‘Running hot’: the Tory priority remains to manage death, not minimise it. But will they get away with the unnecessary loss of life they have caused?
2 May 2020
The debate is now between people who think we should suppress the virus completely and those who think we should run things quite hot, use the spare capacity in the NHS and aim to keep the R number just below one,” one official said. Another senior insider said: “You have to be clear. Running hot means more people are likely to die. That’s the decision the prime minister will have to take.” –Tim Shipman and Caroline Wheeler, The PM’s lockdown dilemma: risk killing the economy or thousands of people?, Sunday Times, 19 April 2020.
In the speculation about the British government’s ‘exit strategy’ (although officials and Tory MPs are not allowed to use the term), too little attention is being given to its fundamental objectives in the Covid-19 crisis and their larger political context. To read much commentary, it is as though Brexit (also no longer to be named) vanished the day the epidemic finally took over UK politics, and Boris Johnson and Dominic Cummings are no longer supremely interested in maintaining their popularity and power.
Clearly the crisis could bring big changes, but it is not clear that it will turn a regime built on privilege and division into an engine for social justice. On the contrary, it seems that Johnson-Cummings could face an uphill battle to fend off a growing sense that the sacrifices have been too great and that the government’s mistaken strategy and general incompetence have played a large role in this situation. This could be even more true to the extent that Johnson chooses to ‘run things hot’, as the hawks are suggesting.
In order to persuade voters to pay the ‘blood price‘ which their policies have already exacted and will continue to require, Johnson’s entirely Brexitised Tories may have little choice but to ramp up their divisive approach. As Anand Menon and Alan Wager have recently argued, the Brexit values divide could be back with a vengeance. But will it be enough to keep Johnson securely in power?
The ‘herd immunity’ phase
It is important to grasp that the government’s notoriously relaxed attitude to the epidemic reflected much more than Johnson’s personal irresponsibility, although that has been breathtaking. After all, he missed no fewer than five consecutive meetings of the government’s emergency COBRA committee; boasted of shaking hands with coronavirus patients; attended a rugby match as late as 8 March; and worked in a wholly un-socially distanced manner to the last. Only when forced to, did he acknowledge the overriding threat which the virus posed.
The main reason for this was however that as the crisis broke, the government was still focused on – indeed fantasising about – its Brexit project, and initially saw Covid-19 as a threat to this. On 2 February, as the horror in Wuhan was becoming clear, Johnson made a flowery speech in which he warned that the response could threaten Brexit, seeing ‘a risk that new diseases such as coronavirus will trigger a panic and a desire for market segregation that go beyond what is medically rational to the point of doing real and unnecessary economic damage‘.
No wonder that the soft-pedalling of the epidemic by the UK’s medical and scientific advisers – who despite clear evidence from China assumed throughout February and early March that Covid-19 could be managed like influenza – was so convenient to Johnson, and their pursuit of ‘herd immunity’ so congenial to the eugenicist Cummings, who was credibly alleged to have talked about ‘herd immunity and let some of the old people die’.
Following from this assumption, it was agreed that a UK epidemic could not be prevented, but should be contained in such a way that maintained the capacity of the National Health Service to cope with serious cases. The principal scientific inputs into UK decision-making appear to have been from epidemiological modellers, primarily interested in the speed with which the virus would spread, and behavioural scientists, who cautioned that controls would prove unacceptable to the public and should therefore be introduced with caution, with too little advice from medical specialists.
Flawed public health messages
In the light of these ’herd immunity’ and ‘pandemic management’ objectives, the public health messages, apart from advice to those with suspected Covid, were also disastrously weak. They initially centred on hand washing, together with a recommendation that the over-70s and those with existing conditions should isolate themselves – so as to ‘cocoon’ them from the epidemic, as a government advisor put it.
It was also frequently emphasised that most cases were ‘mild’ and the impression was therefore given that young and middle-aged adults had little to fear from the disease. This was despite a large amount of evidence from China between late January and mid-February on the frequent, unpredictable severity of the disease, including that half of all fatalities were under the UK government’s arbitrary 70 cut-off for ‘vulnerability’.
The crisis of 12-23 March
Even as the epidemic began to escape the confines of the initial testing and tracing programme in early March, and with the sobering object-lesson of the Italian crisis in full view, the government allowed schools, large-scale public events and public transport to continue as normal. It instituted no checks on travellers from Italy (despite having earlier quarantined all those returning from China) and on 11 March allowed thousands of Atletico Madrid fans – from the region with the largest European epidemic outside Italy, where football was already banned – to travel to Liverpool, while 250,000 racegoers attended the Cheltenham Festival from 10-13 March (the area is now reported as an epidemic hot spot).
On 12 March, the government failed to introduce the general social distancing measures which many expected. Worse, it abandoned community testing and tracing altogether. However many people were adapting their behaviour, sporting organisations cancelled events, and headteachers began to close schools, as public opinion reacted to the growing crisis. On 16 March, the government followed suit, advising the public to avoid unnecessary travel and social events, and a week later finally introduced a lockdown. The 11-day delay is widely regarded as having cost many lives.
After the government finally disavowed ‘herd immunity and introduced a lockdown on 23 March, many still believed this was its objective. In fact, the government appears to have accepted that herd immunity cannot be achieved in the short term – credible estimates of total infection in the population remain well under 10 per cent – but there remain significant continuities in policy. So what are the UK’s objectives?
To understand the government’s aims during (and probably beyond) the lockdown, we need to grasp the reasons for the U-turn in late March. These seem to have been twofold. Reports of the almost-overwhelmed health system in Lombardy, where both general hospital and intensive care facilities were superior to the UK’s, sounded the alarm. Meanwhile epidemiologists warned that the epidemic would overwhelm the NHS.
The Imperial College study published on 15 March, anticipating 250-500,000 deaths without a lockdown, finally concentrated minds. It seemed that the government could not, after all, tolerate mass death on such a scale. Indeed on 17 March the chief scientific advisor, Patrick Vallance, expressed the hope that the toll could be kept to 20,000 (an aspiration which could haunt the government, as it has already been hugely exceeded).
The lockdown brought UK policy closer to that of other European countries, although it was less draconian than most. It also now gained widespread public and cross-party support, which had begun to be threatened. This support was further consolidated after 2 April when it was revealed that Johnson himself was seriously ill and was taken into ICU despite not needing a ventilator. Having ignored the evidence and believed his own propaganda, he was presumably unaware that a fat, 50+ male was vulnerable (Cummings, who is a little younger and not fat, was also quite ill but not hospitalised). Despite his manifest culpability, his acolytes, the sycophantic Tory press and his unofficial propaganda machine (see poster above) have tried to present him as a national hero merely for surviving.
Yet the UK’s hospital death toll continued on a steep upward trajectory because of cases which developed before 23 March, and a month later is barely plateauing. The overall toll, based on excess mortality and therefore including deaths in care homes and at home, as well as those resulting directly and indirectly from Covid but not recorded as such, is currently well over 30,000. It is almost certain that the overall cost of this wave, revealed in the excess of deaths in March, April and May 2020 compared to the same months in earlier years, will be at least around 50,000 lives.
The Johnson government’s aims
This rapidly increasing toll, which may prove to be the highest of any European country, is yet to prove politically damaging to the government. Yet it is clear – if only because for 6 weeks from 12 March they showed no interest in reinstating let alone expanding the community tracing and testing which (together with electronic surveillance) has been crucial to restricting the epidemic South Korea, Germany and other states – that reducing the level of mass death as such has not been their main priority.
Instead, most additional resources for addressing the health emergency have been devoted to the hospital system, whose ICU capacity has been hugely increased, including several new hospitals constructed in exhibition centres and other spaces, while staff resources have been directed towards hospital treatment. The government’s preferred measure of success, therefore, appears to be that the hospital system has ‘coped’ and has not been ‘overwhelmed’, with patients receiving adequate care. It is not an accident that ‘Protect the NHS’ comes before ‘saving lives’ in the government’s key slogans.
The coming dilemma
In late April, it appears that they are claiming success in this effort, as not all the additional capacity created will be utilised in this wave. It is in this context that the following choices for the Government are shaping up:
- How far should they push the limits of the hospital system on a ‘just in time’ basis, allowing the epidemic to continue to the level where most patients who meet their frailty criteria to be treated in ICUs (many of the elderly still being allowed to die in the community), while lifting some social restrictions and allowing more economic activity to recover?
- What priority will they give to a renewed, expanded system of community testing and tracing, which alone could offer a reasonably safe framework for recovery without a vaccine? At the moment, while the Health Secretary is making optimistic announcements, it is reported that the Chief Medical Officer is unconvinced. Given the huge delays in achieving full testing even of health and care workers, is full community testing really on the horizon?
At the moment the best guess may be that the policy, once the peak of the current wave has been seriously flattened, will be a compromise, with some relaxations which cause some increase in cases and deaths, and some testing and tracing which contain them. Wherever the balance is struck, it seems unlikely that the government will wait until a fully comprehensive test-and-trace scheme is available for the whole population – which alone would maximally save lives – before relaxing some restrictions.
These choices could cause a serious crisis inside government. The scientific and medical advisers, having got the first phase badly wrong, may well want to err on the side of caution rather than risk an even worse second peak. On the other hand, Tory MPs are already pressing for relaxations for the sake of small and medium businesses, and some sections of the population (especially in low-infectivity areas?) may be starting to chafe at the restrictions. Johnson will have some difficult choices.
Can Johnson get away with the mass death his government has caused?
However policy for the next phase is resolved, the government will face huge pressure over its squandering of the UK’s early advantages and the unnecessary loss of life which this has caused. Several major factors could make it difficult for Johnson to escape responsibility:
- Although the NHS has been able to increase beds, staffing and equipment (except the supply of ventilators which seems to be a policy disaster) in ICUs, the hospital system has not been adequately protected. It has been unable to provide adequate personal protection equipment (PPE) even to ICU staff, and much less to staff in other hospital areas, primary care, and above all social care.
- The number of NHS doctors, nurses and other staff who have died, and the fact that many of their deaths are perceived to be as a result of inadequate PPE, highlights the cost of this failure and is already throwing a fierce spotlight on the weakness of the government’s planning.
- This approach has barely included the social care system, in which large numbers of elderly residents have been exposed to disease, mostly dying without hospitalisation, in conditions which are far worse for both residents and staff than those which obtain in the ICUs. As far as care homes are concerned, ‘let the old people die’ has indeed come to pass. While many elderly outside care homes may be protected through social distancing, the approach has also left an unknown number of mainly older people to die in their own homes.
- The government’s policy of designating only over-70s as the ‘vulnerable group’ has exposed many middle-aged and some young people to serious illness and death. In some highly publicised cases, call-centre operators or ambulance staff – possibly operating on the official assumption that the illness is milder in the young – have left it too late to hospitalise younger patients. Any relaxation will likely require the Government to revert to this idea of an elderly ‘vulnerable group’, bringing the coherence of their public health message into question.
Lining up the scapegoats
Ministers are already systematically blaming the scientists, and are likely preparing to scapegoat Jeremy Hunt, Philip Hammond & co. for the weak state of the NHS, failure to prepare pandemic capacity, and austerity (Hunt’s remarkably constructive role in the crisis may be partly motivated by an awareness of this danger). There is also a nasty undercurrent of blaming China which may become more prominent.
Once the sense of imminent crisis and national unity wanes, the lockdown honeymoon will be over. Public opinion will likely polarise between those who reject the government’s careless way with life and those who resent the continuing restrictions on life and work. Johnson-Cummings will hope that space for obfuscation will be created by an over-cautious BBC as well as their natural allies. Yet the propaganda machine may need to go into overdrive to browbeat the critics.
In the medium term, at least, it is not certain to work. It is four long years to the next election. Time for people to forget, Johnson will hope. But time also for the idea that Covid-19 was his Iraq to take hold.