Martin McKee: Beyond “following the science”: value judgements and transparency in pandemic decision-making

The following is an edited version of Martin McKee’s remarks at a UK Pandemic Ethics Accelerator event on 23rd May 2022, discussing the place of values in public policy during a pandemic

Professor Martin McKee is Professor of European Public Health and Medical Director at the London School of Hygiene and Tropical Medicine. He trained in medicine and public health and has written extensively on health and health policy. He is Research Director of the European Observatory on Health Systems and Policies, Past President of the European Public Health Association, President of the British Medical Association and a member of Independent SAGE.

The United Kingdom was in a strong position at the beginning of the pandemic. Looking at the science, there were many achievements – the development of the Oxford Astra Zeneca vaccine; the Recovery Trial; the OpenSAFELY work; and genome sequencing. From that point of view it was very promising. More than that, in the Global Health Security Index published in 2019, the UK was second in the world for pandemic preparedness – only the United States was ahead. Everything that we needed was there, at least in theory. However there was one thing our ranking did not take account of – our leadership. We had a political leader who was largely absent at the beginning of the pandemic and who would subsequently pursue a series of poorly thought-through policies.

Weaknesses in advice

I’ve written extensively elsewhere about the weaknesses in preparedness, reflecting how the machinery of government had spent a decade labouring under austerity, with large cuts to the civil service, while those who remained in post had been taken away from their usual roles in a failed attempt to make sense of Brexit. But once the pandemic hit, there were further problems, not least in the advice on which ministers depended. The main source of advice was the Scientific Advisory Group for Emergencies (SAGE). The membership of SAGE varies depending on the threat. Membership was initially secret, as was the advice that was given. We, and others, were concerned about this. We wanted to know whether Ministers were “following the science”, but we couldn’t, unless we knew what the scientific advice was.

I want to stress that I am not criticising the members of SAGE. My concerns relate to its position in the government advisory structure. However there has been some justified criticism of its composition, including from the joint Parliamentary science and health and social care committees, which said that SAGE was “insufficiently informed by public health expertise” and “lacking situational awareness and input from the ground” and that it did not have “sufficient representation from social care”, or give “enough weight to the impact on the social care sector”, and paid “less attention to practical considerations”

The approach to SAGE reflected a strongly held view that science is one thing, and policy is another, and the two should be kept separate; as Margaret Thatcher famously said, “scientists advise, and politicians decide”. However, we think that there was a bigger problem encapsulated by the quotation from Douglas Jay in 1937: “The gentleman in Whitehall really does know better what is good for people than the people know themselves”.  Our concern was that a lot of people who could have contributed to this discussion and to the evidence were not being listened to.

Independent SAGE

We set up Independent SAGE as a group of scientists who came together to provide independent scientific advice. If the United Kingdom Government had been interested, we would have advised them. We advised the devolved administrations, local government, and other sectors. However, it’s not clear that our advice had any impact in the executive in Westminster, although MPs of all parties took an interest.

We’re a group of virologists, immunologists, behavioural scientists, clinicians, public health professionals, and others. We are committed to engaging with ordinary people, listening to their problems, reviewing the evidence transparently, and presenting it to the public in weekly briefings, and in reports etc. What is crucial, as my colleague said in an email reflecting on our role, is that:

“We’re essentially a trans-disciplinary collective. The checks and balances and complementarity of routine communication and sharing of expertise and advice creates both the confidence and competence to construct and communicate what is no longer a uni-disciplinary contribution, but a trans-disciplinary synthesis.”

We spend time every week discussing these difficult issues.

Unheard voices

We remain concerned that a lot of people were not listened to:

  • Foreigners: Jeremy Farrar, a medical researcher and Director of the Wellcome Trust said: “I wish SAGE had drawn on a wider group of experts with first-hand insights from China and the surrounding region” and the Joint report from Parliamentary science and health and social care committees said that the “unwillingness to consider seriously and act on the approach being taken in Taiwan, Singapore or Korea was a serious error.” I saw this from the other side, in my own work within the European Commission and the World Health Organisation. The challenges of engaging with the UK were profound. In the work we did on the COVID Response Monitor, in the European Observatory, we saw significant mistakes made – like putting France on the Amber + list – which seems to have been a simple mistake from a misreading of a web page that could have been easily corrected by dialogue with French scientists. But the channels of communication that existed previously were no longer working.

  • Lab scientists: Experts working in laboratories were also ignored and this had serious consequences. Alan McNally, professor in microbial evolutionary genomics at Birmingham who helped set up the Lighthouse COVID Lab at Milton Keynes said of the Immensa scandal “In the long list of COVID disasters and scandals, this [the Immensa affair] is pretty near the top […] You shouldn’t be relying on anecdotal reports to spot a problem of this size. That’s the unforgivable thing about this …I don’t think it’s going too far to say that an absolute failure of quality in that lab is going to lead to very serious illnesses, maybe hospitalisations, and maybe worse.” Paul Nurse, Director of the Crick Institute, said that talking to ministers was “like poking a blancmange.”

  • Local public health teams were marginalised in the first wave of the pandemic. We put together a diagram to show the complexity of the relationships involved in managing testing and tracing and yet those in local public health – who had real expertise from contact tracing around sexual infections – were not listened to. When we needed to build a system, the government contracted with outsourcing and accountancy firms with no expertise and failed to establish links to local government, the NHS or other stakeholders.
  • Frontline staff: There are many accounts of how people on the frontline felt that they were being ignored and how the advice they were trying to give was not being heard. We tried to help with this. We wrote a paper at the beginning saying COVID-19 is a complex multi-system disorder, convening people from cardiology, urology, intensive care, and respiratory medicine. We were clear that this was not just another respiratory infection; it was much more than that. But there was very little attention paid. In the end health workers were exhausted. The clapping was nice, but PPE and a bit of respect would have been better. We had the expensive fiasco of the Nightingale Hospitals where people were saying: “It’s fine to build these things, but you need the staff. Where will you get the staff from?”  Several doctors, including Dr Rachel Clarke, have written their accounts of this.
  • Patients were largely ignored despite repeated demands to be included in the discourse. There’s been a virtual denial of the existence of Long COVID and there was a concerted effort by some to minimise the risk of it because it was inconvenient for the narrative around opening up. The Long-COVID SOS support group said: “A shocking lack of attention has been paid to this significant group of people of all ages, and many sufferers feel badly let down.”
  • Essential workers: Essential workers and people in precarious employment, or the gig economy were not listened to. Politicians seemed unaware of the lived reality of the poorest families. Many of the measures that were put in place did not work. The isolation payment only covered one in eight workers, and it was complex to apply for.
  • Care home workers: There were particular issues around care. We published a paper on the claims made that the Government had thrown a protective ring around care homes. A recent court judgment on this shows this did not happen. There has been criticism of SAGE’s lack of attention to this area from Parliamentary committees, and John Edmunds (who was a member of SAGE) has said: “I think sometimes [SAGE] were…removed from daily decisions that other organisations were putting in place… I would have liked – personally speaking – a bit more input on the ground. We knew care homes would be a risk. But I remember distinctly the day we first saw the data. ‘Oh my god, there’s a hundred or so outbreaks in care homes in the last week’. Dreadful. But I don’t think we had such good general situational awareness. That background to it. We were missing that.”
  • Procurement experts: I was the rapporteur for a major European Commission report on public procurement that started before the pandemic. It was very clear that we were not learning the lessons from that experience, and not talking to people who had expertise in procurement. Instead we had the VIP Lane, scandals, and numerous failures.
  • School teachers were also ignored. They saw guidance being sent out on Sunday nights to be implemented Monday morning; there was a failure to provide support for remote learning; and a failure to appreciate airborne nature of virus, long after evidence was clear, and as a result a failure to invest in ventilation and filtration. The Government did not seem to understand the challenges of teaching in person and online, and its impact on workload and burnout. And there was a lack of appreciation of challenges of running a school with high rates of absence of children and staff. This was not helped by disingenuous activities from some UK paediatricians who were in denial about major role of schools in transmission of infection and risks to children. One teacher said: “The DfE goes on television promising all sorts and telling people this is going to happen – but it is left for the schools and the parents to pick up the pieces when it doesn’t.”

Failures in policy making

I contend that this is not surprising given what we know about public policy in the UK. There are some things that have never changed. The classic example with which people will be familiar is the attempt to grow groundnuts in colonial-era Tanganyika – which is worth reading about and in which everything that could have gone wrong, did go wrong. The fundamental point was that nobody asked the local people why they didn’t grow groundnuts. Rehousing people into concrete jungles in the 1960s is another example. A contemporary example is helping Ukrainian migrants. Nobody asked those struggling with online forms about what the problems were; those in charge seemed unaware of the fact that you could put QR codes into posters. It is appalling.

The problem is well explained in the classic book “The blunders of our government”. The authors, Anthony King and Ivor Crewe, said there: “One reason that today’s British Government screw up so often is that ministers are reluctant to engage fully with others and to see them as active participants in the policy making process.”

And so it goes on.