Trust and the pandemic
Covid-19 presented scientists and politicians with difficult ethical choices. So why weren’t the values that informed pandemic decision-making more transparent?
Trust is a precious commodity and nowhere more so than in a pandemic. Without trust in science it is difficult to persuade people that viruses are real and present threats, rather than – as some conspiracy theorists seem to believe – products of a Matrix-like simulation. And without trust in government and political decision-making, it is difficult to persuade people to accept lockdowns and other restrictions on their liberty.
Given this, you would have thought that the United Kingdom, which, like other Western democracies, entered the pandemic with high levels of trust in science, plus a Prime Minister with high approval ratings after a landslide election victory, would have enjoyed a “good” pandemic.
But despite being rated the second-best prepared country for a pandemic after the United States on the Global Health Security Index, in the event Britain’s performance was disappointing, with the highest population mortality rate from Covid-19 of any country in Europe, and the fifth highest worldwide after Peru, the United States, Chile and Brazil.
No doubt there are many reasons for this, including scientific complacency at the outset of the pandemic and the government’s desire to put the economy before health – an impulse that the UK shared with the US.
But by far the best predictor of the UK’s poor performance was the wide disparities in health that pre-dated the pandemic. As Professor Sir Michael Marmot, director of University College London’s Institute of Health Equity and an advisor to the World Health Organization on the social determinants of health, puts it, long before anyone had heard of Covid-19 health inequalities were killing people “on a grand scale”.
“Who should we not save?”
I spoke to Marmot for a recent episode of my podcast (also called Going Viral) and asked him to explain how these pre-existing health inequalities, coupled with stalling population longevity, helped account for the patterns of morbidity and mortality observed in the UK during Covid-19.
Made with the support of the UK’s Ethics Accelerator, an academic consortium that applies research expertise in ethics to pandemics, the episode is part of a new series of Going Viral looking at the values that underpinned Britain’s pandemic response and the ethical dilemmas that confronted scientists and policy makers.
These ethical challenges included not only issues of health equity and social and racial justice, but how to weigh the protection of health against other rights and values, such as economic security and individual liberty. Perhaps the most fraught ethical issue of all was how to prevent the National Health Service collapsing under the weight of severely ill patients – a issue that was thrown into sharp relief by the question scribbled on a Downing Street whiteboard by Dominic Cummings seven days before Boris Johnson’s tardy decision to lockdown on 23 March 2020 and which read: “Who should we not save?”
According to Anjana Ahuja, a science writer at the Financial Times who features in the first episode, “Who do we trust in a pandemic?”, and the fourth episode, “How Many Deaths is Too Many?”, that question was an acknowledgment that the NHS did not have the capacity to treat everyone who might contract Covid and that some individuals with severe disease might be denied access to ventilators and intensive care.
But although the government convened a panel of faith leaders and expert ethicists to come up with transparent guidelines for triaging patients, in the event the guidelines were never published. [1] Instead, we were told that a certain level of deaths was inevitable and that, as Boris Johnson put it, “many more families are going to lose their loved ones before their time”.
For Ahuja, the government’s failure to be more open with the public about its reasoning was one of the most “distressing” aspects of the pandemic.
"It means that the decisions that are being made are staying in the shadows,” she told Going Viral. “And you almost wonder if that's a deliberate thing, because we do know that Covid disproportionately affects those on low incomes, ethnic minority communities and those on frontline, often poorly paid jobs.”
We may begin to get an answer to these questions when the independent public inquiry into Covid-19 resumes in March – phase II of the inquiry will look into the UK’s preparedness for a pandemic and “decision-making” in the run-up to the first lockdown. But, presumably, the reason a certain level of deaths was thought to be inevitable was because, at the time, scientists who advised ministers were pursuing a “herd immunity” strategy using faulty modelling based on influenza.
The result was that rather than following the lead of countries like Taiwan and Singapore and testing people at the borders, the government allowed the virus to spread unimpeded though the population. Within weeks, however, it realised this strategy risked crashing the NHS, and with one disease model predicting that as many as 500,000 Britons could die, the policy was quickly reversed, leading to lockdown.
Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, reminded listeners that at the beginning of the pandemic, Sir Patrick Vallance, the UK’s Chief Scientific Advisor, had suggested that if deaths from Covid could be kept to 20,000 it would be “a good result”. But would Vallance have made that statement if the primary victims had been young children rather than the elderly, wondered McKee? And how do we decide what level of deaths are “acceptable" and what are “excessive” in the first place?
A “blight and a revelation”.
According to Marmot, the UK’s death toll from Covid can be traced to the political and ethical choices made since 2010 by Coalition and Conservative governments in the name of “austerity”– choices that pre-dated the pandemic and which, in his view, go to the heart of questions of good governance and trust in political decison-making.
What makes Marmot such a compelling and authoritative witness is that he has been warning about the consequences of ignoring health inequalities – and the inequities they breed - for decades. For example, in his 2015 book, The Health Gap: the challenge of an unequal world, he warned that such disparities risked undermining social cohesion and the ability of health systems to respond effectively to pandemics and other health emergencies.
In February 2020, on the eve of the Covid pandemic, he issued a follow up report to his 2010 Marmot Review – The Marmot Review 10 Years On. The report made shocking reading, showing how since 2010 decades-long improvements in life expectancy in the UK had stalled, with the result that Britain had the lowest improvements in longevity of any OECD country apart from Iceland and the US. However, this trend masked the fact that the largest decreases in life expectancy occurred in the most deprived neighbourhoods of northeast England, while the largest increases were in the least deprived areas of England.
In December 2020, Marmot issued a further review, Build Back Fairer, in which he showed that on several key health indicators the UK’s performance during the first year of the pandemic had been markedly worse than that of comparable European countries, such as Spain and Italy. Far from Covid being a “great leveller”, as some experts had confidently predicted at the outset of the pandemic, the mortality rate in the ten percent most deprived areas of the UK was double that of the 10 percent least deprived areas. The disparities were even sharper in the case of Blacks and ethnic minorities, who were two to three times as likely to die of Covid as whites.
In this way, Marmot suggested, paraphrasing Camus, Covid was both a “blight and a revelation”, exposing the rotten underbelly of society. [2]
“We need a country that has less inequality in all the things that matter, and that'll show up in less inequality in health,” Marmot told me.
“Freedom to be foolish”
Other panellists lamented how libertarians had weaponised arguments around individual liberty to set up a false dichotomy between health and economic security. The impact of lockdown on the economy may have been a valid concern during the initial phase of Covid when we lacked good data, but by 2022 it was clear that countries, such as Germany and Greece, which had locked down harder and longer than the UK also enjoyed stronger economic growth afterwards because they emerged from the pandemic with healthier populations.
“There is copious evidence that healthier populations contribute to economic growth,” said McGee. “They are more productive, measured by earnings per hour, and they participate in the labour force.”
The fault lay with Conservative politicians, he suggested, who had promoted individual liberty, or what he characterised as the “freedom to be foolish”, at the expense of the right to life. Marmot agreed:
“The concept of freedom has been hijacked by the Right. If you're growing up in poverty, in substandard housing, and particularly with the current cost of living crisis where you've got scarcely enough food to eat, what kind of freedom is that?”
According to Halima Begum, chief executive of the Runnymede Trust, the UK's leading race equality thinktank, addressing these disparities will entail more than “levelling up”. It will also require the government to acknowledge the role of racism in exacerbating health inequities and social injustice – something which, until now, it has been conspicuously reluctant to do (see, for example, last year’s report by Tony Sewell for the Commission on Race and Ethnic Disparities which concluded that the UK was not institutionally racist).
“If Covid revealed one thing it’s that race and class intersect together to make communities more vulnerable,” suggested Begum in the second episode of the series, “All in it together”.
These issues go to the heart of whether people can continue to have confidence in the government going forward. With the NHS facing the biggest crisis in its history, and Boris Johnson imminent appearance at the House of Commons’ privileges committee where he will be grilled on rule-breaking during Partygate, these issues remain as pertinent as ever.
But perhaps the last word should go to Dominic Wilkinson, the director of medical ethics at the Oxford Uehiro Centre for Practical Ethics. According to Wilkson, this isn’t the last time we will face the question ‘How many deaths are too many?’’, and whatever answer we give now won't necessarily be the right answer the next time.
“First, we have to recognise that this is an ethical question, not a scientific question, and it involves reflection on things that are deeply important and deeply contested.
“Freedom is a fundamental value and some people hold it incredibly important, potentially even at the cost of their own well-being.
“But we also ought to be asking really serious questions about the structure of our society and inequality, because a more unequal society will have a more unequal response to an acute threat, whether that's a bad winter flu or a pandemic.”
[1] You can see the unpublished triage documents and read more about the background to these discussions in my earlier two-part Substack post on Triage and the Virus.
[2] The quote is from the preface to La Peste: “The pestilence is at once blight and revelation.. it brings the hidden truth of a corrupt world to the surface.”