Those of us who have been tracking the novel coronavirus since December can easily identify its key milestones. There was mid-January, when human to human transmission of coronavirus was confirmed. Then later that month Hubei province hit 500 cases, the unprecedented lockdown extended to almost 60 million people, and the Lancet published a study showing that a third of patients require admission to intensive care, and 29% get so bad that they need ventilation. By the end of February, a sobering WHO-China joint mission press conference illustrated the massive policy response in China – and, on 29 February, the UK saw its first case of local transmission.
In the UK we have had nine weeks to listen, learn and prepare. We have had nine weeks to run outbreak simulations, set up supply chains to ensure sufficient personal protective equipment (PPE) and ventilators, and bring about the availability of rapid, cheap tests. We have had nine weeks to establish algorithms to support contact tracing, and start mass awareness campaigns not only about hand-washing, but about the risks that the virus would pose to social and economic activity if not taken seriously by all. Countries such as Senegal were doing this in January.
The UK’s head start in managing the outbreak continued as our confirmed case count remained lower than our neighbours’. However, on 12 March, Boris Johnson announced that all minor testing and contact tracing would stop and passive self-isolation would be introduced for those with symptoms, all part of a herd immunity strategy supposedly endorsed by the “best science”. After a backlash from scientists, the government clarified that it was not explicitly pursuing herd immunity, but would be taking measures at the “right time guided by the evidence”, all according to a plan which it did not share with the public.
On 17 March, Imperial College released a study noting that it had revised the model the government had been using, and stating that suppressing the virus was in fact the best way to avoid a vast number of people dying. The earlier model did not include the ICU data shared in the Lancet on 24 January. Instead, it was similar, but much later information from Italy, that changed their recommendation.
So, at the end of week, the UK government did a 180-degree turn, reversing what it had said only days previously. It made the decision to take the same measures other countries had in order to delay the spread of virus: closing schools except for the children of key workers, closing pubs and other gathering places, asking households to self-isolate for 14 days and focusing on scaling up testing to 25,000 tests per day over the next month. However, capacity issues and lost time mean that testing will take time to ramp up, PPE supply chains are strained, and all while patient numbers continue to increase as we follow Italy’s path.
The twists and turns described above have created a climate where the public do not trust that the government is responding in their best interests. Many cannot say what the government’s strategy is, or are confused about how serious coronavirus is for their health. Communication during a crisis must be clear, transparent, open and responsive. The confusion over herd immunity, for example, has made people reasonably think that the government wants everyone to get the virus to protect the economy, that it is not taking more decisive action because this is not a serious threat, or that the government does not know what it is doing. None of these are the whole story, but such perceptions are certainly not helpful in a crisis.
We had a choice early on in the UK’s trajectory to go down the South Korean path of mass testing, isolating carriers of the virus (50% of whom are asymptomatic), tracing all contacts to ensure they isolate as well, and at the same time taking soft measures to delay the spread. Instead, we watched and waited, and whether it was academic navel-gazing, political infighting, a sense of British exceptionalism, or a deliberate choice to place minimising economic disruption over saving lives, we have ended up in a position where we are now closer to the Italy scenario than anticipated, and are faced with taking more and more drastic measures.
Perhaps the delay was due to fears about a second wave of the virus, next winter. But why not then work on buying time for the NHS to prepare, for health staff to get PPE, to make testing available, to boost beds and equipment, to trial antiviral treatments, or get us closer to the point that one of the vaccine candidates being investigated might actually work. Why not use the time to learn more about reinfection by the virus, about immune response, which seems to affect who needs ICU care, and about who recovers spontaneously? To understand where this virus came from, whether it is indeed seasonal, and how it could mutate? Why give in at such an early stage unless the goal is to get through this outbreak quickly so that whoever is left can help get the economy back to normal? It is still not clear who exactly is advising the government, who sits on the Scientific Advisory Group for Emergencies, and what factors the prime minister and his colleagues are taking into account in his decision-making.
Where does all this leave us now? Given that we lost the window of containment several weeks ago, the only feasible path forward seems to be to put in stringent physical distancing measures to delay the spread of the virus. But these alone will not be enough. We also need to backtrack and start doing the mass testing, tracing and isolating that are integral to breaking chains of transmission. Putting these measures in place does not mean that we will immediately solve NHS capacity challenges, or that we will not see a massive rise in patients dying. They will, however, help to slow down the spread. We must also continue to push for the protection of the health workforce and frontline responders who are exposed to high viral loads. And we must race to make up for the time lost during two months of passivity.
• Prof Devi Sridhar is chair of global public health at the University of Edinburgh
