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A right pig’s ear

The government panicked over the threat of swine flu – and got its response completely wrong

Brace yourself - swine flu is on the rise again. The second wave coincides with mounting disquiet among doctors about the way we as a nation are responding to the disease. A recent survey by Pulse, a leading GP periodical, found that 61 per cent of family doctors believe the government should review its policy of blanket provision of Tamiflu to all suspected sufferers. It also reported a growing number of cases that have resulted in death or serious harm after conditions such as meningitis have been misdiagnosed as flu, and wrongly treated.

Swine flu has wrong-footed everyone. For many years it was assumed that when the next pandemic arrived, it would create havoc: thousands would die in Britain alone; the exponential demand for services would be mirrored by the decreasing number of healthy doctors able to deliver them; societies would crumble. This projection was based in part on the 1918 global flu pandemic - which caused an estimated 50 to 100 million deaths - coupled with the high fatality rate among the few hundred cases of "bird flu" (H5N1) over the past few years.

In the UK, huge quantities of antiviral drugs were stockpiled, plans for establishing a national pandemic flu phone line were laid, and organisations both public and private were exhorted to draft detailed contingency plans for when the carnage began. Both chambers loaded, the shotgun was trained on the far horizon, the collective eye of the viral surveillance world squinting down the barrel, seeking out the first sign of an emergent threat.

Along came swine flu (H1N1). To be clear: people have died - 82 in the UK and an estimated 4,041 worldwide, at the time of writing. According to the World Health Organisation (WHO), roughly 60 per cent of the severe or fatal cases have occurred in recognised risk groups, such as people with grave underlying health problems; the remaining 40 per cent have affected fit children and adults. Each death is tragic, but the mortality figures are tiny, viewed against the millions of mild cases globally.

Writing in the British Medical Journal in September, Peter Doshi, a doctoral student at the Massachusetts Institute of Technology, proposed a framework to differentiate between disease patterns. Type 1 infections are widespread and severe - exactly the kind towards which the current pandemic flu plans are geared. But swine flu sits in Doshi's type 3 - widespread but usually mild. These different beasts present different challenges, but because pandemic planning failed to anticipate anything other than a type 1 scenario, swine flu has triggered a completely inappropriate response.

Marginal effects

Central to doctors' unease is the National Pandemic Flu Service (NPFS). Telephone-based and web-based assessments of symptoms are made using a computer algorithm. If the computer says "swine flu", patients are given antiviral medication, usually Tamiflu. The problems are twofold.

First, data from the Health Protection Agency, which conducts confirmatory laboratory tests on a sample of cases, shows that less than 10 per cent of NPFS diagnoses are correct. The other 90 per cent of supposed swine flu sufferers have other illnesses whose symptoms happen to overlap. (Doctors fare only slightly better, diagnosing at best a quarter of cases accurately.) Second, the drugs being doled out are by and large worse than useless, even in the correctly diagnosed cases. Tamiflu makes only a marginal difference to the course of uncomplicated flu and causes side effects in up to 40 per cent of people who take it. On the whole, these are just bothersome - vomiting is the most frequent - but serious, even fatally adverse reactions do occasionally occur.

In late August, WHO advised that antivirals were not necessary for fit patients suffering from uncomplicated swine flu. The Department of Health defends its continued policy of Tamiflu-for-all on "safety first" grounds. Its concern is those exceptional cases of severe disease in fit individuals, where Tamiflu might (no one knows for sure) make a difference if started early. However, the logic - that it is better to treat everyone than risk missing those who might have benefited - belongs to a strategy for dealing with a Doshi type 1 pandemic, where the chance of severe disease is high. For swine flu, damage from indiscriminate use of antivirals outweighs the supposed benefits of catching atypical cases early.

The real challenge of a Doshi type 3 pandemic is identifying the small minority who actually and urgently require help. These could be those rare individuals with severe flu, or they might be patients in the early stages of another serious disease such as meningitis. Doctors are good at doing this (though far from infallible) and many GPs believe that only medically qualified staff should be undertaking flu assessments, but this is not achievable, given our capacity for mass hysteria. During the first wave of swine flu - before the NPFS was launched - the NHS front line was overwhelmed by waves of worried callers in flu hot spots. One of the main reasons for setting up the NPFS was to prevent a meltdown in services, but it should now change its focus from diagnosing swine flu (at which it is hopeless) to identifying patients in trouble.

The trickiest problem is when patients who initially feel mildly unwell start to deteriorate. The Department of Health stresses that patients are advised to consult a doctor if they get worse, but this fails to appreciate the Tamiflu effect. Having been "diagnosed" with swine flu and put on antivirals, patients are then falsely reassured that appropriate treatment is under way. By stopping its blanket use of Tamiflu, the NPFS would greatly increase the likelihood of patients consulting a doctor if they deteriorate.

Lessons in planning

Swine flu may in time be seen as a great learning opportunity. It has exposed a rigidity in pandemic planning that needs urgent correction. WHO has a scale to denote the spread of in­fection - level six being pandemic. It needs to develop a simple, parallel system to differen­tiate between Doshi types, one that should trigger responses appropriate to the particular challenge posed.

For now, the Department of Health should stop sticking doggedly to contingencies laid against a very different threat. The public and the NHS need clear identification of the at-risk groups and a message that the danger of swine flu, for everyone else, is almost certain to be minimal. They also need information about the warning signs of a more serious problem. The vast stocks of antivirals should be left on the shelf to go quietly out of date.

Yet it may be too late. Another facet of the Tamiflu effect is that we have educated hordes of people that what they thought felt like just a bad cold (and, most of the time, was just a bad cold) needed treatment with powerful drugs involving mystical rituals with a special authorisation number and a flu friend. Doctors will be dealing with mass hysteria in the face of ­minor illness for some time to come.

Phil Whitaker is a doctor and novelist. He is currently working on his fifth novel, "Sister Sebastian's Library"

 

Computer says flu

What do malaria, meningitis, diabetic coma, leukaemia and appendicitis have in common? They are just a few of the conditions that were originally diagnosed as swine flu during the first wave of the pandemic. Most patients have lived to tell the tale; some have not. The case reports have been appearing in the letters pages of medical journals, and on discussion forums of networking sites for doctors. The GPs reporting them are frequently unsure who in authority should be informed.

In fact, the National Patient Safety Agency (NPSA) has been tasked by the Department of Health with investigating alleged misdiagnoses. In a statement, John Scarpello, NPSA deputy medical director, confirmed that the agency had received "a small number of reports where swine flu may have been misdiagnosed", but was unwilling to go into detail while the facts had not been established. Given that the reporting system is entirely voluntary, and few clinicians know to contact the NPSA, this "small number" of reports is likely to be the tip of an iceberg.

The National Pandemic Flu Service is a first: never before have patients been diagnosed by computer or unqualified call-centre staff. There is a real need for research to examine this approach, yet none appears to be planned. The Department of Health refers inquiries about patient safety to the NPSA, while the NPSA believes commissioning such a study would be outside its capacity and brief.

Phil Whitaker

This article first appeared in the 12 October 2009 issue of the New Statesman, Barack W Bush

BRIAN ADCOCK FOR NEW STATESMAN
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Divided Britain: how the EU referendum exposed Britain’s new culture war

The EU referendum exposed a gaping fault line in our society – and it’s not between left and right.

There are streets in Hampstead, the wealthy northern suburb of London, where the pro-EU posters outnumber cars. A red “Vote Remain” in one. A “Green Yes” in another. The red, white and blue flag of the official campaign sits happily next to a poster from the left-wing campaign Another Europe Is Possible proclaiming that the world already has too many borders.

If you were looking for an equivalent street in Hull, in the north of England, you would look for a long time. In the city centre when I visited one recent morning, the only outward evidence that there was a referendum going on was the special edition of Wetherspoon News plastered on the walls of the William Wilberforce pub in Trinity Wharf. Most of the customers agreed with the message from the chain’s founder, Tim Martin: Britain was better off outside the European Union.

“Far too much Hampstead and not enough Hull” – that was the accusation levelled at the Remain campaign by Andy Burnham in the final weeks of the campaign. He wasn’t talking about geography; Remain’s voice is persuasive to residents of Newland Avenue in Hull, where I drank a latte as I eavesdropped on a couple who were fretting that “racists” would vote to take Britain out of the EU.

Rather, Burnham was talking about an idea, the “Hampstead” that occupies a special place in right-wing demonology as a haven of wealthy liberals who have the temerity to vote in the interests of the poor. The playwright and novelist Michael Frayn, in his 1963 essay on the Festival of Britain, called them “the Herbivores”:

“. . . the radical middle classes, the do-gooders; the readers of the News Chronicle, the Guardian, and the Observer; the signers of petitions; the backbone of the BBC . . . who look out from the lush pastures which are their natural station in life with eyes full of sorrow for less fortunate creatures, guiltily conscious of their advantages, though not usually ceasing to eat the grass.”

For Hampstead then, read swaths of Islington, Hackney, Brighton, Bristol, Cambridge, Edinburgh and Oxford today – all areas that were most strongly in favour of Remain and where Jeremy Corbyn is popular. But Remain never found a tone that won over the other half of Labour England; the campaign struck as duff a note among the diminishing band of pensioners on Hampstead’s remaining council estates as it did on Hull’s Orchard Park Estate.

The rift between “Hampstead and Hull”, in the sense that Andy Burnham meant it, is one that has stealthily divided Britain for years, but it has been brought into sharp focus by the debate over Europe.

Academics use various kinds of shorthand for it: the beer drinkers v the wine drinkers, or the cosmopolitans v the “left behind”. “It’s not just that [Britain] is div­ided between people who buy organic and people who buy own-brand,” says Philip Cowley, a professor of politics at Queen Mary University of London, “but between people who wouldn’t understand how anyone could buy own-brand and people who wouldn’t buy organic if you put a gun to their head.” Equating political preferences with shopping habits might sound flippant, but on 21 June the retail research company Verdict estimated that “half of Waitrose shoppers backed a Remain vote, against just over a third of Morrisons customers”.

The referendum has shown that there is another chasm in British politics, beyond left and right, beyond social conservatism v liberalism, and beyond arguments about the size of the state. The new culture war is about class, and income, and education, but also about culture, race, nationalism and optimism about the future (or lack of it). This divide explains why Ukip’s message has been seductive to former Labour voters and to Tories, and why Boris Johnson, an Old Etonian, led a campaign that purported to despise “elites” and “experts” and spoke of “wanting our country back”.

***

At the start of the campaign, the question that most accurately predicted whether you would back Remain or Leave was consistently: “Are you a graduate?” (Those who answered yes were much more likely to vote in favour of staying in the EU.) Stronger In never found a way to change that and win over those who left education at 18 or earlier. Pollsters also suggested that the much-vaunted Euroscepticism of older voters reflects generations where only one in ten people went to university.

This fissure has been growing for the best part of a decade and a half, but Britain’s first-past-the-post system, which deters newcomers and maintains entrenched parties, has provided a degree of insulation to Labour that its European cousins have lacked. Yet even here in the UK the mid-Noughties brought the brief rise of the British National Party, powered by voter defections from Labour in its strongholds in east London and Yorkshire, as well as the election of the Greens’ first MP on the back of progressive disillusionment with the governments of Tony Blair and Gordon Brown.

In office, both Blair and Brown calculated, wrongly, that Labour’s core vote had “nowhere else to go”. In opposition under Ed Miliband, the party calculated, again wrongly, that discontent with immigration, and the rise of Ukip powered by that discontent, was a problem for the Conservative Party alone.

In a 2014 pamphlet for the Fabian Society, ­Revolt on the Left, the activist Marcus Roberts, the academic Rob Ford and the analyst Ian Warren warned that Labour had “few reasons to cheer about the Ukip insurgency and plenty to worry about”. When the votes were cast in the general election the following year, that prediction turned out to be dispiritingly accurate. Defections from Labour to Ukip led to Labour losing seats to the Conservatives in Gower, Southampton Itchen, Telford and Plymouth Moor View.

For the most part, however, first-past-the-post papered over the cracks in Labour’s broad coalition: cracks that, in the harsh light of the EU referendum, have become obvious. The divide isn’t simply one of class, or income. The social profile and culture of voters in Cumbria are no different from that of voters on the other side of the border – but Scots in the Borders backed a Remain vote while their English peers in the border areas opted for Brexit. Inhospitality towards Brexit proved a stronger indication of city status than a mere cathedral: Vote Leave generally found Britain’s great cities more difficult terrain than the surrounding towns and countryside.

The problem of the fracturing vote is particularly acute for the Labour Party, which for much of the 20th century was able to rely on the Herbivores. In concert with Frayn’s “less fortunate creatures”, they have been enough to guarantee Labour close to 250 seats in the House of Commons and roughly one-third of the popular vote, even in difficult years. But Britain’s EU referendum placed Hampstead and Hull on opposing sides for the first time in modern British political history.

It was Tony Blair who, in his final speech to the Trades Union Congress as Labour leader in September 2006, said that the new debate in politics was not left against right, but “open v closed” – openness to immigration, to diversity, to the idea of Europe. Driven by their commitment to openness, Blair’s outriders dreamed of reshaping Labour as a mirror of the US Democrats – though, ironically, it was Ed Miliband, who repudiated much of Blair’s approach and politics, who achieved this.

At the 2015 election Labour’s coalition was drawn from the young, ethnic minorities and the well educated: the groups that powered Barack Obama’s two election wins in 2008 and 2012. The party was repudiated in the Midlands, went backwards in Wales and was all but wiped out in the east of England. (Scotland was another matter altogether.) Its best results came in Britain’s big cities and university towns.

The Remain campaign gave Labour a glimpse of how Miliband’s manifesto might have fared without the reassuring imprimatur of a red rosette. Britain Stronger In Europe has been rejected in the Midlands and struggled in the east of England. But it also failed to inspire passion in Sunderland, Oldham and Hull – all areas that, for now, return Labour MPs.

***

In appearance, Hull’s city centre is built on blood and sandstone, dotted with memorials to a lost empire and postwar replacements for bombed buildings, all ringed by suburban housing built by the private sector in the 1930s and the state in the 1950s and 1960s. It could be Bristol without the excessive hills, or a smaller Glasgow with a different accent. Unlike in Glasgow or Bristol, however, the residents of Hull are largely hostile to the European Union. Unlike Glasgow and Bristol, Hull is a post-imperial city that has yet to experience a post-colonial second act.

The William Wilberforce is named after a native son who helped destroy the British slave trade, the engine of Hull’s prosperity in the 18th century. The destruction of another local industry – fishing – drives resentment among the pub’s ageing clientele, who were there for breakfast and a bit of company when I visited. They blame its demise squarely on the EU.

Although the Labour Party now has only one MP in Scotland, the back rooms of the labour movement host an outsized Scottish contingent. For that reason – and the continuing threat that the loss of Labour’s seats in Scotland poses to the party’s chances of winning a majority at Westminster – the Scottish independence referendum of 2014 loomed large for Labour throughout the EU campaign.

From the outset, Britain Stronger In struggled to replicate the success of the Scottish No campaign, in part because the price of victory was one that Labour regarded as too high to pay a second time. In Glasgow, in the week before the Scottish referendum, everyone knew where Labour stood on independence – consequently, many voters were already planning to take revenge. The proprietor of one café told me that Labour was “finished in this city, for ever”.

Predictions of this sort were thin on the ground in Hull. Alan Johnson, the head of Labour’s EU campaign, is one of the three Labour MPs whom Hull sent to Westminster in 2015. But even late in the campaign, in his own constituency, I found uncertainty about the party’s official position on the referendum. For that reason, if nothing else, it didn’t have the feeling of a city preparing to break with a half-century-plus of Labour rule, as Glasgow did in 2014. In Scotland, most people I spoke to believed that they were on the brink of independence, which made the eventual result a big blow.

Only among Hull’s pro-European minority could I find any conviction that Britain might actually leave the EU. In September 2014 Kenneth Clarke remarked that Ukip’s supporters were “largely . . . the disappointed elderly, the grumpy old men, people who’ve had a bit of a hard time in life”. To listen to Hull’s Leave voters is to hear tales of the same frustrated potential: they feel that politicians of all stripes have lives entirely removed from theirs. In their defence, they are right – just 4 per cent of MPs in 2010 were from working-class backgrounds.

As for Ken Clarke, he has carved out a second career as every left-winger’s favourite Tory, but that tone of indifference towards the “disappointed lives” of globalisation’s casualties recalls his younger days as a rising star of Margaret Thatcher’s government.

Hull’s residents have been dismissed, first as the regrettable but inevitable consequence of Thatcherite economics, and now as small-minded opponents of social progress and racial diversity. Unsurprisingly, people who feel that their wishes have been ignored and in some cases actively squashed by successive governments of left and right did not expect to wake up on the morning of 24 June to discover that this time, their votes really had changed something.

Equally unsurprisingly, the Remain campaign’s warnings of economic collapse lacked force for people for whom the world’s end had been and gone.

In Glasgow in 2014 Scottish independence was a question of identity in itself, whereas in Hull, hostility towards Europe is the by-product of other identities that feel beleaguered or under threat: fishing, Englishness and whiteness, for the most part.

In Hampstead, a vote for Remain feels more like a statement about the world as you see it. One woman, who walks off before I can probe further, tells me: “Of course I’m voting to stay In. I buy Fairtrade.”

***

Immigration, not the European Union, is the issue that moves voters in Hull. “Britain is full” was the most frequent explanation they gave for an Out vote. Knowing that immigration, rather than the abstract question of sovereignty, would be crucial to winning the contest, Vote Leave tried from the beginning to make it a referendum on border control. Leave’s main theme: the threat of Turkey joining the European Union and, with it, the prospect of all 75 million Turks gaining the right to live and work in Britain.

Although Turkey’s chances of joining the EU are somewhere only just north of its hopes of launching a manned mission to Mars, the tactic worked: according to an ­Ipsos MORI poll released on the morning of 16 June, 45 per cent of Britons believed that Turkey will be fast-tracked into the Union.

That same morning, Nigel Farage posed in front of a poster showing refugees – mostly from Syria and most of them non-white – on the border between Croatia and Slovenia, with a slogan warning that uncontrolled immigration was leaving Britain at “breaking point”. But the row over the poster came to an unpleasant halt just a few hours later as news began to break that Jo Cox, the Labour MP for Batley and Spen, had been shot and stabbed on her way out of a constituency surgery. She died of her injuries a little over an hour later. On 19 June Thomas Mair, who was arrested in connection with the killing, gave his name at Westminster Magistrates’ Court as “Death to traitors, freedom for Britain”.

The circumstances of the killing felt familiar. A little after midnight on 5 June 1968, Robert Kennedy was returning to the Ambassador Hotel in Los Angeles in high spirits. He had just won a crucial victory in the California primary and was well placed to secure the Democratic nomination to run in that year’s presidential election. Going through the kitchen in order to avoid cheering crowds and get straight to his press conference, he was ambushed by a man called Sirhan Sirhan, who fired six shots from a revolver. Kennedy was rushed to hospital, where he died early the following morning.

Five months later Richard Nixon was elected president. The American right held on to the White House for 20 years out of the next 25. Jo Cox’s killing, amid the nativist howling from Farage et al, felt like the beginning of a similar chapter of right-wing advance in the UK.

Labour’s problem, and that of its social-democratic cousins throughout Europe, is the same as the American left’s was in the 1960s. Its founding coalition – of trade unions, the socially concerned middle classes and minorities, ethnic and cultural – is united (barely) on economic issues but irrevocably split on questions of identity. Outside crisis-stricken Greece and Spain, the left looks trapped in permanent opposition, with no politician able to reconsolidate its old base and take power again.

***

When I arrive in Hull, preparations are under way for a vigil in Jo Cox’s honour, but it is the nation of Turkey that is weighing on the minds of undecided voters. On Park Street, residents are divided. Those who have exercised their right to buy and are concerned about their mortgages are flirting with an Out vote but are terrified about negative equity. Those who remain in social housing or the private rented sector are untouched by stories of soaring mortgages. To many residents, the Treasury’s dire warnings seem to be the concerns of people from a different planet, not merely another part of the country. As Rachel, a woman in her mid-fifties who lives alone, puts it: “They say I’d lose four grand a month. I don’t know who they think is earning four grand a month but it certainly isn’t me.”

As Vote Leave knew, the promise that an Out vote will allow people to “take control” always had a particular appeal for those with precious little control – of their rent, of next week’s shift, of whether or not they will be able to afford to turn the heating on next week. Never mind that the control envisaged by Vote Leave would be exercised by the conservative right: the campaign found a message that was able to resonate across class and region, at least to an extent that could yet create a force to be reckoned with under first-past-the-post in Britain.

Four grand a month isn’t a bad salary, even in leafy Hampstead, but in that prosperous corner of north London fears of an Out vote, and what will come after, gained a tight purchase. The worry was coupled with resentment, too, over what would come, should the Outers triumph.

The great risk for the left is that herbivorous resentment is already curdling into contempt towards the people of Hull and the other bastions of Brexitism. That contempt threatens the commodity on which Labour has always relied to get Hull and Hampstead to vote and work together – solidarity. The referendum leaves the Conservatives divided at Westminster. That will give little comfort to Labour if the long-term outcome of the vote is to leave its own ranks divided outside it.

 

Stephen Bush is special correspondent at the New Statesman. He usually writes about politics. 

This article first appeared in the 23 June 2016 issue of the New Statesman, Divided Britain