The government needs to be much firmer in its response to COVID-19
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BY ADAM HAMDY
George Osborne has called for the government to move to a ‘war footing’. Chinese President Jinping has likened the anti-epidemic battle to a people’s war. This is not rhetoric. China has used wartime measures to try to bring its epidemic under control. It has put its economy at risk and taken draconian steps to try to eradicate the virus and protect its people. As the World Health Organization has pointed out, there are no other countries in the world that have the same mindset. Britain needs to get that mindset fast.
The outcome of today’s Cobra meeting will tell us everything we need to know about how serious the government is about containing the COVID-19 virus. If the government continues its policy of telling people to wash their hands, while playing a waiting game, we will know it is not serious about eradicating this virus. Matt Hancock says scientists have told him this virus will become endemic, meaning it will circulate within the population, affecting us on a regular basis, just like the common cold. This is a dangerous attitude from the man coordinating our public health response. We need a Churchillian figure who will muster people and resources and use creative minds to solve this problem.
COVID-19 is a highly contagious virus. According to the World Health Organization, it may survive on surfaces for several days. We still do not know exactly how it spreads. This should be the first cause for alarm. Our public health response and personal hygiene advice is based on a virus we have not understood. We know that soap destroys the membrane of the virus and that alcohol-based hand rubs with a high ethanol content kill it, but we don’t know about transmission methods, exposure time, or the level of contact required for infection.
Another complicating factor is this virus can be spread asymptomatically. We do not have accurate measures of the extent or prevalence of asymptomatic spread. This should be our second cause for alarm. Our existing pandemic models are based on two assumptions. The first is that people spread a virus when they are symptomatic. The second is that if we survive, we develop a long term immunity to the virus. Which brings us to the next and perhaps most significant problem.
The COVID-19 virus belongs to a family of viruses called coronaviruses. There are seven types known to affect humans. We do not develop long term immunity to coronaviruses. Our immunity typically lasts between 1-3 years. Four coronaviruses (229E, NL63, OC43, HKU1) are endemic. They circulate the human population, re-infecting us.
Five and six are MERS-CoV and SARS-CoV, potentially lethal viruses that have been largely eradicated due to excellent containment efforts.
The seventh coronavirus known to affect humans is officially called SARS-COV-2, but we know it as the Coronavirus or COVID-19. I’m going to continue using the COVID-19 colloquialism. If, as seems increasingly likely, governments fail to contain COVID-19, scientists envisage two possible outcomes. The first is that it becomes a seasonal illness, like the flu. There is no evidence so far to support that view. In fact, the virus’ rate of infection in Singapore, which is close to the equator and relatively warm all year round, would suggest it copes well with warm weather. The second view is that COVID-19 will join the four endemic coronaviruses and keep circulating within the human population.
“I think there is a reasonable probability that this becomes the fifth community-acquired coronavirus,” Dr. Amesh Adalja, infectious disease specialist at the John Hopkins Center for Health Security.
“I have a little bit of hope that, OK, we’ll put up with a couple of years of heightened [COVID-19] activity before settling down to something like the other four coronaviruses.” Richard Webby, influenza expert at St. Jude Children’s Research Hospital.
Science is built on evidence and peer review. I have been aghast at the willingness of some academics to make broad pronouncements that will affect the health of almost every person on this planet without rigorous evidence to back up their assertions. I’m not the only one who’s worried. The New York Times recently published an article featuring virologists and epidemiologists raising concerns that because of COVID-19’s novelty, we simply do not know enough about it to make a proper assessment of its long term impact on human health.
If we’re entering a world where it’s OK to base public health decisions on speculation and guesses, here are some of my own based on the characteristics of this virus and clinical observations elsewhere in the world.
First, I don’t believe we would experience only a couple of years of ‘heightened activity’. SARS has a molecular proofreading system that reduces its mutation rate, and the new coronavirus’s similarity to SARS at the genomic level suggests it does, too. I believe that while it is not impossible for this new virus to mutate towards less virulence, it is unlikely. So, in the absence of a cure or vaccine, if this virus becomes endemic and we hope to see reduced healthcare intervention, it will have to be because our body’s immune response improves.
So far, the clinical evidence on the body’s immune response is troubling. There are increasing reports of reinfection of previously recovered patients taking place shortly after recovery all over the world. One response from some scientists has been to say, “you must have tested wrong”. That would be a valid response in a single case, but we’ve now seen many. In fact one hospital says it’s seeing re-infection in 14% of patients.
Another dismissive response to the reinfection issue is to say “we’d expect to see some viral load in recovered patients”. That’s very true, but in order to be discharged from hospital in China one has to test negative twice, 48 hours apart. So this isn’t a case of people registering a positive viral load on discharge, this is a case of people testing negative and then testing positive again. There has been a reported case of a man being released from hospital, and, having recovered, he then went into quarantine for two-weeks before returning home and being re-infected again. His young daughter also tested positive for infection after he’d returned home.
We do not know for sure whether the man caught the virus again from someone else, or whether it was dormant, and resurged causing him to become infectious again. Or whether there is some other explanation, but his lack of immune response is troubling.
Professor Samuel McConkey, deputy dean at the Royal College of Surgeons in Ireland, has said he “already expected that [Covid-19] would reinfect people because that is what happens with the previous coronaviruses”. The emergence of reinfection suggests some people may not develop a natural immunity.
As I write this South Korea has reported its first case of reinfection in a patient.
Another response used to dismiss the potential reinfection problem is that, “it’s very uncommon for coronaviruses to re-infect in less than a year, this must be an outlier.” Uncommon is not impossible. Nor, given the rising number of reports of reinfection, does it seem that it is such an uncommon occurrence with this particular virus.
“I’m not saying that reinfection can’t occur, will never occur, but in that short time it’s unlikely,” Florian Krammer, Icahn School of Medicine.
There is much about this virus that is unlikely, and basing our response to something new on past experience is simply not good enough. In Italy there are 1,577 people who have tested positive for the COVID-19 virus plus 83 recovered who have previously had the virus (yes, Italy has started deducting recoveries from its total case count). Of those 1,577 who still test positive, 639 are hospitalised and 140 of those are in intensive care. There have been 34 deaths. According to Italy’s figures, 40% of cases have required hospitalisation and 9% have required intensive care. This virus is most definitely not the flu and if governments don’t react quickly, and we don’t develop a vaccine or a cure, there’s a chance this challenge will be with us in its current form for a number of years.
Even if immediate re-infection is uncommon, given the characteristics of other Coronaviruses, at best we can expect to develop temporary immunity for 1-3 years. 40% chance of ending up in hospital, which increases as you age. Do you fancy spinning that roulette wheel every couple of years? Do you want to live in a world where you will watch your children reach an age where COVID-19 can start to have a serious effect on them?
Sounds dystopian, right?
We’ve only been aware of this virus circulating in humans for a matter of months. The science isn’t sufficiently established for us to be cavalier about the prospects this virus could either re-infect us rapidly, or that we might carry it in a dormant form.
If it is possible to carry it in a dormant form, we don’t know how long it might stay with us. According to the New York Times, “A report published Thursday in JAMA supports the idea that people may test positive for the virus long after they seem to have recovered. In four medical professionals exposed to the virus in Wuhan, China, the epicenter of the epidemic, a test that detects the viral genetic material remained positive five to 13 days after they were asymptomatic. This does not necessarily mean that they were still able to infect others, however.”
This does not necessarily mean…
Good science requires evidence and discipline. So far our public health response has been based on best guesses, and in the absence of good science, our government is not erring on the side of caution.
The government’s response to pandemic is based on influenza. A disease with a relatively low mortality rate. A disease we develop a long term immunity to. A disease in which carriers don’t become highly infectious until they’re symptomatic.
Two highly regarded, independently conducted studies found that social distancing made a huge difference to the spread of Influenza during the 1918 pandemic.
“Social control measures such as closing schools and banning public gatherings played a significant role in slowing the advance of the 1918 influenza pandemic.”
There was a marked decrease in the mortality rate depending on whether cities closed schools and banned social events sooner rather than later. The smoother infection curve also placed less peak strain on health services, leading to better clinical outcomes.
In its mission report of 28th February 2020, the World Health Organisation says:
“Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China. These are the only measures that are currently proven to interrupt or minimize transmission chains in humans.”
I’m going to repeat that: These are the only measures that are currently proven to interrupt or minimize transmission chains in humans.
China instituted a quarantine of Hubei province in January, over one month ago. It has confined people to their homes, closed schools, businesses, banned free movement, forcibly removed people to quarantine. 40,000 health care workers have been deployed to Wuhan. A team of over 9,000 specialists do nothing but contact tracing in the city, tracking down tens of thousands of contacts daily. This huge contact tracing effort has been in addition to a total shutdown, not instead of.
Early experiences in Italy and South Korea show us it is the height of folly to believe that if we don’t implement rigorous control measures, our NHS might not be overwhelmed in the same way Wuhan’s was. COVID-19 is currently utilising 2% of Italy’s intensive care beds and it is only ten days since their first confirmed case of community infection.
In China, the lower infection rate outside Hubei is a result of drastic isolation and control measures of an entire province of 59 million people and large parts of the country. These are the actions of a government that’s serious about protecting its people.
“But we don’t have that many cases,” people say. “Stop being alarmist.”
Let us be clear, the increasing number of cases with no known source means we are in the early stages of an epidemic. There is still time to act, but that window of opportunity is shrinking. On February 21st Italy had 3 cases, today it has 1,577 (I’m being generous and not including those who’ve recovered). Once an epidemic starts, things move very quickly indeed.
There are some who point to New York in the 1918 pandemic, a city that managed to keep functioning by implementing strict monitoring measures. One can monitor a virus that is spread by people who show symptoms. How does one monitor a virus that can be spread asymptomatically? Especially when we have no idea of the extent or prevalence of asymptomatic spread.
We know COVID-19 is highly infectious. We know it transmits asymptomatically. We know it causes a disease that has the potential to overwhelm the NHS. Clinical reports from the front line suggest we can be re-infected. And if we can, we don’t know whether the virus is dormant, or whether re-infection comes from other carriers. If the virus is dormant long term, we don’t know what the long term implications will be. Imagine if someone had discovered the HIV virus and told people not to worry about it because carriers were asymptomatic. We simply do not know enough about the COVID-19 virus to be cavalier about its effect on human health and manage it in the same way we would a flu pandemic.
So far, the government’s response has been to wait and see. All the while, as the nascent pandemic spreads around the world, procedures at our borders remain largely unchanged. Life has remained largely unchanged. We’re relying on luck to be kind to us, but eventually our luck will run out.
All it takes is a cluster of people being infected in London and we could see a public health crisis of a scale this country has not experienced in modern times. Matt Hancock talks about shutting down cities. China shut down Wuhan when the country had fewer than 700 confirmed cases. They knew that as the number of cases increases, so does the probability of a mass outbreak that causes crisis. The studies cited above prove that early measures reduce an epidemic’s impact and save lives.
Nothing I’ve seen in the government’s response so far suggests they will move with anything like the urgency required. Not only has the government been cavalier and slow to respond to this crisis, the measures it has proposed show it has little understanding of the specific characteristics of this virus.
Let’s take two examples. If a significant number of GPs fall ill, the government plans to call upon retired GPs to fill the gap. It plans to put the cohort most likely to be most severely affected by an infection in frontline care roles. Not only would this response endanger the health of those retired GPs, it would increase the burden on the NHS. Older people have a higher mortality, but they also require more intensive medical care if they become infected.
A government that understood the specific characteristics of this virus and wasn’t simply dusting off an old copy of its pandemic plan, would call upon student doctors to fill the gap and create a remote hub of experienced GPs who could be contacted via Skype or FaceTime to provide support to the student doctors and ensure a high standard of care. Young people are much less likely to suffer severe complications as a result of a COVID-19 infection, so it makes far more sense for them to be in frontline roles.
The second example is the government’s response to schools. Instead of closing schools, it seems the government has plans to concentrate risk. According to the Daily Mail, “New laws will include the ability to suspend maximum class sizes to allow teachers to take on pupils when colleagues are off sick.” Again, this feels to me like a measure taken from that dusty old influenza pandemic plan.
While the mortality rate in children is low, children might play an amplifying role in the spread of COVID-19. Clinical studies suggest infections in children are commonplace, but they rarely become sufficiently symptomatic to require medical treatment and their mortality rate is low. These qualities could make them highly effective carriers of the virus.
The first reported case of community transmission in Oregon was found in a school employee. There have been school-related transmissions in America, the Netherlands and England. Without further analysis of the role of children in transmission, it’s hard to say for sure, but given the clinical characteristics of infected children (asymptomatic or mild symptoms) it is possible schools will become hubs for the spread of infection.
Many countries have chosen to close their schools already. Our government plans to keep them open and increase class sizes. A government that was on a war footing would close schools immediately and in the coming weeks it would make plans for the children of those who cannot make long term alternative arrangements to be taught in special schools with high infection monitoring protocols. Parents who work in the emergency services and healthcare provision, who are worried about their own transmission risk, would be reassured to know their children were being tested on a daily basis. Responding to the specific characteristics of this virus, it would make sense to choose young teachers (sub-35) to teach in these special schools.
On the subject of school closures, speaking as a parent, I can make alternative arrangements now. The chances of my children being infected are low, and I would be comfortable giving them to grandparents or relatives to look after while I continue to work. If a shutdown is forced upon us by a mass outbreak, that situation changes drastically. Widespread infection in the community means it would be irresponsible to ask others to care for a potentially infected child, forcing us all into isolation and accelerating business disruption.
A government that was serious about eradicating this virus, or at least significantly slowing its spread, would institute border infection controls. The COVID-19 pandemic is spreading across the globe. With each passing day, the number of infected people travelling to or through our ports will rise. What is the government’s long term plan for this? It doesn’t matter what measures we take domestically if we don’t find a way to prevent the virus being imported.
There are two types of people. Those who know and accept we’re now living in a pandemic world and those who don’t. Our priorities and decision making processes need to radically change. Trying to impose the pre-pandemic model on the pandemic world, simply won’t work. COVID-19 is a biological fact. If it can quickly re-infect us and/or lie dormant, it is a dangerous biological fact.
Whatever happens, there is going to be disruption to our lives, but if we’re ingenious and use technology effectively, we can minimise that disruption. By responding to the specific threats posed by this virus, Britain can safeguard its citizens and use novel methods to remain open for business. That is a message that just might reassure the stock market.
The economy will function better for longer if we take decisive planned steps to minimise risk. I believe the markets will reward us for keeping our economy and population healthier. And as the world deals with a rapidly out of control pandemic, it will need countries with healthy populations who aren’t myopically focused on their own epidemics to work on a vaccine and/or a cure. China has opted for draconian controls. If we’re innovative and creative and use technology and tailored measures to meet the specific challenges of this virus, our response could set a model for the world to follow and might just help bring this nascent pandemic under control.
If we don’t act now, we risk facing the Sophie’s choice that confronts China. When there is a significant number of infections in a country, how does it get its economy going again without risking another outbreak? It seems the Chinese government plans to keep going until the disease is eradicated, and this costly policy looks as though it’s working. Their infection rate is falling, and most of the cases relate to specific areas or clusters.
If the government acted decisively now, we would not face anywhere near the challenge China has faced, because our epidemic is in its early stages. We need to keep Britain’s population as healthy as possible for as long as possible and figure out a way to make the economy work in this new world. We need to buy time to better understand this virus and find a vaccine or cure. We need to limit the number of people who die or who have serious clinical outcomes as a result of this disease. China has recently conducted its first lung transplant in a patient suffering from COVID-19. This is most definitely not the flu.
It’s worth repeating:
“Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China. These are the only measures that are currently proven to interrupt or minimize transmission chains in humans.” – World Health Organization Mission Report
Unlike other countries, Britain is wealthy and well educated. We are materially ready for what’s going to happen. We need to change our outlook and approach. We need the mentality the WHO talks of.
The government is being advised by scientists who know everything I’ve set out above, and much, much more. If the government chooses not to respond effectively to this growing crisis, it will likely be because the government is trying to protect the economy from widespread disruption. If we see a mass outbreak on the scale of Wuhan, not only will we face a humanitarian crisis, we will face an economic one.
Boris Johnson is expecting a baby. Congratulations. Until we know more about this virus, or are clear we can defeat it through vaccine or cure, do you want your children to grow up in a world where this virus becomes endemic and potentially lowers their life expectancy?
Be better. Do more.
Adam Hamdy is a novelist and screenwriter who has previously worked as a management and healthcare consultant. Follow him on Twitter: @adamhamdy