As I write this, on Sunday 19th April, the number of Covid-19 patients who died in UK hospitals has risen to 16,060. Many more lives have ended in care homes, hospices and at home. Every one of them has grieving family and friends. Then there are countless staff, from the NHS and social care, through to transport and supermarket workers, facing constant risks of exposure to the virus. Still more are experiencing loss of income, going without food on some days just to make ends meet.
Reflecting on how we got here offers no solace now to those suffering, but we must find a collective response capable of bringing this to an end. This requires trust. In this piece I consider the social framing of issues that bring some concerns but not others to the fore, accentuated by fragmented accountabilities and inadequate scrutiny.
Defining risks as public issues
In Images of Organisation, Gareth Morgan describes how, ‘organizations and their members can become enmeshed in cognitive traps’ (page 202), echoing Bourdieu’s observation on how, ’the familiar world tends to be “taken for granted”, perceived as natural’. An example comes from a ‘senior Department of Health insider’, reported by the Sunday Times (paywall): ‘I had watched Wuhan but I assumed we must have not been worried because we did nothing. We just watched’.
This was not just disregard for others. The Prime Minister, Health Secretary, and other Downing Street staff all contracted Covid-19, illustrating that, as The Observer observes, ‘people at the top had not been sufficiently on their guard’. There were undoubtedly distractions, notably those referred to in The Observer’s account, with Boris Johnson reshuffling his cabinet, and his key advisor, Dominic Cummings, ‘waging a war on civil servants in Whitehall’.
But beyond this lie questions about the social construction of risk. The UK’s National Risk Register considers the relative risks of ‘pandemic flu’ and ‘emerging infectious diseases’, explaining in relation to the latter: ‘Over the past 25 years more than 30 new (or newly recognised) emerging infectious diseases have been identified around the world, such as Ebola, Zika and Middle East Respiratory Syndrome. The latter emerged recently in 2012 and poses a global health threat.’
However, for the UK, pandemic flu is identified as having the potential to cause, ‘between 20,000 and 750,000 fatalities and high levels of absence from work’. In contrast, an ‘emerging infectious disease’ might lead to, ‘several thousand people experiencing symptoms, potentially leading to up to 100 fatalities’ (page 34).
A ‘senior Whitehall source’ is quoted in The Observer as saying: ‘Those countries who knew a lot about Sars quickly saw the danger. But in the UK the attitude among politicians and also scientists was that it was really just some form of flu. All the government’s pandemic planning was based on a flu scenario’.
The American sociologist, Harold Wilensky, in his 1967 book, Organizational Intelligence, describes how shared attitudes and understandings between actors in organisations (including regulatory bodies) can contribute to a ‘failure of foresight’ (page 121). Sadly, this remains relevant today. It creates a consensus view that is dismissive of alternative accounts, and too often resistant to scrutiny.
In Monster at the Door: The Global Threat of Avian Flu, Mike Davis refers to the 1918 ‘Spanish Flu’ pandemic, in which around one-third of the world’s population may have been infected, with an estimated 50 million deaths, as ‘modern medicine’s greatest defeat’. Last week, Richard Horton, editor of The Lancet, described, ‘the global response to Sars-Cov-2 as the greatest science policy failure in a generation’.
On 24th January The Lancet published an article by Chinese doctors which drew a comparison between ‘Spanish flu’ and Covid-19: ‘the 1918 influenza pandemic is estimated to have had a case-fatality ratio of less than 5% but had an enormous impact due to widespread transmission, so there is no room for complacency.’ A further Lancet article on 31st January forecasting the current spread of the virus concluded:
‘Large cities overseas with close transport links to China could also become outbreak epicentres, unless substantial public health interventions at both the population and personal levels are implemented immediately. Independent self-sustaining outbreaks in major cities globally could become inevitable because of substantial exportation of presymptomatic cases and in the absence of large-scale public health interventions. Preparedness plans and mitigation interventions should be readied for quick deployment globally.’
On the same day, the World Health Organisation declared a global health emergency. At the time, the UK government scientific advisers reportedly expressed, ‘faith that the country’s plans for a pandemic would prove robust’ (Paywall).
Fragmentation and accountability
In January 2011, the then Secretary of State for Health, Andrew Lansley, introduced the Health & Social Care Bill into the House of Commons. The proposals generated many concerns, with, for example, the Chairman of the British Medical Association arguing, ‘The bill will result in widespread fragmentation of healthcare and work against integration with social care, not to mention the massive cost and destabilisation caused by yet another major reorganisation at a time of huge financial pressures.’ Despite opposition, the Bill received its third reading in the House of Commons in September, completing its committee stage in the House of Lords in December 2011.
At the same time, the World Health Organisation published its, ‘Assessment of health-system crisis preparedness: England’ December 2011. This urged the Department of Health to: ‘ensure, in view of the rapidly changing topography of the health service, the maintenance and strengthening of corporate knowledge and interorganizational collaboration, as well as the maintenance of effective multi-agency command and control arrangements’.
Instead, organisational fragmentation continued. Andrew Lansley’s 181-page engagement diary for the period May 2010 to April 2011 – released by the government in response to a freedom of information request only when directed to by the Court of Appeal in 2017 – includes just two meetings concerned with pandemics, both concerning flu and each of only thirty minutes. Subsequent planning included Exercise Cygnus in 2016, referring to which the then Chief Medical Officer, Sally Davies, told the World Innovation Summit for Health shortly after: “We’ve just had in the UK a three-day exercise on flu on a pandemic that killed a lot of people. It became clear that we could not cope with the excess bodies, for instance. It becomes very worrying about the deaths, and what that will do to society as you start to get all those deaths, [including] the economic impact. If we, as one of the most prepared countries, are going through an exercise and find a lot of things that need improving just on the internal bit, add to it the [lack of] vaccines and then the global traffic and the lack of solidarity … a severe one will stretch everyone.” (Paywall).
Despite this warning, a report, Emergency Preparedness: Resilience and Response, presented to a Board meeting of NHS England on 30th March 2017 informed Board members that: ‘Our preparations for pandemic influenza were exercised in October 2016 with NHS England participating in Exercise Cygnus. The exercise was set seven weeks into a severe pandemic outbreak and challenged the NHS to review its response to an overwhelmed service with reduced staff availability. Plans are currently being revised to incorporate the learning from this exercise and ensure our continued preparedness for future pandemic influenza outbreaks.’
The paper concluded that the Board, ‘receive assurance that NHS England and the NHS in England are prepared to respond to an emergency, and have resilience in relation to the continued provision of safe patient care.’ A video of the Board discussion on this report shows no questioning or scrutiny of these claims (beginning 5 minutes, 45 seconds in).
The Department of Health makes no reference to Exercise Cygnus in its Annual Report, and no assessment has been published. I can find only one mention of it in Hansard, during a debate on the Coronavirus Bill on 30th March 2020, when a Conservative MP described how, ‘our preparedness for a severe pandemic . . . was tested in 2016 through a major three-day exercise called Cygnus . . . It demonstrated a number of things that we do well as a country and a number of things that we need to improve upon, one of which was the drafting of the draft pandemic influenza Bill, which forms the basis of the legislation today.’
Science, society and politics
Government ministers claim they have been ‘following the scientific advice’. But this is not created in a vacuum, nor is it without uncertainty. Reports submitted to the Scientific Advisory Group for Emergencies (SAGE), for example, include several shaped by thinking of the Behavioural Insights Team and ‘nudge theory’, that are not accepted by all behavioural scientists, let alone other social scientists. A YouGov poll on 16th April found only 5% opposed to a further 3-week ‘lockdown’, suggesting that normative constraints on individualist behaviour may be stronger than some imagined. The robustness of mathematical modelling of possible infection outcomes will reflect the assumptions on which they are based.
In 1913, commenting on the need for greater transparency, the American lawyer Louis Brandeis, wrote ‘sunlight is said to be the best disinfectant’. Greater official openness with information is not an end in itself, but looking at how we got here, could make a contribution to finding our collective way through the pandemic. This will become more essential as ‘lockdown’ restrictions continue.
Mike Sheaff is Associate Professor in Sociology at the University of Plymouth. He is author of Privacy, Secrecy & Accountability: Challenges for Social Research (2019) Palgrave Macmillan.
Image: The Experts. Kate Newton, Flickr