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Follow the ScienceJames Butler
Vol. 42 No. 8 · 16 April 2020

Follow the Science

James Butler writes about the government’s response to the virus

4418 words

The​ British government’s risk register ranks scenarios in a matrix: pandemic influenza sits alone in the topmost box. It has the highest ‘impact severity’, but is judged as likely to occur as severe cold weather, utility system failure and space weather. The register says that between 20,000 and 750,000 fatalities are possible, as well as ‘high levels of absence from work’ and severe consequences for the economy and public services. Ranked a little lower on the risk matrix is an ‘emerging infectious disease’ like Zika, Ebola or MERS – the last of these is a novel coronavirus, like Sars-CoV-2, the pathogen causing our current pandemic. The register forecasts a British outbreak of such a disease causing ‘up to a hundred fatalities’. We are already well past that point, of course, and closer to the flu pandemic trajectory.

The register assures readers that the government engages in serious pandemic planning, and that contingency plans exist for other diseases. In October 2016, a NHS pandemic planning operation, Exercise Cygnus – the name perhaps inspired by avian flu, or the belief that it addressed a ‘black swan’ event – revealed the service’s inability to cope with a pandemic surge, and raised particular concerns about the amount of Personal Protective Equipment available for staff and the supply of ventilators. Sally Davies, then the chief medical officer for England, made one of the few public references to the exercise in a speech that year, highlighting the NHS’s inability to ‘cope with the excess bodies’, and warning of the enormous social and economic impact of a pandemic – even in a putatively ‘well-prepared’ country like Britain. Details of Exercise Cygnus have recently dribbled into the press; they weren’t released at the time for fear of ‘terrifying’ the public. Perhaps a little terror would have been useful: not much was done to build up the NHS’s stock of PPE, or its supply of ventilators. Government sources briefing journalists on the story have suggested that attention instead turned to the problem of securing supply chains for vital goods (a category which clearly did not include PPE or ventilators).

Hindsight is perfect, and ‘hindsight is perfect’ is a perfect excuse. In January, the present chief medical officer, Chris Whitty, told the cabinet ‘it either stays in China or it will get everywhere.’ By the end of January – at the latest – it was clear ‘it’ was not going to stay in China. The point of risk strategies and pandemic preparedness exercises is that the cabinet should have them to hand when crisis hits; the weaknesses in NHS capacity, and its shortage not only of ventilators but of trained nurses to operate them, should have been a factor in their decision-making in those crucial early days. Were they? When, in other words, did they realise the risk they were running?

The answer appears to be: not early enough. The UK’s initial response to Covid-19 seems to have been guided partly by its modelling of how to deal with a flu pandemic (carried out in 2011): this recommended mitigation of the worst healthcare effects, shielding the most vulnerable people from infection, and meanwhile allowing the virus to spread – so that the general population eventually acquired ‘herd immunity’. The plan did not involve mass testing, or technological tracking and contact tracing of the kind seen in South Korea and Singapore.

The published minutes of the meetings of the government’s Scientific Advisory Group for Emergencies (Sage) and its subgroups do not mention ‘herd immunity’, though they do consider some of the likely outcomes of the government’s initial mitigation plan for coronavirus. The minutes for the behavioural experts’ subgroup (SPI-B) on 4 March note that there was some internal disagreement about the likely reception of moves to isolate the most vulnerable, and about whether explaining that other ‘members of the community are building some immunity will make this acceptable’. The public interventions by government figures, however, make it much clearer that a mitigation strategy continued to be followed, even as it made Britain an outlier in Europe. The initial government coronavirus action plan, published on 3 March, describes four phases: containment, delay, research and mitigation. The ‘delay’ section doesn’t say anything about social distancing, talking only of handwashing and of what to do if you sneeze or cough (‘catch it, bin it, kill it’): all of this was aimed at delaying (rather than suppressing) the peak of the epidemic until the summer months. Whitty told the Health Select Committee on 5 March that, according to their current plan, 50 per cent of cases would hit in a single three-week period, though he conceded – perhaps with some understatement – that the pressure on the NHS at this point would be ‘huge’.

The phrase ‘herd immunity’ has come to be seen as characterising the government’s early response. It was used by government experts in media appearances: notoriously by David Halpern, head of the Behavioural Insights Team (aka the ‘Nudge Unit’), in a BBC News interview, but also by Patrick Vallance, the government’s chief scientific adviser. As late as 13 March, he told Radio 4 that one of the ‘key things we need to do [is] build up some kind of herd immunity’. On 15 March, under growing pressure as other European states banned mass gatherings, Grant Shapps, the transport secretary, decried ‘populist’ measures that ‘don’t have the right impact’, contrasting Italian and British policy, and claiming that Britain was the only country ‘following the science’.

Matt Hancock, the health secretary, has subsequently insisted that ‘herd immunity’ was never the long-term strategy, instead presenting the government’s policy shift as part of a seamlessly serious response. Hancock is right, in a narrow sense, to say that the early phase of the government response focused on mitigating the virus’s impact – both on the health service, by trying to delay the peak until summer, and on vulnerable populations by ‘cocooning’ them – with herd immunity only one possible outcome at the end of the crisis. But it is not accurate to suggest – as Vallance did to MPs on 16 March, four days after Boris Johnson first signalled the dramatic change in government policy – that the difference between ‘mitigation’ and ‘suppression’ is one of semantics. The shift had been prompted by Whitty’s presentation to a Sage meeting of new modelling suggesting that the number of possible deaths associated with the mitigation strategy was far higher than previously thought, at around 250,000. The curves on his chart are now famous: the sharp peak if no action was taken, reaching 500,000 deaths; the later, slightly flattened hump reaching half that number under the existing strategy; then the peak flattened by drastic suppression measures. The lockdown policy is a belated, crunching reversal, with different goals – flattening and extending the curve, rather than delaying it – from its predecessor.

There are risks attached to the new policy, and some of them – such as whether it was introduced too late or isn’t comprehensive enough – will only become clear as the Covid-19 lag-time unspools. The political danger, for critics of the government, is that this shift will in time become an excuse: that the failure to acquire sufficient protective equipment for NHS workers and to set in train the purchase or production of new ventilators, becomes merely an unfortunate function of the initial strategy. But even that strategy, drawing as it did on the 2011 pandemic influenza plan and the stress-test of Exercise Cygnus, would have necessitated the use of extra PPE and ventilators during the ‘surge’ period. Major hospitals in London regularly run close to 95 per cent capacity; after a decade of austerity there is little slack in the system. Minor blockages – like the social care problems which delayed discharges over the winter of 2016 – cause significant build-up. Even before austerity, in the wake of the swine flu epidemic a decade ago, it was clear that the NHS risked being overwhelmed in a ‘surge’. Hancock took no action on ventilators before 15 March, when he pleaded for any UK manufacturer with capacity to move to producing them; Johnson, on a call with manufacturers the next day, jokily dubbed this ‘Operation Last Gasp’. Government communications since the crisis began have been confused, and at times opaque. Shortly after the policy shift, and to the horror of many experts, Johnson insisted that Britain could ‘turn the tide’ and beat the virus in 12 weeks. Even after the partial imposition of lockdown on 23 March, many workplaces – from construction sites to the warehouses used by internet shopping sites – remain open. Johnson admitted his reluctance to take further action in one of the last press conferences he chaired before himself contracting Covid-19, underlining his belief that Britain was a ‘land of liberty’, though liberty for whom and from what is less clear – freedom may well seem less tangible in a Sports Direct warehouse.

Tory politicians have been keen to emphasise that their policy has strictly followed the science, rather than being dictated by any other concern; one of the justifications for the extraordinary powers granted by the Coronavirus Act – from the requisitioning of businesses to store bodies to enhanced powers of detention of individuals suspected of being infected – was that they would be used only if they became genuinely medically and scientifically necessary. Both the constructive disagreement intrinsic to science and the adversarial scrutiny necessary to politics disappear in this invocation of science as the ultimate authority – this trick will become familiar in the coming months. An extraordinary emergency requires extraordinary powers; no one disagrees with that. But it is politics, not science, which grants these powers legitimacy. How long will they endure? The law provides a mechanism for six-monthly renewal, though it is unclear how effective a means of restraint or scrutiny that is. Few believe Johnson is an Anglo-Orbán, eager to use the crisis to institute rule through decree; but it would be unwise to trust to his ‘natural’ libertarian disposition.

It’s easy enough to trace the alterations in government policy, even in the policies ministers now suggest never existed. But their rationale – and the decisive factors – will be invisible to the public until any future inquiry demands to see Cobra minutes and ministerial paper trails. The SPI-B documents which consider the desirability of school closures say expressly that the committee was not asked to consider economic impacts; reporting in the Guardian suggested, however, that a projected 3 per cent impact on GDP was influential in the government’s delay in shutting schools. The economic calculus cannot be avoided in government; even its physicians speak of economic impact at the same time as clinical outcomes and capacity shortages, as Sally Davies did when discussing the Cygnus exercise. But the most distinctive aspect of the present crisis is that the predicate of economic activity – human work and interaction – is facing off against public health and medical necessity. Instinctively on the side of big business, and as so often an inadvertent oracle for a usually veiled truth, Donald Trump laid out the problem: ‘If it were up to the doctors they may say, “Let’s keep it shut down” … You know we can’t do that.’ It would mean, he said, ‘the cure being worse than the problem’.

The economic question is important: governments have to balance public health against the needs of the economy. Such trade-offs do not ordinarily become scandals, though they often should. Rarely are the two diametrically opposed in the way they are now, but there is a third factor in the decision-making here: the public’s willingness to accept constraints to their civil liberties. The economist Dani Rodrik once described a similar conundrum as a ‘trilemma’: a case where any two conditions can be met, but never the third. Civil liberties – and public tolerance for severe restrictions on freedom of movement and assembly – have not yet played a significant part in the national conversation, but if the lockdown wears on as long as has been suggested, they will become unavoidable. The most unpleasant argument made so far is that, since the majority of fatalities from Covid-19 are older people, the lockdown is an intolerable encroachment on the liberty of the young. A more serious argument might ask where the limits of acceptable risk lie, or might consider – in a pandemic future – whether mass medical surveillance by the state, from automated temperature readings to contagion tracing by phone tracking, is worth tolerating to prevent public health catastrophes.

Theimplications of the global economic situation have not quite acquired political potency yet, but it’s clear that the chancellor is aware of them. In three packages – effectively one budget and two supplementary budgets – Rishi Sunak has laid waste to a decade of Tory economic orthodoxy and Treasury spending dogma. Encompassing a £5 billion funding boost for the NHS and other public services (likely to be swallowed quickly), grants to small businesses, Treasury-backed loans, VAT deferrals and a plan to pay 80 per cent of furloughed workers’ wages, this is the most significant intervention in the economy ever made by a British government in peacetime. A substantial package guaranteed the same percentage of wage income for most of the self-employed. There is probably more to come. In each announcement, Sunak has repeated the same mantra: ‘whatever it takes’.

His calm and authoritative presentation has won him praise from those alarmed by Johnson’s shambling improvisation. Unlike the measures taken to address the virus itself, his policy choices have immediate impacts: he copied the phrase used by Mario Draghi during the last Eurozone crisis in an attempt to quell the most volatile part of the markets. The response from the other political parties has so far been muted: perhaps for fear of looking like seekers of political advantage in a national emergency, or perhaps through sheer disorientation as the lines of political demarcation are erased and redrawn. Labour’s reflex of equating a larger state with socialism has left it with fewer critical rejoinders than it might otherwise possess. Where the opposition has been sharp, though, is in pointing to those who fall through the Treasury net: zero-hours workers, new hires, renters. The universal effects of a pandemic surely require a universal response.

To respond to such unprecedented government intervention by asserting that it is inadequate may look like ingratitude: it is not. The closer Sunak’s measures are examined, the more deliberately they seem designed to be temporary rather than efficient. Loans will sit as liabilities for companies, even at favourable rates, and VAT deferrals will come due – all this on the other side of an extremely turbulent crisis period and in an unpredictable economic environment. Support for the self-employed will not kick in until June, even though many are facing immediate cashflow crises: outgoings on rent, utilities and food will not pause for three months. Temporary top-ups to Universal Credit, which Sunak has described as a stopgap, aren’t sufficient; notwithstanding the currently enormous digital queue to enter the system, the DWP has indicated it has no intention of changing the five-week waiting time for access to payments. The sharpest differential is in the treatment of mortgage-holders and renters: the former have been offered payment holidays, including on buy-to-let mortgages, but the chancellor has so far brought forward very little support for renters, beyond effectively restoring Local Housing Allowance to where it stood before it was cut in 2012. Instead, the government has advised landlords to offer to defer payments, recouping them in a repayment plan levied on top of rent after the crisis – another debt-based solution. The advice also asks landlords to act with compassion, a policy goal perhaps best indexed under ‘pigs, flying’.

The Treasury’s decision to restrict itself to temporary interventions prevents it from taking bolder steps: accepting equity in a firm, for instance, while providing it with capital to weather the storm, or suspending council tax to reduce household outgoings and instead supporting local authorities from central government funding – both of these would prove difficult to undo after the crisis. It also explains Sunak’s obdurate refusal to boost statutory sick pay beyond the £1.60 inflationary rise already planned for this month. If one of the chancellor’s watchwords for the emergency is ‘temporary’, the other is ‘particular’: he has so far resisted calls for universal payments of any kind, preferring caps and means-tested controls, citing the need for fairness and for prudence with taxpayers’ money. This has increased what he has described as the ‘difficulty’ of designing the interventions. But the vast majority of citizens’ details – address, national insurance number, often bank account – are available to the government: universal payments are not difficult in that sense. But universal benefits are the hardest kind to withdraw, and their use would place the Treasury on a more interventionist path. There are many ways to achieve fairness, if that is truly the main criterion – reform of the tax base to recoup payments from the already wealthy would be one obvious option, though a cardinal sin for a neophyte Tory chancellor. Should the economic shock worsen, however, it will become inevitable.

The measures also reveal something of the chancellor’s fledgling economic strategy: where it is possible, keep the economy moving, where it is not, put it into cryogenic storage and defrost it at some later point. The strategy is also evident in the drafting of the regulations restricting individual movement: though much has been made in press conferences of ‘key’ and ‘frontline’ workers – those whose work is essential to fighting the pandemic – the list enumerating them was only offered as a guide to whose children should continue to attend school. The regulations offer no guidance on the nature or importance of particular types of work: instead they suggest only that people should stay at home unless it is ‘not reasonably possible for that person to work, or to provide those services, from the place where they are living’. The same statutory instrument instructs restaurants, pubs and bars to close, and shutters most non-food shops to the public, though allowing them to operate through mail order. But if work cannot be done from home, the implicit preference is that it – for instance, construction of all kinds – should continue. If the pandemic is not brought under control, no doubt the restrictions will become tougher, but this is one example of economic strategy seeming to pull in the opposite direction to public health, at least in the short term. Cryogenics is an inexact science, and not everything survives the frost; many businesses that do will need longer-term support than is currently imagined as they emerge into a profoundly altered economy, with a newly active state but depressed consumption, and probably saddled with new debts. Waves of lockdowns and relaxations in response to Covid-19 resurgences – one scenario envisioned by the chief medical officer – will see fewer each time come back from the cold.

Part of the chancellor’s problem is that this crisis is not like the one in 2008, though the lessons learned by central banks then have prompted more rapid innovation now, especially in the United States. This crisis did not begin within the financial system, but instead proceeds from the basis of our collective economic life: production is slowed or stopped as workplaces close, and businesses with small margins fear not being able to meet their debts; consumption dips as workers’ income diminishes, and they fear not meeting theirs; urban economic centres, close-packed and fast-paced, serve as vast disease transmission centres. It isn’t so much a liquidity crisis as a solvency crisis on both sides. The pandemic, too, follows economic lines, as historic pandemics followed military ones: consumer and business travel, trade routes. Circulation, as fundamental to the economy as money itself, is the problem.

Achancellor​ cannot control the global economy, or the spread of disease, but he does have at his disposal the single most powerful tool for economic co-ordination and planning: the state. In order to shelter British people from the coming storm, Sunak will need to use it with less reluctance. Some possible consequences of a six-month isolation period – which the deputy chief medical officer thinks might be necessary – could be the death of the high street, the downscaling of office space as flexible working becomes the norm, and the effective collapse of business travel. All these have silver linings – whether ecological or simply work-life balance – but will prompt panic among many. George Osborne likes to claim that Sunak’s spending programmes are only possible because he ‘fixed the roof while the sun was shining’. But the reverse is true: the underpreparedness of the NHS is due in part to the near total moratorium on capital spending over the past decade. The wider state is, if anything, even more fragile. A fifth of UK adults have savings of less than £100; Britain’s economy remains regionally unequal and deeply unbalanced, rentierism is rife, and many firms were weak even before the turbulence of Brexit. At least one thing remains constant: the Economist, unflinching disciple of la pensée unique, has declared that the real post-coronavirus challenge will be how to shrink the state.

War is the metaphor of choice for the national effort against the pandemic: it is a fight, or a battle, and NHS workers are heroes; raising questions about government strategy feels treasonous; Johnson issues exhortations in cod-Churchillian style. Even if this is simply the favoured national cliché, it feels wrong: the virus is unmoved by grit and resolve, and the economic problem is quite the opposite of that faced by a war economy – not how to turn over all production to the effort but how to stop everything and survive. But for Johnson at least, the use of patriotic cliché is the strongest – perhaps the only – continuity with the Brexit and election campaigns. The left, too, has its trusted clichés and catechetics. Vulgar Marxism is a more reliable heuristic than most when analysing British politics, but though it might alert us to the slants, gaps and inconsistencies in the government’s support package, it tells us less about how the crisis might permanently change conservatism or the direction of government. To declare the Tories the party of corporate indulgence, organised landlordism and spivvery tells us little about what they might do in an emergency.

Even so, Johnson’s programme for government will be profoundly altered. The end of the Brexit transition period is barrelling towards us, without a deal achieved or likely to be. Everyone knows an extension will be necessary, but agreeing one will require Johnson to break an election pledge and risk a political hit. That Brexit – or, at least, the need to be seen as staunchly pro-Brexit – is still a priority was shown by the government’s shifting excuses for rejecting an offer to participate in EU purchase orders for ventilators. (Michael Gove maintains that they missed an email.) That will soon look like unforgiveable political vanity. But deeper continuities with the Brexit strategy remain: the treatment of every political issue primarily as a matter of image and narrative, with attendant spinning and deceit as needed. The emerging issue on this front is the UK’s failure to bring in mass testing and the excuses offered for it: first obfuscation over the numbers, then claimed delays in supply chains, then an attempt to blame the chemical industry for fictitious shortages. Behind the testing delay lurks the suspicion that government strategy is still guided by the assumptions around mass transmission which informed its initial strategy.

Much of the government’s programme will be sloughed off as it responds to the crisis, though some of its electoral pledges – like increased funding for the NHS – now look absolutely essential. It will have to deliver on its forty promised hospitals; it will also enter the next year with a debt to GDP ratio of over 100 per cent. Austerity, for an economy on crutches, will not seem plausible; not least after an acute demonstration of its consequences. But the re-emergence of the state after such a long period of abeyance will alter Tory politics as well. Perhaps the pandemic will complete the abortive shift begun under Theresa May towards a conservatism less enamoured of the free market, hostile to foreigners, but with her peculiarly ascetic authoritarianism replaced with Johnsonian splurges on national projects – the Garden Bridge writ large. Such a shift would face hostility from many in the party, though its more eccentric elements, like Robert Halfon, have already praised Johnson for establishing a ‘moderate social democratic state’. Keynesians exist on the right as well as the left.

There are few precedents for the political consequences of pandemic: the last, a century ago, arrived well before it was widely accepted that the state had ultimate responsibility, and culpability, for the health of its citizens – still less the public health policies to deal with it. Optimists on the Tory right hope that Covid-19, like Spanish flu, will pass out of collective memory soon enough and everything will revert to normal. But, as R.H. Tawney once observed, shifts to collective provision are only realised after demonstrations that ‘high individual incomes will not purchase the mass of mankind immunity from cholera, typhus and ignorance’: many elements of the coming future ought to be favourable to the left, though only if they are shaped politically, and if blame – always elusive in the UK’s diffuse system of responsibility – is correctly apportioned.

In a preface to his 1906 play The Doctor’s Dilemma, George Bernard Shaw wrote that ‘the characteristic microbe of a disease might be a symptom instead of a cause’: overcrowded soldiers in dirty barracks might lead to an outbreak of smallpox, or filthy water invite King Cholera. In the absence of these particular conditions, an outbreak might never occur. What is the cause of this pandemic? Human rapacity and intrusion into nature, perhaps, or the squalid conditions in which it first developed, or the addiction to air travel that carried it across the world. In the UK we might indict the public management theory for so long used to pare any spare capacity from the NHS, or successive governments’ lack of preparedness. Shaw’s play turns on the conflict between medicine as business and vocation. The Sars outbreak at the beginning of this century was caused by a pathogen very similar to the one now ripping across the world; a research team in Texas spent years developing a vaccine that became ready for human trials in 2016. But vaccine development is unprofitable, and the state wasn’t interested. They couldn’t find the money.

3 April

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