Liam Donaldson: 'My bottom line is that I would go to the wall for the public'

The Monday Interview: Professor Sir Liam Donaldson, Chief Medical Officer

"Everything that needs to be done is being done," says Professor Sir Liam Donaldson, the Government's chief medical officer. Note the choice of words. Not everything that can be done. Does that mean some things are not being done because other needs ­ protecting industry or the economy ­ are greater than the need to protect the public from severe acute respiratory syndrome?

There is a visceral distrust of governments on public health issues, which has grown with successive disasters ­ from the safety of eggs to BSE to foot-and-mouth disease. Since John Gummer, as agriculture minister, fed a hamburger to his daughter for the television cameras to show that British beef was safe, people have asked in every scare since whose interests are being served. Think of the row over the MMR vaccine. And science has been the loser as the distrust of ministers has spread to distrust of the research on which their advice is based.

Sir Liam is the man on whom ministers depend to decide how we should defend ourselves against this new threat. A large, kindly-looking man with sandy hair and small brown eyes that peer out of a slightly forlorn face, he has won admiration during the four and half years he has held the post for his rigorous analysis and sound judgement. A former minister said he was the one senior official who could be relied on for well argued and immaculately presented briefs.

In preparing his advice on Sars he must have to strike a balance between two harms: that potentially caused by the disease and that caused by the measures taken to protect against it. Already, there is growing criticism that there has been an overreaction to Sars and that the global panic is doing more damage than the global epidemic.

Sir Liam's response is robust. "My bottom line is that I would go to the wall for the public because that is who I am there to serve. When there have been problems in the past on public health it is because other considerations have been put before the public health. I would rather be precautionary and warn people of the dangers than laid back and reassuring.

"But you have got to remain extremely flexible. We are living this, breathing it, thinking it every waking hour. We are not static on this. We are ready to respond with any option."

Aged 53, he routinely works 12-hour days, six days a week and attends royal college dinners or other events in the evenings. He has no small talk, colleagues say, and is a man for whom the phrase "work is more fun than having fun" was invented. Public health and public service are in his genes ­ his father was medical officer of health in Rotherham. As the only boy from a professional family in his class at Rotherham grammar school, he was teased when he had to take a letter from his father about school immunisations home to his mother. "I learnt how to blush," he says.

Sars is not the first public health crisis he has had to deal with. There was the meningitis outbreak in 1999 and the continuing battle over MMR, which is etched on his consciousness. "It is one of the most difficult things I have had to handle."

But on Sars, he admits, he has a difficult a path to tread. He is under pressure from Liam Fox, the Tory health spokesman, among others to introduce tougher measures ­ health checks on entry to the UK, quarantine, making Sars a notifiable disease. Has he resisted doing so because of the disruption they would cause? And is he not by his reluctance to implement such measures gambling with the safety of the many to save the inconvenience of a few?

Dr Fox, a former GP, became an instant expert on Sars after visiting Australia and returning to the UK via Singapore last week, where he encountered far more stringent measures in place. He has been a thorn in the Government's side since, accusing it of complacency and failing to give "full protection to British citizens".

But Sir Liam, the polar opposite of the excitable Dr Fox, says calmly that those measures are not needed now when the priority is early detection and isolation of affected individuals. He has not ruled them out. They may become necessary, but not yet. The priority has to be to remain flexible in the face of the biggest problem with the disease ­ our ignorance about it.

"I think there will inevitably be more cases of Sars in this country as there will be in the other 28 countries round the world. The criterion of success will be how we contain the secondary spread beyond the initial traveller who comes in. We can't close our borders to the rest of the world. We need to keep all our options in play. We have had six cases here and none would have been detected by exit or entry screening. The idea that we can block the entry of Sars risks taking our eye off the ball."

On Dr Fox's specific proposal that Sars should become a notifiable disease, he says: "The prime purpose of notification is to ensure detection of all cases of a disease. But it's a very traditional system, based on form-filling. We don't want to be bogged down by a traditional style of reporting. We want to hear about cases quickly, by phone, e-mail and word of mouth. There may be a case for making Sars a notifiable disease, but at the moment getting a high level of surveillance of cases is the priority."

To critics who accuse him of scaremongering ­ the News of the World described the risk from Sars yesterday as less than that of falling downstairs ­ he acknowledges that the risks are currently low but says we do not know what may happen next. "I remain uneasy about the position in the UK. It is unpredictable. It may get better or worse but we have to assume it may get worse. It is difficult to know where Sars stands in the hierarchy of public health villains. We need to learn from events in places like Toronto where it has got significantly out of its box.

"I know and love Toronto, and its image and economy has been damaged. That is the downside. But it's necessary in a situation like this that we act without fear or favour and come down on the side of the public health. The key to everything in something like this is to identify cases in the population and then bring in control measures and treat them."

So how high does he rate the threat from Sars? New diseases are emerging all the time, many the consequence of viruses jumping from animals to humans, as the coronavirus that causes Sars is thought to have done. There have been about 30 new diseases in the past three decades, of which by far the worst has been Aids. Sars, he says, is not in the same league as Aids or as the long-expected rogue strain of influenza that scientists say will one day cause a pandemic possibly on the scale of the 1918 catastrophe, when at least 20 million people died.

"It is a little early to say how big Sars is going to be but it will be nowhere near on that scale. That is the nightmare scenario. But we can never be sure with viruses how they will mutate. It could become more virulent or it could burn itself out. It is unpredictable. We don't know what it is going to do next."

He agrees with Roy Anderson, professor of epidemiology at London University's Imperial College who is due to publish an analysis of the Hong Kong outbreak this week, that the death rate is probably higher than the 5 per cent quoted by the World Health Organisation. Though the total deaths and infections from Sars are a fraction of those caused by other diseases including malaria or tuberculosis or road accidents ­ so far ­ we cannot afford to be complacent, he says.

Travellers to the tropics may be at greater risk of getting malaria (there are up to 200 cases and one or two deaths among British tourists each year) than travellers to the Canada or the Far East have of getting Sars, but the difference is that you can give yourself protection against malaria by taking anti-malarial drugs.

"The chances [of travellers catching Sars] are low but people need to know there is a definite risk in those areas. We don't understand enough about it. When we know more, we may be able to give more tailored information to enable people to reduce the risk to a minimum."

Of the six cases of Sars recorded in the UK so far, only one was contracted here, when a businessman visiting from Hong Kong passed the infection on at a meeting in a Heathrow hotel. But the prospect of a case arriving and triggering an outbreak here similar to that in Toronto is what is constantly at the back of Sir Liam's mind. He has dispatched a specialist to the Canadian city to see what can be learnt from their experience. "That is what we have to combat. That is the big challenge," he says.

When Sir Liam was a regional NHS director in the North, the Gummer hamburger incident during the BSE crisis so appalled him that he vowed when he became chief medical officer that he would always tell it straight, putting the public interest first. He has become more authoritative and more visible than either of his predecessors in the job, growing more comfortable in front of the camera, more relaxed on the podium and more adept at handling the disparate audiences whom he is required to address. He is prone to the occasional nannyism ­ "people must understand ..." is a too-often used phrase ­ but his style has softened as his confidence has grown. He does not seek personal publicity, he says, and is wary of people who do.

"I think there are some people in public life who worry less about what is the right thing to do than what is right for their image. I am proud of what I do and what I achieve but I don't worry what people think of me. I don't pore over the cuttings thinking how is this going to make me look. If you have a big ego, I think it is a highly dangerous quality and by virtue of my genes I suppose I don't fall in that category."

Although he insists he proceeds "without fear or favour" where there is a potential clash between commercial and economic interests and the public health, others around him do worry about the consequences of his advice. There have been some tense moments between the Department of Health and the Foreign Office over the travel restrictions, with the latter questioning their necessity. But Sir Liam, with support from Alan Milburn, the Health Secretary, has got his way.

His biggest concern is that the time he and his team spend on Sars is time lost to the myriad other issues demanding attention. The infectious diseases unit is working on plans to deal with tuberculosis, influenza and hospital acquired infections, all of which are on hold ­ as is work to consolidate reforms in the NHS.

For now, Sars sweeps all before it. And Sir Liam has to try to turn the tide. If he gets it wrong, Sars could get a foothold here, people may die and London could be closed down as Toronto and Hong Kong have been. If he gets it right we will all breathe more easily.