Coronavirus: apportioning blame

30/03/2020

Chris Hopson, chief executive of NHS providers, is not happy with the criticism meted out by the Lancet over the handling of the Covid-19 epidemic. In his view, "We need to ignore the siren voices seeking to divert attention from the task at hand. The time for debate about what could have been done better and why is for later, not now".

In this, Hopson has the support of David Nabarro, described as "a special envoy of the WHO director general". He says that this is not the time for blame, arguing that we need to get ahead of the pandemic. In this rapidly evolving situation, he adds, we must think ahead and react fast. It is far too early to judge what has worked and what has not.

That plea, however, is less impressive when one learns that Nabarro has his feet under the table at Imperial College, London, home of the Covid modellers whose dark arts have done so much to shape the government's response to this epidemic.

Yet, as the epidemic reaches 19,522 cases and 1,228 dead, there is by no means a consensus about shelving any criticism for the time being. Former Defra chief scientific advisor, Ian Boyd, observes that, "The middle of a crisis may not be the best time to suggest why we should learn lessons". But, he says, "many people are more likely to listen now. Certainly, nothing should distract us from getting ahead of Covid-19. My concern is that we should come out of this much wiser".

He is not wrong there. Although Michael Gove asserts that, "once this dreadful epidemic is over there will be an opportunity for all of us to look back and to learn appropriate lessons in order to make sure that our public health system is as resilient as possible", there are endless examples of government inquiries, ranging from BSE to Foot & Mouth, turning out to be useless whitewashes.

Certainly, in addition to this blog, there are others who are not holding back their criticism, not least Peter Hitchens. However, rather than tackling the inadequacy of the government's actions, Hitchens is one of those who is calling into question the whole basis of the crisis, joining what might be called the "Hannan tendency" (pictured).

Referring to the response to the epidemic as the "Great Panic", Hitchens seems to rely on the views of Sucharit Bhakdi, a Germany-based medical microbiologist, who dismisses what he calls the "extreme preventive measures" as "grotesque, absurd and very dangerous".

Strangely, this man – while recognising the epidemic in Italy - attributes the high death rate to "exceptional external factors" such as air pollution, compounded by the multi-generational nature of many Italian families. He thus posits that "scenarios like those in Italy or Spain" are not "realistic" in Germany – an exception which Hitchens takes to apply to the UK.

Hitchens is anxious to talk up the credentials, referring to the professor "as one of the most highly cited medical research scientists in Germany", who was "head of the Institute for Medical Microbiology at the Johannes Gutenberg University of Mainz, one of Germany's most distinguished seats of learning".

This is a classic resort to prestige, amounting to an appeal to authority, but one should note that Bhakdi has no record of any work in the field of epidemiology, and it is very much the case that "medical microbiology" is not a qualification in that very different field.

A balanced view might take account of the doubts about Bhakdi's assertions but, armed with his "expert" Hitchens evidently feels equipped to challenge the entire global medical and scientific establishment.

I have a lot of time for Hitchens and recognise his position, having been there with Salmonella and eggs, the non-existent listeria epidemic, and the furore over BSE. When it comes to the projected figures for UK deaths in this epidemic, it is easy to make the case that some of the estimates are overblown.

Even the famous Foot & Mouth modeller, Neil Ferguson, who recently warned that around 510,000 people in Britain would die if no action was taken to control Covid-19, also predicted that up to 150,000 people could die from CJD transmitted from cattle. To date there have been fewer than 200 deaths and vCJD has all but disappeared.

Nevertheless, I am strongly inclined to the view that the Covid-19 epidemic is real, and serious – even if the peak illness and the mortality rates for the UK are as yet unknown.

On the basis of the facts known about this newly emergent disease and its increasing incidence in the UK, no responsible government could have refused to take action, bearing in mind that epidemics are public events and the response is as much political as it is medical.

If there are valid criticisms to be made – and I believe there are – I would put three specific issues at the top of the agenda.

The first is the deterioration of the epidemiological field service in the UK, which has clearly meant that the early stage "test and trace" response was abandoned – almost certainly prematurely. Richard Horton may be voluble about the failure to act over that last few months, but here we are looking at structural issues which go back decades.

Secondly, one must question the lack of preparedness, even though it was known, after an exercise in October 2016, that the capacity to deal with a major epidemic was wholly inadequate.

Thirdly, I would question the reliance of the NHS on its established "surge" programme, expanding capacity in existing hospitals to deal with the illness generated by the epidemic.

In a situation where the service is dealing with a highly infectious viral disease, for which there is no cure and for which there is no vaccine, it seems to me a higher form of madness to bring affected patients into buildings already populated by the sick and vulnerable.

One could argue that the planners have succumbed to a form of arrogance, amounting to hubris, in assuming that they could manage a rampant infection within existing facilities, when our forefathers – without the benefit of modern medicines and techniques – kept infection away from the general hospitals, in fever hospitals, sanitoriums and the like.

Here, one must also express concern that the conversion of the NHS into a National Covid-19 Service, abandoning patients with other conditions, is not the wisest use of resources.

It is a pity, therefore, that Hitchens (and many of like mind) have launched off in what appears to be the wrong direction, when there are serious issues to confront and where, in the fullness of time, blame must be apportioned. The failures should not be treated solely as "learning opportunities" from which those responsible can walk away with promotions and higher salaries.

Richard Horton argues that something has gone badly wrong in the way the UK has handled Covid-19. Somehow, he says, there was a collective failure among politicians and perhaps even government experts to recognise the signals that Chinese and Italian scientists were sending.

We had, he says, the opportunity and the time to learn from the experience of other countries. For reasons that are not entirely clear, the UK missed those signals. We missed those opportunities and, in due time, there must be a reckoning.

But here, I am with Ian Boyd. Unless the issues are identified in the here and now, and kept alive in the public consciousness, when it comes to the ex post facto evaluations, inconvenient facts will be quietly buried and forgotten.

And even if it turns out that the response to Covid-19 has been overblown and we weather this epidemic, like the proverbial No.9 bus, there is always another one behind. We are paying for this epidemic in blood and treasure. As well as sanctioning the guilty, it would be a tragedy if we did not learn the lessons it gives us.