What Went Wrong?

A Reflection by Public Health Leadership Coalition’s Member – Prof. Martin McKee

What went wrong? In 2019 the Global Health Security Index ranked the United States and the United Kingdom as first and second respectively in their preparedness for a pandemic. Yet, when the pandemic came, these were two of the countries that were hit hardest. It wasn’t that they lacked scientific expertise. By any measure, their research was world beating, a status that was confirmed by the incredible speed with which they developed SARS-CoV-2 vaccines. Nor did they lack experience in the broader aspects of public health, with both countries making significant contributions to our understanding of the determinants of health and, globally, to the control of infectious diseases such as Ebola.

What was lacking was political leadership. Both countries had the misfortune to go into the pandemic led by politicians that were unfit for high office. Donald Trump and Boris Johnson were the poster children of the post truth era. It didn’t matter that what they said was untrue. Rather, what mattered was whether people believed them. They appealed to deep seated prejudices, whether against the Chinese or Mexicans in Trump’s case or the “Brussels bureaucrats” in Johnson’s. They needed to find someone else to blame for the misfortunes affecting so many of their voters, those who had been left behind by the policies promoted by their political backers.

Yet, despite their similarities, there were also important differences. Few would claim that Trump had an understanding of the science necessary to combat the pandemic. His ramblings on the possible benefits of putting bleach or ultraviolet light insight the human body are a testament to his ignorance of the basic laws of physics and chemistry. Johnson, on the other hand, is educated. His problem is an unwillingness to engage with the issue at hand, illustrated by how he missed the initial meetings where the UK’s early response to the pandemic was planned. Sir Jeremy Farrar, a key adviser to the UK government, described “organisational mayhem, with a combination of an absent prime minister, dysfunctional state apparatus and multiple departmental fiefdoms”. Failures of leadership can have many causes.

Faced with a vacuum of political leadership, what can public health leaders do? No-one should pretend it is easy. Should those in government stay the course, doing what they can to limit the damage being done by the politicians? Or should they resign lest they be considered complicit in the mistakes? Dr Tony Fauci has described the dilemma well – “I felt that if I stepped down that would leave a void. Someone’s got to not be afraid to speak out the truth”.

The problem is not new. Ibsen described it well in his play “An enemy of the people” as the hero, Dr Stockmann concludes that “that considerations of expediency turn morality and justice upside down.” Those of us who work in public health face many ethical quandaries. The experience of the COVID pandemic is a reminder that while our traditional association with government brings many opportunities, especially given the important role played by public health law, it also places a responsibility on our shoulders when the government in question is failing to act in the interests of the public to whom we are, ultimately, accountable. There are many ways of displaying leadership in public health but, ultimately, history will judge whether we made the right choice.