It is 100 days since the first coronavirus case was confirmed in the UK on 31 January. The official death toll so far from the epidemic has topped 33,000 and is still rising fast. The actual total could be far higher, many analysts say – leaving Britain among the countries hit hardest by Covid-19.
The government has struggled to get on top of the crisis, facing growing criticism for its lack of early preparation to tackle the virus, its abrupt shifts in strategy, its failure to provide adequate protective equipment for its medical staff and other key workers, and its inability to organise testing on the scale that many say is vital.
And its communications have been widely described as evasive and shambolic – with many left confused last week as the Cabinet battled to provide a coherent account of its plans to lift the lockdown.
Those plans have been complicated by the fact that our infection rate remains stubbornly high and, as a result, any measures announced by Boris Johnson on Sunday are expected to be modest. While some other countries are embarking tentatively on a return to normality, Britain is struggling to meet its criteria for doing so.
Amid a growing perception that the government’s record in confronting the crisis is amongst the worst in the world, the Labour leader Keir Starmer confronted Boris Johnson this week in their first prime minister’s questions meeting with the stark question: “How on earth did it come to this?”
Below Robin McKie, Toby Helm and Emma Graham-Harrison try to answer that question by considering the key factors that might lie behind our disaster.
Politics
Over the past week there have been moments when members of the government have given up pretending that all has gone well. As evidence of the mishandling of the pandemic response has piled up, some ministers have realised they would sound ridiculous if they could not admit that errors had been made.
On Wednesday, James Brokenshire, a home office minister, accepted that more testing early on would have helped. “There is an acknowledgement mistakes have been made – no government is going to get everything right,” he said. Then at Prime Minister’s Questions the same day Boris Johnson admitted his “bitter regret” at the crisis in care homes. But they have been rare admissions.
Over the last few days the UK’s political leaders have been divided over the lockdown and how to keep the public safe. Mid-week, Downing Street was indicating it wanted to end the “stay at home” message while Nicola Sturgeon, Scotland’s First Minister, protested that to do so would risk many more lives. The issue was still being debated at the highest levels on Friday as No 10 appeared to be backing off such a change.
No one can expect politicians to handle a crisis on this scale without things going wrong along the way. Labour, under its new leader Keir Starmer, has acknowledged that. He held back in his criticism until last week, knowing that the country wanted this government to succeed. But he, too, would not have been doing his job had he not highlighted government failings in his first PMQ with Johnson. Why, he asked, had the government been slow on testing, slow on supplying PPE to NHS and care home workers, slow on going into lockdown?
When the inevitable public inquiry is held, Johnson’s government will face hard questions about its response. When many UK scientists were growing increasingly worried about Covid-19 in January and February, Johnson and his team had other things on their minds – enjoying their general election win and “getting Brexit done”.
Johnson inherited public services ill-equipped to handle a pandemic. The NHS lacked enough intensive care beds, protective equipment for staff and, initially, ventilators. The social care sector, shamefully unreformed, was another victim of Tory austerity that has paid the price. Anglo-Saxon economics has left the UK vulnerable, whereas countries which had spent more on their health systems – Germany is the prime example – have fared better.
Decision-making has also been found wanting. The UK ended track-and-trace testing on 12 March, because there was not the capacity to carry on. A sense that the UK could somehow tough it out prevailed for too long.
Early on in the crisis Johnson missed a series of Cobra meetings about Covid-19 and was still proudly shaking hands with people in hospitals in early March. Now, as he tries to find ways to ease the lockdown, while at the same keeping the risk of a second wave to a minimum, the test for the government is to keep the public believing it has the answers. So far much of the evidence has suggested otherwise.
Toby Helm
History
Britain’s pandemic planning was extensive – even if the government did not choose to implement lessons learned from its 2016 simulation, Exercise Cygnus – but the one thing it did not have was recent first-hand experience of a major respiratory disease outbreak.
When Covid-19 arrived, it had been over a century since the Spanish flu swept through the country.
Decades without an airborne epidemic of a new disease may have bred false confidence that viruses like severe acute respiratory syndrome (Sars), which spread from China in 2002, and Ebola, which first appeared in Africa in the 1970s, could be contained near their place of outbreak.
Countries that lived through those outbreaks first hand were among those that moved most swiftly and decisively against coronavirus, the tragic lessons of the past a spur to action.
Before Covid-19 had been identified as a coronavirus, and when it was still being described as a “mystery pneumonia”, Taiwan brought in checks on passengers flying from Wuhan. These soon expanded to over 120 measures including strict quarantine, border controls, testing and contact tracing.
“We learned very harsh lessons from Sars and that experience is something other countries don’t have,” said Chan Chang-chuan, dean of National Taiwan University’s College of Public Health. To date, its Covid-19 death toll is six, despite its very close economic and cultural ties with mainland China, and a high volume of cross-border travel between the two.
South Korea endured Sars and has even more recent memories of a fatal coronavirus epidemic, after Mers (Middle Eastern respiratory syndrome) broke out there in 2015, killing 36 people. It began ramping up testing capacity from January, before the disease had arrived in force.
At one point the country had the highest number of cases outside mainland China, but its testing and careful contact tracing meant it was among the first and most successful countries in flattening the curve.
Experience of Sars may have made governments more confident the public would accept restrictions, and that proved indeed to be the case: many people took proactive measures, such as covering their faces, even before authorities stepped in.
And in Africa, experience of Ebola may have helped Sierra Leone keep cases to just 231 so far; authorities repurposed tracking systems set up in the wake of the 2014 outbreak.
But there are also countries that have not lived through recent outbreaks of respiratory epidemics that have responded fast and kept cases low, from New Zealand to Senegal and Denmark.
So while past experience may have helped some countries, it was not a necessary condition for a rapid and effective response and should not be seen as an explanation for why the UK has been so badly affected.
Emma Graham-Harrison
Demography
Age clearly plays a key part in influencing the outcome of Covid-19 and is highlighted as a cause of some of the widespread variations seen in death tolls from different countries. Italy and Spain have relatively old populations and have suffered high death rates while nations such as Ireland, with lower median ages, have fared better. So could the UK’s relatively elderly population explain our high death rates?
No, said Professor Sarah Harper, founding director of the Oxford Institute of Population Ageing.
“From a demographic point of view, the UK is no different from most other European countries. In fact, we are on the younger side, so you cannot blame the age structure of the UK for this.”
In addition, care homes – claimed by some to be a special UK issue – have proved to be serious problems in other nations with substantial Covid-19 death rates, including France, Belgium and Norway. “Care home outbreaks are almost inevitable without really radical measures to prevent them,” said Professor Noel McCarthy, of Warwick Medical School.
Scientists have also found that individuals from black and minority ethnic (BAME) groups have been disproportionately affected by Covid-19 in Britain. About 13% of the UK population come from BAME backgrounds but they account for a third of virus patients in critical care units. Last week, figures for England and Wales suggested that black people were four times more likely to die from Covid-19 than white people.
However, this picture is not unique to the UK. Nations that include Norway and the US have also reported high Covid-19 death rates among BAME people. Just why this is occurring remains unclear – though scientists point out that BAME groups tend to suffer from higher rates of diabetes, heart disease and obesity, conditions that make people more vulnerable to Covid-19.
Another key risk factor is obesity. Those with a body mass index greater than 30 are more likely to need intensive care than those with healthy weights. Britain is facing a major obesity problem, doctors have pointed out, and this could explain, in part, our high Covid-19 fatality rate of nearly 500 deaths per million people. Yet this picture is confounded by comparisons with other nations. For example, New Zealand has a worse prevalence of obesity than the UK but has a Covid-19 death rate of only 4 per million.
“To be blunt, it was a lack of testing, a failure to shut down society in time, and a lack of care equipment that are to blame for current high Covid-19 death rates,” said Harper.
Robin McKie
Geography
Britain is a densely populated nation containing a very large capital city. More than 9 million people live in London and more than 18 million people arrived in the UK in the first three months of the year: a perfect nursery setting for a new virus to take seed and then increase in numbers in an explosive, exponential manner. Other densely populated places such as New York and northern Italy have also suffered.
So was the UK simply unfortunate? Has its population felt the impact of Covid-19 more deeply because of its geography?
The link is weak, say epidemiologists, who point to many other cramped, bustling cities that have relatively low numbers of Covid-19 cases at present. A good example is provided by India. It is the world’s second most populous nation and its cities – including Delhi, Mumbai, and Kolkata, some of the biggest and most populous urban centres in the world – are renowned for their dense populations and tightly packed housing. Yet Covid-19 death rates are remarkably low there. Last week, the death rate from the disease stood at 1 per million people in India, it was reported. The UK’s rate is reported at nearly 500 per million.
As a result, many UK scientists reject the idea that Britain’s high death toll is simply a matter of unfortunate positioning or a result of the high density of much of its population. “Were we unlucky? No. We just didn’t have a proper plan for dealing with this. Other countries did,” said virologist Professor Nicola Stonehouse, of Leeds University.
This point was backed by consultant cardiologist Amitava Banerjee. “We were not humble enough to look at other countries – China, Italy or Spain – and learn a lesson from them and lock down quickly,” he said. “It is as simple as that.”
“We were arrogant,” added Banerjee, who is also assistant professor of clinical data science at University College London. “We thought we had nothing to learn from other countries and thought we were an exceptional case. In fact, we had a lot to learn but didn’t take the opportunity.”
Taking lessons from past mistakes and from the examples of other nations will be crucial if Britain is to hope to extricate itself from the medical crisis it now faces, say epidemiologists.
Robin McKie
Endgame
How Britain extricates itself from its coronavirus lockdown will be a delicate procedure, scientists agree. In general, they envisage an approach that would maintain restrictions until numbers of Covid-19 cases are low enough to allow the tracking and isolating of individual cases.
However, at the current rate of infections, it is hard to see when that might occur. Last week, the number of new cases of Covid-19 that were being diagnosed every day hovered around the 5,000 mark. That is far too high to allow tracing of newly infected individuals. The tracking system would be overwhelmed in days. The country therefore faces a choice. It could endure even harsher lockdown rules – with no exercise permitted – or maintain the current system for months. Alternatively, it could ease the lockdown in the near future and risk facing a rapidly rising second wave of cases.
Whenever lockdown is relaxed, emphasis is likely to be placed on shielding the vulnerable, in particular those who have high risk factors, such as the elderly. They would be isolated and their visitors given daily tests to show if they had been exposed to the virus.
However, this idea is questioned by Professor Sarah Harper of the Oxford Institute of Population Ageing. “If you look at the mathematical models, you can see that if we remove the over-70s from everyday life we could slow down viral transmission and possibly stave off a second wave of Covid-19. But we would be doing something purely on the basis of age.” And that, said Harper, could be seen as unfair.
“Mathematical models are useful for describing different alternative scenarios but these then have to be considered in the light of societal acceptability by our policy-makers and politicians.
“Older people are not the only ones vulnerable to Covid-19. Men are twice more likely to die of the disease than women, while people from BAME communities also have higher than average death rates. What if the modelling showed that removing all men from society for a longer time would have a similar effect? Would such a plan be acceptable? Probably not.”
A vaccine is a long-term hope but there may be other measures that decrease transmission that are available now, added Professor Noel McCarthy of Warwick Medical School. “For example, if public mask-wearing decreased spread by 20% it would reduce mortality by more than the whole of the lockdown to date – but we need real evidence, such as a large-scale trial, to give evidence to support this in the longer term.”
Robin McKie
