Breathtaking: Inside the NHS in a Time of Pandemic 
by Rachel Clarke.
Abacus, 228 pp., £9.99, September 2021, 978 0 349 14456 6
Show More
Shutdown: How Covid Shook the World’s Economy 
by Adam Tooze.
Allen Lane, 354 pp., £25, September 2021, 978 0 241 48587 3
Show More
Failures of State: The Inside Story of Britain’s Battle with Coronavirus 
by Jonathan Calvert and George Arbuthnott.
Mudlark, 432 pp., £20, March 2021, 978 0 00 843052 8
Show More
Covid by Numbers: Making Sense of the Pandemic with Data 
by David Spiegelhalter and Anthony Masters.
Pelican, 320 pp., £10.99, October 2021, 978 0 241 54773 1
Show More
The Covid Consensus: The New Politics of Global Inequality 
by Toby Green.
Hurst, 294 pp., £14.99, April 2021, 978 1 78738 522 1
Show More
Show More

When​  I had Covid, at the end of March last year, I spent a week in bed with an intermittent fever and a strong feeling that my body was dealing with something unfamiliar. I was lucky: it turned out to be the ‘mild to moderate’ version of Covid. But it wasn’t much fun. I had the semi-delirious sense that my body knew it was dealing with a new illness. I would feel OK and then not OK, in waves. The image that stuck in my mind that week was of being in a room in a not very good hotel where somebody keeps trying to open your door, rattles the lock for a while, then gives up and goes away, only to come back and try again a few hours later. It felt as if Covid was repeatedly returning to try the lock. It was a sensation I’ve never had with any other illness: the feeling that Covid had intentions, and that they were not benign.

On a global level, Covid hasn’t stopped coming back to try the door. I have been reading books about the crisis – and many, many yards of journalistic commentary – for more than a year now, and it has left me feeling that Covid is an almost impossible subject to sum up, because we don’t know where we are in the story. The books written by frontline medics after the first wave of the pandemic – Rachel Clarke’s Breathtaking, Gavin Francis’s Intensive Care and Jim Down’s Life Support – are vivid accounts of what the battle against the disease was like for doctors, but they are very painful to read now, because we know what they couldn’t: that Covid was only just getting started.* Every one of the books I’ve read is situated in a moment in time, and in every case, whether it was the second wave and the Alpha variant, or the third wave and the Delta variant, the disease came up with a new narrative, a new set of unpleasant surprises. Countries, indeed entire continents, which were praised for their successful response would, months or sometimes just weeks later, become epicentres of fresh disaster. In the days since I filed the first draft of this piece, a new ‘variant of concern’, Omicron, has arrived, with a large number of mutations. The World Health Organisation says that ‘preliminary evidence suggests an increased risk of reinfection with this variant.’ The whole world is currently waiting on news about Omicron’s transmissibility, its capacity to escape vaccines and the severity of the illness it causes. I would like to think that the surprises are over, and that we are closer to the end of this than to the beginning. I would like to be confident that the majority of all the people killed by Covid have already died. Unfortunately, we can’t count on either proposition.

For most of history, infectious disease has been one of the central realities of human life. Jared Diamond’s Guns, Germs and Steel (1997) is overly deterministic, but the basic point it makes about the importance of contagious illness to human history remains valid. The map of our planet was shaped by infectious disease: Cortés gets most of the blame/credit, but it was the viruses he brought with him that destroyed the Aztec empire. It’s not just in the past and at population-wide scale that such illnesses have shaped humanity. Both my parents’ lives were fundamentally altered by infectious disease. My father caught polio in childhood in Africa and spent a year in bed with a leg brace; my mother caught tuberculosis as a young woman in Dublin and spent many months in a sanatorium. Her fiancé, whom she’d met in the sanatorium, died. Stories like this were not unusual among people born in the early decades of the last century. One of the main reasons global life expectancy has more than doubled since 1900 is that we have vaccines against diseases such as polio and TB.

The weird world – Western, educated, industrialised, rich and democratic – has responded poorly to Covid, and part of the reason is that the weird world had been existing at a distance from this central reality of human history. As Adam Tooze points out in his brilliant book Shutdown, 91 per cent of deaths in the contemporary West are from noncommunicable diseases like cancers and strokes and heart attacks, many of them illnesses associated with modern lifestyles. The equivalent figure in sub-Saharan Africa is 34 per cent. We have a generation of leaders in the West who have no visceral understanding of the risks posed by infectious illness. In addition, as David Runciman has pointed out, politicians and government don’t get credit for the disasters and failures they prevent. The combination of these two factors – generational obliviousness and the bias away from the good governance of prevention – goes a long way to explaining why the UK government, despite having had the possibility of pandemic at the top of its risk register since that register was instituted in 2008, was so woefully unprepared for an event it was its job to predict and either prevent or mitigate.

The story of the UK is not the whole story of the global pandemic, but it is worth taking a moment to look at the local specifics. We could take as a benchmark the All England Club, which manages Wimbledon. In 2003, having learned from the experience of Sars, Wimbledon began paying around £1.5 million a year to insure against the cost of a pandemic. As a result, when Covid hit, the club trousered cheques totalling £174 million to cover the cost of the cancelled 2020 tournament. That is what competent governance looks like. What would the UK response have looked like if the All England Club had been in charge? What would the Wimbledon number – the death toll assuming competent government – have been?

In fairness, the number would always have been relatively high. The UK is densely populated; its population is old by global standards, with a median age of 40.4; it has the fattest population in Europe, with 27.8 per cent of adults categorised obese; a significant proportion of its population lives in crowded intergenerational households; it is unequal, with a high Gini coefficient by European standards, and major disparities in health outcomes between classes and ethnicities; and it is a travel hub, with 23.7 million international arrivals in the first three months of 2020. In other words, the UK is crowded, old, fat, cramped, unequal and much visited, and all of those things increase the impact of Covid.

In an alternative reality, these factors, all of them well known, could have explained the UK’s particular attentiveness to the risks of pandemic and the alertness of its response. Instead, they turned into the starting conditions for an unprecedented failure of governance and health policy. The mistakes can be broadly categorised as failures of preparation and failures of response. The second kind of failure has dominated the headlines over the last twenty months, but the first kind is just as important and, at its simplest, lay in the underfunding of health and social care. The UK had a thought-through and thorough pandemic plan – ‘We were the envy of the world,’ according to one Downing Street adviser quoted by Jonathan Calvert and George Arbuthnott in their excoriating Failures of State. Unfortunately, the reality was that the NHS had a chronic shortage of the necessary equipment and a plan that was reliant on exactly the kind of ‘just in time’ supply methods most likely to be affected by a pandemic. Personal protective equipment that had passed its sell-by date during the austerity years simply had stickers with new sell-by dates stuck on top of the old ones; and sometimes, when that new date passed, a fresh set of stickers with another new date would be added. Austerity had hollowed out the system’s preparedness. Germany had 33.8 intensive care beds for every hundred thousand members of the population; Spain had 9.7; the UK had 7.3. During a crisis that resulted in an increased demand for acute critical care, this relative lack of provision directly translated into increased deaths.

One of the biggest scandals of the pandemic was the deaths of elderly patients caused by their being decanted from hospital wards into care homes, without being tested for Covid, and indeed without precautions of any kind being taken. The sudden and reckless nature of that decision is justifiably a source of outrage, but that can help distract from the systemic failure of social care which underlies it. Why were all those people blocking beds in hospitals in the first place? Because British social care is a disaster, which no government of either party has had the gumption to tackle. In her hospital doctor’s account of the first pandemic wave, Rachel Clarke points out that in the last twenty years there have been seventeen white papers, green papers and reviews of funding concerning social care, but no actual change. Social care wasn’t a disaster waiting to happen, it was a disaster that was already happening, in slow motion and full public view; but the only people who noticed or cared were those directly engaged with the system.

Failures of State is the best full account of the British response to Covid. Calvert and Arbuthnott were members of the Sunday Times team whose article of 19 April 2020 was the first detailed reporting of the government’s chaotic and lackadaisical initial response to the pandemic. It triggered a government response in the form of a bizarre, error-riddled two-thousand-word blogpost which served only to show how rattled the Johnson administration had been by the piece. The book is essentially a longer sequel to that initial exposé, which in all important points overlaps with the critique launched by the joint health and social care and science and technology committees: ‘one of the most important public health failures the United Kingdom has ever experienced’. The gravamen of the charge is as follows, from the committee’s report:

It seems astonishing looking back that – despite the documented experiences of other countries; despite the then secretary of state [Matt Hancock] referring to data with a Reasonable Worst Case Scenario of 820,000 deaths; despite the raw mathematics of a virus which, if it affected two-thirds of the adult population and if 1 per cent of people contracting it died, would lead to 400,000 deaths – it was not until 16 March that Sage advised the government to embark on a full lockdown (having said on 13 March that ‘it was unanimous that measures seeking to completely suppress the spread of Covid-19 will cause a second peak’) and not until 23 March that the government announced it.

There’s a lot to unpack in that. ‘Astonishing’ – yes. By the time the UK locked down, Covid cases were doubling every three days. In the nine days during which Johnson procrastinated, the number of cases rose from 200,000 to 1.5 million. That delay caused many thousands of deaths. It is apparent that the government’s strategy in the upcoming inquiry will be to blame the scientists. The report, frank in many respects, has an echoing, cathedral-like silence around the personal responsibility of the prime minister. But as Calvert and Arbuthnott make clear, Johnson’s leadership, or lack of it, was central to the government’s failure, then and later.

What the UK needed in early 2020, more than anything else, was for the pandemic to be taken seriously. We needed someone willing to look at what had happened in Wuhan and Lombardy, and make the most of the few weeks’ notice the UK had providentially been granted. Unfortunately, in Johnson it had a prime minister whose entire personality and philosophy are based on not taking things seriously. This was to have tragic consequences. In the early months of 2020, when the news about Sars-CoV-2 was emerging and getting rapidly, frighteningly worse, Johnson failed to chair five consecutive meetings of Cobra, the government’s crisis committee. It is almost unknown for the prime minister not to chair Cobra when he or she is in London. According to David King, the former government chief scientific adviser, Blair and Brown never failed to chair a Cobra meeting. Johnson failed five times in a row, always on the subject of Covid. The reason isn’t far to seek: he didn’t understand it and didn’t take it seriously. In the early months of 2020, the UK government had 25,000 civil servants working on Brexit, which Johnson was well aware lay somewhere on the spectrum between a mistake and a disaster. His private life was on the same spectrum. In the months after becoming prime minister, Johnson became the first holder of that office to get divorced, get married and have a baby, more or less simultaneously. Covid was not a priority. It’s amazing he showed up to any Cobra meetings at all.

The procurement of PPE was a failure; Test and Trace was a failure; the Nightingale hospitals were a failure; the missed circuit-breaker lockdown in autumn 2020 was a failure; the decision to go ahead with Christmas was a failure. The official line is that the NHS was never overwhelmed and that everyone who needed acute care got it, but as Failures of State makes clear, that claim is not entirely true. During the first wave, 47,000 people died of Covid, but only about five thousand received the top level of critical care. At the peak of the first wave, only 2.5 per cent of patients in intensive care were over the age of eighty. Most people who died did so on ordinary wards. In the second wave, the average age for admittance to critical care was 61; the average age of death was 83. The official version is that the old did less well in intensive care, and were as a result less likely to be sent there – but the survival rate for over-80s who were admitted to ICUs was 40 per cent. Some form of triage was taking place. Rationing has long been a daily reality in the NHS, but it is a reality that is not discussed, let alone understood or accepted, by the public. ‘Everyone who needed care got it and the system was not overwhelmed’ is a different story from ‘Most people under the age of 75 who needed ICU care got it, but quite a few older people who would have benefited from it didn’t get it and died as a result.’

Some of these failures were operational (PPE, Test and Trace) and some ideological, along half-baked libertarian lines. The principal example of the second group was the refusal to introduce lockdown measures in autumn 2020, in direct defiance of scientific advice. The government will try to stick the February/March mistakes on the scientists, but they’re going to find it much harder to do the same with September/October, because the consensus advice from the scientists was clear. It is simple common sense that failing to lock down early enough or hard enough causes a longer, harder lockdown later – a bias towards liberty logically involves earlier lockdown. But that was, and is, too much for many Tories to grasp. Sage called for a lockdown on 21 September, but Johnson refused to act on its advice until the case and death toll had mounted too high even for him to ignore; a second lockdown was instituted on 31 October. Scientists at Imperial College think the delay caused an extra 2.5 million infections. Add these to the infections caused by the delay in the spring, and four million UK citizens caught Covid after it was obvious that the country should have gone into lockdown. With an infection fatality rate of 1 per cent, that is forty thousand deaths. And the government’s bias towards inaction has remained. The UK’s Wimbledon number, the death toll that would have ensued with competent government, is tens of thousands lower than the actual death toll.

It isn’t always possible to draw a straight line from someone’s personal life to their public works. Johnson’s private life is his business. But one thing you can say about a man responsible for at least nine pregnancies by at least four different women is that he is prone to wishful thinking. That wishful thinking is the common theme in the government’s failures from spring 2020 to autumn 2020 to now. Johnson doesn’t want certain things to be true, so he acts as if they can be ignored. That strategy has worked for him in domestic politics. It was at the heart of his advocacy for Brexit. But it doesn’t work in economics, and it doesn’t work in dealing with a pandemic.

This is not to say that lockdowns are a panacea. They are clearly damaging, but there is a mysterious absence of evidence as to just how much harm they cause. I don’t mean economically – we can see the rough impact in the contractions of GDP all over the world – but to health and well-being. Hospital attendance for non-Covid illnesses crashed during the pandemic, causing doctors to wonder, in the words of Clarke looking around her empty hospital, ‘Where, we keep thinking, is everyone else?’ Waiting lists grew ever longer: there are currently a record 5.8 million people waiting for NHS treatment in England. That is a huge load of misery indirectly caused by Covid. I wonder, though, whether the deepest cost of the pandemic, after the immediate burden of illness and death, won’t be in the area of mental health. The young have had their education and their socialisation disrupted, with consequences that may take years to play out – that may, for all we know, be irreversible. Covid has involved an upturning of the contract between the generations: children have been conscripted to protect adults, and have paid the price. To protect people from a disease whose median victim was 83 years old, children missed 18 months of interacting with one another, at the stage of life when they need it most. It is depressing that there has been no national discussion about how the old are going to make it up to the young.

This increase in intergenerational unfairness has been one way in which Covid has worsened already existing social tensions. The pandemic has been vividly summed up as ‘middle class hiding while working-class people bring them things’ – and the data supports that idea. In David Spiegelhalter and Anthony Masters’s excellent collection of Covid statistics, Covid by Numbers, we learn that three of the jobs with the highest UK levels of Covid mortality were chefs, cab drivers and bus drivers. No surprises there. The less well-off people are, the less likely they are to work from home; the more likely they are to have to work in jobs involving close contact with other people and to live in crowded housing. This feeds into shocking ethnic disparities in outcomes: in the first wave, the Covid death rate for women of Black African ethnicity in the UK was three times higher than for the white population, and four times higher for men. There doesn’t appear to be any inherent difference in ethnic susceptibility to the disease, so these outcomes are determined by already existing social and economic inequality. Meanwhile the rich – surprise! – have got richer. In the US, Congress passed $2.7 trillion in economic support through the CARES Act, but as Tooze points out, less than a third of that, $610 billion, went to households; most of the money went to business. The CARES Act was ‘the largest slug of fiscal support ever delivered to an economy – anywhere, ever’. The result was a huge boom in asset prices – and who has the most assets? Duh: the rich. US household wealth rose by $18 trillion. Amazon hired 628,000 new employees, and the growth in its share price made Jeff Bezos the richest man in the world.

As that example shows, the fact that Covid has worsened existing tensions is a global theme, not just a UK one. The British government’s response to Covid has been poor, but it has not been uniquely so. The double failures of spring and winter 2020 have been counteracted by success in the area of vaccines and science: the randomised Recovery trial of Covid treatments has saved a million lives globally, and the UK leads the world in the genetic sequencing of Covid variants. The NHS teetered but did not keel over, mainly thanks to the efforts of its staff, leaving the UK squarely mid-table in the rankings of excess deaths: 25th in Europe. (Since different countries use different methods for counting deaths and don’t always have good statistics, excess mortality is the best metric for measuring the impact of Covid.) Eastern and Central Europe have the worst levels of mortality in the continent, indeed some of the worst in the world, thanks to the low uptake of vaccines, reluctance to lock down and creaky healthcare systems. Their difficulties are also a reminder that Covid is an ongoing crisis which has already undergone multiple plot twists. A Guardian headline from May 2020: ‘Why has Eastern Europe suffered less from coronavirus than the West?’ An Economist headline from February 2021: ‘Covid-19’s second wave has devastated Eastern European countries.’

We can’t entirely rely on official data to measure the impact of Covid. The official global death toll is five million, which we can be sure is an underestimate. The Economist’s data team, studying the raw numbers from a range of sources, put the real death count at 17.5 million. Europe is not the hardest hit continent. Covid feeds on inequality, so it is no surprise that Latin America, ‘the most unequal continent in the world’, in Tooze’s words, currently has the highest death toll. Peru has the world’s worst official Covid death rate: its large informal workforce had no choice but to keep working as the pandemic raged. Mexico, Bolivia and Ecuador have also been devastated.

In the developed world, Covid has made everything worse, along already existing faultlines. The one glimmer of relief in this jet black prospect lies in the fact that some of the developing world has not been hit as hard. Sub-Saharan Africa, in particular, hasn’t suffered as much as Europe and the Americas. It’s not entirely clear why. Africa is the world’s youngest continent, which helps: the median age of the population is 19.7, against a Western European median of 43.9. Since the risk of dying from Covid doubles with every six years of age, it follows that, everything else being equal, the median European Covid sufferer is 16 times more likely to die than his African equivalent. (I say ‘his’ because a consistent majority of Covid victims are men: the biggest meta-analysis of the various studies suggests that the global gender split is about half and half in cases, but 63/37 in ICU admissions and 57/43 in deaths.) Shorter life expectancies mean there is a smaller population of old people to die of Covid: 80-year-olds can’t die of it because they’re already dead (if you see what I mean). Africa also has more experience of infectious disease than the rich world. The continent’s traumatic recent experiences with Ebola are relevant: African governments did not need to be reminded how frightening new zoonotic diseases can be. In his bracing anti-lockdown polemic The Covid Consensus, Toby Green suggests that previous exposure to coronavirus-like illnesses has conferred a degree of immunity in Africa. Taken together, these factors have led to a mercifully low death toll in the world’s poorest continent. The East Asian experience of Sars had a similar impact on Asia’s governments: they took Covid seriously right from the beginning, and have the lower death rates to prove it.

The best book​  about Covid from a global perspective is Tooze’s Shutdown. He focuses on the economic impact of the disease and the economic response to it. When the pandemic hit, 95 per cent of the world’s economies contracted at the same time. At one point the global economy had shrunk by 20 per cent, an unprecedented number, but hardly surprising when you bear in mind that three billion adults had been furloughed or were working from home, and 1.5 billion children were prevented from going to school. Nothing even vaguely like this has ever happened before. The world’s capacity to absorb this degree of economic punishment is, as Tooze points out, a sign of how rich the world now is. During the darkest days of lockdown I often found myself wondering what the pandemic would have been like if it hadn’t been for the internet. The answer can only be that we would have pushed on through as best we could, and very many more people would have died. As it was, the thing that helped the world economy recover is very simple: money. Huge amounts of money. At the peak of the crisis, the US Treasury was buying back its own debt at the rate of $1 million a second. The total stimulus measures in the global economy were estimated by the IMF to have hit $14 trillion by January this year. Even Germany finally allowed the EU to turn on the money taps and create a €750 billion Next Generation EU package. Those of us with an interest in the workings of the global financial system will find in Shutdown an unsurpassably clear and comprehensive account of the way the world responded to the pandemic.

There is a huge problem here, though. The economic response to Covid has been a technocratic masterpiece, saving the world from what could easily have been worse than the Great Depression. But it has done so by ripping up the economic rule book, the ‘Washington consensus’ which has been central to the running of the world economy for the last four decades. In order to create the necessary economic stimulus, central banks have been buying back their own debt with newly created money. It works like this: imagine I’m the central bank. You have $100 million of my debt, paying an interest rate of, say, 2 per cent. I say: I’ll take that back off you, and in return, I’ll electronically create a new deposit in your name to the tune of $100 million. That’s money you can go out and spend, and that spending is what will stimulate the economy. This is called monetising the debt: turning government debt into cash. It’s ingenious, but it’s also the exact opposite of what central banks are supposed to do, according to the neoliberal economic rule book. Tooze has a wonderful quote from the prominent MIT economist Rüdiger Dornbusch from 2000: in the past twenty years, he says, ‘the very rise of independent central banks [has been] all about getting priorities right, getting rid of democratic money, which is always short-sighted, bad money’. Central banks, according to this system, are explicitly forbidden from monetising debt, because that would make their actions subordinate to the impulses of politicians. But now, it turns out, the thing that was completely banned – monetising government debt – is actually fine. Central banks can’t print money for political reasons, but it’s perfectly OK for them to print money when it’s necessary to keep the system running. It’s sometimes said that a certain kind of technocratic insider wants to keep democracy safe for capitalism. This is what that looks like: banks and governments doing things for economic reasons they would be forbidden from doing for political reasons. Printing money to keep the system running? Fine! Printing money to fulfil democratically mandated political objectives? Verboten!

Back when I was writing about the global financial crisis, I often found myself brooding on a parable. The tribe had an idol sitting on an altar, and had been taught, and had come to believe, that the idol was permanent, immovable, and that they had to worship it, because the idol was the embodiment of all immutable truth. Then one day there was a great rumbling noise and the immovable, permanent idol fell off the altar and landed on the ground with a huge crack. There was a terrible silence. The tribe shuffled their feet and looked at one another and didn’t know what to think. The silence stretched. Eventually, some members of the tribe, embarrassed and baffled, picked up the idol and put it back on the altar, and they all went back to worshipping it because they couldn’t think what else to do. The financial crisis exposed the fact that the central tenet of neoliberalism – markets can be trusted to regulate themselves, and the most important thing government can do is get out of the way of the market – was untrue. But nobody knew what else to believe, or how else to think: they had grown so used to a particular package of economic doctrines that they had come to accept them as fundamental principles of reality, instead of merely a description of the way some segments of the world economy had operated for a short stretch of time. So they went back to acting as if what had just happened hadn’t happened. They put the idol back on the altar. The economic response to Covid has seen that idol fall off the altar again, and this time it hasn’t just cracked, it has actually split in half. We can’t be about to put it back on the altar again, can we? Can we?

Tooze’s account of this process is both admiring of the technocratic competence involved in the economic rescue, and alert to the troubling void of ideology and politics it exposes. The idea that we’re going to lurch along from one crisis to the next and rely on the technocrats to fix problems when everything blows up, while inequalities rise and the rich get ever richer – is that really the best we can do? He ends Shutdown with an unusual and rather moving admission that he has been writing ‘in medias res’. With Covid, there’s no mistaking that the planet is in medias res. Much of the poorer part of the world is still susceptible to the disease, and as long as it is, many more people will die, and the risk of new and more dangerous variants will remain. In May 2020, the estimated cost of vaccinating the entire planet was $25 billion. That’s a lot of money. On the other hand, $20.2 billion is what the US military spent on air-conditioning each year in Afghanistan and Iraq. It might turn out to have been a very stupid $25 billion for the rich world to have saved. Covid is still here, 44 per cent of the world’s population is unvaccinated, and the lock is still rattling.

Listen to John Lanchester discuss this piece on the LRB Podcast.

Send Letters To:

The Editor
London Review of Books,
28 Little Russell Street
London, WC1A 2HN

Please include name, address, and a telephone number.

Read anywhere with the London Review of Books app, available now from the App Store for Apple devices, Google Play for Android devices and Amazon for your Kindle Fire.

Sign up to our newsletter

For highlights from the latest issue, our archive and the blog, as well as news, events and exclusive promotions.

Newsletter Preferences