As the current wave of the pandemic in the UK wanes, a new one threatens. It is appropriate to reflect on where we are and what lessons we have learnt. A look around the world tells us that the pandemic is far from over, with heart-rending pictures from Brazil and India, whereas in the Far East life has almost been back to their normal. Nevertheless, almost every populous country has now seen at least three waves of infection.
In the UK, the extent of the first wave was generally underestimated through lack of testing facilities, the second started as public health measures were relaxed, and the third seems likely to have been largely due to a more transmissible variant which rapidly spread round the world. Where vaccination has started, there has been a clear reduction in mortality.
Europe, in general, is still in the grip of the combined second and third waves, but the UK looked finally to have got better control of the infection. It is noteworthy that the mutation that occurred first in Kent is the one that has in large part been responsible for the current wave in Europe and is an important contributor to the awful outbreak in India. And now one Indian variant is widely present in parts of the UK including Glasgow, introduced mainly by family members returning from the sub-continent.
An unfortunate feature of epidemic disease nowadays is this ability to spread rapidly worldwide through air travel. Another is the number of national leaders who have a poor grasp of biological facts. Our export of the UK variant should urge caution on us, as our failure to control spread in the UK after the initial wave, which led to this variant evolving, is being replicated in Brazil and India; the more infected people, the greater the chances of new and possibly more hostile variants to evolve and come back to our shores. Some are likely to be resistant to the antibodies induced by infections and vaccination; this explains why a very cautious opening-up of society is essential with rigorous local control of any new outbreaks, alongside continuing emphasis on vaccinating everybody other than young children.
Any satisfaction with our position now must be tempered by an acknowledgement that we did not initially manage this pandemic well in the UK, resulting in amongst the highest death rates so far in the world. Even if we get control of the effects of this one, it will not be the last. We need to apply the lessons that we have learnt, in order to mitigate the effects of other epidemics in the future. This explains why we need to take a critical look at what went well and what did not; to guide our current and future behaviour rather than to distribute blame.
The positive outcomes
There was initially a lot of discussion of the willingness of people to comply with restrictive or tiresome measures, to the extent that political ideology on individual freedom became an issue. Those who have lived through a time of serious external threats, such as the last war, will know that when confronted with such reality people in general are highly compliant with extremely restrictive measures, though they may complain about them. This proved to be the case; the population generally readily accepted wearing of masks, social distancing and isolation, and repressive policing was not necessary. The key to this was good communication by trustworthy people, notably in Scotland and Wales by the First Ministers and in England by professors Whitty and Van Tam. The egregious behaviour of those advisors who failed to accept their own rules in Scotland and England attracted universal disapproval.
Fears that the economy would collapse were not realised, partly through the rapid introduction of the furlough scheme which reduced the adverse effects on employment and commerce, though these have nevertheless been significant. Life continued and most organisations found a way through the inevitable difficulties; indeed, ingenuity flourished. Services were maintained by perhaps under-appreciated groups of willing workers, mail, goods and food were delivered, supermarkets and the internet providers thrived, and waste was collected and disposed of. Importantly, hard work by undertakers allowed cremations and burials to continue.
The effects of lockdown on the poorest and the young have been disproportionately great, and this toll is as yet unquantified. Nevertheless, education continued thanks to the remarkable efforts of teachers, the parents of school-age children and the staff of universities, all of whom have had to adapt their lives. And we should not forget the willingness of most young people to continue learning in these circumstances; I suspect many will be stronger for having had this early lesson in overcoming difficulties and in later life will speak proudly of how they managed.
For those few who did not previously appreciate it, there can now be little doubt about the value of a national health service. The commercial model of healthcare that has been encroaching on the NHS was forgotten and private practice ceased temporarily. The management of hospitals was essentially taken over by the front-line medical and nursing staff, and others moved to where they were needed. This was the difference between the UK and many other countries, including the USA and India, where healthcare is far less efficiently and equitably distributed. This again was apparent when vaccines became available, and the NHS did the bulk of the work in ensuring distribution.
In addition, the structure of the NHS allowed rapid introduction of trials of many drugs used for other inflammatory conditions that might be beneficial in COVID-19; at least two of these proved to reduce death rates and need for intensive care. Swift dissemination of the results of these trials of disease management was of international benefit.
A common response to pessimism about the future is that technology will find an answer. This complacency is justified historically but such answers come at a cost. Part of the answer to this pandemic will turn out to be vaccines but the cost is in time and money, and delays cost lives; worldwide so far 3.2 million have died of COVID-19. Nevertheless, the rapid discovery and testing of multiple effective vaccines will be seen historically as one of the great triumphs of international science.
No one vaccine is the effort of one country alone. The basic science and the technologies behind them are international, in most cases relying on public-funded universities and health services collaborating with the manufacturing and distribution skills of the private sector. Several different technologies allow these vaccines to be modified relatively rapidly to counter resistant variants, so there is a chance that this virus may have met its match. However, this depends on the world being vaccinated swiftly; good public health measures are also likely to be necessary alongside vaccines for much longer.
Another remarkable advance has been the rapid development of methods of testing for the presence of infection, even to the point of self-testing and getting a probable answer within a few minutes. This also has been based on the extraordinary scientific advances in genetics in universities combined with private sector enterprise.
What went wrong
The consequences of the pandemic have differed greatly between countries from the very beginning. It is notable that those countries with strong locally-based public health systems, in the Far East, much of Africa and most of the Nordic countries, have kept better control of the infection. Those countries with leaders who appeared not to grasp the biological facts, notably the UK, USA, Brazil, and Turkey have done worst. However, the consequences of having authoritarian regimes differ, as can be seen by contrasting China and Brazil; they can influence the outcome either way.
Lack of preparedness
Despite warnings both from its own advisory mechanisms and from the experience of China and other Oriental countries, the UK was ill-prepared. It had no plan, inadequate provision of protective equipment, and no agreement on how to test for the virus. Its advice on protection of hospital workers seems to have been based on what equipment was available rather than on what was then known about aerosol transmission. Even the Prime Minister showed his disregard for simple preventive measures until he learnt the hard way, and some key advisors, including scientists, seemed to think that the rules did not apply to them. The ancient Greeks warned against hubris.
Erratic control of borders
For a trading nation like the UK, this raises very difficult issues but other islands (eg New Zealand, Taiwan) effectively controlled their borders whereas we did not, both exporting our variant and importing the Indian one. In the UK, Wales has been more successful than the other nations in this respect.
Waste of money on private sector
In what appeared to be panic but based on ideology, the government poured vast sums of public money into private companies, often related to Conservative supporters, for testing and tracing and production of such items as masks and respirators. This has not yet been accounted for but must be; it appears that the available UK-wide public health resources already available in the NHS, local authorities and universities were disregarded. Equivalent sums of money directed there would have been much more efficient and effective. There is a well-established local public health network dating back to Victorian times in the UK, but over the past 20 years political decisions allowed or even encouraged it to deteriorate, losing much of its diagnostic capacity and becoming inadequately staffed. Centralisation of public health viral diagnostics in England led to it being overwhelmed and the UK was very slow to use facilities available widely in universities; this is where the money wasted on large corporations would have made a huge difference.
Failure of track, trace and isolate
It was initially apparent that the pandemic would be impossible to control without repressive measures, since the virus transmits before symptoms start and there was no adequate diagnostic test available in sufficient numbers. There seems to have been a belief that the problems of finding cases and their contacts could be solved by ‘world-beating’ apps, and there was a drive to get us all to install these on our mobile phones.
The traditional method of contact tracing, known to work, involves people phoning or visiting suspected cases and contacts and is locally based. It has proved very effective for other infectious diseases but is heavily reliant on trained people and can only cope when numbers of patients are relatively low. Many retired doctors and nurses were available to man telephones and, after vaccination, to help with contact tracing in person, but were barely used. Failure of contact tracing and isolation when the first wave declined made a serious contribution to the severe outcome of the second wave.
It is unclear how far the contacts who were detected complied with advice to self-isolate. For those who were furloughed, presumably most did so but loss of income must have been a serious problem for many, especially those self- or precariously employed. Basic financial support for what is in effect an altruistic act would have alleviated this problem.
Poor timing of lockdowns
From the start in March 2020, the severity of the pandemic in UK was foreseen from the doubling rate of hospitalisations, even while it was known that many cases of COVID-19 were going undiagnosed and that the disease was transmissible before symptoms occurred. Political reluctance to impose lockdown seemed to stem from fear that British people would react adversely. This, with the failure of contact tracing and isolation, contributed also to the severity of the second wave and allowed the new UK variant to get a grip and initiate a third wave superimposed on the second.
Consequences in the NHS, social care and education
The pandemic was not treated as a hospital or nosocomial infection, even though it was obvious from Italian and Chinese experience that hospital staff were at high risk of infection. Normal measures to isolate patients became impossible, so doctors, nurses and those in other patient-associated roles became spreaders of infection and passed the virus to each other and to their families. The public quickly learned to avoid hospitals if possible, but many patients who were admitted with other conditions caught COVID-19 while there. It is possible that the spread to care homes was contributed to by early discharge of COVID-19 patients to them, though it is more likely that this was inadvertently introduced by care home staff themselves. Many homes had great problems initially in locating protective equipment, compounding their difficulties.
The consequence of diverting all resources to the pandemic clearly had a big effect on the normal activities of the NHS, essentially stopping all non-urgent treatment; this inevitably has led to lengthening waiting lists and will cause big problems for NHS managers as well as patients. Similarly, the effects of the disruption of education will be apparent in the future but are likely to increase further the already marked disadvantage of those less well-off whose accommodation and family resources could not provide the necessary support.
What we have learned so far
1. The pandemic many feared, one caused by a virus that spreads on breath, mutates frequently and transmits infection before symptoms are present, is now happening and is becoming endemic. We need a national plan for the coming wave and the next virus, including a guaranteed supply of essential equipment, drugs and gases.
2. A rapid public health response, controlled nationally and internationally but based on local expertise and personnel should be started early, guided by the known infectivity of the virus. Local public health services should consider having a reserve of health professionals available for call-up when needed, both for clinical care and contract tracing.
3. The NHS and social care sector must also have a plan to prevent them becoming nuclei of infection. Staff require proper protection themselves and there should be separation as far as possible of infected patients from others. Occupational physicians should be involved. We now know how to provide emergency hospitals; these could be mothballed and emergency staff recruited who can transfer to them early when needed. We need to decide what these hospitals should be used for; it might be possible to use them exclusively for infected patients from the start of any outbreak. Military input in planning this would be essential.
4. The importance of the workplace in general in allowing spread of infection has been seriously under-emphasised in the current pandemic. Most workplaces where people necessarily congregate now know this and are taking steps to reduce risks. Tracking of contacts must take account of workplace interactions.
5. People generally behave sensibly if given good explanations and many people do even better, by helping others. We are all indebted to our posties, delivery people, workers in foodbanks, and the caring and other essential activities that have kept us safe and looked after our friends and relatives.
6. Rapid and equitable distribution of vaccines has proved a major problem that can only be solved by international collaboration through WHO. It is in every country’s interest to work out how to achieve this.
Do we need an enquiry?
A public enquiry is promised but will probably take years and is likely to be confronted with a huge mass of information. People may expect it to point the finger of guilt at politicians, and lawyers may anticipate an opportunity (a legal chair would guarantee this). In framing the remit of the enquiry, I hope that it will be charged rather with identifying the lessons learned from our management of this pandemic so far without threat of legal penalties. As I write, complacency and pressures from the media for ‘freedom’ may allow the Indian or another variant to get out of control, escape our antibodies, and put us back to square one. We must be ready for this. I have pointed to some of the lessons and believe most have already learned from them.
The most encouraging thing I have heard recently was Mark Drakeford, Welsh First Minister, saying that the current outbreaks of infection with the Indian variant in Wales are being dealt with by the local public health authorities. Only effective tracing and isolation in this way will prevent wave four until we are all vaccinated. It is good to hear that the Army is now being involved in this. A fourth wave of cases of COVID-19 is to be expected but a rise in the number of hospitalisations over the next few weeks will indicate we are losing control. As I have said repeatedly, please remember how the virus spreads and continue to protect yourselves and others.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own