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Coronavirus: governing in a time of crisis

JILL RUTTER: Science can inform, but politicians have to decide

Coronavirus

The Covid-19 crisis is putting a burden on government and public services not seen for generations.

Of course, we have had national emergencies before. We have had economic crises: the three-day week and the dash to the IMF in the 1970s, followed by stock market crashes and the need to rescue the banking system in 2008. We have had animal health crises: BSE, which preoccupied policy for a year in the late 1990s, and foot-and-mouth in 2001, which led to funeral pyres of cattle in the countryside. And we have had near misses – not least on swine flu and SARS in the last couple of decades. 

But the UK has not seen an all-embracing crisis like coronavirus since the second world war. The whole of society is affected by it to some extent.

First and foremost it is a nationwide public health crisis, necessitating stringent curbs on normal activity and placing huge demands not just on hospitals, but on all links in the healthcare chain – primary care, residential care homes mostly in the private sector, community services, mortuary and funeral services, testing labs and the whole health supply chain – from PPE to critical medicines and chemicals. This involves not just the UK government but the devolved administrations and local authorities.

It is an economic crisis, with the potential to dwarf the impact of the 2008 global financial crisis, lead to massive job losses and leave a legacy of huge public debt. The government has announced a massive response – but seems to be struggling with delivery. That burden is being borne by the frontline at the Department of Work and Pensions and HMRC, to name just two, but also depends on the banks doing their part.

It is a personal crisis, as people are being forced to live their lives very differently and many are already losing friends, family and colleagues in horrible circumstances. Already-vulnerable communities seem to be bearing a greater brunt of the impact of infection.

And it is on the cusp of becoming an international crisis. It is already exacerbating tensions as nations adopt different approaches and close borders and citizens find themselves stranded in a macabre game of musical chairs. But it also has the potential to take a massive toll in poorer countries at a time when the richer world will be hugely preoccupied.

The government throughout seems to have been playing catch-up. Why was government so unprepared? And has it overestimated what scientific advice can do?

The government had contingency plans – but for the wrong type of disease

Governments know they may have to deal with this sort of crisis. The UK government undertakes a biannual National Risk Assessment (under an exercise conducted by the Cabinet Office) and publishes a National Risk Register. The highest impact/highest likelihood risk in the most recent assessment was “pandemic influenza” – and there were plans including assuring availability of vaccines.

But interestingly, the risk register was much more dismissive of the risks of other new infectious diseases spreading to the UK:

“The likelihood of a new disease like SARS spreading to the UK is low, but if an outbreak of an emerging infectious disease occurred in the UK, and preventative measures were not put in place swiftly, the impact seen could be on the scale of the SARS outbreak in Toronto, Canada. Toronto had 251 cases of SARS in two waves over a period of several months. For every patient with confirmed SARS, 10 potential cases were investigated and 100 followed up.”  

It concluded with an overly sanguine view that what had worked before would work in the future:

“The containment of the SARS outbreaks globally reconfirmed that traditional public health and infection control measures can be successful in containing a new infectious disease,” it said.

Science can inform, but politicians have to decide

That assessment was presumably made by many of the same science advisers that the government is now relying on to help it manage the outbreak. What analysis of the papers released on the advice to government suggests is that those advisers were slow to change their risk rating – and when they did raise it in the light of developments in Italy they did not put the UK on instant red alert.

Ministers’ defence throughout has been that their approach is science-led – and the UK not only has very well respected people as Chief Scientific Adviser (a post established in 1964) and Chief Medical Officer (a post dating from the mid-19th century), but those posts are occupied by a professor of medicine and a leading epidemiologist. They are supported by a network of expert scientific committees to feed advice into government – not just on what is happening and likely to happen, but also on how the government might need to react.

But there are limits to what science advice can do. Scientists can advise governments of the potential course of a disease. But scientists disagree – and non-scientists need to probe and challenge the assumptions. Many people have suggested that more transparency on the underlying modelling would have avoided the risk of “confirmation bias” – of people selecting evidence that accords with their previous opinion and rationalising away inconvenient advice that doesn’t seem to fit. And it is always worth asking “What if?” when there are high levels of uncertainty.

Scientists can also advise on what measures might change the course of the disease. But as we have seen, it is difficult to model the impact. Ministers are reportedly surprised at how people have reacted: the behavioural experts assumed higher levels of non-compliance – but they had no evidence on how people would react to a global pandemic in a mass communication environment. There was no prior experiment to draw on.

But scientists cannot make the trade-offs between extreme prevention and the potential cost to the economy or society, nor on the political acceptability of measures. Those are all decisions that politicians have to make.

Nor, as we have seen, does science rule when it loses public consent. The government was bounced into cancelling mass gatherings, despite the view it took then that they were relatively low-risk, when public opinion – and the sporting governing bodies – acted pre-emptively. Moreover, the public has shown little taste for divergence. Ministers are suffering from having their efforts benchmarked against those of other countries. Only Sweden is managing to stay an outlier. 

Science cannot be the only factor in determining the exit strategy

The big policy decisions have now been made: virtual lockdown, a giant economic support package and a “ramping up” of both testing and NHS capacity. The challenge now is to make good on the promises and manage through the next few weeks as strains show, illness takes its toll and pressures mount on government. The government has to be ready to deal with a crisis that could last not days and weeks but weeks and months (at best).

But one of the hardest decisions for government is how to emerge from the crisis. The risk is that ending some of the measures too soon wastes many of the benefits of action now – but going on too long, beyond when people can see an obvious justification, may lose public consent and multiply the economic cost.

Science can help, and will be the ultimate solution through development of a vaccine or a treatment that renders Covid-19 much less of a threat. Scientists can advise on the risks that different sorts of loosening may make to a flare-up once we are through the “peak” and NHS managers think they have enough capacity. But the final decision will have to be for politicians.

Jill Rutter is a Senior Fellow at the UK in a Changing Europe and a Visiting Professor at the Policy Institute, King’s College London.