28 Oct 2020

In the UK, we have been living with the full impact of the Covid-19 pandemic for nearly seven months now, moving remorselessly through the predicted pandemic stages: first the spike, then the summer lull and now the second wave, to coincide with the arrival of the normal pressures for the NHS in winter. It was also inevitable that politicians in the home countries would seek to assert their independence by developing different health policies, causing public confusion. Equally predictable are the tensions between a national (Conservative) government and local (mainly Labour) city leaders. Having a previous Labour Secretary of State for Health as mayor of Manchester (overseeing the first integrated health and social care system) was always going to lead to confrontation. 

What was not predictable is that I find myself as a public health physician in sympathy with the viewpoint of the Vice-Chair of the Conservative 1922 committee of backbench Tory MPs, Charles Walker.

Let me explain. 

At 6pm on the 20 October I participated in a virtual conversation as part of the King’s College London Alumni Association centenary celebrations. This consisted of a series of conversations on Covid and how King’s was responding to the challenge. In my session, I was invited to explore the ethical challenges of Covid. I was joined by the ARC South London lead for implementation, Dr Natasha Curran, who gave a clinical view and described the new ethics support structure that has been established in south London for GPs. I was to give the public health perspective.  While preparing my talk I was not intending to be controversial, but as I tried to make sense of what is happening to our communities, I became increasingly concerned that we were making a fundamental mistake. I am anxious that history will judge us harshly in that we treated the disease successfully, but the patient died (in this case our society and economy). I came to the conclusion that we are prioritising the wrong patients. 

During his many Covid press conferences, Professor Chris Whitty, the Chief Medical Officer for England, often referred to the fact that Covid-19 can kill in four ways. This is covered in his Gresham College public lecture

First, are the direct causes of deaths from Covid-19, assuming that the health service is functioning optimally – these tend to occur in the elderly and those with existing morbidity. The second cause of death is indirect – should the health service becomes overwhelmed and therefore be unable to treat people with Covid-19, and also potentially other emergencies. The anxiety that this could occur has driven (and continues to drive) current policy. But indirect deaths can also occur because the health service has to cancel routine work to make space for the surge of people who had Covid-19 coming into the NHS. Already estimates of the number of patients likely to die of cancer because of the cancellation of the national screening programmes are being published. 

Third, are likely to be indirect deaths, because people are afraid to come into hospital or do not want to overwhelm the system and stay at home, despite the fact that they have heart attacks, strokes, or other severe causes of mortality. These are also beginning to be estimated.

The final cause of mortality (group 4), is that the very societal interventions that are being put in place to minimise the first three causes of mortality have a huge social and economic impact, which will lead to excessive public morbidity and mortality in years to come. This will particularly impact on the most deprived areas and communities, further increasing inequalities in health. Quantifying the impact at this stage is difficult, but it could be huge.

paper from a group of American bioethicists identifies why governments in most countries have ended up concentrating on the short-term challenges. 

They highlight what they call four cognitive biases. The first is “Identifiable Lives Bias” – it is difficult not to prioritise  “identifiable” patients, hence the focus on Covid-19 patients and initiatives like the Nightingale hospitals (which were hardly used) and a focus on expanding access to ventilators, which in public health terms were never going to have a huge impact. The second is “Optimism Bias” – in disaster circumstances a common human feeling is that something will “come up”,  hence the considerable hope and resource expended on drug research and vaccine development. (Although in the UK, I think we may have taken a more pessimistic view as it is the worst-case scenarios developed by the mathematical modellers that are the ones presented in the press and driving policy). The third is “Present Bias” – most of us prefer a benefit now, rather than having an even bigger benefit in the future. And finally, there is “Omission Bias” – we would rather suffer a harm being the result of us not doing something, than because of something we have done. The authors conclude that all these together resulted in us managing the pandemic framed from a clinical bioethical perspective instead of taking the more appropriate public health approach. My belief is that this means that we should now switch our emphasis to groups three and four, even if doing so means that deaths in groups one and two are higher than they might have been.

My viewpoint and concerns are certainly not novel – similar messages are being heard from a range of differing commentators ­– a strange alliance is being created. When I was listening to the Radio 4 PM programme on the 12 October, Conservative politician Charles Walker was being interviewed by Evan Davies (an economist as well as a brilliant interviewer).  Walker was very worried about the lockdown policy. When most politicians are arguing the details of the tier system and financial support, he was challenging the continuation of the policy itself. He was advocating (probably without knowing it) an ethical approach called “Fair Innings” – a health economic philosophic perspective as advocated by the late Professor Alan Williams, keen supporter of cost-effectiveness maximisation and champion of quality-adjusted life years (QALYs).

Walker started by stating that: “This is an illness that very sadly really afflicts the elderly and those with underlying health conditions… Our focus should be on protecting them, not limiting the life chances of young people and people of middle age who are responsible for running and owning businesses.” ……… the fact is people in their 80s and 90s die, we just can’t save every life, you cannot abolish death.”

He went on to say: “The economic impact of strict lockdown rules risks bankrupting the economy and pushing younger people into unemployment, first-world public services do require a first-world economy.”

As a public health physician, I believe that the biggest determinant of health are socio-economic factors.  Even some members of Sage have concerns about the profound effect current policies are likely to have on children and are concerned that government is not listening to them.  

This view has also been expressed by a group of GPs who were worried about the indirect deaths and wrote an open letter to Matt Hancock advising against a second lockdown.

We should have a public debate about this before it is too late. Recently NHS England London commissioned Imperial and IPSOS to ask the public through a process of deliberation their views on how the NHS in London has responded to the crisis and importantly how it should move forward

We need a similar approach to find out what the public think of the continuation of lockdown policies until a vaccine is widely available.