What shapes public health policy – the threat of harm or the state of ‘politics’?

‘Politics’ does, sometimes, recognise the harm caused by disease. Think 1986 and HIV/AIDS.  Health ministers recognised the possible harm to the population from HIV/epidemic and faced up to it. 

They used knowledge of the potential harm to overcome reservations among politically squeamish colleagues to set priorities and make effective public health policy. It’s not always like this.  We recognise now that active vigilance and a prompt response are crucial in tackling outbreaks of infectious disease.  Witness the rapid response to Ebola and the planning to combat a new deadly epidemic – Disease X[1].  Concern about the possible scale of Disease X – with hundreds of millions of people affected – is rooted in the experience of the 1918/19 flu pandemic.

This pandemic was responsible for almost a quarter of a million deaths in Britain and between 50 and 100 million worldwide.  It was the worst public health disaster of the 20th century. Even though our knowledge of flu – and how to respond to it – has improved over the last 100 years, the lack of responsiveness to the 1918/19 pandemic in Britain remains striking.  Looking back, it almost seems to have passed by without anyone noticing. How could this be?  What are the lessons for the future?

Policymakers today have to set priorities balancing political commitments, resources, the available evidence and external events. They also have to be aware that decisions sometimes have unintended consequences, with unfortunate results for the policymakers as well as the population. Consider the Windrush scandal. The process seems to have been different 100 years ago when the Spanish flu pandemic struck.  There was no priority setting, no policy response with little consideration of the consequences of the pandemic. We need help from the great detective to explain this one.

In Silver Blaze, one of Sherlock Holmes’ most popular stories, a famous racehorse is stolen from a remote stable without the alarm being raised[2].  Holmes draws attention to the curious incident in the night – the dog that didn’t bark. The dog was silent because he knew the guilty man. It was this knowledge that allowed the theft to take place without alarm. Apart from Holmes, who could have predicted the man – so familiar and upstanding – would turn bad in the end?

Perhaps it was this kind of familiarity that caught policymakers off-guard and delayed an official response to the pandemic. After all, ‘flu was as a regular visitor to these islands. An irritant certainly, but generally without serious hazard even if not fully understood. Who could have predicted it would be different in 1918?

This familiarity might also explain why insufficient attention was paid to the unpredictable character of the disease and the low levels of immunity in the population. Poor ‘sanitary’ conditions, the strain promoted by the war, and the mass movement of peoples, all increased opportunities for infection and ill-health. There was a lack of data too, and uncertainty about how to respond. Maybe war had even inured people to the randomness of death and disease?

Although Spanish flu was first identified in March 1918, the first wave hit Britain in late June, the second – and most deadly – in the autumn, and a third wave in winter/spring 1918/19. Developing an adequate response would have required all the policymaker’s skill: responsiveness, flexibility, strategic vision and a recognition of the need to act sometimes even when not in full possession of the facts. Yet, none of these skills were deployed at the time, and the initiative shown in tackling other public health issues during the war was distinctly lacking.

Without strong leadership, the extent of the ’flu pandemic was insufficient to achieve policy change. Barriers were created by public scepticism, at least initially (how bad is it really?) and the social and cultural drivers that shaped national policy. Above all, by the iron grip that war exerted on policy. Yet, the lack of political interest was palpable.  Only at the end of October was the pandemic raised in Parliament, reaching the agenda of the war cabinet just once.

Public health action before and during the First World War had led to improvements in civilian health and medical arrangements for the fighting men[3]. Trench warfare, however, created perilous conditions for the health and survival of the individual soldier and of the army itself. This explains the close attention paid to lesser complaints like ‘trench foot’ which threatened to decimate whole units.

Venereal disease (VD) was a recognised public health problem.  The army regarded it as a ‘self-inflicted wound’.  Its spread could undermine fighting efficiency since it enabled those affected to avoid front-line service. A Royal Commission set up before the war, reported in 1916 just as the threat was recognised. The report provided the evidence and recommendations to inform a policy response, based on effective treatment. These recommendations were adopted as emergency regulations with “startling rapidity”. Contemporary judgements deemed “the conditions brought about by the war” as having “moved the government to issue its regulations with unwonted, but certainly justifiable speed”[4].

These recommendations included municipal VD clinics for diagnosis and treatment, provided free of charge, without class distinction or stigma, and mainly paid for by central government. A considerable achievement given that this policy broached several political shibboleths of the time.  It showed what could be done in an emergency, as well as anticipating some of the principles around the NHS.

‘Flu was a different kind of problem. Deemed unlikely to be of much relevance to the war effort or, so it was supposed. The virulence of the 1918/19 outbreaks exposed a lack of policy preparedness. Although knowledge about the nature and spread of the disease was sketchy, there was a seeming reluctance to engage with the issue that might have averted its worst consequences.

The Local Government Board (LGB) – the responsible government department – resisted any inclination to formulate national policy. It said it would be difficult to introduce preventive measures in wartime. It delayed distributing advice about the pandemic because the nation’s first duty was “to carry on”. Eventually, it dusted down the regulations from an earlier pandemic – the Russian flu of 1892 – which urged people “to avoid…overcrowding…dirtiness and dusty conditions”.  It fell to local areas to do what they could in the face of the emergency, with scant resources and a shortage of medical and nursing staff.

This ‘do nothing’ approach was widely supported by doctors and the press.  Doctors were guilty of a ‘failure of expertise’ when they “counselled the public to ignore [the] ravages [of the pandemic]”[5].  Ultimately, senior policymakers made the judgement that “relentless needs of warfare justified incurring this risk of spreading infection”[6]. But were they right?

Contemporary accounts show that the pandemic was shaping up to be a major public health problem.  It started to interfere with the war effort in the spring and summer of 1918. The effects were felt at home through dislocations in munitions production, transport, communications and the medical services charged with getting soldiers fit and back to the trenches. It also undermined fighting capability at the front, with soldiers reporting sick in droves.  It got worse as summer turned to autumn, posing a greater threat than either VD or ‘trench foot’.

Accepting the spread of disease was a poor choice, both for the war effort and the people who contracted the disease, Britain’s wartime Prime Minister Lloyd George among them.  While recognising that they didn’t have all the answers, the policymakers’ response lacked leadership, urgency and purpose, in stark contrast to their ‘rapid response’ to the threat of VD. Other countries did better, where the pandemic became an issue at the very highest level.

The Spanish ‘flu pandemic of 1918/19 was an event both exceptional – unique in its ability to carry off a quarter of a million people almost unnoticed by people at the highest level; and unexceptional – how mundane, it’s just the ‘flu[7] – which stifled an effective response. A shame then that Sherlock Holmes wasn’t on hand to point out the silence that echoed in Whitehall corridors during the biggest public health crisis on the 20th century.

Fortunately, current national and international policymakers seem to learnt from Mr Holmes, though the risk remains ever-present, not least through growing anti-microbial resistance. Active vigilance and preparedness underpin today’s plans for responding to any repetition of the Spanish flu pandemic or Disease X. This proactive response stems – at least in part – from yesterday’s public health policy failure in Britain in 1918/19. A lesson that can be summed up for today’s policymakers as ‘don’t do what we did, do the opposite’.

Credits: This post was written by Dr Ray Earwicker, honorary research fellow at the Centre for Medical History, University of Exeter, and formerly a senior policy adviser at the Department of Health

[1] Whittam-Smith, A (2018) One hundred years on from the Spanish flu, we are facing another major pandemic https://www.independent.co.uk/news/long_reads/spanish-flu-disease-x-are-we-facing-another-pandemic-a8250611.html

[2] Conan Doyle, A (1892) Silver Blaze in The Penguin Complete Sherlock Holmes pp.335-349

[3] Winter, J. (1985) The Great War and the British People

[4] Gibson, T. (1916) The Final Report of the Royal Commission on Venereal Diseases Public Health – Vol 30 (1916-17), pp 15-21

[5] Tompkins, S.M. (1992) The Failure of Expertise: Public Health Policy in Britain During the 1918-19 Influenza Epidemic in Social History of Medicine, volume 5.3 pp 435-454

[6] Johnson, N (2006) Britain and the 1918-19 Influenza Pandemic – a dark epilogue p. 124

[7] See for example, Stevenson, D (2004) 1914-18 The History of the First World War pp 498-99