Blinded by Corona E-Book

John Ashton

• Herausgeber: Gibson Square
• Kategorie: Ratgeber
• Sprache: Englisch
• Veröffentlichungsjahr: 2020

Seitenzahl: 366

Beschreibung

A gripping view of our fight against corona Professor Ashton has deep practical understanding of the science of public health - a discipline invented in Britain - as a former Director of Public Health. In this jargon-free fly-on-the-wall tale he sets the UK government's measures to deal with COVID-19 from January against two centuries of home-grown knowledge. How do the government's experts and the UK's reliance on web-based solutions such as Test&Trace measure up against the past, for example the 2008 Swine 'Flu epidemic?

Leseprobe

Early Praise

‘Everyone should read this book. Its powerful and penetrating insight holds our leaders to account - and finds them wanting.’

PROFESSOR ROGER KIRBY, PRESIDENT ROYAL SOCIETY OF MEDICINE

‘Once you start reading this book, it is hard to put down. It puts COVID-19 into the wider trajectory of public health within Britain, and is absolutely devastating on the response of the UK government to the COVID-19 crisis. A must-read for all those interested in understanding what went wrong and why.’

PROFESSOR DEVI SRIDHAR, CHAIR OF PUBLIC HEALTH, UNIVERSITY OF EDINBURGH

‘As with the Hillsborough disaster, the fuel crisis, needle exchange and other crises John Ashton is calling this one correctly here. He was speaking out on COVID-19 before any politician was awake.’

PROFESSOR GABRIEL SCALLY, MEMBER OF INDEPENDENT SAGE,

PRESIDENT OF EPIDEMIOLOGY & PUBLIC HEALTH ROYAL SOCIETY OF MEDICINE

‘John Ashton’s views are erudite, uncompromising, and humane. He has judged how this pandemic would unfold better than computer simulations and politicians. The answers are in these pages and governments should listen.’

PROFESSOR KAMRAN ABBASI, EXECUTIVE EDITOR BRITISH MEDICAL JOURNAL

‘This is an important book. John Ashton shows how and why the catastrophic actions of Boris Johnson’s government failed its people and led to many thousands of unnecessary deaths. If we are to avoid similar disasters, read this scorching indictment of those in power.’

KEN LOACH

‘Professor Ashton’s counsel and knowledge has proven him to be an authoritative figure on how the threat of COVID-19 should be responded to. His early calls for mass testing were quickly heeded to in the Kingdom of Bahrain, and established him as one of the world’s leading public health experts on countering COVID-19.’

SALMAN BIN KHALIFA, FINANCE MINISTER BAHRAIN

‘In 1847 the much celebrated and revered Doctor William Henry Duncan was appointed as Liverpool’s first Medical Officer of Health. Like Dr Duncan, and motivated by a passion for the common good, John Ashton sees the world through the lens of public health. From the outset of the Coronavirus pandemic he has offered trenchant and coherent arguments about how the Government and public-health authorities needed to respond. His insightful book provides a valuable compass and road map as we continue to navigate our way through this pandemic. He also offers sound advice on how to be better prepared for fresh waves of Covid and other potential threats to public health. As Dr Duncan might have said—just what the doctor ordered.’

LORD ALTON

‘There will be many analyses of the UK’s response to corona virus, but Professor Ashton has not only been vocal in his view of the UK's response, he has put his theories into practice in leading the response of The Kingdom of Bahrain. At time of writing, Bahrain's response is seen as a global exemplar. Vocalising an opinion is easy; devising and executing a successful pandemic strategy is not. It is for that reason that Professor Ashton's book is so informative and so important.’

FORMER MP Charlotte Leslie, CHAIR OF CMEC

‘John Ashton has been the voice of Cassandra throughout the pandemic. He has earned the right to be the first to tell the whole story, showing that we had both experience and knowledge, but failed to use it. But in the face of the arrogance of centralisation, Ashton gives us hope that local communities and expertise are equipped to bring the 2020 pandemic to its conclusion.’

CRISPIN PAILING

Blinded by Corona

The year 2020 will go down in world history as the ‘Year of the COVID-19 Pandemic’, taking its place in the annals of public health, alongside the Black Death of the fourteenth century, the Great Plague of London of 1665, the so-called ‘Spanish ’flu’ of 1919 and other major epidemics that have swept the world both before and since with enormous loss of life, together with tumultuous economic and political ramifications.

    What is different about COVID is that it had been long anticipated and that despite a century of an ascendant medical science and a rhetoric of preparedness, many countries were caught out. Not least among them was the UK.

    To understand the root causes of this catastrophic failure it is necessary to address seventy years of neglect of the public-health system since the Second World War and to recognise that the very success of scientific medicine over that time brought with it the seeds of this major public-health disaster. It is also important to make the connection between biological phenomena like the pandemic and the way we live on the planet with global economies, rapid urbanisation and their impacts on biological systems and sustainability. We inhabit the earth on sufferance with no inalienable right to survive more than other animal species that have come and gone. The story of COVID-19 is a story of hubris, the hubris of humans as a species, together with the hubris of political and scientific leaders who lacked the humility to ask themselves the difficult questions early enough and to be open and transparent with the public.

    The British government, under the recently elected Prime Minister Boris Johnson, was caught flat-footed and stands accused of doing too little, too late. When it comes to the specific COVID-19 failings of the Johnson cabinet and its scientific advisers in the United Kingdom we might reflect, with Tolstoy, that successful countries are all alike whilst every unsuccessful country is unsuccessful in its own way and that tens of thousands of British people have almost certainly died wantonly.

    It is the dream of scientists to defeat the pathogens and other agents that can wreak havoc in human populations. With each victory the hope is that a definitive blow has been dealt in the fight to ward of illness. In the scientific age the hospital has come to replace the cathedral as the focus of hope for eternal life.

    This dream is especially grandiose when it comes to ever evolving infectious diseases that can be found in the reservoir of other species that we come into contact with as we exploit the natural environment for our own comfort and convenience. After we have managed to control and suppress an epidemic, perhaps with the aid of a vaccine and modern medicines, there is a feeling of congratulation and invincibility.

    Too often scientists and politicians seem to forget that in a world population of 8 billion sharing habitats and environments with multiple other species, from other mammals to the humblest but most versatile of simple life forms such as RNA viruses, respect for nature is a prerequisite for survival. René Dubos, the American microbiologist and author of Mirage of Health, who coined the phrase ‘Think globally, act locally’, reminded us that ‘at some unpredictable time, and in some unforeseeable manner, nature will strike back’.

    The known unknown is that there will be another epidemic, and later another, and another. Just what isn’t known is the why, how, and when before it is too late. There will be no sabre-rattling beforehand and how well a population can mitigate an epidemic will depend on its preparedness, resilience and public mobilisation acting in concert with the evidence and the science. The advantage that nature will always have over mankind is the element of surprise and the arrogance of leaders who think they have all the answers.

    I have spent over forty years in a public-health career encompassing academia as well as hands-on public-health practice at all levels; from the neighbourhood to the global with the World Health Organization, I have dealt with a wide range of major public-health emergencies and knew that one day the world would face a crisis on the scale of the Influenza pandemic of 1918-19. What none of us knew was whether it would be in our lifetime.

    When the first news broke of the unfolding epidemic in China it seemed possible that this might be the big one. It felt necessary to sound the alarm in the interview I gave to Sky News on February 1, outside Arrowe Park Hospital on the Wirral, Merseyside, as the first returnees from Wuhan went into quarantine there, and the first cases were reported in York.

    My comments then were, ‘What we are seeing now are the first couple of cases in York, there are likely to be more. With these situations it’s like the millennial bug when we took a lot of precautions coming up to 2000 to stop computers crashing. When it didn’t happen people said “what a waste of money”. You have to be prepared. You have to put the effort in and if it doesn’t happen — great! People should be concerned in order to take action.’

    My official involvement with the global response was not in the UK but started in the second week of February when I was contacted by the Crown Prince of Bahrain to give advice on the country’s response to the Corona threat. He had watched the Sky News broadcast on February 1 and wished to assure himself that his country was prepared and that the country’s response that was being put in place would be robust.

    Crown Prince Salman, who was also the First Deputy Prime Minister and deputy commander of the Bahrain army, had been alert to the threat of the new virus from mid-January. On February 3 he had set up a Task Force in a dedicated War Room with an extensive multidisciplinary team, led clinically by Lt-Colonel Dr Manaf Al-Quatani.

    Prince Salman asked me to examine the Task Force’s arrangements forensically and to identify any weak points in the chain of defence against the virus and its threat to the people of Bahrain. Over two visits in February and March, and subsequently via Skype calls as Britain was locked down, I became embedded within the Task Force and had the immense satisfaction of being able to make recommendations that were in the most part immediately acted on. The Crown Prince’s team brought home an impressive victory against the pandemic, being praised by the Director General of the World Health Organization for its response. It ranks among the best in the world in creating an effective blueprint.

    Meanwhile I was taken aback to see what was happening in the UK in comparison to Bahrain. No country could have been fully ready for what was coming in January 2020, especially with a novel virus as contagious and potentially lethal as COVID-19. Also, the proud tradition of public health in the UK, but especially in England, had suffered body blows with ten years of austerity and chaotic structural reforms in 2013. The country went into the crisis with a dysfunctional scientific advisory system and an over-centralised public-health agency, Public Health England (PHE). Nevertheless, at the heart of it was a highly skilled public-health and NHS workforce with some outstanding local leadership standing ready to respond as if in the Battle of Stalingrad from street to street, house to house, workplace to workplace.

    What followed was shocking. Unlike what happened in Bahrain, Britain’s NHS and public-health teams were failed by the lack of prompt and effective leadership at the top, political, professional and organisational. There is still zero interest in a coherent plan to fight the pandemic efficiently and effectively. To this day, all we get is an initiative that is good for a column headline: here today, gone tomorrow.

    What the NHS and the Public Health Service needed and need is attentive, competent direction. Instead Boris Johnson—flanked by Dominic Cummings, Dominic Raab and Matt Hancock—was in charge. By so-called ‘Independence Day’ on July 4 an estimated 65,000 people had perished in the UK from COVID-19, about half of them in the nation’s care homes. A majority of these deaths could have been avoided. In addition, much of the harm to the economy, education, medical care for those with illnesses, social care for the aged and vulnerable, and the nation’s health in general, that came from the ensuing lockdown might have been averted. Instead, England suffered unnecessarily on these fronts and others that may yet open up.

    Six months into the pandemic, Johnson’s cabinet had the worst results of all G20 countries, if not the world—apart from Belgium. The country that invented epidemiology was still struggling with what to do about COVID—apart from chancellor Rishi Sunak borrowing up to half a trillion pounds according to Office of National Statistics estimates in order to offer tax breaks, fund businesses’ payrolls and other indirect pandemic monies. It was announced on 17 August that the name Public Health England would disappear to be replaced with a plaque called National Institute for Health Protection. Writing cheques, changing words, and musical chairs for two of London’s civil-servants, however, did not amount to a wrench against the pandemic’s attack on Britain’s health and wealth.

    The future remains uncertain. We know much more than at the beginning of the pandemic. But with a novel virus such as COVID-19 many aspects remain a mystery. Whether it will just fade away as did its near relative and the cause of SARS (Severe, Acute Respiratory Syndrome) in 2003, or return in further waves, either more or less severe, we have yet to find out. In July there was a resurgence of the pandemic looking likely in many countries and the failure to squash it to zero levels of infection in England and Wales. There were dozens of local outbreaks.

    It is to chronicle what we could have done and what we did do, the tragedy of errors, that prompted this book. Specifically, there are the factors that created in Britain the greatest systemic public-health failures of all time at the beginning of the crisis. Separately, there is the absentee leadership once the crisis got going. A reasonably competent leadership would have dealt with legacy issues head on rather than with their head in the clouds. The public inquiry that has been announced will need to examine both these aspects on their own.

    During the COVID pandemic many people have lost and many more will regretfully yet lose loved ones. This book is also written to give them an insight into the question whether the Johnson cabinet rose to the occasion, or let their relatives down with tragic consequences.

1 Plagues in History

The idea of epidemics as ‘plagues’ has a provenance dating back to the book of Exodus in the Old Testament of the Bible. There the term was used generically to apply to catastrophic events, including a population being overwhelmed by frogs, lice, boils and locusts among the ten disasters inflicted on Egypt by the God of Israel to force the Pharaoh into allowing the Israelites to escape from slavery.

    It was not until the sixth century, with the first recorded pandemic of infectious disease, that the term acquired a connotation that is understandable in terms of modern biological knowledge. That Justinian plague from 541-549 AD, caused by the bacterium Yersinia Pestis was carried by rat fleas and spread on board ships throughout the Mediterranean and Near East. With the centre of the epidemic in Constantinople, the disease affected the Roman Emperor, Justinian, who recovered from it, but it killed an estimated fifth of the capital’s population. However, probably the two best known outbreaks of the plague in the western world are the Black Death of the fourteenth century and the Great Plague of London of 1665-66, immortalised in Daniel Defoe’s Journal of the Plague Year published in 1722.

    The Black Death, or Bubonic Plague, also carried by infected fleas, is claimed to have been the most fatal pandemic in human history. Deaths are estimated at between 75-200 million worldwide including over one third of the European population, having arrived in Europe via the trade routes from Asia. The pattern of the clinical infection was unremitting, causing inflamed lymph glands or ‘buboes’ especially in the groin, swollen tongues, spitting headaches, severe vomiting and blackening of the skin, generally leading to an agonising death.

    200 years later, when the Great Plague of London decimated the population, the epidemic spread from overcrowded parish to overcrowded parish in the rapidly growing city, with escalating death rates, especially among the poor. The wealthy fled to their country properties where they could, taking the infection with them to smaller towns and rural areas. The most notorious rural outbreak was in the village of Eyam, in Derbyshire, where 80% of the villagers died having stayed put and self- quarantined to avoid spreading the plague to other settlements.

    In Defoe’s retrospective account there was speculation among Londoners that the causes of the plague went beyond the overcrowding of the slums to more mystical, religious and magical explanations as foretold by the appearance of comets and stars. Other aspects of Defoe’s observations that have resonance with recent experience with COVID-19 include efforts to certify people as free from disease to allow them to travel; measures put in place to achieve social distancing by pedestrians walking down the centre of highways to avoid affected households; the challenges of mass burial, and arguments about the validity of death statistics. Defoe noted that the numbers of ordinary burials in which plague was not mentioned as a cause of death, increased substantially during the period of the epidemic in those parishes most affected, drawing attention in effect to the greater validity of measuring all-cause mortality in assessing its impact.

    However in terms of plague literature it is Albert Camus’ novel The Plague that provides the most enigmatic account. Set in Oran, a coastal town in Algeria, where the writer had lived, the novel explores many themes of an epidemic in a closed community in lockdown which have become familiar during the COVID emergency. These include vacillation over calling the epidemic, conflicts over quarantine and the lockdown itself, the vulnerability of the poor and disadvantaged, the pain of separation, complacency and hubris, the role of religious assembly in disease transmission, censorship of the press and news management, arguments over the science, the handling of mass funerals and rows about calling an end to the epidemic.

    Although it is these well-known and devastating, large scale epidemics that have captured popular imagination, other infectious diseases have periodically demanded concerted action by governments and later by international agencies. Historically outbreaks have often been associated with population movements and mixing relating to trade, colonial exploitation, war, and travel for leisure, especially when travellers have introduced previously unexposed populations to new infectious agents.

    Whilst it is true to say that in most wars disease accounts for more deaths than the actual fighting, it is especially the case that venereal infection is strongly associated with military mobilisation. Syphilis seems to have been brought back to Europe by Columbus’s 1492 expedition to the New World leading to an outbreak in the French army during the battle of Naples of 1495 and was second only to the Spanish ’flu as a cause of sickness absence among American troops in World War I. Such were the levels of venereal infection among British troops returning from the trenches in 1919 that a network of special clinics was established by local authorities to treat the long term complications.

    In 1778 measles was believed to be introduced into the Pacific islands by Captain Cook’s voyages and has been blamed for the crash of Tahiti’s population from 135,000 in 1820 to around 60,000 a hundred years later. However it was the regular pandemics of cholera that emanated from Asia and spread by maritime trade to the burgeoning slums of industrialising Western countries that provided the impetus for the development of the Victorian public-health movement, leaving an international legacy of institutional arrangements, not least in the UK which was in the vanguard.

The Great Influenza of 1919, ‘The Spanish ’flu’

While accounts such as those by Defoe and Camus provide insights into the social, political and cultural impacts of a pandemic caused by a bacterium, it is the so-called Spanish ’flu of 1918-1920 that provides the first chronicled example of a virus wreaking havoc at a global scale. The most likely origin of what has been called ‘The Great Influenza’ was in the rural and poverty stricken county of Haskell, in Texas, in 1918.

    In his comprehensive description of the lead up to the outbreak and subsequent course of the pandemic as it went global, John Barry recounts how a handful of cases of a most virulent strain of influenza were first brought to the attention of Loring Miner, an unusual rural doctor with a taste for the classics.

    A man rather in the tradition of the celebrated Wensleydale general practitioner, Will Pickles, who charted the spread of childhood infections such as measles through his country practice in the Yorkshire Dales in the 1930’s, Miner was a medical scientist before such a breed had barely taken root in the US. In January and early February of 1918, he saw a succession of patients who were brought down with violent headaches and body aches, a high fever and a non-productive cough, killing many of them. Dr Miner, who was ahead of his time in having created his own, small laboratory in the practice, explored the blood, urine and sputum of his patients in a desperate effort to identify the causes of the illness, searched the literature, discussed with colleagues, and reported his experience to the US Public Health Service. The latter, according to Barry, offered him neither assistance nor advice. And then the disease seemingly disappeared.

    The influenza soon reappeared in a large military camp 300 miles away where thousands of young recruits were being mobilised to join the allied forces in Europe for the final phases of World War I. In a bitterly cold winter and in overcrowded, underheated conditions, where they were huddled together for warmth, these and hundreds of thousands of brother squaddies in many similar camps across the country, had been cooped up waiting for mobilisation.

    At the beginning of March, the same clinical picture that Dr Miner had seen in Haskell began to emerge here, and later other camps, and ravaged through the troops. Before long it seems to have travelled with them into the battlefields of France and Belgium and soon impacted on the German troops, if anything with greater ferocity (possibly contributing to their failure to secure victory).

    The virus subsequently returned to the US, as it did to all corners of the world, becoming known as the ‘Spanish ’flu’ only because censorship in the field of war had failed to report its Texan antecedents.

    The tendency to blame other countries for epidemic diseases is a well-established one, not least when they carry a social stigma as in the case of venereal infection, syphilis most notoriously having been known as French pox in England and the English Disease in France. The habit of attributing geographical labels with political connotations to epidemics of viral pneumonia would be something that would arouse great emotion with COVID-19. By the time of the last Spanish ’flu victim in December 1920, the pandemic had accounted for between 50 and 100 million lives worldwide. A distinguishing feature of the pandemic was that its victims tended to be much younger than those normally affected by influenza viruses.

    Barry’s account reminds us that a century ago virology was in its infancy, as indeed was scientific medicine, and that the American medical schools had only recently emerged from domination by quackery and religion with the establishment of Johns Hopkins University in 1876. The Great Influenza provides rich insights into the personalities, characters, competitiveness, strengths and weaknesses, foibles and peccadilloes of many of the giants of American medicine of the times as they struggled to throw light on the nature of the new virus. For much of the time they were thrown off track by the unusual clinical presentation of atypical pneumonia that also affected a range of other organs and systems beside the lungs; something that resonates with the experience of COVID-19, perhaps even now raising questions as to the diagnostic accuracy at that time.

    The virus involved in the 1919 pandemic has long been held to have belonged to the influenza group of viruses and therefore different from the coronavirus, COVID-19, but in many ways, in addition to its multi-organ clinical presentations it bears an uncanny resemblance. Not only did the 1918-19 pandemic creep up silently on an unprepared world but its social, political and economic impact provided a foretaste of what the world is grappling with in 2020.

    Hesitancy and resistance in the face of a growing emergency, a weak public-health system and a political leader, President Woodrow Wilson, preoccupied by his sense of mission towards Europe, albeit a desire to join the war to defeat Germany rather than a battle for Brexit, distracted attention from the enemy virus within the USA that was biding its time, ready to wreak havoc on an unknowing world.

    Wilson’s single-minded focus on the war effort enabled mass gatherings to take place that undoubtedly seeded the initial epidemic around the country, together with a succession of unmonitored marine sea movements of troops and merchant vessels plying between the ports and army camps of the eastern seaboard.

    One day we may know whether among the main SAGE advisers to the UK government there was a public-health historian. It doesn’t seem likely.

2 Straws in the Wind

‘Problems worthy of attack, prove their worth by hitting back.’

Piet Hein, Danish polymath

It is crucial to understand the evolution of human urbanisation in order to understand modern epidemics in general and COVID-19 in particular. The history of patterns of health and disease in human populations is intimately bound up with it.

    The population of England and Wales in 1086 was of the order of 1.25 million, as estimated in the Domesday Book. For the next 600 years there was slow overall growth, interrupted by dramatic decline caused by the Black Death, and by 1695 the population stood at about 5.5 million. Accurate figures are available from the decennial census that has been conducted since 1801 when the population was nearly 9 million. The population doubled in the first half of the nineteenth century and nearly doubled again in the second half to about 35 million. Over one million British military personnel perished during both world wars. After 1901 the population increase slowed with deferment of the birth of first children, dramatic reductions in family size towards one- or two-child families and a significant proportion of women, perhaps as high as 20%, electing to have no children or being childless at the end of the childbearing years.

    What drove the quadrupling? The possible explanations for a change in population size include a positive balance of migration, an increase in the birth-rate or a decline in the death-rate. Historically migration does not appear to have been an important factor until recently, and it is unlikely that the population increase before the middle of the nineteenth century was caused by an increasing birth rate. This was already high and had begun to decline in the latter part of the century; it is more likely that the dramatic increase in population was accounted for by a reduction in death rates, especially among children. Significant immigration of younger workers from Europe and beyond has been the main contributor to increases in the overall population in recent decades.

    The overall effect of demographic trends since the World War II, and especially since the 1970’s, has been a dramatic change in the age distribution of the population with many fewer children and young people together with a much greater proportion of people living well beyond the biblical three score years and ten, into their 80’s, 90’s and beyond. These trends have not been distributed equally with corresponding growing gaps opening up in both life expectancy and healthy life expectancy between the most fortunate and the most disadvantaged.

    During most of the existence of the human race a large proportion of all children probably died in the first few years of life. The sustained reductions in deaths from the eighteenth century onwards have to a large extent been attributable to reduction in the toll from infectious diseases associated with nutritional and environmental factors. Simply put, healthier nutrition and more hygienic environment shrank the national death-rate from infection for infants. The most important of these have been tuberculosis, chest infections, and the water- and food-borne diarrhoeal diseases.

    Paradoxically, it meant that the share of deaths caused by infection grew among the entire population. The predominance of infectious disease as a cause of death probably dates from the rapid urbanisation and creation of urban slums that followed the agricultural and industrial revolutions. In this sense the disturbance of longstanding human habitats with disruption of the relationship between people and their environments, thrown together into overcrowded slums, was critical in creating fertile conditions in which epidemic disease could become established and spread. We see the same in parts of the world that are currently urbanising.

    Particularly the underprivileged benefitted from local public-health management. During the nineteenth century, increased food production stemming from changes in agriculture led to significant nutritional benefits and later reduced family size from the widespread adoption of birth control has been a significant factor in improving the prospects of children from poorer households by increasing their share of available resources including food. From the 1840’s onwards the systematic public-health responses of local public-health teams based in the town hall and supported by central government, substantially designed out many of the environmental conditions that undermined healthy living. This was achieved through close working relationships with town planners producing a wide range of initiatives such as slum improvement and the building of council housing, the provision of safe water and sanitation, paving of streets and refuse collection, the creation of urban parks, and wash houses.

    Today, all of these are all taken for granted and considered preconditions of a robust economy. But it is good to remember at one point or another, they were controversial public-health initiatives that had to overcome government inertia if not staunch resistance of those who thought they knew better or that the status quo was good enough.

    What is remarkable to many is the recognition that, with the exception of vaccination against smallpox, it is unlikely that immunisation or medical treatment had a significant impact on mortality from infectious disease before the twentieth century. In particular, and a most important message when we come to consider COVID-19, most of the reduction in mortality from tuberculosis, bronchitis, pneumonia and influenza, whooping cough and food and water-borne diseases had already occurred before effective immunisation or treatment was available.

    To those who think a COVID-vaccine will be the silver bullet this recognition may give some pause for thought. It is only since the advances in scientific medicine and pharmacology after World War II that the contributions from these two fields of endeavour have been able to take their meaningful place alongside those from environmental, political, economic and social measures. Even so, the operative words are ‘take their meaningful place alongside’, not by any stretch of the imagination ‘replace’.

    Since World War II the remarkable progress in scientific medicine has delivered huge benefits to population health, not least through the development of an extensive range of vaccinations that have all but eliminated many of the childhood infectious diseases that used to kill and maim thousands every year. Measles, mumps, rubella, polio, diphtheria, whooping cough, and some forms of meningitis are among those that were much feared by previous generations of parents and tuberculosis, smallpox, epidemic pneumonia and winter seasonal ’flu have all been significantly reduced in their impact through the application of vaccination in countries with well-developed health systems.

    Nevertheless the shadow of the Spanish Influenza Pandemic of 1918-19 has always hung around in the background. There have been regular reminders of the possibility of a future return by lesser pandemics in 1957 and 1968, both believed to have originated in Asia, which caused respectively one million and as many as four million deaths worldwide. These three outbreaks have been attributed to three different antigenic subtypes of the influenza group A virus: H1N1, H2N2, and H3H2, respectively. In addition an epidemic of H1N1 in 1951, originating in Liverpool, accounted for more weekly deaths in the city than had occurred in 1919 and the most deaths in one week since the cholera epidemic of 1849, only exceeded by those from aerial bombardment during the May blitz of the docklands in 1941.

    What makes the influenza strains so different compared to the more manageable infectious diseases? One of the challenges that ’flu viruses pose to public health is that these simple life forms are constantly evolving and mutating, such that any immunity that has been acquired from exposure to a previous strain may be useless when a novel variant emerges.

    Medical science is just not as nimble as the virus itself. Efforts to anticipate the circulating strains of virus and pre-empt serious outbreaks have come to take the form of influenza vaccines containing the three or four most prevalent strains with the ambition of achieving high population levels of vaccination coverage each year in the winter ’flu season. Despite energetic efforts, coverage levels vary and a significant toll of deaths and complications is a regular feature of the winter period in many countries, affecting usually older, more vulnerable people and those suffering from pre-existing medical conditions. Typically several hundred thousands of people perish globally each year from seasonal influenza, representing a mortality rate of below 0.1% of those affected.

    It is worth, therefore, noting that immediately effective low-cost public-health solutions are available apart from not entirely reliable medical wizardry. Simply wearing face masks when symptomatic, or washing hands frequently, are impressively effective hygienic barriers to curb the spread of such diseases through aerosols or touch. A common refrain against public health is that it is impossible to change habits of a lifetime. But one only has to point at Britain’s sustained campaign regarding smoking habits to see what is possible if one makes a start.

    The belief that the advent of modern medicine together with immunisation and vaccination was leading to the demise of infectious disease was in part behind the post-war rundown of public health in many countries, not least in the UK. The abolition of the local-government post of Medical Officer of Health in 1974 and the move of public health into the National Health Service was followed in 1988 by serious failures of response that led to the deaths of 19 patients from salmonella food poisoning at the Stanley Royd psychogeriatric hospital in Wakefield and of 22 patients from legionella at Stafford hospital resulting from poor links between the NHS and environmental health in local government. Later in the year a major national epidemic of salmonella in poultry eggs became a national scandal that ended the career of junior health minister Edwina Currie and resulted in the slaughter of 4 million hens.

    The importance of this period in time and its relevance to COVID in 2020 is in demonstrating the delicate and potentially explosive relationship between political and technical advice on public health matters and whether the science informs the politics or whether the politics shapes the expression of the science.

    Putting all eggs in a medical-science basket probably seemed smart as a matter of trimming public expenditure. But it was penny-wise pound foolish and no lessons were drawn from these scandals whose national, economic impact belied their local origins. Although some measures were taken by the Chief Medical Officer of the time, Sir Donald Acheson, to strengthen public health, the under-valuing of public health in Britain continued.

    The salmonella and legionella incidents were but a foretaste of what was to come, not least from a series of novel infections and variants on the old theme of Influenza and other viruses. HIV, with a 100% death rate, was followed a few years later by Bovine Spongiform Encephalitis, BSE or Mad Cow Disease, which led to exposure of the population at large. Caused by an unusual pathogenic organism known as a prion and associated with the recycling of animal meat into the foodstuffs of herbivores, it had appeared in 1986, again with a devastating agricultural impact and serious political ramifications. Hong Kong or Avian ’flu occurred in 1997, caused by the H5N1 virus; Severe Acute Respiratory Syndrome, caused by the SARS-CoV virus, a relative of COVID-19, in 2003; Swine ’flu, caused by subtypes of the influenza A virus, including H1N1, H3N2, and H2N3 in 2009; and in 2014, Ebola, a severe viral haemorrhaging fever with high infectivity and very high mortality, caused by the virus EBV, and emerging from the same area of sub-Saharan Africa as the HIV virus which had gone global in the 1980’s with the loss of almost one million people at the most recent count. In 2001 a massive outbreak of foot-and-mouth disease in cattle affected herds across the country. To prevent them entering the human food chain tens of thousands were slaughtered and cremated with devastating impact on farm economies and the mental health of farm workers.

    We will return to more detail below, but if ever there was truth in Piet Hein’s short poem at the beginning of this chapter it was contained in this succession of left-field viral attacks on Britain’s population and the enormous costs they left in their wake.

Britain’s shoe-leather public-health response

At its best, the long tradition of public health in Britain can trace its roots back 200 years to the practical application of ‘shoe leather epidemiology’ in the cholera epidemics of the 1840’s and 50’s. The pioneering work of the country’s first Medical Officer of Health, William Henry Duncan, in Liverpool is a reference point for all public-health students. He tackled the 1849 cholera epidemic in the city together with his colleagues, sanitary engineer Thomas Fresh and borough engineer James Newlands. There is also the much celebrated work of John Snow in London, whose detective work during the 1854 epidemic led to the handle being taken off a street-water pump, ending the outbreak in Broad Street. The late Geoffrey Rose, clinical epidemiologist at the London School of Hygiene and Tropical Medicine, summed up their ethos succinctly. To be effective in public health it is necessary to have ‘a clean mind and dirty hands’. It is a tradition that has been the root of all practise of public health down the generations in Britain.

    Health-emergency planners categorise emergencies into one of three types: the Slow Burn, the Rising Tide, or the Big Bang. That is not to say that there is one characteristic they all share. If the planners are permitted to do their job well, and prevent a lethal catastrophe, there will be a loud chorus of nay-sayers clamouring about the measures that were taken, ‘What was all that about?’ As happened with the Millennium Bug, the absence of mayhem is taken as proof after the fact that there was no emergency. This reaction is practically a given in public health. It is part of human nature and there is no easy answer to it. A false positive—an emergency response to virus that turns out not to have the virulence to cause a global pandemic—will dial down the public-health approach to the next emergency as we will see with Ebola.

    Whilst each major incident is unique in its own way, and has its own ‘battle rhythm’, triage of the emergency can usually be established within a very short space of time after the first occurrence. The combination of epidemiological description together with shoe-leather epidemiology and social science in the form of applied anthropology proved to be crucial in unravelling the mystery of HIV/AIDS, an extraordinarily lethal virus, when it first came to attention around 1980 among gay men in North America.

    In the case of HIV/AIDS the pandemic initially had the characteristics of a ‘Slow Burn’. Through most of the developed world there was initially little interest in a novel disease that seemed to only affect a stigmatised minority of gay men. It was of little interest to mainstream clinicians and researchers, the pharmaceutical industry, politicians, the mass media or the general public. It was only once women and children began to fall ill, along with recipients of infected blood products, straight men and injecting drug users that those responsible for protecting public health woke up.

    Randy Shilts, in 1987 in And the Band Played On, painted a comprehensive picture of the evolution of the pandemic among gays, with tentative links to its origins in sub-Saharan Africa, and of which he was to die as one of its victims in 1994. But it was Peter Piot, who was later to become the Dean of the London school of Hygiene and Tropical Medicine, who filled in many of the gaps in his account of the virus’s spread through Africa and out into the world. A laboratory medic with a fascination for both field work and anthropology, Piot found himself working as a young Belgian doctor in the 1970’s in the Belgian Congo area of Africa, researching the exotic viruses that are responsible for the highly contagious and deadly haemorrhagic fevers.

    If serendipity favours the prepared mind, he was most fortunate to find himself among a group that would throw light not only on HIV but also on the Ebola virus, which was to cause a major global public-health emergency almost 40 years later. In his account of his work in Africa, No Time to Lose, Piot describes the conditions under which it seems that some of these novel viruses emerge in human populations, having jumped species.

    Centuries ago, outbreaks of viruses could take off like wild fire when previously unexposed humans would encounter a new culture, as happened with measles and the Pacific Islanders. The preconditions, however, for this to happen in our time appear to be where rapid urbanisation and sprawling slum settlements bring poverty-stricken and undernourished people into intimate contact with animals that may be harbouring commensal organisms. The animals themselves may be long adapted by evolution to these organisms, but they turn out to be pathogens for humans.

    In the case of HIV and Ebola theories for these unknown viruses jumping species (the so-called zoonoses), include their ingestion in food through ‘jungle meat’ of one kind and another, perhaps monkeys or bats. In the case of HIV, Piot makes the argument that, once the virus had made its appearance in humans, its prevalence was amplified through the re-use of contaminated syringes by nursing nuns in a maternity unit; once it had infected poor women, some of whom were actively working in the sex industry and plying their trade among the truck drivers along the highway south to the mining regions and the miners of Southern Africa, the virus was well on its way to becoming a sexually transmitted disease.

    When HIV arrived in the United Kingdom around 1984 it was in the middle of an epidemic of heroin injection among young people unable to find work. It took a Chief Medical Officer of an exceptional calibre, Sir Donald Acheson, to look beyond the social red-herrings. He prevented the slow-motion public-health car-crash by giving active support to local initiatives organised by individual public-health authorities in Liverpool and elsewhere.

    The Irish-born Sir Donald Acheson was a clinical epidemiologist with an impressive track record of ground-breaking research into cancer of the nasal sinuses in woodworkers and the incrimination of blue asbestos into the crippling and fatal disease of asbestosis. Having established the new medical school in Southampton in 1970 as its inaugural Dean, his appointment as England’s Chief Medical Officer in 1984 presented him with a set of enormous challenges.