CIB chairman Edward Spalton explains why the relentless centralisation of public health responsibilities from the 1970s onwards has undermined our ability to contain infectious diseases like COVID-19. We need to return to a more localised approach to enable effective measures such as contact tracing and quarantine.
“…There’s nothing more lonesome, morbid or drear,
Than to stand in the bar of a pub with no beer…”
Actually, I thought this Australian lament had got it wrong as I walked past the front of my local pub – a welcoming place – but, thanks to the government’s lockdown, as far out of bounds until further notice as if it were on Alpha Centauri. It was only by gracious permission of the government that I was allowed to take my walk past it – once per day and no more! (Unless, of course, I decided to walk somewhere else – but only once per day. That has relaxed a little now, provided I am ‘alert’.)
My wife and I are not great pub-goers but we did enjoy having this welcoming place nearby, providing excellent meals as this official notice in the window reminded me – and at the sort of prices which encouraged quite frequent visits.
The notice also set off another train of thought, concerning the question of public health generally. It was the Environmental Health Officers of South Derbyshire District Council who had inspected the pub and given it their highest rating. Now that all the pubs, hotels and restaurants were closed, they must have had quite a lot of time on their hands and a great deal of unused expertise in epidemiology which ought to have contributed to ending the COVID-19 pandemic. Across the country as a whole, here was a large corps of experienced public health experts who could be deployed quickly and be expanded with recruits from recently retired colleagues – people needed just as urgently as additional nursing staff in hospitals. More so, in fact, because to stop an epidemic it is necessary to trace, track and isolate those infected very quickly before they spread the disease to the wider community.
This was exactly the sort of thing for which local government was established, from around 1854, when it had been discovered that the dreadful disease of cholera was transmitted through the water supply. The ‘Great Stink’ of 1858 brought it home – even to the delicate noses of MPs and high-born Peers – that the Thames had become one great sewer. Throughout the country ‘sanitary districts’ were established to clean things up and to combat infectious diseases with the best available knowledge, but under local control. Whilst the problems were nation-wide, they were experienced locally and could only be dealt with locally. Every district had its own Medical Officer of Health in charge of a team, originally called Public Health Inspectors but now known as Environmental Health Officers.
With infectious diseases, it was quickly established that infected people should be isolated from the healthy population as quickly as possible. Indeed I can remember the seriousness with which this was taken in 1948 when my big sister Sue got scarlet fever. She disappeared. An old curtain soaked in disinfectant was hung across her bedroom door. Any clothes or bedclothes which came out had previously been soaked in a bath of disinfectant before they emerged. The doctor had to be satisfied before my sister could be allowed to reappear. It was what was called a ‘notifiable disease’. Something must have worked because I didn’t catch scarlet fever!
This local system, composed of over three hundred districts by the early Seventies, was supported by more than 40 local Public Health Laboratories. But the local authority Medical Officers of Health were abolished in 1974 and replaced by community physicians, drawn from different levels in the NHS.
Relentless centralisation – way beyond any local control – followed. In Blairite reforms, the Health Protection Agency was established in 2003 and public health laboratories were transferred to NHS hospitals. Responsibility for public health was carved out of the NHS in 2012 by the Conservative Health & Social Care Act which created the quango Public Health England (PHE), supposedly to protect the public from infectious disease. It is reported that PHE staff clocked up 5.1 million air miles in the last three years and so its staff have been very busy at something – academic junkets to far away, exotic places – but it is obviously semi-detached from the well-established, basic procedures of local responsibility in Britain, necessary for control of infectious diseases and known for over a century.
Many things went wrong in the Seventies which built towards the present situation. On top of outsourcing many supreme legislative powers of Parliament to the European Economic Community (a super-quango above all quangos and parliaments), the Heath government reorganised the NHS. Whilst change is inevitable, I cannot forget my aunt, a senior nurse, sitting amidst piles of glossy folders and manuals. ‘I have read everything,’ she said, ‘and I can’t find a mention of the patients anywhere.’ The same sort of thing continued under governments of all colours in many areas of life from then onwards.
Looking for some deeper wisdom, I enquired of a wiser man. Lord Stoddart of Swindon has spent decades campaigning for Britain’s liberation from the EU as a Labour MP and peer; since 2002 he has sat in the Lords as Independent Labour. But prior to entering national politics in 1970, he had a distinguished career in local government. He answered as follows:
‘Local government has been stripped of many powers which have been handed over to unaccountable, expensive quangos. I was a member of Reading County Borough Council for eighteen years and its leader for seven of them. Our powers were extensive since the county boroughs exercised all the powers of counties, boroughs, rural district and parish councils. Leaders of county boroughs were often known as the local “prime minister”!’
‘It was the 1888 Local Government Act which gave real powers to local authorities, but that Act was ruthlessly unravelled under Heath by the 1972 Local Government Act, which destroyed the county boroughs and removed important powers from local government which they had carried out reasonably well over the years. Heath and, later, Thatcher did not understand that the way to make local authorities more efficient was to give them additional powers not fewer…’
If they had been ‘alert’, the airmiles addicts of Public Health England could have learned in advance from those countries which have been far more successful at containing the infection than ourselves – places such as Singapore, South Korea, Japan, Hong Kong, New Zealand and Australia. All moved very quickly to quarantine incoming travellers and to identify and isolate people with the infection or in contact with infected people. Far fewer people died and their economies were in a position to recover more quickly.
Yet Public Health England stopped effective tracing from 12th March. The daily government briefings have obscured rather than clarified this dereliction of normal epidemiological practice. They are exercises in public relations and propaganda rather than anything else. On 11th March, following Nadine Dorries MP testing positive for coronavirus, Health Secretary Matt Hancock informed the House, ‘Public Health England has world-class expertise in contact tracing which it initiated as soon as her case was confirmed.’ He did not tell MPs that they were discontinuing the programme on the following day.
Only now is the government establishing a smartphone app-based system of tracking. This is imposed from the top down. The locally available expertise was spurned in favour of an ‘eye-catching initiative’, staffed by minimum wage operators, given scripts and a day or two’s training at the most – and only now is the government considering placing incoming airport arrivals in quarantine. Meanwhile the Manchester Evening News informs us that the local authorities there still do not know how many of the people tested in their area are infected – because they cannot get the information from the government!
Now it is only fair to mention that English local authorities have been kept short of resources and that the prosperous Eastern countries which I have mentioned so far have well-established administrations and health services. But money is not the only requisite. The Indian state of Kerala has a population about half of the UK’s and its gross domestic product (GDP) per head is only £2,200, compared with £33,100 in the UK. Yet Kerala has done amazingly well under its vigorous Minister of Health, a lady called KK Shailaja.
On January 20th she had read about this dangerous new virus in China and asked one of her medical advisers ‘Will it come to us?’ ‘Definitely, Madam,’ came the reply. So she immediately began preparations and set up a control room on January 24th. By the time the first case arrived on January 27th on a flight from Wuhan, Kerala had already introduced the policy of test, trace, isolate and support. Three passengers found to be feverish were isolated in hospital and the remaining passengers placed in quarantine.
At the height of the crisis 170,000 people were quarantined at the state government’s expense but the rest of the 35 million population could – with care – go about their business. Other precautions were taken, such as restricting public meetings and temple services etc.
After 4 months, Kerala reported only 524 cases of COVID-19 and 4 deaths. The number of cases is since reported to have risen to 690 (19th May) with no further fatalities. Even allowing for some optimistic reporting, it is far below our total, now pushing towards 40,000 deaths in the UK. The statistics from Kerala were so extraordinarily good that I doubted them and cross-checked. This highly circumstantial account by a lady doctor, entering the state and experiencing the quarantine controls, will show the sort of thing which our authorities could and should have done, avoiding many British deaths and permitting the continuance of a working economy.
However we got here, we are where we are and must now hope that the lethal arrogance, incompetence and slovenliness which the government has displayed so far will soon be at an end. Then perhaps my local will be able to open again.