In their contribution to HWO’s feature ‘Apocalypse Then and Now’, Guillame Lachenal and Gaetan Thomas argued that sometimes history has no lessons. To some extent, I agree: there can be facile ‘comparisons’ or, those dreaded words, ‘historical parallels’ with past epidemics. In recent years, perhaps coinciding with its impending and then actual centenary, the 1918 Spanish flu epidemic has gained particular prominence in outbreak discussions. Such comparisons pay little attention to the very different social and political structures which underpinned responses in the past.
Yet, as an historian who has studied HIV/AIDS policymaking, I can recognise the power that the past can exert at a time of crisis. Roy Porter’s famous editorial in the British Medical Journal in 1986, ‘History Says No To the Policeman’s Response to AIDS’, gave historical credibility and justification to a nonunitive public health policy response by government at that time. It was evidence for policy makers, an example of what they would now call ‘following the science’.
Lachenal and Thomas refer to the historicity of pandemics: that they resist well-worn frameworks of historical interpretation. In contrast,I want to argue for two functions for history in relation to understanding the present: that it helps us understand why government has responded as it did through looking at the immediate past; and that it assists us in asking critical questions, based on historical knowledge, about the nature of the response.
Why government responded as it did : the shadow of swine flu 2009-10
Before he became British Chief Medical Officer, Chris Whitty in 2018 gave a series of lectures at London’s Gresham College. One dealt with the history of pandemics and how to deal with them. Whitty referred to the most recent epidemic which had affected the UK, swine flu in 2009. He stated:
‘The last pandemic we had, H1N1 in 2009, was relatively low virulence but very substantial numbers. It spread very quickly with somewhere between 40 and 90 million cases. The peak of transmission in the UK came on fast.’
What happened with swine flu in 2009-10 significantly shaped responses to the next pandemic in 2020. It was the ‘crisis which never was’, one in which the government was criticised for overreaction. In a study funded by what was then called the Health Protection Agency (now Public Health England) in 2011-12, but only published last year, a colleague and I conducted oral history interviews with agency staff who had been involved in the response to swine flu and who had wanted to ensure their story was told.
What emerged from the interviews, as it did from an official follow up report at the time, was a story of overreaction and unplanned responses, with the HPA taking the lead initially rather than the NHS. At the local level, for example in ‘hotspots’ such as Birmingham (again a hotspot this time), there was confusion between agencies, with the NHS, the HPA and local government services operating in uneasy relationships, with no one quite sure who was actually in charge. The policy initially was one of containment of spread (as it was initially in 2020) with testing, contact tracing and the prescription of antivirals. This proved impossible to manage, and our interviews showed what strain this put staff under as the epidemic spread. Only a political visit to Birmingham from Andy Burnham as the new health minister brought this strategy to an end.
In general politicians, advised by the committees now involved in the current crisis, were unwilling to drop the crisis mode. As one interviewee put it:
‘The people on the committee wanted the containment phase to continue because it, public confidence, was high in the government’s response, people did feel the right things were being done, public confidence was high and to a politician, if you are doing something and the public are with you, why on earth would you stop doing it […] So that’s why it took several weeks to convince them that we actually needed to change.’
In an official report on the response to the crisis published subsequently and authored by Dame Deirdre Hine, the Welsh CMO, other issues emerged. Among them was the nature of public risk communication, which it was felt had been unnecessarily apocalyptic. There had been an over reliance on modelling in terms of scientific advice. Our interviews and the follow-up report felt that population-based surveillance serology would have provided a better picture of actual spread. Everyone interviewed favoured the public availability of scientific advice and forecasting. Several wanted a different membership of official advisory committees, possibly with the addition of public health personnel from the coal face, the local level. Treatment had been problematic, with antivirals of uncertain efficacy and possibly causing harm. The government was subsequently criticised for the over-purchase of stocks of the vaccine when it became available.
It may already be obvious to readers that some issues have remained remarkably similar, or indeed unresolved, in the intervening decade. The ‘overreaction’ in 2009, the inability to maintain containment with testing and contract tracing, have framed the more recent response in 2020. How to manage containment, when testing and contact tracing is to be stopped; the problems of modelling and other modes of predicting spread; the political response to crisis; the role and membership of expert committees, health agencies and coordination: all these issues have echoes in the present. The so-called ‘overreaction’ to swine flu must have affected the government’s mindset prior to this crisis. It is arguable that the history set out here helps us make sense of some recent responses. What happened with swine flu overshadowed the initial response to COVID.
Questions to ask about the current response based on history
Looking at those developments, and the wider history of public health, also help us to question what is not happening. Some things have changed since 2009-10. Public Health England (PHE) has been established at the national and regional level replacing the HPA. This pending development worried our interviewees. A closer relationship with government might prevent independent advice – HPA kept the government at arms-length. It is indeed noticeable currently that PHE has said little in public in the way in which it did for swine flu. Another change was the move of public health out of the NHS and into local government in 2013. This happened as part of the reorganisation of health services in the controversial reforms initiated by health minister Andrew Lansley.
To historians, this was a potentially welcome development carrying with it implications from the past. Back in the interwar years, before the advent of the NHS, local government public health had been the nascent national health service, performing many of the roles the NHS would take on. Historians have discussed intensively its role and efficacy at the local level. Certainly its role in infection control, testing, and contact tracing was of great importance at a time when public health was much more focussed on infectious disease than it became after World War Two.
As the lockdown took effect, colleagues and I discussed this eagerly during our Zoom meetings. Why, in our London borough (Camden), was nothing being said in public about the public health department? Why did public information from the council say nothing about its public health workforce? Martin Gorsky and I managed to conduct an interview with the Director of Public Health and discovered the borough (Camden and Islington) had a workforce of 70 public health staff. It was generally in a subsidiary role, with some coordination, to PHE, which operated at a regional level covering a wider range of local government public health boundaries. Subsequently the relative invisibility of public health at the local level has been raised by policy commentators. Our knowledge of that history has enabled us to raise issues about the nature of the response which seemed to be invisible to national commentators and, indeed, to government. Only belatedly has the idea of localism in pandemic control through contact tracing been discussed. Yet to historians of public health, this was an obvious issue right from the start.
So history does have a role, but not the one often ascribed to it. Response to pandemics and epidemics is what policy scientists would call ‘path dependent’, an area in which historians, those analysts of change, are also expert. As critical analysts of policy, they are well placed to question responses, to ask what has not happened and why as well as what has. But of course, there are no historians on SAGE.
Virginia Berridge is Professor of History and Health Policy at the London School of Hygiene and Tropical Medicine.She has written on the history of illicit drug policy, alcohol, smoking and HIV/AIDS policy making. Recent work includes a cross national study of policy responses to e-cigarettes in the context of history and research on swine flu 2009.