The pandemic – questions around Government governance: a blog from David Osborn

Summary

My last blog, "Forgotten heroes" – the sequel, built upon a very moving BBC Panorama programme Forgotten heroes of the Covid front line. The BBC documentary told the sad story of healthcare workers (HCWs) who had bravely and knowingly put themselves in harm's way to care for their patients during the darkest days of the pandemic. Many lost their lives, while many more were rendered so severely injured by the disease (Long Covid) that they were (and remain) unable to work and have been unceremoniously sacked by their NHS Health Trusts/Boards.

The way that an organisation manages its activities is known as 'governance'. Good governance will lead to high standards of ethics, morality, care and compassion for the people who work within it and those who may be affected by its acts and omissions. Hence, when applied to a whole country, it is known as 'Government', its departments and agencies.

In this blog, I propose a possible hypothetical scenario that may have led to the tragic situation revealed by the BBC documentary. I hope this will lead you to consider the standards of 'governance' that apply to the 'duty of care' which a Government owes to its HCWs during a pandemic and what, morally and ethically, should be done to support those "forgotten heroes" if the Government’s governance should be found to be severely lacking.

But is the scenario I am asking you to imagine hypothetical or is it real? I shall leave that to your judgement – and that of the Covid-19 Public Inquiry. 

Content

The hypothetical scenario

In the wake of the SARS outbreak (Severe Acute Respiratory Syndrome) in 2003, an enlightened Chief Scientific Advisor set a plan in motion to prepare the country for a major pandemic. All epidemiologists worth their salt knew that this was inevitable and would happen one day.

Thoughts began to turn towards how HCWs should be protected while caring for infected patients. After all, if large numbers of them became infected then who would look after the rest of us? The health service would most likely be overwhelmed and the country would be thrown into chaos and civil disorder.

So a laboratory run by scientists from the country’s foremost health and safety regulatory body undertook some research to discover how well the standard surgical masks (‘medical masks’) would fare in a pandemic. The results were unambiguous – “badly”!

The scientists found live viruses behind every surgical mask tested, including fluid resistant surgical masks (FRSMs), when presented with an artificially generated sneeze or cough. The scientists were quite clear in recommending that HCWs should wear respiratory protective equipment (RPE) in order to be properly protected against inhalation of harmful (pathogenic) viruses in the event of a pandemic.

There are several types of RPE, the disposable respirator known as FFP3 (filtering facepiece) and some other reusable types as well, which give good protection.

Not long afterwards, the 'Swine flu' pandemic raced across the world. This triggered the Government to invest in a massive stockpile of RPE. As the years rolled by, this equipment reached its expiry date but, instead of renewing them, stickers were over the expiry dates extending their life after what were called ‘stringent tests’.

One has to question how ‘stringent’, when it is known that some of the materials from which they are made degrade over time and this impairs their efficiency. Tests (even ‘stringent’ ones) can only show how a mask performs at the time of the test and not predict how it will perform in a few years’ time.

Manufacturers assign an ‘expiry date’ for a very good reason – when used beyond that date they may fail in such a way that the wearer is unwittingly inhaling the hazardous airborne materials, such as dusts or virus-laden aerosols from which they thought they were being protected. Or, also dangerous, bits of the degrading mask may be inhaled by the wearer presenting a choking hazard.

Around that same time. some of the health department’s experts that concluded that SARS coronaviruses were transmitted by droplets and the airborne route via aerosols and tiny particles known as 'droplet nuclei'. They recommended that RPE such as FFP3 respirators should be used when providing routine care to infectious patients.

The years passed by and the stockpile came up for review again. Experts from the Government’s health department met to decide what to do. After all, there would be a significant cost to the country in renewing the stockpile, most of which was well out of date.

The experts came up with a bright idea –- why not implement a process called 'stock rotation' where PPE would be withdrawn from the stockpile in good time before its expiry date and sent for use in the NHS, replacing it with new PPE. One might question why this simple process wasn't thought of back when the stockpile was first established – after all, it is a fairly commonplace practice in warehousing perishable goods with a shelf-life.

This group was fortunate in that it included one of the experts who had authored the above-mentioned paper. Curiously though, they decided that all general ward, community, ambulance and social care staff would only be equipped with FRSMs who they considered need not be protected with proper RPE. Perhaps their attention had wandered away from SARS and were focused on other respiratory diseases like flu (notwithstanding the massive loss of life these caused during the last century).

Roll forward a few more years and a SARS pandemic starts to spread out from a place called Wuhan in China with a virus that was 80% similar to its predecessor from 2003, which had been proven to spread by airborne/aerosol transmission..

The new disease was classified as an airborne HCID (high consequence infectious disease) for which the country’s health and safety rules required that HCWs be equipped with RPE (not surgical masks). The Director-General of the World Health Organization (WHO) announces to the world that the disease was airborne (although apparently ‘not in a military sense’ which is a little difficult to understand). A senior medical officer tells a committee of politicians that the disease approaching the country had a very strong force of transmission and is airborne.

Then the pandemic arrived in the country, after having wreaked havoc with health services elsewhere in Europe.

However, what the pandemic planners did not seem to have taken into account was that the health and safety rules associated with HCIDs required that RPE must be worn by healthcare workers when caring for infectious patients and now the stockpile of respirators was far too low. With not enough respirators to go round, what on earth was to be done?

A Government Committee met to consider this dilemma. Two of the experts were present who had authored the paper mentioned above which had explicitly stated that RPE should be worn for SARS coronaviruses, and one of these experts had made the fateful recommendations about the PPE stockpile. This must have all been terribly embarrassing. Anyway they came up with a pragmatic answer to the problem.

Solution:

• Declassify the disease so it isn’t an HCID any more. Done with a phone call to the right person and a quick confirmatory letter back from them. The disease was no longer ‘high consequence’ (just two days after a global pandemic had been declared by the WHO and the worldwide death toll was on a sharp upward trajectory).

But oh dear! There is still a problem.

Regardless of any HCID rules, the country’s health and safety laws say that if a hazard is airborne then RPE is required (which, as we know, does not include these paper surgical masks). The emergency pandemic legislation brought in by the country’s government had not repealed, revoked or suspended any of the health and safety laws and so they were still in force. This, being 'criminal law' was something that people could be jailed for breaching.

Solution:

• Despite existing evidence that SARS coronaviruses (and other respiratory infectious diseases, such as tuberculosis) are transmissible via the airborne route, the health department pronounces that the virus causing the current pandemic is actually no longer airborne. They say that it is only transmissible via droplets that quickly fall to the ground or onto surfaces. They say that they will only cause infection if they land on someone’s mouth, nose or eyes or a person touches those surfaces and then touches their mouth, nose or eyes.

So the country’s response strategy centres around keeping people 2 metres apart and handwashing. The airborne route is largely ignored except for some HCWs who don’t believe them and buy their own RPE – only to be instructed by the hospital authorities to take them off (on pain of disciplinary) and put on surgical masks instead. After all, if they wore these respirators it might scare the patients.

But there is yet another problem. When any pathogenic viruses are ‘on the loose’ then the country’s health and safety law says that approved PPE must be worn to protect the wearer if no other, more effective risk control measures can be implemented. For administering close-quarter care to infectious patients no other risk control measures are practical other than PPE.

The problem is that surgical masks are not approved 'PPE'. They are designated as ‘medical devices’ which are intended to protect the patient from drops of mucus or saliva that may come out of a HCW’s nose or mouth and may infect the patient. Furthermore the European standard for surgical masks says that they are not intended for protection of the wearer.

Solution:

• We’ll call surgical masks 'PPE' anyway – after all the middle 'P' (protective) has a nice ring to it and should lead HCWs to believe they’re being protected (despite the underlying risk that they may be lulled into a false security and actually become more vulnerable as a result).

The health and safety regulator appears somewhat concerned by this turn of events and makes representations to the other Government departments and the NHS that they should refer to RPE (such as FFP3s) as 'respirators' not 'masks' in order to ensure that the distinction is properly understood. However, this is ignored and FFP3s continue to be referred to as 'masks. So you now have 'FFP3 masks' and 'surgical masks'. After all, one mask sounds much the same as another doesn’t it? After all, if you were to refer to one as a 'respirator' (which sounds much better and more efficient) and the other as a 'mask' (which doesn’t) then workers might begin to question why they are not being given the best protection.

Furthermore, all politicians, media and just about everyone else in the country started referring to surgical masks as PPE despite the fact that they are not. When concerns are raised with the safety regulator about this, their response is that, whilst they agree surgical masks are not PPE, the term PPE has now entered common parlance and it would be difficult, if not impossible, to reverse this. And so the myth that surgical masks are personal protective equipment persists to this day.

A few days after the ‘downgrade’ from RPE to surgical masks, with the first wave now really taking hold, a doctor in Accident and Emergency at one hospital describes their situation to a politician as carnage and chaos. They were distraught as they didn’t have any proper PPE and needed FFP3s. The doctor felt as though they were being thrown to the wolves. They thought it likely that some of them were going to die as a result.

Of course, sadly, that doctor was not wrong. Many did die. Many, many more became very ill with very serious and long-lasting health effects.

But where, one might ask, is that regulatory body that is supposed to ensure that workers are kept healthy, safe and properly protected against the hazards they’re working with? Well, they say that decisions about respirators and masks in healthcare sector have nothing whatsoever to do with them. They say that it is the country’s health department and the public health people who issue the guidance about mask-wearing in the healthcare sector. It is they who are responsible for these decisions.

Then another problem arises. Oh dear, don't health and safety laws just keep getting in the way when you’re trying to manage a pandemic!

For instance, there’s one which says that when a worker contracts a serious disease through their work (or dies of it), then it must be reported to that health and safety regulator as 'occupational exposure'. However, it wouldn’t be good for morale amongst healthcare workers if the true impact the disease was having upon them became widely known.

Neither would it be good for those people in the health department who had been responsible (and accountable) for decisions they made about the stockpile the instruction they had given to downgrade from respirators to surgical masks.

Solution:

• Discourage such reporting – ideally stop it altogether! Perhaps, when employers do make such reports, the safety regulator should reject them on the grounds that the healthcare workers probably didn’t catch their disease from the infectious patients they were working with (coughing their germs into the air around them) but more likely ‘out in the community’.

So these unfortunate healthcare workers have no official record made of their 'occupational exposure' to the disease and any such suggestion is vigorously denied by their employers. This has the potential to severely hamper those workers when, after a year of sick pay, they are unceremoniously sacked and may need evidence that their disablement was caused through their work.

Well, that brings us to the end of our hypothetical scenario.

What do you think? Truth or fiction?

Related reading:

Since the publication of this blog, A Byline Times' investigative journalist has delved deeper into the story and his findings, published here, provide more detail.

About the Author

David Osborn is a chartered occupational safety and health practitioner, having been in practice for 28 years. He has a background in biochemistry, microbiology, epidemiology and emergency planning. Any blogs or letters that David writes to Government departments, Agencies or the NHS are written entirely on a personal and individual basis and do not necessarily reflect the views of any organisations to which he is affiliated.