Sun Tzu, the great Chinese military commander, said that all battles are won or lost before they are ever fought. By first week of February, the UK and many other European countries had lost the battle against coronavirus. Another of my favourite life sayings is that ‘Assumption is the mother of all screw-ups’. Assumptions by UK government, Sage, NHS, Public Health England and the Department of Health and Social Care were certainly the mother and father of this one.
The NHS, PHE and Sage thought they were well prepared for a pandemic: there were dozens of reports, response strategies, protocols, operating plans, models, transmission studies — you name it, there was a long document about it. There was even a full simulation, Exercise Cygnus, in 2016. Just one problem: all the preparations and models were essentially based around influenza. And Covid-19 is not the flu.
Returning to military analogies, when the Covid-19 outbreak began to spread, the UK was fully prepared for a full-frontal onslaught by infantry, tanks and traditional forces arriving from China. But instead, large numbers of undetected undercover agents swarmed in from Italy and Spain in early and mid February and suddenly executed shattering attacks on our most vulnerable targets. Morale was destroyed, the battle was lost.
Classic influenza epidemic guidance from NHS and PHE as to what symptoms to look out for were broadly useless, because Covid-19 is frequently asymptomatic or very mild in young healthy people. It was silently carried into inpatient hospital wards, where it exploded — and turned out to be lethal to the elderly and the ill. Was this allowed for in the preparations or assumed in the models? No preparation had been done to protect institutions housing the sick or frail. Pictures of hospital corridors in Italy hit the media and there was panic.
So the first and biggest mistake was made before the beginning: the government had war-gamed for a flu outbreak and no one had bothered questioning what was appropriate for a new virus with some critically different characteristics. But the second and possibly even bigger mistake was made in March: to clear the hospital wards for the supposed rush of incoming patients, so as to avoid a repeat of the situation in Italy, thousands of untested patients were discharged into care homes. This was a catastrophic error.
Let’s consider for a moment just how dumb this actually was: by early March, Sage, NHS, PHE, everyone knew that Covid-19 was selectively extraordinarily lethal to old and ill people — and frequently mild or asymptomatic in others. Infection controls may have been problematic in hospital wards but they were completely nonexistent in many care homes. Their residents were sitting ducks. The NHS — and PHE — then set about those sitting ducks with a heavy machine-gun.
When this is all over (and if we are ever told the true numbers of deaths that resulted from infection acquired either in a hospital or a care home) I suspect we shall see that actually this was most of the entire death toll. Deaths from infection within the wider community will probably have been significantly lower than a bad flu season and will mainly have been limited to households where the elderly share homes with younger family members or carers, who unwittingly infected them.
Outside of care homes and hospitals, there are signs that a number of us may have innate immunity or at least some resistance. The disease is mild for most people and rarely fatal. The herd immunity threshold is probably 20 per cent in towns (as London appears to demonstrate) and lower outside. Not 60 per cent, as modelled by the discredited Imperial crew. With or without lockdown, the epidemic would have been mild and died out quickly for those living in their own homes.
We don’t need theoretical and speculative epidemiological models now we have hard data from all around the world. We have countries that executed hard lockdowns, soft lockdowns and no lockdowns; we have individual states of the USA that responded in different ways. Countries and states that implemented hard lockdowns suffered no fewer deaths than those that did not. The facts now speak for themselves.
More difficult to unravel is what did actually make the difference. How did countries such as Japan or Germany do so relatively well? Many of the answers that get trotted out simply do not stack up: Japan, for example, has a very elderly population and extremely crowded cities, yet had limited lockdown and did very few tests — and to suggest that the tiny death toll is because they have a lower obesity rate and eat a lot of fish is statistically absurd. Once again, the answer seems to lie in care homes and hospitals.
Countries that suffered very low death tolls did not see high numbers of deaths in hospitals and care homes. Either — like Japan, and to some extent Germany — they had in place far better infection controls to prevent the spread of (any) infection around hospital wards and into care homes, or, like other less developed countries, they simply don’t have an extensive network of care homes and long-term inpatient hospital wards. Personally, I am optimistic that Africa, or at least most of it, may be the big dog that didn’t bark: coronavirus may not be a big problem there. So let us hope that indirect results of the epidemic do not create a different health issue.
So what have we learned? That theoretical mathematical models are broadly useless, with far too wide a range of outcomes to have any meaning until the outbreak is well established (by which time it is too late). Instead, the medical facts about the disease need to be closely examined as soon as they are known, and careful preparations made that address these specific practical characteristics of the disease.
Does the virus kills old people? Then protect old people. If it can be carried asymptomatically, you need a lot of testing and infection control in hospitals. A mathematical model will not inform these decisions. Above all, we need to make practical preparation for the disease that is — not theoretical preparations for the disease we thought might be.
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