The UK government yesterday announced stronger “social distancing” measures to combat coronavirus – but its overall strategy is still unclear to medical specialists.
They have called for more transparency, as well as speedier implementation of “social distancing” and testing.
Until the end of last week, officials were suggesting that the government’s strategy aimed to allow the virus to spread through healthy sections of the population in order to build up “herd
immunity”. This was roundly denounced by epidemiologists – and on Sunday that produced some backpedalling by Matthew Hancock, the health secretary.
But still, today, the logic is opaque. Scientists’ requests to see the government’s data have fallen on deaf ears. And the UK’s “social distancing” measures are still far behind the Scottish and Irish governments, sports governing bodies and most of Europe.
Here I will try to summarise the way the rift between doctors and the government has deepened since I posted about it on Friday. I have no medical training; I am just trying to clarify what is going on.
Along with many thousands of others, I have joined a local Coronavirus mutual aid group – and to take matters into our own hands effectively, we need accurate information. If you think I have got something wrong, please say so in the comments.
■ The government is not sharing information with the country’s epidemiologists and other specialists.
This was the main point made in a letter to the Times on Saturday by six senior epidemiologists and public health specialists, and supported by 630 others and counting. The UK’s response to coronavirus is “demonstrably different” to other countries’, they wrote. There is “no clear indication that the UK’s response is being informed by the experiences of other countries”.
The signatories “request that the government urgently and openly shares the scientific evidence, data and models it is using to inform its decisions on the Covid-19 public health interventions in the UK”. Without this, the “understanding, cooperation and trust” of the public, healthcare workers and scientists could not be retained.
A letter from the British Society for Immunology president, Arne Akbar, echoed this, calling on the government “to release their modelling data to allow scrutiny from the scientific community to better predict the course of this outbreak”.
■ Health researchers think that the government plans to allow the virus to infect the healthy part of the population in order to create herd immunity soon – and that this is a disastrous mistake.
The specialists were alarmed at this, partly because of the way they learned about it: via a remark made on Thursday by Patrick Vallance, the chief scientific officer, and tweeets and an article by the political journalist Robert Peston, apparently written on the basis of off-the-record briefings.
William Hanage, who teaches epidemiology at Harvard University in the US, wrote that he “assumed that reports of the UK policy were satire. […] But they are all too real.”
We talk about vaccines generating herd immunity, so why is this different? Because this is not a vaccine. This is an actual pandemic that will make a very large number of people sick, and some of them will die. Even though the mortality rate is likely quite low, a small fraction of a very large number is still a large number. And the mortality rate will climb when the NHS is overwhelmed.
Hanage was sceptical about Vallance’s argument that the government’s approach is designed to stop a “second wave” of infection, after a first wave is suppressed.
Second waves are real things, and we have seen them in flu pandemics. This is not a flu pandemic. Flu rules to not apply. There might well be a second wave, I honestly don’t know.
Policy should be directed at slowing the outbreak to a (more) manageable rate. What this looks like is strong social distancing.
It’s well worth reading his whole article.
Jeffrey Rossman, a virologist at the University of Kent, wrote that “it is not clear how much of this discussion of herd immunity […] is actual government policy”. (I would add – and that is no-one’s fault but the government’s.) Nevertheless, Rossman spelled out the implications:
Achieving herd immunity would require well over 47 million people to be infected in the UK. Current estimates are that Covid-19 has a 2.3% case-fatality rate and a 19% rate of severe disease. This means that achieving herd immunity to Covid-19 in the UK could result in the deaths of more than a million people with a further eight million severe infections requiring critical care.
Ian Donald, a psychologist who studies behavioural factors in anti-microbial resistance, was less hostile to government policy, saying in a twitter thread that it is “potentially very effective”. But, he added, “it is also riskier”.
■ Doctors fear that this strategy – of aiming for “herd immunity” sooner, rather than trying to suppress the virus as firmly as possible, as soon as possible – underlies the government’s reluctance to enforce stronger “social distancing” measures.
The need for “social distancing” measures, sooner and stronger, is something on which all the medical experts seem to agree. Anthony Costello, a former director of the World Health Organisation and paediatrician, wrote:
The WHO policy – practised by China, South Korea, Singapore, Taiwan and Hong Kong – is to keep things damped down until drugs and a vaccine are available. Vaccines are a safer way to develop herd immunity, without the risks associated with the disease itself. […]
On the precautionary principle, shouldn’t we go all out to damp this epidemic down, with all possible measures, whether evidence is strong, uncertain or weak, and worry about herd immunity when we have more evidence?
What has happened in China shows that quarantine, social distancing, and isolation of infected populations can contain the epidemic. […] However, it is unclear whether other countries can implement the stringent measures China eventually adopted.
(If you want a proper description of the factors that researchers believe will shape the course of the epidemic – and an account of how much about Covid-19 is unknown – that article is definitely for you. It’s free to download.)
Another open letter by 240 scientists, published on Saturday, called for “more restrictive” social distancing measures, “immediately”. The letter argued that:
Under unconstrained growth, this outbreak will affect millions of people in the next few weeks. This will most probably put the NHS at serious risk of not being able to cope with the flow of patients needing intensive care. […] Going for “herd immunity” at this point does not seem a viable option.
A friend of mine cautions that the letter is from mathematicians and computer scientists, not medical researchers. Point taken. But still, these are people who understand what it means to “flatten peaks” and stuff like exponential growth.
For those of us who struggle with the maths, these graphics in the Washington Post are useful. The conclusion: “moderate social distancing will usually outperform [an] attempted quarantine, and extensive social distancing usually works best of all”.
The British Society for Immunology also stated that “more needs to be done to ensure social distancing”. The society’s “significant questions” about the government strategy include a concern that it only works “if, when building immunity, vulnerable individuals are protected from becoming ill, for example through social distancing”. It warned, too, that there are “many unknowns”.
Yesterday, after the government finally announced firmer “social distancing” measures, some scientists applauded. We will not know for some time whether we will all pay a price for its previous reluctance to go that way.
■ Doctors are slamming the government for the inadequacy of its testing programme.
Anthony Costello, the former WHO director, said he had written to the chief medical officer, Chris Whitty, urging more testing. He said:
The key principles from WHO are intensive surveillance. You test the population like crazy, find out where the cases are, immediately quarantine them and do contact tracing and get them out of the community.
This is the “bedrock” of policy, used by China, South Korean, Japan, Hong Kong and Taiwan, Costello said – while the UK had stopped tests outside of hospitals, and healthcare workers were demanding that they be prioritised for testing, so that they do not have to self-isolate unnecessarily.
Yesterday, at Boris Johnson’s press conference, commitments were given to step up testing.
■ The World Health Organisation has implicitly – but not explicitly – criticised the UK government’s approach.
On Saturday, as the controversy about the UK government’s approach raged, WHO director-general Tedros Adhanom Ghebreyesus told a press briefing:
You can’t fight a virus if you don’t know where it is. Find, isolate, test and treat every case, to break the chains of transmission. Every case we find and treat limits the expansion of the disease. […]
Our message to countries continues to be: you must take a comprehensive approach. Not testing alone. Not contact tracing alone. Not quarantine alone. Not social distancing alone. Do it all. Any country that looks at the experience of other countries with large epidemics and thinks ‘that won’t happen to us’ is making a deadly mistake.
The implicit criticism of the UK government – which on Thursday had pulled back from “social distancing” measures, and had stopped testing, except for hospital patients – was fairly clear.
Tedros returned to the theme yesterday:
You cannot fight the fire blindfolded. And we cannot stop this pandemic, if we don’t know who is infected. We have a simple message for all countries – test, test, test.
■ Medical experts advocate community mobilisation, which the government seems neither to care about nor to understand.
Anthony Costello, the former WHO director, describing the Chinese authorities’ response to the coronavirus, wrote:
Above all, they mobilised communities. They didn’t leave it all to messages and nudge behavioural methods. Yes, Wuhan was in lockdown, but across the country local authorities had high autonomy to help people abide by these best public health principles. This was not a terrorised population but one passionate about tackling an existential threat. They also used apps and smartphones to get messages across, to share information about local clusters and for data collection. Everyone in Wuhan, a city of 11 million, ordered their food online, and had it delivered. And the strategy worked. In seven weeks China stopped the epidemic in its tracks. It now reports only 10 to 20 new cases per day in a population of nearly 1.4 billion. Deaths have plummeted. Several other countries, including South Korea, Japan, Singapore and Taiwan, have copied this strategy, with local modifications, with similar results.
Costello added that “the challenge of how to loosen up” was a real one, and the danger of further outbreaks loomed, but China had a nationwide system to deal with them.
The aim is to wait and hope for drugs and vaccines to emerge in the next 12 months to enable them to treat cases and to build proper herd immunity from a vaccine. […]
I had assumed that the UK would do the same, that the authorities would be building their resources and plans around nationwide testing, contact tracing, quarantine and a progressive policy of social distancing.
Even after yesterday’s announcements, in the UK we are still far from such a coherent policy. And while communities are mobilising, that is not part of government plans.
The government’s lack of enthusiasm for, even fear of, communities taking action goes hand in hand with its inability to be honest with the population it supposedly serves.
In a narrow political frame, this is seen as a “shambolic communications approach”. To my mind, it is a reflection of something more deepgoing in ruling-class attitudes: a patrician contempt for the population, and a belief that it is there to be manipulated, sloganised to and patronised, but not to be given agency.
■ Specialists fear that the government is influenced by dodgy “behavioural science”, which plays into its innate dislike of telling the truth.
On Wednesday (11 March), Bloomberg news reported:
A little-known team of advisers specialising in behavioural psychology is helping to steer the prime minister’s response to the health crisis, shunning headline measures like travel restrictions and quarantines to focus on a more banal task: finding ways to persuade people to wash their hands.
Bloomberg quoted David Halpern, chief executive of the government’s Behavioural Insights Team, who said:
We’re trying, in a way that hasn’t been done before, to use all the tools to hand: medical and mathematical but also behavioural.
Bloomberg said that the government’s Scientific Advisory Group for Emergencies (SAGE) “have so far resisted calls for more draconian measures, such as banning people from attending soccer matches, or closing schools”. Halpern also gave an interview to the BBC, talking about achieving “herd immunity” more quickly and shielding vulnerable people from it.
The Financial Times reported on Friday that “both of the government’s three-word mantras for coronavirus” – “wash your hands” and “stay at home” – came from focus groups, a “favoured tool” of Boris Johnson’s chief adviser Dominic Cummings. The paper’s reporters saw these strategies as linked to the policy of allowing the virus to expand to produce “herd immunity”.
None of this was a policy announcement. None of it came from a government minister. Maybe someone was flying a kite. Maybe Cummings was performing his usual behind-the-scenes social experiments. But a group of actual behavioural scientists, deprived of clear information and assuming these advisers have the government’s ear, became alarmed. On Saturday they published an open letter warning:
Current government thinking seems to crucially involve the idea of “behavioural fatigue”. This is the worry that, if implemented too early, measures limiting social contact will be undercut just at the point at which they are most required, because people will have tired of the limitations and will revert to prior behaviour.
While we fully support an evidence-based approach to policy that draws on behavioural science, we are not convinced that enough is known about “behavioural fatigue” or to what extent these insights apply to the current exceptional circumstances. Such evidence is necessary if we are to base a high-risk public health strategy on it.
More broadly, it appears that concerns about behavioural fatigue lead the government to believe that halting the spread of the disease is impossible, and the only solution is to slow the progress of the disease across most of the population, until herd immunity is achieved. But radical behaviour change may be able to do much better than this, and would, if successful, save very large numbers of lives.
The signatories, of which there were 641 by yesterday, urged the government – just as the epidemiologists and immunologists had done – to “share an adequate evidence base” in support of its approach. It hasn’t.
Yesterday, the letter’s authors said they had taken action, above all, because of their concern at the delay in introducing “social distancing” measures. Society was running ahead of the government on “social distancing”, with football authorities, workplaces and universities deciding on it themselves.
While the government hesitated, the idea of “behavioural fatigue” had been used by officials to justify delay, but remained “vague”. They continued:
The burden of proof, therefore, lies with the government to explain its reason for delay. But can this burden of proof be met? Is behavioural fatigue a sound reason for delaying social distancing?
■ Socialists including me think that the government’s approach is underpinned by an inhuman focus on “keeping Britain open for business”.
“Why are they acting like this?” a friend asked yesterday. “They don’t actually want to get people killed, do they?”
Governments do take decisions that get people killed, as the history of wars down the ages shows. But I do not think this is about the government wanting people to get killed – not directly
– or about it wishing apocalypse on the National Health Service in order to finish breaking it up (although plenty of Tories want that). That’s not how politics works.
In my view, we are seeing the government lurching into a big crisis – and, by the way, a global economic recession – with little more than their distrust of “experts”, shreds of neo-liberal ideology, and underlying hatreds of foreigners and working-class people, to guide it.
So they shrink from the sort of emergency measures to support people that continental European governments have taken – from generous funding for sick pay to, in Spain’s case, taking over private health care providers.
On the other hand, “keeping open for business” is a key priority for Johnson and co. The Financial Times claimed on Friday that this was the rationale for the government’s delay in implementing “social distancing”.
The reporters dug up a speech, made by Johnson in 2007, in which he said that the true hero of the movie Jaws was the “laudable” mayor, Larry Vaughn, who kept his seaside town open for business in spite of hysteria around a series of shark attacks. Johnson told a business audience:
A gigantic fish is eating all your constituents, and he decides to keep the beach open. It turned out he was wrong, But it remains that he was heroically right in principle.
Now of course you could find old quotations from Johnson saying more or less anything. But I think the reporters were right: this helps to explain the prime minister’s state of mind.
What will these Tories prioritise? The Lancet article mentioned earlier starts by warning:
Governments will not be able to minimise both deaths from coronavirus […] and the economic impact of viral spread. Keeping mortality as low as possible will be the highest priority for individuals; hence governments must put in place measures to ameliorate the inevitable economic downturn.
This way of posing the issues is anathema to me. But leave that aside. This is surely the way that the government and its advisers see it: they will not be able both to minimise deaths and to minimise economic impact.
Like the lords and masters they believe themselves to be, they will make a “balanced” choice.
The huge surge of community activity around coronavirus, and the fierce reaction of the medical profession to the government’s inaction, shows that it will not be the government that decides this by itself. It’s about what we all do. GL, 17 March 2020.
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