terms of pandemic readiness and the UK second (Cameron et al, 2019).

There have been successes in dealing with COVID-​19 (especially in respect of treatment by the NHS and on the part of biomedical researchers seeking drug treatments and vaccines). The most important immediate successes were the rapid reconfiguration of existing hospitals⁶ and the reorganisation of primary care, alongside the dedication of NHS frontline staff, which elicited displays of gratitude from the public on a weekly basis over two months in the form of handclaps for carers. The response of clinical staff and hospital managers was rapid, and was a professional triumph in the face of extreme and extraordinary pressure (notably in respect of the shortage or absence of personal protective equipment in the early months), grounded in a strong professional culture and the public ethos of the NHS, with its commitment to a universal service available free to all at the point of need. However, the failures regarding control of the pandemic are of a number and seriousness to warrant attention from a policy perspective. Control of the pandemic was a matter for public health provision in the first instance, and while the main fear early on was that the NHS would be overwhelmed –​ which was avoided during the first wave –​ it is widely agreed that the ongoing struggle to control the pandemic has proved to be extremely difficult.

This ‘rapid response’ contribution focuses on the COVID-​19 policies adopted by the UK Government (elected in 2019 with a large majority) in respect of England. The devolved administrations of Northern Ireland, Scotland and Wales have followed the UK Government’s prescriptions in large measure, but there have been significant differences in timing, for example, of lockdowns, and public health messaging in particular. Interestingly, polling for the BBC in Scotland gave the First Minister, Nicola Sturgeon, a net approval rating of plus 61 for her handling of the pandemic, while Prime Minister Boris Johnson was given a net rating of minus 43 (Ipsos Mori, 18 November 2020). Further exploration of the differences in policy approaches between the four countries, as well as between the UK and other European countries, must be left for a later stage in the analysis of the pandemic.

Press commentary and the public debate have tended to focus on the short-​term causes of the major problems that have arisen, particularly the shortcomings of Government ministers. These have been significant, but in a pandemic, governments are reliant both on scientific experts for advice as to how a new virus such as COVID-​19 is behaving and what might be done about it, and on particular groups of people to operationalise its decisions. Public health practitioners have played a strong and important role in controlling epidemics in the past. However, in responding to COVID-​19, the Government relied as much, and often more, on the private sector to tackle crucial dimensions of what have historically been the responsibility of specialists in public health, such as tracing those who might have contracted the virus. In addition, given the vulnerability of older people to COVID-​19, more engagement with specialists in social care might also have been expected.

What follows explores the Government’s approach to controlling COVID-​19, the relationship between ministers, scientists and public health doctors and officials, and also the structural issues that have underpinned two major issues: (i) the difficulties in securing effective testing for the virus, together with tracing and isolating those infected by it, that is, in establishing the major public health instrument necessary for the control of COVID-​19; (ii) the problems of controlling the virus in care homes, which experienced extremely high death rates. Both these problems demonstrate the impact of short-​term government failures resulting from the nature of the approach taken by the Government, whether for reasons of poor advice, poor understanding, or the sheer immensity of the difficulties in operationalising the decisions taken. However, problematic patterns of decision-​making and operational failure repeated themselves during the first wave, underpinned by systemic problems of structure and governance. As Gaskell et al (2020) have pointed out, the degree of centralisation and lack of coordination in the Government’s response to COVID-​19 have been striking (see also Nickson et al, 2020).

The first chapter reviews the approach of the Government in relation to the advice provided by scientists on the steps necessary to control the pandemic in February and March, the period in which COVID-​19 cases surged, resulting in the UK finally ‘locking down’ on 23 March. Chapter 2 examines the position of public health in the healthcare system and then focuses on the setting up and operation of the test, trace and isolate (TTI) programme. Unlike the wearing of face masks, the maintaining of social distance and handwashing, which depend more on the individual (but do also require careful and effective public health messaging), the TTI system is entirely within the Government’s responsibility to organise and is crucial to controlling the pandemic. Chapter 3 focuses on policies towards and the structural problems of residential and nursing homes for elderly people. I argue that the approach of the Government to policymaking has been a very important factor in explaining the problems that have arisen, but that it is also crucial to understand the longstanding structural problems of public health and social care provision in the form of care homes, alongside the continuing preference of the Government to favour private providers and central over local government. Indeed, similarities in the systemic issues affecting the policy responses to these two very different problems are striking. It is also important to remember that the background to these problems was one of austerity over the previous decade, particularly for local government, which has operational responsibility for public health work on the ground as well as responsibility for shaping the social care market.

The aim is not to attribute blame, for example, between Government ministers and scientists (see Cairney, 2020 on this), or to come to conclusions as to what should or could have been done, which would require a much closer interrogation of the scientific evidence available, as well as establishing who knew what about the pandemic when, and to whom the information was passed. Rather, I use primary, documentary sources and historical methods in order to explore the policy decisions on pandemic control that were taken and what characterised the nature of decision-​making. I present a chronological, detailed account and analysis of the establishment of the TTI system and the problems experienced by care homes, from which cross-​cutting themes are identified and discussed. While chronology in and of itself explains nothing, it is a basic underpinning for the analysis of a fast-​moving pandemic. It stretches the concept of contemporary history to attempt analysis of an issue as soon as I do here, but my attempt is closer to this than ‘high journalism’, which necessarily focuses on providing an even more immediate commentary. In short, historical analysis is usually inductive, relying on as extensive an exploration of the documentation as possible in order to arrive at explanatory variables. My analysis is thus not theoretically driven, but provides support for the importance of some of the frameworks that have been used and developed by political scientists in the course of their early inquiries into the policy response to COVID-​19, particularly the degree and nature of centralisation, the effect of fragmentation, and the difficulty of securing coordination (see especially Gaskell et al, 2020; Weible et al, 2020). I focus particularly on the period from early March to 19 June 2020, when the threat level from the virus was lowered from 4 to 3 by the new Joint Biosecurity Centre,⁷ with a somewhat less detailed account of what followed between July and September, when the threat level was once again raised to 4 as the infection rate rose.