29 May 2020

Never in the history of UK health policy have politicians been so keen to be seen to be basing their decisions on the best research evidence. Or as the First Secretary of State Dominic Raab put it on 7 May at the daily Number 10 Covid press conference, We’ve always been guided by the science.”

Indeed, “Informed by the science” is the first of the five guiding principles laid out in the Government’s “Our plan to rebuild; The UK Government’s COVID-19 recovery strategy” (section 2.5) published on 11 May. The other four are: fairness; proportionality; privacy; and transparency.

It was perhaps inevitable that the Labour Leader, Sir Keir Starmer, on the day (6 May) that it was announced that the UK had the highest Covid mortality rates in Europe, should ask the Prime Minister Boris Johnson at question time: How on Earth did it come to this?.

Was the science wrong? Was the science misinterpreted by politicians? Was the implementation deficient? Or is there something unique about the UK that made it a special case, outside the scientific norms? Currently the official response is that it is too early to come to a definite conclusion on the UK response – we will only really know our comparative mortality performance when we have “all cause excess death” data. This will take some time and will form part of the inevitable post-pandemic review. However early signs suggest that the final number will not be reassuring –  currently estimated to be approaching 60,000 extra deaths.

There are already some hints of where the problem lies:

First, and perhaps the most obvious, is that research evidence is itself a contested concept. Differerent scientists will have different views based on the same evidence. This is not new. Back in the 17th and 18th centuries when scientific understanding of the natural world was surging and Sir Isaac Newton discovered the laws of physics, English visionary artist and poet William Blake expressed caution that “God forbid that Truth be Confined to Mathmatical Demonstration”.

As well as being an artist and poet, Blake was an English radical, sceptical of institutions, alert to inequality and abuse of power, and representative of a different kind of Englishness perhaps. His work, like science, is also contested – for example, the poem Jerusalem, whose words were put to music by Sir Hubert Parry to create the famous hymn of the same name, is now a popular anthem with both the left and right.

Blake is often portrayed as being “anti-science”. But his celebrated painting of Newton (1795-1805) revealed that Blake had a premonition of how profound the contested nature of evidence would become.

In his portayal of Newton (pictured above), universal truths were not to be presented God-like from on high, but to be cleaved and clawed from the planet itself. Blake portrays the great scientist not as a demure older man sitting under a tree, suffering a fallen apple on his head. In Blake’s image, a young and muscular Newton is found naked on the seabed, seemingly battling with the very laws of nature. In fact, in 1665, the year before Newton published his definitive work, the scientist was “self isolating”, sent home from Cambridge to Woolsthorpe Manor, the family estate close to Grantham, as the Great Plague ran its course in London, killing a quarter of the city’s population.

Blake’s concern was with the possibility that the “single vision” of the world according to scientists and philosophers of the age would diminish the richness of Blake’s personal “four-fold” experience of what it was to be human (wisdom, love, power, and sense of identity).

Today, given the lack of scientific consenus, you have to rely on a rigorous open process of challenge and questioning. That is why the government’s Special Advisory Group of Experts (Sage) has come under such close scrutiny and has itself become the subject of controversy and forced to routinely publish its membership.

But what is still lacking is details of the advice, although Sage is now beginning to recognise that the public want the evidence base to be made available before making decisions for themselves, and particularly their children.

Some members of Sage are already saying it was a mistake to drop the ‘test, track and trace’ strategy in early March.

This reinforces the former health secretary Jeremy Hunt’s consistent view that: It is pretty clear now that community testing for the virus should not have been abandoned by the government on 12 March”. Asked on Radio 4’s Today programme (14 May), why Sage didn’t model the South Korean ‘test, track and trace’ approach that the UK is now adopting, right at the beginning, Hunt said:

The Government was given two very extreme options, the sort of extreme lockdown we’re just coming out of, or a kind of mitigated herd immunity. That middle way, the South Korean route, wasn’t modelled.

Jeremy Hunt, former health secretary

Even alternative fora for scientific debate have been established  and have produced their first report, which is supported by the BMJ.

Returning to Blake, he said, “What is now proved was once only imagined”. This raises the issue of  having to make policy on emerging evidence and deciding when there is enough evidence to change policy, especially when the policy affects every member of the public. It is always easier to review the evidence base in retrospect rather than real time. Scientists will need to feel that they will not be given the blame when things go wrong.

Poor implementation of evidence has also been voiced as an issue – many are saying that the advice was acted upon too late to have the necessary impact. Also, other forms of evidence such as that produced by the pandemic case study Operation Cygnet were not acted upon.

It may well be that our obsession with Brexit over the last years has led to other key issues  being de-prioritised. There are also concerns that the centralisation of public health following the Lansley reforms and the reduced funding of public health within the local authorities has compounded the difficulties of mounting an effective response.

Blake’s visionary power seems to have relevance to the proposed differential relaxing of the lockdown that we are now embarking on. His observation that: “One Law for the Lion and Ox is Oppression” (Marriage of Heaven and Hell, plate 24, picturedseems to turn on its head the maxim that law or rules should be equally applied to all.

We may soon have different groups of people being granted different levels of freedom from the restrictions of lockdown based on a risk assessment of preventing a second peak. Even during the peak of the crisis some were inspired by this sentiment.

Faced with a lack of transparency on the reasoning behind the easing of the Covid lockdown, we are seeing an end to the consensus between the home countries and between local and national government.

Finally, is the UK unique? Certainly it is a relatively small, densely populated island, with an elderly population, that acts as a global travel hub – all of which presents serious challenges to control any infection. However, South Korea and Japan, both have higher population densities and face many of the same challenges, yet appear to have managed the pandemic more successfully. In the UK, the division between the delivery and organisation of health and social care is also an issue. Perhaps the unfolding Covid tragedy in care homes will act as a stimulus to develop an integrated and coherent health and social care strategy promised for so long by successive governments.

Where does this leave us? As researchers and policymakers, we all advocate evidence-based policy, but we need to be realistic about the limits of science, and have a much more open debate of the benefits and risks of different approaches to managing the pandemic. Fortunately, what is emerging in UK is not a diminution in the public regard for science (unlike in the USA), but a resurgence of the desire for research and a recognition of how it can help us to navigate these complex challenges. Most obviously, we all hope that science can find a cure and an effective vaccination (UK recruitment into trials is high), but also to understand why some groups are more affected by the virus than others.

Gone are the days when UK politicians, such as Michael Gove, said “People have had enough of experts!

But there remains the question what do we mean by “science”? I have concerns that different disciplines are beginning to be set against each other in the public debate – for example, data science, behavioural, epidemiological, and public health. All have a role to play and what is required is careful calibration of their value and the weight to attach to them at different periods in the evolution of the pandemic. Blake has the final word in in his poem The Four Zoas, when he ends with “sweet Science reigns.