A Social Democratic Future

Summary (added 29th July)

This is a detailed but personal narrative of the UK’s public policy response to Covid to the decision to lockdown on 23rd March.

Minutes and papers of the government’s main scientific advisory group (SAGE) are used along with subsequent parliamentary committees to investigate and analyse the claim made by some members of SAGE and other informed commentators that up to 25,000 of the 45,000-plus hitherto recorded deaths were avoidable.

It concludes that undue retrospective focus on the one week or more delay in the imposition of lockdown diverts from understanding , and acting to remedy the underlying causes of the UK’s (and England’s) high per capita Covid death rate: lack of government preparedness; of foresight; and of focused flexibility, manifested in the concentration of Covid-deaths within its care homes for the elderly as result of negligent acts of both commission and omission.

The last section uses international comparisons to highlight lessons to be learnt that simply put are: learn, learn, and learn; test, test, and test.

Introduction

The first worldwide Covid case was confirmed on 31 December in Wuhan, a large inland Chinese provincial city, home to 11 million people. An animal-based virus had switched across to humans, probably via its under-regulated live food markets.

Dribs and drabs of information concerning its emergence and spread circulated but elicited little focused concern within the policy-making citadels of Europe and America.  Many stockmarkets, apparently unperturbed that a pandemic might soon be unleashed and wreak economic havoc, continued to climb to near-record highs. Aviation traffic continued unabated.

Personally, I travelled from Kolkata in India – my wife’s family home – back to my London home on the 14^th January to return to work, without a thought about Covid, then still known by the generic label, Coranavirus.  Before long, like most of us, I was to learn much more.

The first public awareness watershed was Wuhan’s lockdown on January 23. This was imposed by the Chinese government to prevent the further propagation of the virus by city residents travelling for their Lunar New year celebrations. Many already had. Pictures percolated within mainstream media of deserted Wuhan streets. The opening of a 1000 bed pop-up hospital built in short scratch to relieve pressure on its locally overwhelmed health system briefly made the headlines in early February.

Yet all that was still over there; for most people still a distant and unknown continent: there was no suggestion, nor did it cross my mind, that London would begin to endure an even longer lockdown before March was out.

On 31 January – the same day that the UK exited the EU – Chris Whitty, England’s chief medical officer (and principal medical adviser to the UK government) confirmed the first Covid cases in England.

A few days earlier the World Health Organisation (WHO) had declared Covid a public health emergency of international concern.

Cobr(a) – the inter-departmental group named after the cabinet briefing room where it met – convened usually to plan government responses to terrorist threats and to emergencies, such as flooding, had already assembled the first time to consider the threat from Covid.

It was, however, an emerging threat still very much overshadowed by the wider political backdrop, most particularly the continuing Brexit saga.

A 3 February a keynote speech in which the new prime minister predicted a ‘supercharged’ free trading future for a UK now freshly freed from its EU shackles grabbed the headlines. Covid was not going to be allowed to get in the way of that.

The same day, the UK-registered Diamond Princess cruise ship returned to Yokohama port in Japan. 3,711 passengers and crew were quarantined there on board for 14 days.  Some were repatriated by the US and other governments prior to the completion of that initial quarantine period. Others, testing positive but not hospitalized, remained on board throughout much of February, even into March.

711 people (19%) on that ship ultimately tested positive for Covid, many of whom were transferred to over-stretched local health facilities. 13 died, including the first UK national to suffer a reported Covid-related death.

The propensity of the virus to spread quickly but unevenly among an elderly passenger demographic sharing common facilities had been demonstrated: the World Health Organization (WHO) advised that Diamond Princess accounted for half of all Covid cases then reported outside China.

The lesson that was there to be learnt concerning the protection of their respective resident care home populations was not learnt either by the UK government or its devolved administrations or many other European governments.

The initial UK public health policy response was one of containment: detect early cases, follow up close contacts, to prevent the disease taking hold, for as long as possible.

In line with that international travelers from infected areas were taken under police escort to requisitioned hotels for 14 days quarantine. Identified actual cases in the UK were few – fingers on one hand. International airlines withdrew their Chinese flights.

Half-hearted efforts were also made to introduce contact tracing. This identified that a middle-aged Hove man, after apparently contracting Covid in Singapore on a business trip before interrupted his journey home to take a short break in a French ski-chalet, had apparently infected at least five people – a high proportion of the total hitherto recorded as Covid-infected – at least in England.

The part-time scout master was later interviewed in magazine-style format as a bit of curiosity, in rude health following his period of quarantine in a London hospital, reflecting the prevailing media noise, which then seemed as likely to recede than to intensify.

The European response to Covid continued to be muted, restrained, and, in retrospect, blasé throughout much of February; to the point of negligence, even.

Across the Channel in newly liberated Blighty, the political and public policy response to Covid was likewise lacklustre, not ‘supercharged’. In mid-February, Boris Johnson enjoyed an extended period of ‘down time’ at his Kent ‘grace and favour’ historic mansion, apparently basking in the glow of having got both a 80 seat majority for his party – its largest since 1987 – and ‘Brexit Done’. It later transpired that his new partner was pregnant.

And as the days gradually got longer the attention of the wider population drifted rather to the future joys of spring replacing the partial and chosen hibernation encouraged by a dull and wet winter.

The last week of February was half-term. The more affluent jetted-off for skiing holidays in alpine Europe; greater numbers headed to packed domestic attractions. I, myself, organized a short break to Bavaria for the end of March, looking forward to crossing much of the region by public transport, sampling the local sights and amenities.

Poignantly, later, in May, Sir Patrick Vallance, the UK’s chief scientific adviser, was to tell MPs that a wave of imported Covid-19 infections had flowed into the UK in early March – a flow quite possibly accounted for by returning half-term vacationers. Hindsight is both a wonderful and cruel thing.

Although Cobra continued to meet and consider Covid in the prime minister’s absence, the emerging pandemic persisted in media portrayal as primarily a Chinese problem producing incidental issues elsewhere that threatened to become larger.

Nearly all the c.3,000 deaths recorded as Covid-related by the end of February had been recorded in China, save for less than 100 elsewhere in the world.

By the end of March, however, as we will shortly see, the picture had already both burst its frame and inverted: China accounted for c3,300 of a worldwide total of c39,000 deaths.

Boris Johnson finally attended his first Cobra meeting on Covid on the 2 March.

Science, SAGE, and public policy to lockdown

The Scientific Group for Emergencies (SAGE) remit is to provide timely and coordinated scientific advice to decision makers within Cobra, Cabinet, and right across government.

Co-chaired by the government’s chief scientific and medical advisers, mainly comprising independent academics within specialist supporting expert groups, such as the Scientific Pandemic Influenza Group on Modelling (SPI-M): a key group focused on infectious disease modelling and epidemiology. Another was NERVTAG, the novel and emerging respiratory infections group.

From January onwards SAGE met regularly – usually twice-weekly – on Covid. Its operations and deliberations and feeder groups were initially opaque and mysterious, but following accusations of non-transparency, minutes of its meetings, consensual statements, with some supporting papers, were belatedly published, albeit weeks in arrears.

These show that its meetings and papers were marked by uncertainty and tentativeness, practically until lockdown was announced.

There was a reliance, well into February, upon models predicated on assumptions derived from the experience of previous influenza epidemics. Undue weight was placed on transmission by children. The exceptional exposure risk to the very elderly – in care home settings especially – that Covid posed was an absent parameter (not factored-in) in the models assembled for, and considered by, SAGE.

These models therefore missed a key real-world determinant of Covid outcomes across the UK: an omission later explained by Sir Patrick Vallance and other key SAGE members as due to lack of data.

A 3 February statement concluded that without a better evidence base concerning the transmissibility of the virus, the impact of potential interventions and their interaction on Covid spread would be hard to determine, noting, for example, that little direct evidence was available on the effects of cancelling large public events.

And, a 25 February supporting paper considering the impacts of various non-pharmaceutical interventions (NPI’s), concluded that, excepting for school closure, reliable estimates of their impact were lacking, even for influenza. That meant, in turn, that there was “insufficient data to parameterise the simulation model (used here) accurately enough to give a high level of confidence in model predictions of individual policies”.

The ‘science’ was flying mainly blind as the coming Covid storm gathered strength and speed.

What was better understood, however, within SAGE, was that without action a future pandemic would overwhelm the NHS before its peak was reached, but that a sustained application of NPI’s, especially if combined and introduced early, should help to delay and flatten that peak.

Such NPI’s included the:

• closure of schools and universities;
• home isolation of symptomatic cases;
• voluntary household quarantine on occurrence of a symptomatic case in a household; and,
• social distancing, where all non-household social contact ceased, bar ‘essentials’ and attending school and work.

A 26 February paper extended that conclusion and made explicit an assumption: an alternative strategy focused on the household isolation of over 65’s and other vulnerable groups  and on special measures around care homes, would mean that ‘‘the majority of the population would then develop immunity, hopefully preventing any second wave, while reducing pressure on the NHS”.

It went on to note that it “was a political decision to consider whether it is preferable to enact stricter measures at first, lifting them gradually as required or to start with fewer measures and add further measures if required”.

27 February SAGE minutes recorded (minute 6) that ‘extended mitigations’ could be expected to change the shape of the epidemic curve or the timing of a first or second peak, but it was unlikely they would reduce the overall number of total infections (the attack rate). In other words, such mitigations would re-distribute infections and deaths temporally (over time) but not reduce them.

An action was also recorded for UK academic modelling groups (Imperial, Oxford, London School of Hygiene and Tropical Medicine) with NHS planners to organise a working group (starting week 2 March 2020) to analyse key clinical variables for a reasonable worst case planning scenario for the NHS, which could then be reviewed by SPI-M for subsequent discussion at SAGE.

In the public arena, the government’s first forward-looking Coronavirus Action Plan, published on 3 March, reflected the underlying scientific ambivalence and uncertainty swirling within and emanating from SAGE.

The plan’s declared primary public policy aim was to flatten the peak of the epidemic to provide more time for the NHS to prepare for it. This was hopefully to buy time for a vaccine and/or therapies to be developed. Meanwhile measures to first delay and then mitigate the onset and impact of Covid were to be introduced as part of the plan; but only when assessed “as necessary”, following consideration of their social costs and impacts.

By February it was already known that Covid disproportionately impacted upon the very elderly. Chinese case fatality data reported a c15% death rate for over 80’s, compared to 0.32% for people in the 20-49  bracket, (see, for example: https://www.cebm.net/covid-19/global-covid-19-case-fatality-rates/).

Later datasets have continued to confirm the proclivity of the virus to affect the very elderly people, especially those suffering other respiratory-based and other co-morbidities.

Epidemiological and modelling data, according to the 5 March SAGE minutes,  was by then available to support delay and mitigation measures to modify the epidemic peak and to reduce mortality rates (author note: presumably short-term ones in line with its 27 February minute 6).

In that light, minute two recommended the implementation – within 1-2 weeks (author emphasis) – of:

• individual home isolation (symptomatic individuals to stay at home for 14 days);
• whole family isolation (fellow household members of symptomatic individuals to stay at home for 14 days after last family member becomes unwell).

Minute three further advised that scientific data was also available to support implementation – roughly two weeks later (author emphasis) – of the social isolation (cocooning) for those over 65 or with underlying medical conditions, for the same purpose.

Consistent with such advice, on 7 March, the government asked people exhibiting Covid symptoms to self-isolate for seven days.

Both the science and the politics, however, were soon to be swamped by events in Italy.

There – on the back of an earlier exponential spread of infections – an uncontrolled demand surge in admissions and demand for intensive-bed care support had by early March clearly overwhelmed local health systems. Lombardy was the worst hit.  Much of Italy, where deaths rose exponentially in days, was put into severe lockdown.  Spain soon followed suit.

As the empirical situation across Europe and the UK became both clearer and more concerning, unease grew across SAGE and wider scientific community.

Surveillance data, including Covid patients in intensive care units without a travel history, showed that community transmission of the virus within UK communities had begun: the 10 March SAGE minutes  highlighted that the UK was likely harbouring thousands of Covid cases – as many as 5,000 to 10,000 – geographically spread nationally (minute five),  and that transmission was already underway across both community and nosocomial (i.e. hospital) settings (minute six).

The genie was already out of the bottle.

An accordant action was recorded by SAGE that day for the Department of Health and Social Care (DHSC) and the Cabinet Secretariat to develop policy around implementation of: case isolation, household isolation, social distancing for elderly and vulnerable) interventions; data clarifying eligibility, numbers affected, and essential symptoms, was then to be shared with SAGE and its advisory groups.

Minute 14 endorsed the advice of a sub-group that individual case self-isolation should last for seven days from onset of symptoms. Minute 20 recommended that all members of a household should isolate for 14 days from the time that its first member exbibits symptoms. It went on to add that in the event of the first symptomatic person becoming well after seven days, that person can exit isolation but not the other member(s).

Minute 18 reported modelling that suggested, however, that the UK was still 10-14 weeks (author emphasis) from the epidemic peak (not attached with estimates of deaths) if no mitigations were introduced.

Insofar the actual peak was experienced less than one month later, on 8 April to mid-month despite the introduction of mitigation and then suppression measures, this proved over-optimistic.

Minute 30 noted again that special policy consideration should be given to care homes and various types of retirement communities where residents were more independent. No related action or monitoring process was attached to that minute, however.

Its lack of application was to greatly increase the Covid-related death toll over the next couple of months, with care home residents accounting for nearly half of such deaths.

On March 12 efforts to introduce contact tracing evaporated and finally ended. This the 3 March government plan had predicted, noting that as Covid becomes established,  large-scale preventative measures, such as intensive contact tracing, ‘‘may lose their effectiveness’’, which would mean that ‘’resources would be more effectively used elsewhere’’.

In short, the existing UK testing and tracing infrastructure could only cope with a limited number of cases, which no longer was the case: confirmed Covid cases had risen from four on March 3 to 76 by March 9.

Chris Whitty, in a subsequent and rather fraught 21 July attendance before the Health and Social Care parliamentary select committee, justified that decision as “correct given the (then) current capacity”, as  he did the related one to concentrate on providing swab tests to hospital patients.

Beyond SAGE, bars and pubs were still sometimes packed. The young Italian owners of one Chiswick bar were incredulous that no lockdown restrictions had yet been introduced, as Covid ‘’was sure to spread here.’’

In turn, I ventured surprise, on one hand, that the Italian government had demonstrated the wherewithal to implement a comprehensive lockdown; and, on the other, doubt that the economic impact of such a lockdown, on young people especially, would be tolerated in the capital where all of us worked, whereas the youth unemployment rate in Italy constituted a constant and accommodating endemic societal fact of life that the very presence of my hosts partly evidenced.

They got it right; I got it wrong. More to the point, they correctly predicted the need for quicker more concerted action from the government (against their own short-term economic interests) than was forthcoming.

Others had also by then made more evidenced warnings that Covid was sure to spread exponentially soon in countries such as the UK, most notably a 10 March Medium post: Coranavirus: Act today or People will Die that was viewed by 40 million people. The author, Tomas Pueyo, a Californian software engineer made the point that the true number of Covid cases is likely to exceed many times the official recorded number of diagnosed Covid cases. Applying a few assumptions, namely, an average time from onset of infection to death of  17.3 days, a case fatality ratio of 1%, and a doubling time of 6.2 days, he estimated, for instance, after ignoring cases apparently clustered,  that given a figure of 22 Covid-deaths recorded across Washington state on the western seaboard of the United States (US) that the true number cases in that state was c3,000.

His message was simple but stark: The coronavirus is coming to you; it’s coming at an exponential speed: gradually, and then suddenly; it’s a matter of days; maybe a week or two; when it does, your healthcare system will be overwhelmed. It was largely dismissed as in the ‘amateur armchair epidemiologist’ category.

Some schools in the UK, however, by then had already shut their doors by local decision. Responding to the threat of the virus, public behaviour had also begun to change in late February, causing both car and public transport movements to fall. More people began to work from home and to stop unnecessary shopping and leisure trips.

Social distancing and homeworking continued to be encouraged by the government but, however, were not yet made subject to centrally imposed regulation or enforcement.

In that light, the  13 March SAGE minutes highlighted the “risk that current proposed measures (individual and household isolation and social distancing) will not reduce demand (for health care) enough: they may need to be coupled with more intensive actions to enable the NHS to cope, whether regionally or nationally” (minute nine).

Yet minute 21 also recorded that SAGE was unanimous “that measures seeking to completely suppress spread of Covid will cause a second peak”  and “it is a near certainty that countries such as China, where heavy suppression is underway, will experience a second peak once measures are relaxed”: a conclusion in line with the analytic thrust of its earlier published background February papers and minutes.

And, in the public arena that morning , the chair of SAGE, Sir Patrick Vallance, told the BBC Today programme that “if you suppress something very, very hard, when you release those measures it bounces back and it bounces back at the wrong time”; the aim, therefore, was “to try to reduce the peak, broaden the peak, not suppress it completely”, so as “to build up some kind of herd immunity”.

That very same Friday 13^th March, 70,000 people, including some of my work colleagues, herded together to watch the Cheltenham Gold Cup, returning to work next week to tell of their luck with the bookies.

Two evenings previously, 52,000 watched Liverpool play Atletico Madrid, including thousands traveling from a country and a city where cases were rising at one of the highest European rates.

Both events provided a swansong for life as until then we had known it. That very evening, the government announced that mass gatherings would be banned from the following weekend.

Matt Hancock, the Health secretary, in a televised interview on Sunday 15 March, denied that herd immunity was government policy. He advised instead that “our goal is to protect life, and our policy is to fight the virus and protect the vulnerable and protect the NHS…(and to do that) … we need to bring the (rising) infection rate down” (and this might involve) “some quite extraordinary interventions that you don’t normally have in peacetime”.

Hours earlier, the preceding Saturday evening, measures to close restaurants, shops, other than  pharmacies and supermarkets, and to shield the vulnerable over 70 age group by means of strict quarantining within their own home or are homes for an extended period, had been trailed through the media  as comprising “part of a ‘wartime-style mobilisation effort” that would likely to be enforced within the next 20 days”. Hancock refused to rule out that their introduction was imminent.

Also leaked to the press that weekend were dramatic claims that without radical action the Covid death toll could reach 512,000 deaths in Great Britain and of 2.2m in the US.

That Imperial College Study, when released, on 16 March, was not ambiguous. According to the modelling assumptions that it applied, even the most effective mitigation strategy (case isolation; household quarantine; and social distancing of the elderly), would see general ward and ICU beds surge limits exceeded by at least 8-fold, resulting in the order of 250,000 deaths in GB, and of 1.1-1.2m in the US.

It concluded that epidemic suppression, where the rate of Covid-transmission or reproduction (the R-rate) was reduced to below one (each infected person on average goes on to infect less than one person: R<1) and then, crucially, was kept below that level, provided the only current viable strategy, and that there was an imminent need for UK to implement it.

Such effective suppression of the epidemic, as a minimum, rather than the more limited mitigation measures (author note: as the SAGE 13 March minutes recommended) would need instead to comprise a ‘”combination of social distancing of the entire population, home isolation of cases and household quarantine of their family members”, supplemented by school and university closures, even though ”such closures may have negative impacts on health systems due to increased absenteeism”. Population-wide social distancing was modelled within the report to have the largest impact.

It further noted that these measures could need to last for 18 months or more – or even indefinitely – until a vaccine(s) was readily available, though with some likely periods of alternating relaxation and re-imposition of individual measures, where and when the emergent data justified, that could vary geographically.

The Imperial modelling chimed with the unravelling Italian experience. It served to highlight the prospect that without a radical change in approach that the UK’s lower per capita intensive bed capacity would cause our NHS to be even more overwhelmed than had proved the case in Italy. UK deaths at the time were beginning to double exponentially across days.

The  published 16 March Consensus view  of SPI-M concluded that a combination of general social distancing and school closures (author note: that is suppression) with case isolation, household isolation and the concerted social distancing of vulnerable groups would be likely to control the epidemic, subject to them being kept in place for a long period.

It noted that SPI-M agreed that this strategy should be followed “as soon as practical”, at least in the first instance.

Sir Patrick Vallance later, when the sole witness to the 16 July Science and Techology Select Committee, appeared to claim that this was when SAGE provided clear advice to government, in effect, to lockdown –  done on the back of emergent data (presumably the Imperial report) that Covid infections were doubling every three days.

Foe the record his precise answer was (Q1041):  “When the SAGE sub-group on modelling, SPI-M, saw that the doubling time had gone down to three days, which was in the middle of March, that was when the advice SAGE issued was that the remainder of the measures should be introduced as soon as possible. I think that advice was given on 16 or 18 March, and that was when those data became available. Looking back, you can see that the data may have preceded that, but the data were not available before that. Knowledge of the three-day doubling rate became evident during the week before” (that is week beginning 9 March).

His chief medical adviser counterpart, Chris Whitty, was later to highlight,  during his appearance at the 21 July Health and Social Care Committee that following consultation with Vallance that “there was an intention on the 16th very strongly to say that more measures were needed, and that is indeed what happened. If you look at the minutes of SAGE, it is clear that there was a package of things that were strongly recommended on the 16th, and those happened then. There was subsequently clear advice to close schools, which previously had not been advised. That happened subsequently”, and that the ‘operational’ difficulties involved in imposing a full lockdown immediately should be recognized.

The Secretary of State, Matt Hancock, himself advised the 21 July Science and Technology Select Committee  that, “If you take 16 March, for instance, on that day we received advice from SAGE advising that the virus was accelerating. By that evening, I was in the Chamber announcing that there should be no social contact unless absolutely necessary and no travel unless necessary. In my eight years in Government, I have never seen faster decision-making on such big issues than happened then, translating scientific advice into Government action with unbelievable urgency”.

By July, however, the ‘science’ and the politics was becoming blurred. So back to the narrative.

On March 17, Sir Simon Stevens, the chief executive of the NHS, wrote a letter to local acute care providers asking them to be ready to postpone all non-urgent elective operations from 15th April at the latest, for at least three months to provide an additional 30,000 acute care beds across England on top of the existing 100,000.

He also urged them to potentially provide half of that new addition (15,000) by ensuring the urgent discharge of patients awaiting discharge or with lengths of stay over 21 days, while community health providers and social care providers were likewise asked to free up community hospital and intermediate care beds “that could be used flexibly within the next fortnight” so as to possibly release up to another 10,000 beds for acute Covid care cases.

Many of the discharged patients were very elderly people who returned to, or were allocated a place in, residential and nursing care homes. They did not begin to get tested for Covid (testing capacity was inadequate even for NHS staff) until 15 April, after when the transfers had begun.

Unsurprisingly an unknown proportion of the elderly and frail were incubating the virus for onward transmission to their fellow residents – in age and morbidity, the group most vulnerable and exposed to it.

That St. Patrick’s Day no parades took place in Ireland as these and other public events had already been banned by the Irish government. The UK government now did likewise. Shielding was also introduced for the most vulnerable. The British public were exhorted to cease non-essential contact and travel.

The closure of schools was announced next day. Exceptions covered the children of critical health workers and vulnerable children when they needed to attend in person – about 2% of the total school population.

That Friday March 20, one week after the Cheltenham Gold Cup, I joined most of the working population in homeworking; much of the working office-based population had begun to do so earlier that week, when I cancelled my planned forthcoming trip to Bavaria.

Pubs, restaurants, and indoor leisure venues were shuttered across the UK from midnight 20 March. The closure of non-essential shops was announced on the following Monday 23 March.

That evening, the Prime Minister, in a  nationwide television address  confirmed the essential components of the UK lockdown that we were to experience well into May: that people should stay at home, save to shop for basic necessities, and then infrequently as possible; to take one form of exercise a day – for example, to run, walk, or cycle – but alone or only with members of your household; to access any medical need; to provide care or to help a vulnerable person; and to travel to and from work, but only where absolutely necessary, where homeworking was not possible.

Non-essential movement was duly restricted from Wednesday March 24. The emergency Coranavirus Act 2020 was passed with regulations enacted on 26 March prohibiting all gatherings of more than two people in public, other than those living in the same household.

The closure of all shops selling non-essential goods​ including clothing and electronics was enforced.

Premises, including libraries, playgrounds and outdoor gyms, and places of worship, were likewise compulsorily shut by statutory requirement.

Similar regulations were enacted by the devolved administrations. The constituent nations of the UK, initially at least, were united in their Covid public policy response.
‍A State-imposed Lockdown unprecedented in scale and reach since the world wars of the last century had been imposed in just one momentous week across the UK, tagged with the public health slogan: Stay at Home – Protect the NHS – Save Lives.

 We were not alone. Across ’every state, every district, every lane, every village’ of India, an even more stringent and remarkable lockdown had begun for its c1.4bn population. The Hindu-nationalist prime minister, Narendra Modi, announced the lockdown likewise on television on March 23, giving Indians less than four hours’ notice before it took full effect that midnight.

The largest urban centres, such as Delhi and Kolkata, had already seen shop closures and scaled down public transport.

The phenomenal and previously unimaginable impact that lockdown had on the previous sheer cacophony of crowded cities like Kolkata can be glimpsed on this video, showing a city of a solitude, quietness, and clear air, never seen before,  an environment that economically and socially could not be sustained.

 India and other low-income countries with limited health systems and high-density urban populations appeared to be the most exposed to Covid. Initially, at least, however the Indian lockdown was successful in securing adherence and stunting community transmission of the virus.

It did attach accompanying grave hardship however on the poorest segments of the community. For example, migrant wage labourers stripped of their source of employment income were forced to trudge back to their family homes often hundreds of miles away in rural India, risking the transmission of the virus there.

Unfortunately, across recent weeks India has experienced a concerning steady rise in infections and deaths (quite possibly under-reported), resulting in the intermittent re-imposition of national, state, and local lockdowns, amid with officially reported cases of Covid, approaching one million, with true cases likely – given limited testing incidence –  likely to be much higher.

My wife whom I had left in her Kolkata family home back in January was unable to fly back to London as planned. As I write, she is still waiting for international flights to be reinstated, and local spikes of Covid cases in my wife’s neighbourhood have become common with police enforcing their transfer to state isolation facilities.

Individual US states in March progressively applied their own lockdown versions, subject also to local variation. States neighboring NY City, and California, led the way.

Their governors sidestepped a reluctant and sceptical president, whom appeared more concerned about avoiding an economic hit that could undermine his November re-election pitch:  that is, essentially, he had improved the employment and income of his blue-collar supporters at the same time as giving the elite political and cultural establishment a bloody nose.

Trump’s blandishments to inject bleach and to take an anti-malarial drug as effective antidotes to Covid, however, were scientifically rebuffed, and generally attracted ridicule across much of the mainstream media.

By the end of March, according to the invaluable open access  OurWorldinData website, the UK accounted for approximately 2,000 of the worldwide cumulative total of c39,000 Covid-related deaths.

Italy reported the largest number at c12,000 due to its early epidemic curve (author rounding of figures due to their uncertainty, variation of definition and reporting process, etc).

But by the end of the next month,  the highest world-total of Covid-related deaths were recorded in the world’s richest large nation: the United States (US) with 61,000 deaths, with New York City particularly hard hit with some other hotspots, such as California.

The north European countries of Italy, France, Spain, and the UK reported cumulative deaths in the c24,000 to 28,000 range. The UK figure was c26,000.

These four advanced economies with the US accounted for something like three quarters of the world total of c228,000 Covid-related deaths at the end of April.

Covid may have started in China, but its initial spread was now concentrated in some of the high-income countries of Europe, and in the US. China and most of its close East Asia neighbours seemed to have escaped much of worst effects of Covid.

Shortly some of the societal systemic and public policy reasons for that will be explored, but first the question has to be posed:  did up to 20,000-25,000 too many avoidable UK Covid-related deaths occur during the spring lockdown period; and, if so, why.

Late lockdown: cause or symptom?

With the benefit of hindsight viewed through a backward-looking lens amok a rising toll of 45,000-plus recorded UK Covid-related deaths (leaving aside for the purpose of this post definitional issues, including that excess deaths will prove ultimately best measure), it seems clear that the government clearly took the decision to lockdown in mid-March too late, with resulting tragic consequences.

Greg Clark, the chair of the 10 June House of Commons Science and Technology Select Committee,  after referring Professor Neil Ferguson, the lead author of the Imperial study, to evidence made to an earlier 25 March meeting that Covid deaths would be unlikely to exceed 20,000, asked him why that proved to be such an under-estimate.

Ferguson replied: “that the epidemic was doubling every three to four days before lockdown interventions were introduced, and so, had we introduced lockdown measures a week earlier, we would have reduced the final death toll by at least a half”, a statement that captured the news headlines for the rest of that day.

Two other members of SPI-M giving evidence with Ferguson that day, Professor Matt Keeling and Dr. Nicholas Davies, made the less dramatic, but still stark point that an earlier imposed lockdown would have “significantly reduced the death toll” – a conclusion echoed by other SAGE members across different mediums, and now embedded within the mainstream consensus.

Sir Patrick Vallance, back in March, had also indicated then that 20,000 deaths would be a ‘good outcome’ but in July conceded that the subsequent UK outcome was “not good”.

A late lockdown provides one explanation. Ferguson suggested to the committee two others.

The first one is consistent with a late lockdown, considered below. The second one relates to the concentration of Covid deaths in care homes, which will be considered in the next section alongside the stream of evidence on that, which came on stream in June and July.

A heavier seeding of infections from foreign visitors – 1,500-2,000 cases from Italy and Spain, but only picked up in subsequent surveillance data and reported in early June – was taking place in early March. Ferguson confirmed that this was neither known nor factored into models at the time.

An exponentially rising tide of Covid infections from late February onwards certainly over-ran the analytic capacity of both the SAGE and Whitehall to respond in a stepped, calibrated, and planned way, with catastrophic consequences.

The first UK Covid-related death had been recorded at the beginning of March. Such deaths, however, lag three weeks or so from the time of causative infection. The models used to project future deaths, hence require accurate information on infection levels that was not available.

That lack of accurate information on the actual infection curve meant that the true incidence of the virus and its likely propensity to spread was not identified by the epidemiological models that SAGE relied heavily upon to inform its wider assessments and recommendations.

The UK simply did not have in place a fit-for-purpose comprehensive fit-for-purpose track, test, and isolate infrastructure, including serological (blood or plasma-based) antibody testing data – denoting current infection levels, whatever the degree of symptoms infected individuals exhibited, to the timely degree of accuracy that the occasion then demanded.

Even when fast forwarding to July, data reported from the dedicated and latest ONS Covid Infection Survey is still attached with wide ranges of uncertainty (confidence intervals). During the 14-day period from 22 June to 5 July 2020, it reported an estimated two new Covid infections for every 10,000 individuals per week in the community population in England, equating to an estimated 1,700 new cases per day at a 95% confidence interval of 700 to 3,700.

Public Health England (PHE) also publishes daily positive cases confirmed by lab tests. These, however, because of the continuing limited coverage of the track and testing regime that has been progressively rolled-out in recent months, still provide only a partial picture of numbers of people infected.

Lack of accurate and comprehensive testing thus provides the underlying reason why the ‘science’ – as was marshalled and offered by SAGE and its supporting scientific community – was simply too ambiguous and uncertain to provide a clear public policy route-map to combat Covid, at least in real-time.

No clear backing or steer was given to government to introduce a comprehensive lockdown to suppress the spread of the epidemic until the 16 March, when it was already too late. Even then that advice, as we have seen, was added with the rider, “as soon as practicable”; hardly a ringing call for urgent immediate action on a ‘clear the decks’ basis.

Even graduated mitigation measures to delay and flatten its peak were only definitely recommended by SAGE in early March (see minutes of March 5 and 13 meetings, reproduced in the previous section).

Instead the mortality figures that the Imperial study modelled were used as a banner cover by the responsible politicians to justify the abrupt policy shift from mitigation to lockdown.

Published on the 16 March, it claimed to have “informed policymaking in the UK and other countries in the last weeks”. Professor Ferguson, more specifically claimed in a BBC Panorama programme broadcast on the 20 July that he had advised SAGE of its main results and implications as early as on the 5 March, but these were not fully accepted by his peers at the time. Perhaps the pessimism bias of epidemiologists in modeling determining variables of morbidity and fatality incidence, did not help.

That be as that it may, but the published study itself acknowledged, however, that its modelling assumptions were only updated in the week prior to the weekend of March 14-15; and that its conclusions had only been reached “in the last few days following  the refinement of estimates of likely Intensive Care Unit (ICU) demand due to Covid based on experience in Italy and the UK”.

Professor Mark Woolhouse, who sits on SPI-M and on the Scottish Government’s Covid-19 Advisory Group, when giving evidence to the same June Science and Technology Committee that Ferguson gave evidence to, (noting that Woolhouse is sympathetic to alternative Swedish approach of partial and voluntary lockdown) asserted that the UK lockdown was a short-term panic measure taken here and elsewhere because “we could not think of anything better to do given the information we had available”, adding that its application should have adjusted quickly in step with emerging outcomes and evidence (Q. 808).

On the available evidence, lockdown – based on a ‘suppression strategy’ reliant on near-confinement of most of UK population (except for prescribed health and other key-workers) – does appear to have been introduced by political decision makers apparently suddenly panicked by a rushing Covid tide that threatened to turn into a tsunami.

Their previously preferred ‘mitigation strategy’ based on two-week quarantines of infected households was swept away, practically before it had even started in earnest.

The argument now made – with hindsight – by many commentators, mirroring Ferguson and some other members of SAGE, is that the UK government, in effect, has blood on its hands, due to it locking down too late, dithering indecisively when the overwhelming of local Italian health systems by Covid, especially in Lombardy, was known, and when the government was beginning at last to receive more assertive prompts from SAGE to quickly introduce some form of restrictions, if not yet full lockdown, to counter its spread.

Perhaps. Italy, Spain, and France, in that order, imposed a full lockdown by or during the period beginning March 9 and ending 16 March, while the UK did so between 16 and 24 March, a period little more than a week in duration.

If the metric taken to measure responsiveness is rather the time period taken to impose a full lockdown after the third or a similar low number of Covid-related death, then the delay, when Italy is taken as the comparator, increases to two weeks,  and to over a week when France and Spain are so taken, along with Belgium and Germany.

These last two countries locked-down about the same time or just before UK did, even though they were slightly behind the epidemic curve in terms of Covid-deaths reported. Germany shut down its land borders on the 16 March.

Such metrics, however, are somewhat abstract, and hindsight-based; prone, in any case, to cross-national and intrinsic ‘like-for like’ data measurement and definitional issues.

That said, once it was decided that lockdown was necessary, the conclusion that then at the very least it should have been done with a very minimum of delay and with concerted urgency and effectiveness appears difficult to argue with.

According to an 16 July FT magazine review Cobra at its 16 March meeting  – with its members presumably by then cognisant of the Imperial modelling and the 16 March SAGE injunction to introduce measures of suppression –  that required sense of urgency was palpably lacking; instead, according to one participant, discussion took place about how the bell-curve of the disease might still be flattened and how people ‘might feel fatigued’ if restrictions were introduced too early.

Was lockdown necessary in the first place?

The author remains reluctant to rush to pass damning judgment on the government’s lateness to lockdown. In part, that is because of the uncertainty of the science.

Also, as might be gleaned from this narrative, it is because I was blasé about the risk that Covid posed myself.

I took the view during February that it would not be sensible to over-react and cause actual economic and indirect social/health damage to counter a potential risk that might or might not arise.

Also by then I had begun to articulate in my mind, if hazily and only in part, that if the purpose of lockdown was to continually suppress the incidence of the virus until its demise, in contrast to delay and flatten its initial peak, in logic, any such  lockdown would need to be both prolonged and combined with measures of strict border control and/or effective entry testing, until a workable vaccine or treatments became available.

Any intermittent lifting and re-imposition of the lockdown, however, at a national level would risk intolerable economic uncertainty and damage.

The other alternative, save for the availability of a safe, effective, vaccine a scale and/or effective treatments remains the acquisition of national herd immunity was acquired through infection (60-70% of population infected), or that the virus becomes otherwise neutered or less virulent over time.

That, essentially, remains the case.

The government at the time of writing is betting that the current state of relaxed national lockdown (re-opened businesses, pubs and businesses, internal and international travel, renewed household contact, but maintenance of social distancing, combined with other adjustments, such as increased use of face masks) can be maintained indefinitely, until a vaccine(s) and/or treatments come to the rescue.

Across the world lifting of lockdown restrictions has largely followed, and been allowed by, a sufficiently reduced level of infection, but with such lifting made conditional on the maintenance of a low and steady infection level, with some notable exceptions, such as some US states, which then have suffered a resurgence of the virus to the point where it again threatens to spread exponentially.

The UK cannot be sure that another national lockdown may prove once again to be the only option left to stem a second peak of deaths – the prime minister declared hope that ‘it may be over by Christmas’ is simply that, irresponsible, as well as unevidenced.

In the autumn and winter, when the schools re-open and office working resumes in earnest, climatic conditions considered more conducive to the spread of the virus will be present. A 14 July Academy of Medical Sciences government commissioned report, in that vein, warned of a reoccurrence of Covid, which combining with the winter influenza peak,  could  on a realistic worst case scenario” – without effective mitigation  measures focused on health and care home settings – surpass by far that of the spring 2020 peak.

The government hopes that the national testing and track infrastructure by then will be sufficiently robust and comprehensive to identify local outbreaks in time for local customized interventions to effectively snuff them out. Leicester has been in local lockdown since June, with some considerable damage to its local economy.

Avoiding another national lockdown does rather assume that  that the current worldwide exponential growth in infections – that even with under-reporting is likely to exceed 15 million by the end of July – does not translate again into another national rising tide of infections that washes over the capacity of localized responses.

Seasonal flu in a bad year can cause excess deaths, when measured against a five-year rolling average. As recently as in 2017-18, according to the AMS report referenced above, England and Wales experienced approximately 50,000 excess winter deaths (seasonal concentration of deaths, not total excess deaths recorded during a period relative to five year average of the same previous period, as is reported by the ONS).

Yet the government does not disrupt the economy to prevent and reduce the flu death toll. To persuade myself that I was not being callous on that score, back in February  I consoled myself with the thought that if Covid proved such an event,  it would enforce attention on the need to take more effective measures to counter the impact of flu on the elderly and vulnerable as well, reducing its future perennial toll, perhaps contributing thus to the net saving of life and morbidity outcomes over time.

Of course, I did not possess the responsibility of, and collective resources and knowledge available to, government; yet it is difficult to conceive that a responsible government would have locked-down in late February, or even very early March, and prevented international travel: such a reaction according to the then available evidence, including from what we now know was coming out of SAGE at the time, would have been an over-reaction in the eyes of most, remembering that the UK is an international air hub: one that is crucial to the functioning of its economy at activity and employment levels consistent with expected real income growth and public financing requirements.

In the aftermath of the initial Covid wave and its consequences, international movements remain very constrained. That, if unchanged, threatens to bankrupt many airlines with resulting impacts on national economies and employment levels. If movements, however, recover they will provide increased opportunities for the spread of the virus back into Europe and UK.

The government, in that light, unexpectedly announced during the last weekend of July an imminent re-imposition of quarantine requirements for travelers from Spain, instantly disrupting the holiday plans of those lulled into booking their usual summer holiday, when the original blanket quarantine requirement was lifted for most European holiday destinations.

The UK remains an international air hub. It is not like Taiwan or New Zealand that can relatively easily impose a shutdown of its airports to ensure in tandem with other effective measures a low or negligible Covid incidence.

The UK with its stake and dependence on the international economy coupled with the high propensity of its population to travel to myriad destinations, is especially exposed to seeding of a second Covid wave through international transmission.

In that light, it is telling that some major airlines, such as British Airways, are now taking the initiative to campaign for a more coherent and international coordinated approach to testing international travelers.

There is also a school of argument that concerted measures of mitigation and voluntary social distancing, as employed by Sweden, would have achieved much the same result with less economic disruption. Proponents point to evidence that the R-value was decreasing before full lockdown was imposed.

Others, such as the leader of an Oxford University research group, have gone further.  In  a May interview  she advised that “I think that the epidemic has largely come and is on its way out in this country so I think it would be definitely less than 1 in 1000 and probably closer to 1 in 10,000”, making the UK Infection Fatality Rate (IPF) – mortality rate of population truly infected –  somewhere between 0.1% and 0.01%., before going on to cast doubt on whether the government back in March should have acted on a ‘reasonable’ worst case scenario.

Professor Johan Giesecke, an advisor to the Swedish Government, and whose protégé, Anders Tegnel, has directed it,  have consistently argued that the Covid IPR is of the region of 0.1%, compared to the 1% modelled by Imperial – a figure consistent with around 50% of the UK and Swedish population having already been infected, mirroring that for seasonal flu.

He further ventured in an UnHerd summary piece contentiously (and inaccurately) that ‘‘Covid-19 is a mild disease and similar to the flu, and it was the novelty of the disease that scared people’’, before concluding that subsequent flattening of the curve in the UK, is due to the most vulnerable dying first, as much as to the effect of our lockdown, and  that ‘’the ultimate result will eventually be similar for all countries”. According to him, the UK public policy ‘’180 degree U-turn’’ in favour of suppression in March was therefore wrong, as the previous approach was ‘‘better’’, noting that the change was based on an unpublished non-peer-reviewed paper (the Imperial Study) that applied too pessimistic modelling assumptions, according to a mathematical modelling methodology that was unsuited ”in any case” for public policy development.

Well, again, perhaps, at least in some respects. Professor Ferguson, the lead author of the Imperial study, himself has taken a more nuanced and less categorical stance in favour of the suppression strategy, suggesting even that up to two-thirds of excess deaths attributable to Covid could turn out to come from the collateral fall out from lockdown, including cancelled and delayed appointments for acute conditions, and the reluctance of people needing such intervention to seek medical help.

Evidence that the stock level of Covid infection – whether displayed or asymptomatic – is anything like approaching 50% in any country, is certainly lacking. Ongoing serological (antibody) studies have reported an incidence of generally below 10% across various population samples, although some counter that future population resistance to Covid will depend upon the prior and innate genetical and other propensities of individuals rather than rely on an increased stock of infected individuals with Covid antibodies.

Such claims, however, come across as reliant more on faith-based assertion or belief, than on scientific-based conclusion secured from supportive evidence that can be validated – well, it well may be true, but it may equally well be wrong, when no-one really knows.  A bit like both epidemiological modelling and politics, then.

Certainly not to shift to strict suppression during that week March 16-23 would have been a very brave, but dangerous course of action for the government to take on the information then available given the then close and present danger that the NHS would be overwhelmed without drastic steps.

Comparing the UK and Swedish approaches using imperfect and uncertain information that can’t be determined with more certainty until the pattern of excess deaths attributable both directly to Covid and  indirectly from the impacts of lockdown is known (and after taking account of factors such as age structure and population density), is a red herring, as is a fruitless retrospective focus on what precise date the UK should have fully locked-down that Professor Ferguson, regrettably, for whatever reason(s), seems to want to fan.

Why the UK lockdown was late 

The key point that has to be learnt and applied in the here and now is that government room to maneuver had by March been lost by lack of preparedness; of foresight; and, of related focused but flexible planning arrangements for, and then in responding to, Covid.

It is these connected failures that can truly and fairly be laid at the door of the UK government, and which need to be understood to allow the lessons to be drawn, necessary to maximise the prospect that a future combined Covid- and Jobocalypse is avoided.

• Lack of preparedness, in terms of stockpiling and then procuring adequate PPE in both and quality terms, and in providing a fit for purpose test and track infrastructure in waiting for a pandemic previously identified as the biggest future risk to UK national security. Two fundamental and crucial failures.

At the start of the outbreak, the only central stockpile – held by PHE – was designed for a flu pandemic, lacking items such as gowns and visors. Since then money (c£14bn for 2020-21) has been thrown at its procurement but the belated response has meant both unnecessary deaths and likely poor value-for-money.

Swab-based antigen testing, which determines whether a person currently has the virus, with antibody testing, which shows whether a person has previously had it, still needs to be scaled up.

• Lack of focused flexibility, in terms of an absence of effective and creative civil service and special adviser scanning of what was happening across the world in real time and translating the lessons of that experience into effective mechanisms of policy planning and action at the necessary pace.

Cobra itself proved itself as inadequate institutional mechanism to respond to the Covid crisis. Whether that failure was the result of intrinsic and endemic problems in the wider machinery of government is the crucial question.  Cobra seems to have been replaced by two dedicated Cabinet sub-committees focused on strategic and operational matters: Covid-S and Covid-O.

• Lack of foresight, in terms of its failure to identify the need and act upon it to protect the care home population against an epidemic, which, even by early February, was identified as mainly a killer of the very elderly and the otherwise medically vulnerable. The care home population given its characteristics and setting was clearly a group likely to be the most susceptible and exposed to the virus.

That last dreadful and shameful failure, in large part, appears to explain the UK’s relatively poor per capita Covid death rate comparative to its close neighbour European peers.

The care home scandal

The second reason that Ferguson gave to the Science and Technology Committee in June as to why actual Covid-related deaths exceeded his and other estimates of 20,000 was the concentration of infections and deaths in residential care homes, related to the disease risk profile of their residents and the tendency of care workers to work within and to hop between close clusters of such homes.

Recently published evidence is depressingly compelling.  ONS  data released on 12 June reviewing deaths occurring in the UK across the entire March and April 2020 period, registered up to 15 May, reported 45,000 excess deaths for that period, 43% more than the average for the same time period over the last five years, 2015 to 2019.

44,628 deaths of care home residents were reported for the period, compared to the five-year average of 22,587, (figure 6 of the linked ONS publication), indicating that they accounted for half of the total excess deaths reported for the period.

England reported the highest percentage of deaths above average within care homes, with 102.0% more deaths than the five-year average for deaths within this group. 44.4% of these recorded deaths mentioned Covid on the applicable death certificate.

In total, as of 12 June 2020, 30% of Covid fatalities in England, 28% in Wales, 46% in Scotland and 42.4% in Northern Ireland were in care homes, according to an even more recent government report.

ONS survey data and analysis of 9,801 care homes in England and their resident population and staff for the period 26 May to 19 June (the Vivaldi Study) also provides supporting evidence of, and possible reasons for, the concentration of the impact of Covid on care home residents.

Across the 56% of the surveyed homes that reported at least one case of coronavirus, 20% of their residents, as reported by care home managers, were estimated as testing positive for Covid (95% confidence interval: 19% to 21%), during that period.

In such homes 7% of staff were similarly estimated to have tested positive (95% confidence interval: 6% to 8%).

Common factors identified in care homes with higher levels of infections amongst residents included the prevalence of infection in staff, especially those making more frequent use of agency nurses or carers.

An association was also found between care homes where staff receive sick pay and lower levels of infection in residents, but, conversely, higher levels of infection cases where care homes employ staff working across multiple sites.

In June, a  National Audit Office (NAO) report pointed out that prior to the Covid outbreak, no process was in place to collect a wide range of daily data from care providers.

DHSC was ignorant on how many people were receiving care in each area. Local authorities generally only kept records on residents whose care they paid for.

It was only from early April that data at a national level was collated on workforce absences, and on PPE levels and overall risks from nursing and residential homes registered with the Care Quality Commission (CQC).

The supply of masks, aprons, gloves, and visors and other (PPE) suitable for use in residential care home settings remained slow and inadequate, only meeting some of the modelled requirements received from health and social care providers, according to the NAO (para 20), until mid-May.

The resident care and nursing home population was the most Covid-vulnerable group, but, in terms of effective public policy attention, it was the most neglected.

From a social policy perspective, it is an outcome that is difficult to divorce from the client group’s lack of possession of political ‘voice’ power.

The needs of mentally ill  patients discharged from asylums built in the Victorian era – often ear-marked for future lucrative redevelopment – into illusory ‘community care’  lacking replacement residential care facilities or adequate personal social work support, provides an example from earlier decades, continued into the present day by the relative neglect of the mentally ill by fragmented health and social services.

Yet the negligence was not one solely of omission, but also of commission.

The NAO in its report (para 6) advised that around 25,000 people were discharged from hospitals into care homes, without testing for Covid,  as part of the expected measures to free up hospital acute bed capacity that the 17 March Simon Stevens letter to NHS bosses set out – a practice that continued to 15 April.

This central failure in the UK Covid response was not an aberration, but was instead intrinsically related to, and a product of, the long-standing fragmentation of its health and social care systems.

This is with respect to the planning, funding, provision, and oversight, of social care and its separation from the nationally funded and coordinated health system.

That core structural problem has been compounded by systemic under-funding that got far worse during the post-2010 austerity years, with funding for local authority support for adult social care reduced by 50% or greater in some cases between 2010 and 2018, or, as Ian Birrell in a Tortoise Media piece reported: over the past decade, government spending fell in real terms on social care by about £300m, despite a 21 per cent rise in the number of citizens aged over 65, compared to  rise in national health spending  of £26bn: what one part of the system taketh, it has taken away from another.

Since 1980 there has been a shift from direct local authority funded care to a ‘mixed economy’ or out-sourced system, where independent for-profit and not-for-profit providers have grown share, with the largest independent providers consolidating the ‘market’, using private equity to provide larger purpose built homes often in the more affluent parts of the country, where self-funding residents are more likely to be located.  Independent providers now account for 243,000 residential care beds compared to 76,811 in the 1980s.

If there is to be only one positive legacy of the Covid-crisis, it is that core structural problem that must finally be addressed in concerted and comprehensive manner.

The UK – England, especially, high per capita Covid death rates cannot be divorced from our societal value-base and patterned inequalities, as well as from functional government sub-performance.

A national health and care system funded in a sustainable and equitable manner is the required legacy.

A related recasting of the working conditions across the catering, cleaning, and care sectors, whose workers tend to have insecure working conditions reliant on the minimum wage and zero hour contracts,  and where BAME groups, especially foreign-born workers, are over-represented (also making them susceptible to Covid, and then, because of their disproportionate dependence on a low wage and their lack of eligibility for sick pay, generated pressure on them to continue working despite displaying Covid symptoms), is also long overdue.

Easy to say, of course, given such a recasting would require substantial additional public spending,  whether funded from national or local sources, during a period of public finance pressure. It is a case of you get what you pay for, while change requires cross-party support for a new settlement, not tinkering at the edges.

International lessons to be learnt

The future Covid landscape is shrouded in the fog of uncertainty.

The tension between a mitigation-based strategy more costly in terms of lives immediately lost and a more draconian suppression strategy that, in turn, has more direct and immediate impacts on the wider economy, which themselves engender longer-term indirect and real health and social future impacts (with any final total apportionment unquantifiable to any precise degree remains. It threatens to continue to bedevil UK policy.

The aim is to navigate away away from the worst of both worlds we inherited in May of high relative per capita death rates and massive macro-economic damage to a ‘new normal’  where low infection rates are maintained, avoiding the need for a any new national lockdown.

The prime minister in characteristically optimistic and swashbuckling style has confirmed that is the UK government objective. In effect, he is relying on hope.

A hope that the above tension can be reconciled by a more empirical evidence-based data-driven approach that can avoid the dire and likely unsustainable economic consequences of another full lockdown based on suppression of the virus.

The genesis of that hope was first set out in the government’s 11 May Recovery Plan.   This heralded a second ‘smarter control’ phase of the public policy response to the epidemic, involving the application of effective testing, tracing, and tracking of the infection.

Public health interventions could then be aligned better to risk, allowing the timely detection of infection outbreaks at a more localised level, and a more tailored, targeted, and effective public response at that level.

The problem remains one of implementation. The debacle of Matt Hancock’s hoisting his 100,000 daily tests to the mast of an end of April target that relegated purpose and effectiveness to supposed and sometimes spurious target figure was followed by a subsequent pattern of patchy and slow development of testing capacity.

A continuing example of the lack of sufficient government focused flexibility: the core cause of the UK’s poor and inadequate Covid performance.

Realization of the hope that we combine a continuing relaxation of lockdown with a containment of Covid, in an international context where reported Covid infections are mounting, and which threaten to rise exponentially, requires that shortcoming to be overturned.

Otherwise we are simply relying on an effective vaccine(s) or treatments to ride quickly to the rescue.

The reluctance and, perhaps, systemic tendency to learn from and to apply international lessons, as summarized below, in a considered and evidence-driven way in a way that works for Britain, will also have to reverse.

The strategies adopted by most east Asian countries have proved invariably and overwhelmingly more effective than the UK’s, when measured against per capita infection and death rates.

This is almost beyond comparison, as starkly conveyed by the Covid-caused deaths per one million people (rounded up to nearest whole number) data, reported below and  extracted from  the Our World in Data  website on 14 July for the following countries.

Japan:                    8;                                                  Thailand:    1;

South Korea:        5;                                                  Myanmar:   0;

Singapore:            4;                                                  Vietnam:      0.

The UK ratio is 660. The disparity speaks for itself.

Although variations exist between these countries in relation to the strictness or otherwise of the lockdowns they imposed, and with respect to their political systems, their strategies  to combat Covid, were, and are, marked by focused and systemic regimes of testing and contact tracing and the quarantine of affected individuals combined usually with effective immigration control.

Both sets of interventions were effectively imposed and implemented at a timely and early enough point in the infection curve.

Vietnam, a low-income country of 93 million with a population of an average per capita income of less than $4,000 has reported no deaths at all and negligible infections attributable to Covid. This almost breath-taking outcome was achieved through the use of comprehensive testing and then quarantining of infected individuals.

Its communist government is now preparing for growth and recovery through the fast tracking of public infrastructure projects, including a north-south highway, two metro lines and a new Ho Chi Minh City (its capital: formerly Hanoi, when the country was divided into southern and northern segments) airport.

A striking portend of the touted coming ‘Asian century’, if ever one can be comprehended. Near neighbours, Laos and Cambodia, have also reported nil Covid deaths.

Although most of these societies possess young age structures, 20% of Japan’s population is over 75, compared to c12-13%, in the case of Sweden and the UK. The success of the E.Asian model to combat Covid cannot possibly be explained away by the relative youth of their populations, therefore.

Institutional factors based on their history and melding of societal value-base and culture with public policy design and implementation systems do appear relevant to their success.

Previous experience of responding to the 2003 SARS or to the MERS outbreak also provided their policy makers with a workable template, and an awareness of the task in hand with the associated imperative for timely and concerted policy response to an emerging epidemic.

In short, their governments  were able to impose in some cases draconian directive measures of control, including quarantining, with ready public consent and acquiescence,  while possessing the wherewithal (and the foresight) to marshal and direct resources to ensure effective and comprehensive implementation of testing and quarantining systems – all  in co-operation with their wider populations and across particular community-settings.

Although the lessons to be learnt are not always precisely replicable to the UK context given their own distinctive political and social cultures and socio-economic realities, the theme of public policy planning and implementation systems that combine focus with flexibility, and that put a higher weighting on effective action and results, not short-term noise, cannot, and should not, be ignored.

The UK per capita 660 per one million death rate is the highest in Europe, save for Belgium; higher than that of Italy, which has the highest proportion of very elderly people susceptible to Covid, and nearly six times higher than that of Germany, which also has an aging population structure.

The figures reported below are less mind-boggling than the Asian comparison, but still revealing, nevertheless.

UK:                         660;                                        Netherlands:                     353;

Spain:                    607;                                       Ireland:                                 354;

Sweden:                475;                                        Germany:                            108;

France;                 460;                                        Denmark:                            105.

Germany  through the application of a timely and proportionate lockdown in March, effective testing infrastructure, and, perhaps, most significantly at all, effective protection of its elderly and vulnerable population especially those residing in care homes (helped by spare capacity within its health system), has succeeded in contained Covid-related deaths to a fraction of the UK’s, despite its elderly age distribution – an achievement that  demonstrates that an European democratic culture is no bar to success.

Test, test more, and test more, again, while infections are low, is the overriding message.