There follows a guest post by George Santayana, the pseudonym of a senior executive of a pharmaceutical company, who says it all went wrong when the focus of public health changed to be about minimising COVID-19 at all costs.
A few months ago, I heard a discussion on the Today programme about the lifting of ‘Plan B’ restrictions in care homes. What was most notable (and depressing) about this was the casual way the contributors talked about the impact these restrictions had had on the care home residents and how the endless cycle of COVID-19 testing and resulting constant trickle of positive results meant that effectively some homes were in permanent lockdown. Meaning that frail, vulnerable people were effectively locked in their rooms for days, if not weeks, on end, with relatives unable to visit and staff close to breaking point. What was so tragic was the matter-of-fact way in which this was discussed. The ‘we-had-no-choice-ness’ of the conversation and the fact that although it was obvious that this was cruel and inhumane, what else could we do? And to give the contributors their due, they didn’t really have much choice as they had to either follow COVID-19 guidance or shut down.
But it got me thinking, how did we get here? How can it be that the very people we were aiming to protect from COVID-19 became victims to policies that essentially resulted in their incarceration, swapping the risks of a significant respiratory infection for the realities of a miserable, isolated existence? How did we get to the point where we had to destroy living in order to save lives?
I think the answer to this question goes right back to the beginning of the pandemic and the shift in public health policy that occurred in the first few weeks of COVID-19 hitting our shores.
When COVID-19 emerged as a significant new human disease, it was inevitable that lots of people would get ill and that some, unfortunately, would die. Chris Whitty said as much at the beginning. Given these facts, what should have been the public health response? Simply put, it should have been to minimise the impact of COVID-19 on the health and wellbeing of the population. An aim that while recognising the seriousness of COVID-19, doesn’t make it a special case but instead something to be managed within the broader context of overall public health. By considering this broader context and recognising that there are other health needs within the population, attention would focus on achieving the ‘biggest bang for the buck’ and in protecting those most vulnerable. We’d anticipate beefing up of necessary medical support and, for the longer-term, investing in the development of new treatments, including vaccinations. There would be advice and guidance, but government would most likely be promoting a ‘keep calm and carry on’ approach, especially once it became clear that the disease was not significant to a large segment of the population. As we learned more about COVID-19, so our approaches would evolve and become more refined.
Broadly speaking, this sort of thinking is what sits behind proposals like the Great Barrington Declaration and other focused protection initiatives. Ironically, such approaches have been criticised for being ‘discriminatory’ because they would have resulted in vulnerable people shouldering the burden of restrictions. But judging by the discussions about care homes I heard, it’s difficult to see how much more burdensome they could have been. But this is an aside.
The trouble is that strategies which focus on minimising the impacts of COVID-19 are balanced and mean accepting that some people will inevitably die of COVID-19. It is this point that makes them politically extremely challenging. Something I suspect that the newly minted public health experts at No.10 armed with a whiteboard and a few marker pens probably realised fairly soon into the pandemic. And so, whipped on by a generally scientifically illiterate media crying ‘for something to be done’, an opposition poised to jump on any misstep and supported by dubious computer modelling and highly vocal computer modellers predicting corpses piling up in the street, the Government altered the original public health aim from ‘trying to minimise the impact of COVID-19’ to ‘trying to minimise
the impact of COVID-19′. A goal that is politically much easier to state and build policy around.
Although superficially similar (and of course one way of minimising the impact of COVID-19 is to minimise the amount of the disease), these two aims are profoundly different because by making the goal the minimisation of COVID-19 elevates COVID-19 to a unique position amongst diseases and disorders. It places COVID-19 and its reduction/elimination above everything else. In effect we turn a new coronavirus infection into Space Plague; a disease unknown to man against which any measures are justified as long as they might reduce the number of COVID-19 cases and deaths. Almost everything that has happened during the pandemic flows from this apparently simple change in public health focus.
To illustrate the impact of this change in focus you only have to look at lockdowns. Under the broader public health aim, the question would not be whether lockdowns reduce the amount of COVID-19 in the country, but whether they are effective at reducing its impact. Answering this question means seeing whether lockdowns stack up against the twin needs of having a positive balance of benefit and risk and being cost-effective. Taking each in turn.
To understand the balance of benefit and risk of lockdown we’d not only consider how many COVID-19 infections and subsequent deaths might be avoided (the benefit) but its negative impact on non-COVID-19 health and wellbeing (the risk). As is now becoming clearer and clearer, the negative impacts of lockdowns are profound, broad, long-lived, and given that almost every person under lockdown suffers from a loss of quality of life to some extent, probably vastly outweigh any positive benefits. So, from the perspective of an impact on public health and wellbeing, lockdowns clearly fail the benefit/risk test.
Looking now at the cost-effectiveness of lockdowns. From a purely pounds spent point of view the costs of lockdowns are eye-watering – for example, think of the billions spent on keeping healthy people off work. But analysing the cost-effectiveness of lockdown is not just about the money spent on it but recognising that with finite resources (and resources are always finite) spending money on one thing means not spending it on something else, the so-called lost opportunity costs. For lockdowns, the lost opportunity costs are staggering; all the treatments we didn’t do as we tooled up the health service to focus only on COVID-19, all the cancer screening visits missed, all the operations cancelled, all the R&D pounds and dollars redirected to COVID-19 that now won’t be spent on other diseases. The lost careers, the lost businesses and livelihoods, the lost years of schooling, the lost visits to loved ones, the lost opportunities for millions of people both young and old. These are the true costs of lockdowns and goodness only knows what they really are and what their impacts will be in the long-term. So, again, lockdowns spectacularly fail to meet the grade.
When you look at lockdowns in this way, it is hardly surprising that the original pandemic plan dismissed them as an unviable approach and groups like the WHO originally didn’t support their use. From a public health perspective they simply create more issues than they solve. But the trouble is that the modified public health aim of ‘minimise COVID-19’ queers the pitch because COVID-19 cases and deaths count above everything else. So, just like the discussion that I heard on care homes, it isn’t that we’re blind to the side effects or the costs, it’s just that compared to the goal of minimising COVID-19 they are deemed unimportant. Is it any wonder that sceptical voices failed to be heard? The arguments against lockdown aren’t really about how effective it is at ‘limiting the spread’ or reducing deaths due to COVID-19 (probably not very as it turns out) but how much harm and damage it does in meeting this aim. But if we only focus on a singular aim as important, then who cares about the other stuff?
Lockdowns, masks, screening, social distancing, self-isolation, school and business closures, travel restrictions, vaccinations of healthy youngsters etc., etc. – all are valid whatever the cost or collateral damage as long as they might reduce COVID-19. It’s this COVID-19 monomania that also justifies the use of dubious psychological fear tactics to ensure compliance and is why we came to obsess over COVID-19 screening results and deaths in isolation from all other diseases or causes of injury and death. It’s how we ended up with a disease whose only symptom might be two lines on a testing stick, but which then demands that healthy people suffer days of self-imposed, isolated existence.
All medicine is about the balance of benefit and risk. There’s a good reason why ‘first do no harm’ is part of the medical mantra as it recognises that medical intervention has the real potential to make things worse rather than better. Non-pharmaceutical interventions shouldn’t be immune from this kind of thinking – why should they be? Why shouldn’t we look at the mental, physical, and financial misery caused by things like lockdown and weigh these up against the perceived COVID-19 benefits? This isn’t putting money over lives, it’s recognising that non-COVID-19 suffering is as equally important as COVID-19 suffering.
I wouldn’t want to be a politician facing the challenges of COVID-19, as there are no easy decisions. There is no ‘zero deaths’ option that sets the clock back to pre-COVID-19. Regardless of what is done, some people will suffer and no doubt this suffering will be writ large in newspaper pages, social media posts and websites. COVID-19 might be the cause of this suffering, but it doesn’t mean that should be the sole focus of our efforts to reduce its impact.
Finally, I am fearful that the Public Inquiry will also be skewed by assuming the special status of COVID-19 and accepting the false prospectus that the aim of policy should have been to ‘reduce COVID-19’. If this happens, it will inevitably conclude a ‘should have been faster and harder’ outcome. No doubt there will be acknowledgement of the harms caused, and being caused, by our response to COVID-19, but ultimately, rather like that discussion on the harms to vulnerable people in care homes, they will be simply written off as ‘we-had-no-choice’ and an acceptable price for the greater goal of trying to minimise COVID-19.
I still feel all of this hangs over us like the sword of Damocles and it will only take enough bleating in Boris’s ear for us to move back into restrictions and mandates.
But today I’m going to enjoy the sun and maybe head to the pub for a few beers with friends. If lockdown has taught us anything, it is to not take things for granted and enjoy life when and where you can.