The UK’s successful rolling out of its vaccination programme, the attendant government and media hype, not least with respect to how our ‘world beating’ science, technology and enterprise culture ‘beat the virus’, should not be allowed to gloss over the UK’s extremely high Covid death rate and the extent to which this reflects the government’s pre-vaccination Covid-19 policies. Though it must be stressed that it is easy to be wise after the event and none of the major Western countries with their advanced economies and well-developed health systems performed well, particularly compared to East Asia (Tables 1 and 2). This raises many questions which in the UK should be addressed by the public enquiry that the government has proposed to initiate during 2022, with the announcement of the Chair promised by the Prime Minister before Christmas 2021. This has been given increased impetus by the recent UK Parliamentary Committee Report which highlights a number of catastrophic failures, notwithstanding a successful vaccination programme.
It is imperative that the terms of the public enquiry are not drawn too narrowly and, given the currency of ‘blame culture’, not to focus on apportioning blame to particular individuals and institutions. A judge-led enquiry would be preferable, with evidence given on oath. The objective must be to lay the basis for building the capacity and resilience to deal with either a major resurgence of Covid-19 stemming from variants that may be resistant to existing vaccines, further pandemics, or indeed other public emergencies, not least those related to climate change. To this end, it is essential to get to the root of the UK’s lamentable handling of the pandemic.
This Opinion piece sets the UK Covid-19 death rates in their international context, contrasts the UK’s handling of the pandemic with that of the East Asian countries, and outlines the issues that need to be raised over key policy failures.
Perspective on the UK death rate
It is important to stress that there are issues with the Covid-19 death data in every country, not least the UK, particularly for the 2020 first wave, and there have been (and will be more) significant upward revisions. However, while since the very early stages of the pandemic doubts have been cast over East Asian Covid-19 death data, particularly China, there exists little if any evidence to suggest that the enormous gap between East Asia and the major Western country Covid-19 death rates (Table 1 and 2) can be accounted for by the accuracy of the body counts, what is recorded as a Covid-19 death or differing data collection methodologies.
As can be seen from Table 3, at the time of writing (October 2021) the UK has the world’s eighth-largest number of Covid-19 deaths, with only one of the higher ranks (Peru) having a smaller population. While the UK situation looks better in terms of deaths / million people, with a rank of 26, this becomes 8 for all countries with more than 12 million people. On both total deaths and deaths / million the UK’s position has improved during 2021 as the virus has spread in Latin America, and Eastern and South-Eastern Europe. While the UK may well move further down the rankings, this should not be allowed to detract from the prominent position it held for so long. However, it is also important to note that during September and October 2021 the UK’s global position in terms of the daily new Covid-19 cases was shifting between second and third place, and 8th and 12th in terms of daily deaths. Though these case levels must be seen in the context of an exceptionally high level of testing.
The UK and East Asia
The East Asian success rested on early and rapid responses, strict social controls, lockdowns, the closing of international borders, maintenance of high levels of vigilance and willingness to rapidly reimpose restrictions in response to even comparatively minor resurgences of the virus. In several cases, such as Vietnam, remarkably effective track, trace, and isolate strategies were implemented with very limited resources. In all cases, the restrictions saw high levels of compliance, even in cases, such as Hong Kong and Thailand where the government was in general terms far from popular.
This early and strict social control reflects significant health consciousness amongst populations, derived from recent health emergencies, notably SARs in 2002. This outbreak was also a factor in promoting a high degree of preparedness against new pandemics in East Asia. The rapid identification of Covid-19 as an extremely contagious disease prompted strict lockdown and travel restrictions, internal as well as external border controls across the entire region.
Overall, the East Asian Covid-19 management benefitted enormously from the general acceptance by the population of direction from legitimate authority and that community interest can override those of the individual. For many Western commentaries rooted in liberal democracy and liberal individualism, the ‘authoritarian’ and often highly intrusive East Asian approach was not merely something that could not be implemented in the West, but also something that should not be allowed to become an acceptable model for handling a pandemic, because of its threat to civil liberties.
In the event, many Western countries did put in place extremely tight restrictions for lengthy periods, with what appears to have been a very high level of compliance (not least in the UK). However, they were very much slower to do so than East Asian governments, with implementation often attended by considerable public, media and parliamentary debate over the legal and human rights issues involved. While East Asia responded rapidly to the warnings coming from China – with many measures taken in early January 2020, particularly with respect to border controls – the West took little notice, indeed February was described as a ‘lost month’. In addition, in general, the East Asian economies, not only took rapid action but appear to have been much more persistent, with the aim of:
…the complete elimination of domestically transmitted SARS-CoV-2, whereas those in the West generally only sought to bring the pandemic under control at a level at which the hospitals could cope. For a period of time, infections in Sweden and the United Kingdom were even allowed to spread toward the (hoped for) level that would confer herd immunity.
As the pandemic unfolded in the West, there was a ‘blindness’ about learning from the experiences of East Asian countries (and New Zealand), authorities in the West initially sought refuge in the idea of ‘herd immunity’, rather than appreciating that Covid-19 could be suppressed sufficiently using social control methods. This blindness extended to ignoring advice from the WHO on the 28th of February 2020 arguing that countries needed to suppress Covid-19. as early as possible. The significance of this advice was highlighted by Richard Horton in the Lancet, yet attracted little attention in the UK. Health authorities in the UK persisted in being ‘exceptional’ by prevaricating over when, how, in what depth, social control measures should and could be introduced and then maintained to the point where clear improvements in the numbers of new cases and deaths were sufficiently reduced to claim that the NHS had been “saved”.
East Asia, in contrast, focused on a much higher level of suppression than was true for the UK, where there was too great a willingness to lift restrictions too early and considerable reluctance to re-impose them. This unwillingness to persist with suppression measures was evident in all three of the UK Covid waves and lockdowns. The attitude seems to have been ‘virus sufficiently suppressed to protect the NHS capacity, job done, let’s get back to normal life’. Interesting to note that the public view was to ‘save the NHS’, not to save people’s lives. There was some dissonance within the UK on these policies, with the devolved nations of Wales, Scotland and Northern Ireland deviating from the English ‘line” on Covid, something that has exacerbated other political tensions within the United Kingdom.
What is clear in the UK is that by December 2020, the scale and stubbornness of the second and third wave of infections and deaths, due to the tardy imposition of lockdowns, and the imminent availability of vaccines, saw a shift to a vaccine-centred approach. Initially, the main impact of the vaccines was to reduce the death rate amongst vulnerable and elderly people, the vaccines on their own do not necessarily reduce the rate of infection in the population. Nevertheless, UK health authorities were keen to claim that it was the vaccines that were reducing infection rates, rather than attributing this to the maintenance of strict social control measures which lasted until July 19th, a date that happily coincided with the beginning of school summer holidays.
The government then went on to claim (falsely) that the vaccinations, and not the social control measures that led to the reduction in new cases and a fall in the death rate “saved” between 6.4 and 6.9 million infections and 26,000 to 27,000 deaths respectively. The role of the Covid social restrictions was greatly under-played with the government emphasizing what it regarded as its success in implementing the vaccine roll-out, diverting attention away from early policy failures around the late and ineffective introduction of social control measures.
The government gave the impression of wishing to move as far and rapidly away from its earlier policy failures in the interests of promoting the one area where they could claim some success and, as being the country with the fastest roll out of the new anti-Covid vaccines.
The key policy area failures and the questions that need to be asked
In any overview of the UK’s handling of the pandemic, it is difficult to escape the conclusion that it has been overseen by a far from competent government that lacked anything like a coherent strategy, seemed incapable of agreeing policies and communicating then in a clear an unambiguous manner. With frequent open disagreements between the Department of Health, Public Health England, the Treasury; local authorities; devolved regional governments; and one might add, between the more pro-science Jeremy Hunt when Minister of Health, and a Number 10, more interested in public opinion and in remaining ‘popular’. The overall dominance of the latter giving the lie to the claim that the government was ‘led by the science’ when in fact it was led by the politically inspired choice of dates, particularly around holiday seasons, bank holidays and the lobbying interests noted below.
The whole episode has been characteristic by delay, confusion, mixed messaging, contradictions, abrupt reversals, and partial information, if not outright lies. This has been particularly well exposed in the Amnesty International report on the disastrous treatment of care home sector.
However, behind the confusion and distractions there are a series of government positions, perspectives and ideological constructs that significantly shaped the policies towards the pandemic:
- A strong prejudice against the public sector and preference for private sector involvement, such as sourcing of PPE and the initial Track and Trace programme – which could have been run from the outset by Public Heath England with its well-established local networks, contacts, and knowledge. At times it appeared that Ministers were not even aware of the nature and operation of the UK’s public health administration.
- Strongly centralising tendencies in one of the world’s already most centralised states. As shown in the general bypassing and ignoring of local authorities, and the primary health care system (GPs) and, to an extent, the devolved administrations – with which there were repeated disputes. It seemed that the primacy of Westminster and the preservation of the ‘Union’ were major drivers of policy.
- Highly susceptible to lobbying by powerful interest groups, of which the travel and hospitality groups are only the most obvious and perhaps the most heavily supported by the mainstream media. Many of these groups are also generous donors and supporters of the Conservative Party. While the fiasco of the June-August 2021 ‘pingdemic’ where a storm of business and media protest resulted in an adjustment of the NHS App to produce an ‘acceptable’ level of self-isolating, rather than one that reflected the level of actual Covid-19 infections.
- A Westminster bubble in which ministers and officials were conspicuously out of touch with much of the population – ‘if someone in your household tests positive for Covid-19 they should sleep in a separate bedroom and use a separate bathroom’!
- A belief in British ‘exceptionalism’ that was reflected in the ‘blindness’ noted above with respect to learning from other countries or the advice of international bodies.
The impact of the policy failures was exacerbated by a range of long-term and, in many cases deeply embedded social, economic and political issues, which were brought into sharp relief by the pandemic. Many of these have been intensified by the policies of previous governments, particular since 2010, notable with respect to public sector funding cuts, privatisation and outsourcing. Some, like the care sector have long been on the political radar but had been repeatedly ‘kicked down the road’.
Particularly disturbing issues include:
- The large number of people that have low and precarious incomes, inadequate accommodation, no cash reserves, no bank accounts or access to the internet, which makes them both highly vulnerable under lockdown and closures of major sectors of the economy, with many effectively beyond the reach of state support and public sector services in general. Covid-19 has been a disaster for the poor and marginal members of society
- The generally poor health of the population, with 30% classed as clinically obese and another partly overlapping 30% with a range of morbidities – both almost certainly underestimates, given the lack of anything like a comprehensive national health database, in part a reflection of the high levels of ‘health exclusion’.
- The comparatively low level of heath provision with the numbers of doctors, intensive care beds, nurses are all much lower than in countries such as France, Germany, and across much of the rest of Western Europe. This a direct consequence of long-term underfunding.
- The poor integration of the public sector which was at its clearest and had the most disastrous consequences, in the care sector.
Against an examination of the above government positions and long-term issues, the many questions that the enquiry should consider include:
- Why was the UK so poorly prepared for a pandemic and the government so slow to react? Particularly given that between 2015 and 2019 there were 11 pandemic preparedness exercises, which were neither made public nor reported to parliament on grounds of national security. Once their existence was established Matt Handcock told parliament they were not relevant because they dealt with influenza which was very different from coronavirus, yet the exercises also covered MERS, Avian flu, Ebola, and Lassa fever. Why were the reports and recommendations of these exercises not made available and utilised at the outset of the pandemic?
- Why were the UK borders not more rapidly, fully, consistently and effectively controlled? With Brexit the UK had gained full control of its borders and being an island group, was in a position to rapidly impose very tight restrictions on the entry of people from areas of significant Covid-19 infection rates. While such border control was not initially flagged up by the WTO, it was a major factor in the early containment of the virus in East Asia.
- Why did the government not make use of existing legislation and established mechanisms? Notably: The Local Government and Public Involvement in Health Act 2007 which was designed to create a more harmonious approach to public health measures that incorporated Local Authority inputs; and the Emergency Powers Act – this would have given the government all the authority it needed but had significant checks and balances that would have ensured parliamentary oversight. Instead, the government cobbled together a string of measures with as little parliamentary involvement and oversight as possible, this left considerable uncertainty over the legal status of measures and enforcement. Not helped by the general lack of clarity in government statements noted above.
- Why did the government not engage from the outset with Public Health England, GPs and other frontline NHS staff, preferring to rely on an extraordinary array of parallel structures, some of which were voluntary, but dominantly private companies, often with little relevant experience, limited vetting and even less oversight?
- Why were vulnerable groups so narrowly drawn and incompletely identified? How far did this reflect the lack of a comprehensive database, low levels of screening, the level of ‘health exclusion’ and a lack of the resources that a more inclusive coverage would have necessitated?
- Why was community testing not central to the government’s handling of the pandemic from the outset, as recommended by the WHO?
Any examination of the Covid-19 death data reveals that it was predominantly a pandemic of the poor, the sick and the elderly frail. However, a disturbing feature of so much that has been exposed is that it is treated as a consequence of the pandemic and not as something deeply embedded in the UK’s economic, political, and social systems. This is particularly, well-illustrated by the establishment of temporary provisions for the homeless during the lockdowns that ends when the restrictions are lifted. The homeless are now back on the streets again.
In our view a clear understanding of why the UK had such a high number of Covid-19 deaths can only be achieved by the remit of the Public Enquiry covering not just the Covid-19 related policies implemented since early 2020 (important as these are), but the much wider questions of the state of the UK on the eve of the pandemic, the broader issues of government competence, ideology, and perspectives., and of previous governments. It must also take on board the generally poor response of the other advanced Western countries and, in evaluating policies, consider what was known when they were implemented as against what we now know.
The fear is that the public enquiry will be delayed, extremely protracted, and focused on particular individual and institutional failures, including the WHO and the Chinese government. That is, it will provide no meaningful direction for capacity building and contingency preparedness. In addition, given the likely protracted fallout from the pandemic and Brexit, the government may have little economic or political space to spare and be happy to see Covid-19 consigned to the ‘once in a hundred years’ category capped by a suitable memorial in St Paul’s Cathedral.
It is vital that the UK and wider Western failures must be firmly and repeatedly highlighted and analysed, not least, in the context of those countries, most strikingly in East Asia, where Covid-19 was brought under control well, via a concerted attempt to supress its prevalence and prevent widespread contagion, before mass vaccination was a possibility. Only in this way can the establishment of a more robust pandemic and wider UK health contingency system be adequately informed, in time for the next pandemic.
 UK Government ‘Coronavirus: Lessons learned to date’, House of Commons, Health and Social Care and Science and Technology Committees, 21 September 2021, retrieved on 11 October 2021, from: https://committees.parliament.uk/publications/7497/documents/78688/default/
 The gap remains wide despite the recent Delta variant driven surge in East Asia which has seen some sharp rises in death rates – most notably in Malaysia. See Chris Dixon ‘East Asia’s Covid-19 surge in context’, GPI Opinion 19 September 2021, https://gpilondon.com/publications/east-asias-covid-19-surges-in-context
 Though it should be remembered that variations are within an overall very low median IFR (infection fatality rate) now generally accepted to be only 0.2%.
 18 September – USA (129,013), India (30,809), UK (29,612); 30 September – USA (123,260), UK (36,662); 12 October – USA (92,005), UK (38,076); 25 October – USA (43,811), UK (39,806).
 18 September – the UK in 10th place behind, the USA, Brazil, Russia, Iran, Malaysia, the Philippines, Thailand, Vietnam and Mexico – of which only Malaysia had a smaller population; 12 October – 8th place behind USA, Brazil, India, Mexico, Russia, Peru and Indonesia, of which only Peru had a smaller population; 25 October in 11th place behind Russia, India, Ukraine, Romania, Mexico, Turkey, Iran and Brazil place behind, of which only Ukraine and Romania had smaller populations.
 As of 25 October only the USA and India had carried out more tests. While in terms of tests / million people the UK was 10th, it was the only country in the top 28 with a population of more than 11 million.
 In a number of cases, most strikingly Taiwan, SARS exposed the weakness of provision and resulted in major revision and upgrading.
 ‘Covid-19: Make it the last Pandemic’, The Independent Panel for Pandemic Preparedness and Response, 12 May 2021, retrieved on 11 October 2021 from: https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-Make-it-the-Last-Pandemic_final.pdf. A point that had been previously made by Richard Horton on 28 March 2020 (see Note 11).
 Dean T Jamison and Kin Bing Wu (2021‘The East–West Divide in Response to COVID-19’, Engineering (Beijing), online from 12 June 2021 at https://doi.org/10.1016/j.eng.2021.05.008
 WHO ‘Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)’, issued on 28 February 2020, retrieved on 10 October 2021 from: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf
 Richard Horton ‘Covid -19 and the NHS – a national scandal’, The Lancet, 28 March 2020, retrieved on 11 October from, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30727-3/fulltext (Our attention was drawn to this by Dr Greg Philo’s letter ‘Failed Covid strategy demands honesty’, The Guardian 5 October 2021).
 Amnesty International ‘As if expendable: The UK government’s failure to protect older people in care homes during the Covid-19 pandemic’, April 2020, retrieved on 20 September 2021 from: https://www.amnesty.org.uk/care-homes-report
 These comments are drawn from: Clare Dyer ‘Pandemic preparedness: UK government kept coronavirus modelling secret’, British Medical Journal, 11 June 2021, https://www.bmj.com/content/373/bmj.n1501; and Victoria Rees ‘UK Government launches Pandemic Preparedness Partnership, Drugs Target Review, 16 April 2021, retrieved on 12 August 2021 from: https://www.drugtargetreview.com/news/89981/uk-government-launches-pandemic-preparedness-partnership-group/
 The timing and operation of the track and trace system has been the subject of much criticism, notable by the Parliamentary Committees cited in Note 1.
Jeremy Hancock, the Minister of Health during the first 3 Covid waves, is a likely ‘fall guy’ who will be blamed for the collective mistakes made by the government.