The coronavirus pandemic is the United Kingdom’s gravest crisis since the Second World War and we are now facing possibly the most severe economic downturn for 300 years. As we grapple with the consequences, there are lessons to be learned from history. In a recent New Statesman webinar, Laura Spinney, author of Pale Rider: The Spanish Flu of 1918 and How it Changed the World (2017); Dr Phil Whitaker, our medical columnist; and Professor Michael Barrett, an infection biologist at Glasgow University, joined Jason Cowley to discuss the government’s response and much else.
Jason Cowley Laura, in an earlier conversation you used a resonant phrase to describe our response to coronavirus. You said we have a “peculiar memory for pandemics”. What do you mean by that?
Laura Spinney When I wrote my book it was because there seemed to be this huge hole in our collective memory of the 20th century where we just forgot the worst catastrophe in it: the Spanish flu, which killed an estimated 50 to 100 million people in 1918. Little did I know that just three years on we’d be talking about nothing else. If I judge by the questions I’ve had since this pandemic declared itself, I’d say that we do have a very peculiar memory for pandemics, because everybody is immediately reaching for that historical reference, as the closest comparison to what we’re experiencing now, and it probably isn’t the best comparison.
There were two other flu pandemics in the 20th century: the 1957 Asian flu and the 1968 Hong Kong flu. The former didn’t kill more than two million people and the latter not more than four million, depending on who you ask. That is a lot of people, but it’s nowhere near the 1918 Spanish flu. You can see that those more recent pandemics are better references. But people are not talking about them.
JC Why do you think that is?
LS I don’t know, but I think it’s a problem. If we understood how frequent pandemics are then we might be able to plan in a calmer, more rational way, rather than getting to the next one, panicking, and not having put in place the preparations which the likes of the World Health Organisation [WHO] have been telling us to for decades.
JC The WHO has been under pressure – not least from Donald Trump – for being too slow to declare coronavirus a pandemic. It has also been criticised for being too soft on, or allowing itself to be overly influenced by, China.
LS I don’t think that’s particularly fair. The WHO was accused of overreacting to the 2009 Swine flu pandemic, which was a little bit of an anticlimax, and of under-reacting to Ebola at first. It’s always trying to get it right, but of course it hasn’t got a crystal ball. It declared a global health emergency at the end of January, and that step released the maximum powers and resources it had. It waited until 11 March to declare a pandemic. The WHO was trying to steer a fine line between panic and complacency. Then when they saw that governments were not reacting they declared a pandemic to stimulate them to do more.
JC Phil, how has it been for you working as a doctor on the front line interacting with and treating Covid-19 patients?
Phil Whitaker We are in the West Country, one of the least affected areas of the UK, and I’m glad, because as well as being a GP in practice, I also do work out of hours. Just to try to give you a sense of the scale here, usually out of hours, there might be 20, perhaps 30, telephone triage calls on the screen – these are patients we’ve got to call back and advise about their problem. In the early part of April, there would be about 170 calls, most of them related to coronavirus. That’s in a part of the country where we’ve had some of the lowest rates.
The virus has had the most enormous impact on the NHS. In that late March period, we went into a rapid reconfiguration of the health service, separating it into two parts: one, emergency and urgent things only; second, gearing up capacity both in hospital and out in the community to deal with the surges of cases expected. Perhaps at the moment, the creation of the new Nightingale Hospitals look like they haven’t necessarily been needed – that’s good. But certainly at the time they were set up, we thought that kind of capacity would be required. The hospital sector has coped only because it has doubled or trebled its intensive care capacity. In general practice, we have set up dedicated “hot hubs” – surgeries or premises where all suspected coronavirus patients can be assessed away from the rest of the health service – to keep viral transmission down.
JC Mike, you’ve been involved in an ambitious project in Glasgow, working with the team constructing one of the three Lighthouse diagnostic testing laboratories to help the government meet its target of 100,000 tests a day. Can you tell us a bit about what’s been going on?
Michael Barrett It was late March when we were asked to set up a lab to join the national network looking to diagnose NHS workers and then key workers. We had to completely transform laboratories into a sort of factory, taking swab samples from drive-through centres, isolating the virus, taking RNA [ribonucleic acid], putting them through a PCR [polymerase chain reaction], getting a result, and having that result analysed and fed back to the people coming in [to the drive-through testing centre] – all within 24 hours. We’re running through many thousands of tests a day. I’ve found the experience extraordinary. There have been hurdles; there are huge supply chain issues. It’s been a little frustrating watching the media looking at this 100,000 number and questioning it. The reality is that the numbers have gone up. The capacity is reaching a level where it will become routine that 100,000 are going through every day.
JC What do we know about the biology of the disease?
MB Some of the initial modelling and thinking was done based on predictions of how a flu virus pandemic might pan out. The Sars epidemic of 2003-04 also contributed to these models. As the epidemic or pandemic proceeds, you get more information to make the models ever more refined. One of the issues was that looking at the new virus and thinking of the 2003-04 Sars virus, there was an assumption it might be rather similar. But that initial Sars virus was relatively non-transmissible.
JC And Sars had a very high fatality rate, didn’t it?
MB It had a much higher fatality rate in those who got infected, but because it was primarily infecting the lower respiratory tract rather than also the upper respiratory tract, it was much more difficult to transmit. We knew when people had the original Sars virus, because they were pretty sick, and they hadn’t been transmitting it before they were pretty sick and put into isolation. The big problem with Covid-19 is that it replicates in the upper respiratory tract. There are many people who are asymptomatic but can spread the virus. That’s really been largely responsible for the huge and rapid spread.
The people’s PPE: Red Guards in protective masks during the Hong Kong flu epidemic of 1968
JC After news that a novel coronavirus had been discovered, and was spreading rapidly in Hubei province in China with lethal effects, began to be more widely known in January, you warned in a New Statesman article about what in effect has come to pass. You were deeply alarmed when many governments and experts were not. Why were you so alarmed early on?
MB The thing that alarmed me more than anything was that the Chinese were taking it so seriously. They’d been the epicentre of the Sars outbreak in 2003-04, and we now understand that the reason they acted in the way that they did is they had developed policies for any possible rerun of the original Sars epidemic. You could see that this new virus was being transmitted pretty quickly. The whole concept of closing down 11-million-people cities was extraordinary. I was a little bit surprised the rest of the world didn’t catch on more quickly.
JC Laura, what are the lessons today from the Spanish flu pandemic, in which as many as 50 million people died, many in the Global South?
LS In some ways, the 1918 pandemic was one that followed its natural course. There were public health measures in some parts of the world, but they weren’t terribly effective. And, of course, there was no vaccine, there were no antiviral drugs, there were no antibiotics, which would have helped with the bacterial pneumonia that killed most people. It was a very different world. In many ways, we are better off. We have much better disease surveillance; we saw this coming. But we’ve also repeated many of the errors.
You asked me about the WHO, and of it being accused of showing bias towards the Chinese. It may have looked like that to some, but maybe they were just trying to draw lessons from the Chinese. In general, I think, we failed: we saw it coming and we failed. Each nation looked at the last one to be affected and said, “What did they do wrong?” rather than, “What can we learn from them?”
JC Phil, do you think “failure” is the right word to describe the British government’s response to the crisis?
PW Probably. It’s just one word and it’s a complex situation. There were a couple of weeks in early March where we were looking at Italy and thinking we were going to be different. It’s difficult to know exactly, but I wonder whether there was an over-reliance on theoretical models that was somehow blinkering us to what was happening in real time in another western European country with not dissimilar demographics. In the very early phases, we were testing and tracing contacts and isolating people, when numbers were tiny. I think the other failure was to abandon that process of testing and tracing.
JC Do you know why that was abandoned?
PW The lack of testing capacity was a factor. There were two other things. One, this idea that the modelling was based quite strongly on flu, but Covid-19 – and also other coronavirus infections – is very different from flu. Covid-19 has got the capacity to send quite a proportion of affected people into hospital and into intensive care, which is what happened in Italy. The health service was overwhelmed. The modelling didn’t strongly take into account that sort of hospital, critical-care capacity surge. The clinical picture of the virus causing so many people to require hospital care was a missed point that we perhaps should have seen from Wuhan, and certainly from Italy. The other thing is that Wuhan was the epicentre. The Chinese reacted extremely vigorously to control it there.
JC Although initially wasn’t there an attempt to suppress the truth? According to reports, medical whistleblowers were arrested and intimidated.
PW That’s true, but once the Chinese got the measure that they had another big problem on their hands, a bit like Sars, they tackled it very vigorously. But they had an advantage over us, in that they had an epicentre which they could try to close down, whereas we got a lot of seeding. The other failure was not to inhibit travel from affected areas. We didn’t do any kind of border control or quarantining, which allowed multiple areas of seeding.
JC Mike, on Laura’s theme of executive failure, what do you think?
MB The key issue is that people just didn’t take it seriously enough, quickly enough, in government. I think that’s partly to do with the fact that it was a faraway event. It wasn’t something that anybody could really relate to based on our experiences in the UK. Even when it was in northern Italy, I don’t think people understood or realised that this was happening here and now. It was when Italy locked down and Spain locked down and France was locking down, that the UK said, “OK, we need to lock down.” I think there was a failure of understanding how big a problem this was likely to be.
JC I have a question here from one of our online audience: “The number of deaths is high in the United Kingdom, but compared to the Spanish flu and other pandemics these numbers are small, although still every lost life is tragic. Is the crisis really that serious?”
MB That’s a big question. I would say, yes, it is serious. Through April we’ve been seeing a doubling of the death rate in the UK. We appear to have got over the worst of the epidemic now, though we could see a bounce-back. It is serious to get these numbers of people dying, but certainly we’re not experiencing mass death of the population.
LS What happens next depends on us, and if we collectively don’t take it seriously and don’t come out of confinement in a gradual way, we could trigger another surge. I wanted to make another point about failure, having criticised the government. You asked me for lessons from history. One of the really interesting things that comes out of 1918 is that the optimal response in one place wasn’t necessarily the optimal response in another. In 1918, just to give you one example, in many advanced countries the knee-jerk reaction was to close the schools. But there were two places that really interestingly didn’t do that. One was New York City. They wanted to keep the kids visible in a city that was going through a huge wave of immigration. And in Odessa, which was in Russia at the time, which was in the grip of a civil war, they decided to keep the kids in school because it was the one safe place. In defence of our government, the right decision for one country might not be the right decision for another.
JC Do you expect a second wave in Europe as we begin to unlock – especially during the autumn and early winter, when seasonal flu will also be circulating?
LS It really depends on how seriously people take this lockdown. From the scientists I’ve spoken to, even they won’t make predictions because this famous R number [the reproduction rate of Covid-19], which is what lots of these decisions are based on, is just an average. We don’t have a picture of what is happening precisely across the population. It could come roaring back out of some pocket of high prevalence, such as a migrant camp or care homes. We have to understand that the world has changed. The world now contains Covid-19, and we shouldn’t assume a new normal for some time yet. If we do, then we will provoke another wave.
JC Is there overconfidence about the capacity to produce a Covid-19 vaccine in the next 12 to 24 months?
MB Yes, we’re overconfident. We’ve seen technologies that could in principle give us a fast-track vaccine, but that doesn’t mean that they will create the right kind of immune response. That’s why I don’t think we’re going to get there quickly. The end of this year will be the first indication as to whether or not we have got any sort of activity – which in itself is record time for getting any kind of vaccine to that level – but we shouldn’t assume that we’re going to have a protective vaccine any time soon.
JC So, we will just have to learn to live with and adapt to the virus?
MB If the vaccine does work, that will make things a lot easier, but I foresee that we will come out into a world that will be guided by some of the behavioural changes we’re now seeing. We’ll start wearing masks, we will socially distance. Goodness knows what is going to happen to some of those enjoyable aspects of our lives that involve mass gatherings, but I think for many months we shouldn’t engage in those kinds of activities. I suspect we may be looking at a different way of living and working, possibly for years to come.
JC BAME communities seem to be disproportionately affected by Covid-19. How alarmed and worried are doctors?
PW Increasingly. We know that in socioeconomic terms, BAME communities are relatively disadvantaged, and that socioeconomic disadvantage makes people more susceptible to ill health. But if you try to take all of that out of the picture, there does seem to be probably around a two times higher, maybe slightly under, mortality rate among BAME individuals who contract Covid-19 compared to those who are Caucasian. That tells me there’s something genetic going on. What particularly worries me is that colleagues who are from those black and ethnic minority backgrounds have been succumbing at a really worrying rate. We need even more swiftly to take people out of the firing line in virus-heavy clinical areas, because the outcomes for people from a different genetic heritage just look to be much worse.
JC Laura, what happened in the end to the Spanish flu?
LS For most of the 20th century people didn’t have any idea of the scale of that disaster. They thought of it as a footnote to the First World War. Now that we have a much better understanding of it, I think there’s a need to go back and think about some of the things that changed from the 1920s onwards, and see how the pandemic might have contributed to them. For example, the emergence of socialised medicine. It had been talked about before, but you see it being implemented from the 1920s. It’s difficult to argue that the pandemic didn’t contribute to that.
This is an edited transcript of a New Statesman webinar that took place on 7 May; a full video of the discussion can be viewed here
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This article appears in the 13 May 2020 issue of the New Statesman, Land of confusion