The coronavirus pandemic was a battle where old met new. It catapulted the frailties of the past into a population that had grown complacent of its own security. It confronted an age that had supposedly mastered knowledge and technology, with one of history’s most common conflicts. People against disease. It revealed the limits of global economies and societies, while proving human emotions as old as time remained fundamental to the functioning of our lives no matter how bureaucratic or sophisticated our governments had become. Fear, bravery, and trust influenced countless decisions made across the world. At the heart of this story were investigation and decision. Two actions our ancestors relied upon to protect them in the hunt for food or shelter, and which now determined the lives of millions. This was a disease that reminded the modern world of its insecurity and that no matter how far knowledge can be advanced, the unknown will always be possible. This was a new virus that connected the world with its past. The confidence of our modern age was destroyed within the space of three unprecedented and torturous months.
The month of discovery: January
Looking back at the progression of coronavirus and the world’s response to it conjures that feeling of unease when one studies photos taken in a time of innocence but that proceeded a scene of crisis or pain. It’s only the ability of hindsight that makes us feel this way and indeed how unaware the photo’s participants are of their incoming danger is what adds to its horror. A snapshot of the world in January would create such feelings. Analysing the thoughts and actions of the World Health Organisation and the UK’s Scientific Advisory Group for Emergencies reveals a month where scientists were engaged in the discovery of a disease that was as yet unknown. It was an investigation hampered by a lack of information and mistrust that was the product of conflicting ideologies and fraught diplomatic relations between countries. Whilst politics disrupted the world of science, for many Britons celebrating on New Year’s Eve, the turn of the decade was a moment to abandon the political uncertainty and drama of the recent past. Yet as 2019 was left behind, the World Health Organisation was being informed of a cluster of pneumonia cases within the Chinese city of Wuhan which would subsequently allow nobody to simply move on from 2020.
Within the largest city of Hubei Province China – an area where 58million reside – the WHO had been informed of 44 patients suffering from pneumonia of an unknown cause. The warning was delivered to the organisation’s China County Office on the 31st December and by the 5th January, the WHO published the first report on what would later become known as Covid-19.
It read that 11 of the 44 patients were ‘severely ill’ whilst 33 were in a ‘stable condition’. Based on preliminary information from ‘the Chinese investigation team’ there was ‘no evidence of significant human-to-human transmission’. This was a significant early finding and one which scientists in the UK wrestled with throughout January. By the time British scientists first met to discuss the outbreak, China had confirmed the death of a 61-year-old man with underlying health problems and that his pneumonia had been caused by a ‘novel coronavirus’ related to previous SARS and MERS outbreaks. During the morning of their first meeting, a case was confirmed in Thailand in a person who had travelled from Wuhan.
NERVTAG is the UK’s Department of Health expert committee whose role is to provide risk assessment and advice on ‘new and emerging respiratory viruses’. On the 13th January, it met for the first time and was tasked with the investigation of this novel coronavirus. Questions focussed on transmission and the disease’s lethality. It is striking the lack of information they had.
The committee requested that the UK Government ask China for data on excess mortality statistics, whilst Public Health England informed the group, that they were unsure about available access to any genomic sequences of the disease. After being informed that the first reported case fell ill on the 12th December, the scientists questioned the WHO’s findings over transmission. Yet with such little evidence available were ‘cautious in making conclusions’.
It was judged that the risk of the disease to the UK population was ‘very low’ and from the information available its impact was ‘low to moderate’. NERVTAG agreed that the UK’s Chief Medical Officer should be alerted to the virus, along with health ministers and the Government Office of Science.
As early as the 17th January, scientists were openly warning about the validity of the data being released from China. Imperial College London (ICL) published a report that estimated a total of 1,723 cases had onset of symptoms by 12th January, suggesting that ‘substantially more cases of moderate or severe respiratory illness than currently being reported’.
This was the first instance of many in which maths and science combined to fight against significant gaps of information; caused by how new this virus was, as well as the actions of an authoritarian regime in China which sought to downplay the threat. The university used the total number of cases detected outside of China to infer the number within Wuhan City. In stark contrast to the over a thousand cases ICL estimated, on the 20th January only 282 cases had been officially recorded with two now in Thailand, one in Japan, and one in South Korea.
Whilst the UK newspapers reported on a mixture of royalty, terrorism laws, and schooling, the investigation into the virus was beginning to accelerate. At their second meeting on the 21st January, NERVATG argued ‘that there was clear evidence of human-to-human transmission’ after a super spreading event in Wuhan involving the infection of 15 healthcare workers had been reported overnight. The following day the World Health Organisation publicly agreed. Although the route of transmission the disease took was now beginning to be understood, the extent of transmission between humans remained unclear, as did the virus’ lethality.
Noting that there was ‘no data on infectiousness in relation to symptoms and whether asymptomatic patients are infectious’ it was determined that the current global case fatality rate of 2.1% ‘cannot be interpreted as reliable’. It was believed that of 100 people who caught the disease approximately 2 would die. Citing the report that had been released from Imperial College, NERVTAG concluded it ‘was likely that cases would be seen in the UK’. From the very early days of the virus, containment in China was never truly considered. These estimations of lethality and spread marked the first in a series of alarming numbers that influenced government policy.
In view of Westminster Abbey, and half a mile from 10 Downing Street, scientists and health officials gathered at 10 Victoria Street, London, for the first SAGE meeting. Chaired by Sir Patrick Vallance, the Government’s Chief Scientific Advisor, alongside the UK’s Chief Medical Officer Professor Chris Whitty, in total eighteen attended the meeting. It was the job of those gathered to provide the Government with the best scientific advice to deal with the new coronavirus. Those involved with SAGE are at pains to point out that the crafting of policy was not their role.
Repeating the concerns from NERVTAG and Imperial College that the world was undercounting cases of the virus, SAGE was unable to conclude the incubation period of the disease (the time between contracting the virus to when symptoms start) and any relationship between the level of symptoms and someone’s infectiousness. It remained unknown who was infectious and when they could pass the disease to others. In the face of such uncertainty, the spread of the coronavirus was accelerating. It was judged that the reproduction rate (R rate) was above one in Wuhan.
The Department for Health had asked NERVTAG and SAGE to discuss the effectiveness of screening individuals from Wuhan on entering the UK. They were informed that although China had implemented ‘no enhanced measures’, the screening of people’s temperature was taking place. It was thus decided that no isolation or screening of people should occur once they had arrived in the UK.
This meeting provides the first evidence of why scientists believed entry screening or isolation of those coming into the UK from virus-hit areas was ‘unlikely to be of value’. NERVTAG concluded that ‘if there was efficient transmission in China, even closing the borders to 50% of people would only delay the outbreak not prevent it’, and screening would miss a ‘large proportion of cases entering the country’ because of its low ‘efficiency’.
The meeting ended with advice to the Government that ‘no practical preventative actions’ could be undertaken ahead of the Chinese New Year, where 3 billion trips were made worldwide as people travelled home for the celebrations. Consequently, the only change at the border was that a health team would be available to those travelling from Wuhan to provide advice and check for symptoms. Elsewhere, in South Korea, Singapore, Vietnam, and Thailand, airport entry screening had been introduced. There were three direct flights from Wuhan to the UK each week.
Meanwhile SAGE was confident in the testing capacity of the UK. The minutes state that scientists agreed the country has ‘good centralised diagnostic capacity and is days away from a specific test, which is scalable across the UK in weeks’. The importance of testing was emphasised further as Imperial College increased their estimates of cases in Wuhan to ‘4,000 with symptoms by 18th January’. ICL stated that ‘enhanced rapid case detection will be essential if the outbreak is to be controlled’. Officially 440 cases had been confirmed in China.
The following day was the first instance when coronavirus dominated news headlines. The Daily Mail asked, ‘Is the killer virus here?’ whilst the Times reported ‘growing fears in Britain’. Fears that were increased when news came from China that authorities in Wuhan had announced the suspension of public transport, and outbound flights and trains. The first city in the world had been locked down. It was an unprecedented moment and for now interested Europe not as a preview of their own future, but as a case study for how an authoritarian government could respond to a virus outbreak. Video emerged of a new 1,000-bed hospital being built in five days and of police drones chasing people back inside their homes.
This lockdown experiment felt dystopian, foreign. The closing down of an infected area was an age-old public health measure. But this time extrapolated onto a modern megacity and combined with C21st technology and surveillance. Old once against combined with new. Yet it was the interconnectedness of our global world that undermined such traditional health tactics. The Chinese Railway administration reported that 100,000 people had already departed from Wuhan before the introduction of lockdown.
Whilst the world was marvelling at China, the WHO remained divided over whether the coronavirus constituted the calling of a PHEIC – a Public Health Emergency of International Concern. With new evidence that ‘R was between 1.4-2.5, and 25% of reported cases were severe’ members decided ‘it was still too early to declare’ one. Matt Hancock informed the British public that the risk to them ‘remained low’ and Chris Whitty assured the country of its ‘excellent readiness against infectious disease’.
Behind these projections of assurance, real uncertainty remained amongst British scientists. There was ‘no reliable estimates of the case fatality ratio’ or of the ‘severity of symptoms’. But as new information was published, the apparent spread and transmissibility of the virus caused concern. On the 25th January, an Imperial College report wrote that on average each case ‘infected 2.6 other people’. This meant that measures to prevent the outbreak from escaping China would need to ‘block well over 60% of transmission’. The idea that the spread of the virus could not be stopped from entering the UK was once again strengthened.
Lancaster University’s Johnathan Read estimated a slightly larger R rate of 3.11, with 105,077 people in Wuhan infected. Globally only 2,798 cases had been confirmed. This rapid growth in cases was judged ‘much greater than that observed’ during the previous coronavirus outbreaks SARS and MERS.
On the 24th January, France became the first European country to confirm cases of coronavirus, with three patients hospitalized after travelling from Wuhan. Following increasing evidence of the spread of the virus, Matt Hancock on the 27th January announced to the House of Commons the UK’s first significant public health measure. Anyone who had returned from Wuhan in the last fourteen days was now ‘to self-isolate’. Whilst uncertainty remained over its infectiousness and lethality, becoming clear to the world was how quickly the virus was spreading and how dramatically China had understated its number of cases.
Between the 28th and the 30th January two further NERVTAG meetings and a second SAGE meeting were held. Concern was raised over the possibility of asymptomatic transmission, with scientists discussing evidence reported in the Lancet of transmission from individuals who had experienced no symptoms. Advancement, nevertheless, had been made in gaining knowledge in other areas of the disease. Scientists now understood the incubation period to be on average 5 days and that 14 days was a reasonable estimate for the duration of infectivity.
It was reported that 50% of new cases in China were now occurring outside of Wuhan and thus scientists and Department of Health officials debated whether to expand ‘surveillance’ to travellers from the whole of mainland China. At the heart of this debate were concerns over the UK’s testing capabilities. At a meeting on the 28th January, NERVTAG officials talked of a balance that needed to be struck ‘between the capacity of the health system under winter pressures’ and any expansion of surveillance to try and ‘control the spread’ of the disease.
Public Health England answered that a specific coronavirus test should be ready by the end of the week, with the capacity to run between ‘400 and 500 tests per day’. As a result, surveillance was extended to those from mainland China and the Foreign Office now advised against all but essential travel to the country.
By the end of the month, the very features of our modern world that made it such a globalised entity were beginning to be broken. The United States imposed a travel ban on all foreign nationals who had visited China in the last 14 days. Vietnam, Italy, France, and Russia all followed in closing their borders to China.
As the clock ticked towards 11 pm jubilant crowds gathered in Parliament Square. Inside Downing Street, a private party was taking place, which would involve the Prime Minister’s most Senior Advisor breaking down in tears of joy. Brexit had been delivered. The existential political, social, and economic crisis of the last four years had been resolved. A new world awaited.
Indeed it did. Just not the world anyone had promised or predicted. Discussion of trade deals and EU-UK relations would soon wane into insignificance. The world had spent January discovering a new respiratory disease. It found something deadlier, harder to control, and far more widespread than it had anticipated.
Approximately 7 million people left Wuhan in January. Outbreaks of the disease were accelerating in some of China’s largest cities, including Beijing and Shanghai. Thousands had flown out of China. Some 900 went to New York, 2,200 to Sydney and over 15,000 visited Bangkok. In over 30 cities across 26 countries, cases of coronavirus had been seeded. In Europe, a total of 6 cases had been counted in France, 5 in Germany, and 2 in Italy.
In the UK it was announced that two Chinese nationals, staying at an apartment hotel in York had tested positive for coronavirus. On the same day one crisis was resolved. Another had reached this island’s shores. A crisis that would make Brexit seem like the drawback of water before the tsunami wave hits.
“Every battle is won before it is fought”.
The month of planning: February
Focus shifted from investigation to planning. Modelling became of paramount importance. Against a backdrop of a worsening international situation, the UK contemplated what could be done to fight the virus once transmission within the country began. During February, SAGE spent countless hours drawing up possible responses and discussing the feasibility of contact tracing. Most significantly a complete lockdown wasn’t contemplated. As similar to the previous month, February was buttressed by two major events either side of it. For the world, the first reported death from coronavirus outside of China came on February 2nd in the Philippines. By the end of the month, the sudden outbreak of the virus in Italy and on the Diamond Princess Cruise ship showed the extent to which coronavirus was speeding of Government responses across the world. For the UK, the month ended with the first known case of the virus being transmitted inside the country.
Whilst accepting that transmission of the virus within the UK was inevitable, SAGE spent the first days of February calculating how best to delay its arrival. Aiming to ‘push any outbreak beyond the winter respiratory season’ to improve ‘NHS readiness’. It was calculated that travel restrictions that reduced the level of imported infections by 50% would ‘delay the onset of the epidemic by five days’ whilst measures that stop 90% of infections would ‘buy an additional’ two weeks. On the 4th February, the Foreign Office advised ‘against all but essential travel to mainland China’ and directed British citizens to leave the country.
What stands out from these SAGE meetings is that despite the implementation of such restrictions and extension modelling of domestic health measures, many scientists were resigned to the fact that delaying the spread of the virus would be a significant challenge.
The sub-group charged with modelling the impact of these measures was called SPI-M-O, which on the 4th February presented its initial findings to SAGE. The question was if any of the following would be effective in delaying an epidemic: restrictions on travel from countries with outbreaks, restrictions on all countries or on nation travel within the UK, mass closure of schools and universities, contact tracing of cases, the wearing of facemasks, voluntary home isolation if displaying symptoms, voluntary home isolation of all contacts if someone has symptoms, and quarantining people returning from China or other affected countries.
The answer was prescient of what would later come in March. SPI-M-O concluded that ‘the impact of any individual intervention would be relatively small, and none would be expected to delay a UK epidemic by a month’. Although in late March the solution to this problem would be the combination of all these measures and more – lockdown – at this stage focus remained on finding which of these measures would be most effective.
SAGE calculated that shutting down public transport or restricting public gatherings would be ineffective in delaying the spread of the virus. ‘Little direct evidence was found on the effects of cancelling large public events’. It was determined that the closure of schools and voluntary isolation of those with symptoms and of their contacts would be most effective.
The closure of schools would be ‘most useful early on’ in the outbreak. ‘Mass school closures’ however could ‘increase the overall rate if done at the wrong time’. Modelling was presenting scientists and ministers with precarious judgements to make. Timing was to be crucial to a successful response. But so too were the assumptions underlining these predictions.
Whilst SAGE agreed that a lack of data sharing from China ‘was seriously hampering understanding of the coronavirus’, an assumption that the UK could rely on its extensive planning for an influenza pandemic was just as damaging.
In 2017 the UK Government’s ‘National Risk Register’ noted that ‘the emergence of new infectious diseases may become more frequent’ because of climate change, increases in world travel, and more people ‘encroaching on the habitat of wild animals’. Yet it was judged that the risk to the UK from such diseases, although judged highly – an impact severity score of 3/5, comparable to ‘space weather’ and ‘heatwaves’ and a likelihood of occurring in the next five years score of ‘4/5’ – was lower than from pandemic influenza. Which was judged to have an impact severity score of ‘5/5’ and was seen just as likely to occur in the next five years.
Since the Spanish Flu of 1918, there had been three further global flu pandemics in 1957, 1968, and most recently Swine Flu in 2009. The latter, also known as H1N1, spread rapidly across the world causing between 150,000 and 575,000 deaths, and had a greater impact on those under 65. Compared to most seasonal influenza epidemics where 70-90% of deaths occur in people over 65.
In contrast, whilst most people around the world are infected with ‘common human coronaviruses’, which cause the ‘common cold’, two additional dangerous strains had been seen since 2000. In 2003 SARS caused an estimated 774 deaths, with an alarming case fatality rate of 11%, and was fortunately contained within four months. In 2012 the first identified case of MERS was reported in Saudi Arabia, with a large outbreak then occurring in South Korea in 2015. An estimated 866 people were killed, and 2,500 cases were reported. Whilst the UK had been largely unaffected by these two pandemics, the increasing frequency and risk from coronaviruses were undeniable.
Focus however remained solely on planning for a flu pandemic. With a national strategy plan created in 2011 and a cross-government exercise – named Exercise Cygnus – taking place in 2016 to assess the UK’s ‘preparedness and response to pandemic influenza’. The exercise was based on a flu outbreak which would affect up to 50% of the population and cause between 200,000 and 400,000 excess deaths.
Alarmingly, the conclusions of the report – published privately in October 2016 – stated that the ‘the UK’s preparedness and response, in terms of its plans, policies, and capability, is not sufficient to cope with the extreme demands of a severe pandemic’. Failures included several plans with bits missing or having ‘not been trained to’ and ‘the reaction of the public’ failing to be factored into key decisions taken. Concerns were also raised about the social care sector. During the exercise ‘capacity was extremely difficult to locate ‘if patients were moved from hospitals into’ care. Whilst staff ‘absenteeism through illness combined with widespread infection of the vulnerable could be very challenging’.
Following the exercise, the Government insists that recommended changes were made and only two years later in its 2018 Biological Security Strategy, the UK insisted it was ‘globally renowned for the quality of our preparedness planning, and world-leading capabilities’.
Whether this plan would have survived a flu pandemic is unknown but the reliance on this plan and the absence of one tailored to dealing with a coronavirus pandemic was detrimental when preparing the UK’s response during February.
Aspects of the plan can be seen echoing through several early assumptions made by SAGE and the UK Government. The flu strategy concluded that the ‘speed of with which the virus spreads and its severity’ will make it ‘not possible to halt the spread of the pandemic and it would be a waste of public health resources to attempt to do so’. Any plan for contact tracing was not evident.
It stated that restrictions on ‘mass gatherings will’ likely have ‘no significant effect’ and would be an important tool to ‘help maintain public morale’. Internal travel restrictions were argued against, as well as the wearing of face masks, with emphasis on encouraging those who have symptoms to stay at home. Also, behavioural concerns over how long restrictions can be maintained are prevalent.
As a result of having no pre-prepared plan for dealing with a coronavirus outbreak, combined with a constantly changing scientific understanding of the disease, efforts throughout February were focussed on modelling different health interventions. Each filled with uncertainty having never been tested.
Following the UK’s third reported coronavirus case, on the 7th February, the UK Government raised the risk to the public from ‘low to moderate’. New regulations meant that anyone who had travelled from Wuhan or Hubei Province in the last fourteen days had to now isolate, even if they were without symptoms.
Imperial College meanwhile revised down its estimate of case fatality rate to 1%. This was calculated by analysing the prevalence of infection amongst repatriated expatriates returning to their home countries from Wuhan. For instance, out of 206 passengers on a flight to Japan, 2 symptomatic cases were confirmed as well as 2 asymptomatic ones. This meant a prevalence of the disease in Wuhan of approximately 2%.
On the 11th February, the disease was named ‘Covid-19’ with 2560 new cases in the previous 24 hours. In the UK 8 cases had been confirmed and in Italy 3, with no deaths across Europe reported.
At that day’s SAGE meeting, a paper prepared by SPI-M-O was discussed, which outlined the scientific explanation for not stopping public gatherings. It read that stopping large gatherings like football matches could lead to more dangerous replacement activities, with fans meeting in a pub instead, ‘potentially accelerating epidemic spread’. Small private gatherings that happen more frequently were judged more dangerous with ‘contacts less intimate and shorter at public gatherings than with family members and co-workers’. At a meeting two days later SAGE concluded that neither travel restrictions within the UK or prevention of mass gatherings would ‘be effective in limiting transmission’.
Conclusions regarding the former corresponded to a paper published by teams at Essex, Bristol, and Warwick universities. Using 2011 census data, they investigated a range of starting points for the virus in various cities. It was predicted that ‘the initial location of cases had some but limited impact on the timing of the epidemic in England and Wales’. Outbreaks ‘seeded in Brighton, London, Birmingham and Sheffield, resulted in synchronised epidemics’.
Paramount to this modelling and to SAGE calculating when best to recommend restrictions were enforced, was accurate data. Crucially, how quickly the virus was spreading in countries where community transmission had begun, and how many days the UK was from experiencing the beginning of an outbreak.
SAGE concluded that from the information available, the epidemic in Wuhan was close to peaking ‘potentially in the next 1 to 3 weeks’ and that there was limited ‘on-going transmission detected outside China’ with case numbers still correlating with air travel volumes from the country. It was ‘realistic sustained transmission’ was already occurring in the UK or ‘that it will become established in the coming weeks’. This estimation was crucial because it was believed that a peak in case numbers would be seen 2-4 months after sustained transmission was established. The aforementioned paper based their models on the assumption that a peak ‘would therefore occur in June’, with person to person transmission persisting from February.
A day later France announced the first coronavirus death in Europe – an 80-year-old Chinese tourist. Meanwhile, Public Health England was working on a paper to be presented at the next SAGE meeting on the efficacy of contact tracing. The information that could be gained from tracing and testing contacts would offer more accurate estimates of the progression of the disease in the UK and help contain any outbreak.
The efficacy of contact tracing had been highlighted in two papers published on the 17th and 18th February. PHE set the definition for a close contact as a person whom an infected individual met for 15 minutes within two meters. Using this definition, scientists from Warwick, Oxford, and Lancaster University calculated that on average the number of such contacts an individual makes during a two week period is 217. Of these total encounters, ‘an average of 59 contacts meet the definition of a close contact’ and of these 59 ‘an average of 36 are individuals known to the infected case’. This meant that ‘93% of all cases meet the definition of close contact and can be identified’.
Under the optimistic assumption that the contact tracing system would be ‘rapid and highly effective’, it could reduce the R rate from 3.11 to 0.21. Similarly, the Centre for Mathematical Modelling of Infectious Diseases said that from their analysis of Wuhan, ‘it may take several introductions’ of the virus for an outbreak to establish. This is because of ‘high individual-level variation in transmission’ making new chains of transmission ‘more fragile and less likely that a single infection will generate an outbreak’. They concluded that ‘this highlights the importance of rapid case identification’.
Thus why was the Public Health England conclusion so pessimistic? Primarily it was down to capacity. It was reported that PHE could only ‘cope with 5 new cases of Covid-19 a week’ which would require the isolation of 800 contacts. It was believed that capacity could be increased by tenfold, to being able to manage ‘8,000 contacts per day’ but that if this was exceeded ‘any further provision would probably not be justified’.
This was a significant calculation by PHE. If more than 8,000 contacts a day would need to be traced then a strategy of contact tracing should be stopped. SAGE agreed with this assessment, believing that in the event of sustained transmission it ‘is no longer effective’. From SAGE minutes and Government statements available, it is unclear as to why ministers did not insist on increasing capacity at this point. The success of which was seen in April, when the Department of Health worked alongside private labs to increase testing capacity to 100,000.
To emphasise how insufficient the capacity to manage five new cases a week was, it has since been estimated that the UK experienced 1,356 separate incursions of the virus from abroad, with 80% occurring between 28th February and 29th March. 33.6% of infections came from Spain, 28.5% from France, and 14.4% from Italy. Only 0.1% are estimated to have come from China.
In part due to the lack of testing in the UK and because of global underreporting of cases, scientists could not agree whether sustained transmission was underway and if not, how close it was. SPI-M-O reported that ‘some believe it is a realistic possibility it will become established in the coming weeks while others believe there may already be sustained transmission’. Scientists attending SAGE on the 18th February added that there was evidence of local transmission in Japan, Korea, and Iran. At a NERVTAG meeting that same day, it was decided that the risk assessment to the UK population should remain moderate. Yet divergence within the committee was present. After the meeting, Professor John Edmunds emailed that ‘for some technical reason he could not be heard’. Edmunds believed ‘that the risk to the UK population should be high as there is evidence of ongoing transmission’ elsewhere in Asia.
Illustrating how extensive underreporting was, Iran on February 21st announced two new cases of Covid-19, and then hours later said that both had died. On the same day ICL published a report compounding such concerns. ‘We estimate that two-thirds of Covid-19 cases exported from mainland China have remained undetected, resulting in multiple chains of as yet undetected human to human transmission’.
Notably by the end of this week, SAGE was still asking for clarity from the Department of Health over what the central objective was behind seeking to manage the epidemic: ‘flattening the peak, spreading the duration, or avoiding winter – all informed by key challenges that the NHS is seeking to mitigate’.
Being analysed by scientists across the world were findings from a floating Petri Dish now docked in Yokohama port under the strict control of the Japanese government. On the 25th January, 5 days into the cruise ship’s journey around Japan, Vietnam, and Taiwan, a passenger disembarked in Hong Kong. The passenger had ‘presented a cough since 23rd January and was confirmed positive for Covid-19 on 1st February’. Consequently, none of the crew or passengers were allowed to leave the ship. Out in Yokohama port were a total of 3,711 individuals all isolated to their cabins, onboard a ship where Covid-19 was suspected to have been spreading for days. A 14-day quarantine thus begun, with those testing positive removed to isolation wards or hospital facilities.
Back in London, Johnathan Van Tam, the UK’s Deputy Chief Medical Officer, was analysing data that had been reported from the ship. Much focus was on a significant number of reported asymptomatic cases. Of the total onboard, 14% had tested positive for Covid-19 with 255 confirmed asymptomatic cases, and 276 confirmed symptomatic cases.
A total of 14 passengers died as a result of the outbreak on the ship, including the first UK citizen to die from coronavirus. Cases on the ship accounted for more than half the reported Covid-19 cases outside China at the time. Importantly, the Diamond Princess Cruise Ship provided concrete evidence of how significant asymptomatic cases were in the transmission of the disease, and thus underlined the possibility raised by ICL of thousands of cases being missed. NERVTAG discussed evidence that suggested ‘40% of virologically confirmed cases’ were asymptomatic. A further advance in understanding the virus had been made, with NERVTAG establishing on the 21st February that ‘severe disease is most frequent in adults over 50 and those with co-morbidities’.
As the penultimate week of February came to a close, an explosion of cases in northern Italy alarmed the world. On the 6th of February, 3 cases of Covid-19 had been reported. The next set of cases reported came on the 21st when 20 new cases revealed an avalanche of virus spread. On the 22nd a total of 79 cases were reported, followed by 150 on Sunday 23rd.
Over the next 6 days, an average increase of 40% in cases occurred. On the final day of February – Saturday 29th – Italy had 1,128 cases of Covid-19 and 29 reported deaths, an increase of 38% from the previous day. This rapid exponential increase alarmed the world, and as suddenly as the virus had arrived, so did a lockdown policy that only weeks earlier had seemed distinctively Chinese. On the 23rd February, Italy introduced strict measures that placed almost 50,000 people in lockdown, focussing on the northern regions of Lombardy and Veneto.
In the UK the measures were described as ‘draconian’. There was a distinct sense from the British Government that the UK was not close to seeing the outbreaks Italy was experiencing.
On the 25th February, SAGE gathered to consult several papers published by Imperial College, SPI-M-O, and Cambridge University laying out measures that could be taken to slow the spread of the virus in the UK.
|Closure of schools and universities||Contact outside household for student families increases by 25%. Contact inside household increases by 50%.|
|Home isolation of symptomatic case||65% of symptomatic cases isolate for 7 days, reduces non-household contacts by 75%.|
|Voluntary household quarantine for 14 days on occurrence of symptomatic case||All contact outside household reduces by 75% (assuming 50% of households comply)|
|Social distancing||All households reduce contacts outside the household or school/workplace by 75% Work contact reduces 25%, school contact unchanged. Contact inside household increases by 25%.|
On modelling several different policy responses, the ICL paper concluded that a ‘combination of’ these ‘policies are predicted to be sufficiently effective at reducing transmission’. Potentially ‘slowing epidemic R rate to below 1′ with evidence from China supporting ‘this conclusion’. When the measures are lifted, however, then a second peak can be expected. ‘The overall impact on’ the total number of cases ‘is therefore limited’, though ‘if measures are fine-tuned to allow sufficient transmission’ for a population to reach herd immunity then ‘significant reductions’ are possible. The conclusion was that if measures were too successful initially then they ‘merely push all transmission to the period after they are lifted’.
The paper published by Julia Gog at Cambridge University outlined how the success of the measures was determined by two factors: them being the correct measure, and them being implemented at the optimum time.
The graph illustrates how during an epidemic with an R rate of 2.2, timing is crucial in the success of the above measures. For instance, measures being implemented (triggered) once the virus has infected 10% of the population could lead to over 80% reduction in total cases. In contrast, the same measures being triggered when 50% of the population are infected lead to just over 40% reduction in total cases. This was yet another study which showed the importance of holding accurate estimates of the number of cases in the UK.
SAGE also reviewed a Public Health England publication that outlined their proposal for if an outbreak occurred. It presented two sets of scenarios: one for the containment of an outbreak, the second for slowing the overall spread of the virus. For either scenario several questions remained to be answered, revealing how little planning had been done for a coronavirus epidemic.
Under proposals to contain a community-based outbreak, PHE suggested contact tracing, and the isolation of high-risk contacts. PHE queried whether residential areas should be closed if linked to the outbreak, if school closures in the wider area may be necessary, and what benefits could be gained from ‘testing close contacts who are asymptomatic’.
Equally vacuous were proposals for a scenario aiming to slow the spread of the virus. The immediate response was to ‘warn and inform known contacts’ with ‘limited investigation and contact tracing’. The report asked modellers to answer whether public gatherings should be closed on a rolling basis, if general social distancing measures would be beneficial or if there was any advantage to be gained from quarantining whole households rather than the infected individual.
SAGE was confident however in the UK’s ability to spot an oncoming peak. Modelling an uncontrolled epidemic, it was estimated that sentinel surveillance in Intensive Care Units and GP surgeries would detect Covid-19 cases ‘9 to 11 weeks prior to the peak of the epidemic’. It was also noted that PHE was ‘sourcing commercial solutions for point of care testing in hospitals as a priority’.
The meeting established that contact tracing remained the primary response to new cases. But confirmed that interventions should ‘seek to contain, delay and reduce the peak incidence of cases in that order’. The capacity of the NHS was at the heart of considerations over when and what measures to implement. Data from Hong Kong, Wuhan, and Singapore was reassuring if the UK decided to delay the peak of the virus. The closure of schools along with social distancing was calculated as having reduced the reproduction rate by 50-60%. Yet the acceptance that any combination of measures would not be able ‘to halt an epidemic’ remained.
Whilst SAGE concluded that any risk of public disorder ‘is assessed to very low in response to an epidemic’ a sub-group named SPI-B was welcomed to the meetings. The group would be tasked with providing evidence to COBRA, SAGE, and the Home Office on possible responses from the public during the epidemic. It recommended that clear expectations and early messaging would be crucial, as well as the promotion of collectivism.
As a result of these discussions, the Health Secretary Matt Hancock made a statement to the House of Commons the following day. ‘As of this morning 7,132 people in the UK have been tested, 13 tested positive of whom 8 have now been discharged from hospital’. Hancock went on to outline the basis for the Government response. ‘We have a clear four-part plan: contain, delay, research, and mitigate’.
Yet for now, the tone remained reassuring. No ‘special measures’ were needed in a workplace or school whilst an individual was being tested for the virus and ‘in most cases’ the closure of educational or childcare ‘settings will be unnecessary’. Travel advice had been expanded, meaning that anyone travelling from the lockdown areas of Northern Italy, as well as from Iran, and the ‘special care zone in South Korea’ should self-isolate even if they show no symptoms. In a question to Greg Clarke MP, Hancock assured that plans were in place with private companies to extend testing in the event of a mass outbreak.
Notably, in PMQ’s that day, there was no question on the coronavirus. The Leader of the Opposition Jeremy Corbyn instead focussed on recent flooding in the north of England. He criticised that COBRA hadn’t been called and that the Prime Minister wasn’t taking the flooding issue seriously. Whether because of hubris in the country’s ability to deal with the virus, or the firm belief it remained many weeks away, even in the last PMQ’s of February, very few MP’s were publicly concerned.
The following day on the 27th February discussion of the virus filled the airwaves. Headlines focussed on the country being urged not to panic. By midday, the country would enter a new and significant stage in its Covid-19 story.
Gathered at 10 Victoria Street London, SAGE was holding its final meeting of the month. Focus was on analysing the impact of several restrictions that were being proposed, accepting that ‘without action the NHS will be unable to meet all the demands placed upon it well before peak is reached’. It was decided that a combination of interventions that could ‘delay the peak and/or reduce the size of the peak, whilst increasing the duration of the pandemic are likely to be helpful provided the pandemic is not extended into late autumn/winter’.
With these parameters stated the scientists set out to discuss what combination would be best and when it should be implemented. It was agreed that the closure of schools, along with for 13 weeks, home isolation of symptomatic cases, voluntary household quarantine and social distancing, would ‘reduce R to 1’ but then ‘result in a second large epidemic once lifted’.
Thus it was judged that implementing the first three and omitting total social distancing, ‘would still substantially reduce peak incidence, while making a second wave of infection in autumn less likely’. They concluded this ‘might be the preferred outcome for the NHS’. This was despite social distancing on its own being calculated as possibly able to reduce the peak by up to 50-60% and delay it by 3-5 weeks.
SAGE stressed that it would be a ‘political decision whether to enact stricter measures first’ or apply ‘more intense measures on those most at risk’ for instance isolating people over 65. This was based on the view that the majority of the population could be allowed to develop immunity, which would prevent a second wave; whilst protecting the vulnerable would reduce pressures on the NHS.
If this was the first real indication of the professed herd immunity strategy, it’s worth underlining the assumptions behind it. First, the scientists explained that the proposal would be able to reduce pressures on the NHS, thus implying mass casualties were not expected at this stage. Nevertheless, a 1% fatality rate was the working assumption. Secondly, this was not an outright advocation of such a measure. The report added that ‘SPI-M-O has not looked at the feasibility or effectiveness of such methods’.
The meeting ended with SAGE agreeing that ‘earlier interventions have more significant impact’ on reducing total number of cases and in delaying the peak of the virus.
After a month of planning and discussing which measures were best to be implemented, minds were now turning to when. 83,652 cases had been confirmed globally, with the WHO increasing the assessment of the risk of spread and impact ‘to very high’. Outside of China, 51 countries had reported cases, with five new countries in the last 24 hours including the Netherlands. There was a total of 19 deaths in Europe – 17 in Italy and 2 in France.
By 1 pm on the 27th February, a statement by the UK’s Chief Medical Officer marked the beginning of a new stage in the epidemic. It was revealed that the 20th reported case of Covid-19 in the UK, was the first who had contracted the virus from within the country. The man’s local GP centre entered deep cleaning on Friday morning, and contact tracing began.
This was likely evidence of community transmission. The Prime Minister announced an emergency COBRA committee meeting would be held on Monday and stated that preparing for an outbreak was now the Government’s ‘top priority’.
This new case provoked fundamental questions: was it evidence of mass community transmission, and if so for how long had it been underway without detection. Britain had spent a month preparing for what to do in this scenario, but the fact these questions remained so difficult to answer, spoke to long term faults that no month days of planning could have fixed. The country could only cope with five new cases of Covid-19 a day. The Government had no road-tested plan to call upon. This was a disease that the infrastructure of the British state had not been built for.
Less than a month away was a moment when such statements would struggle to provoke the darkest gallows humour. As the UK entered the third month of 2020, it was unsure of its response to a disease only three months old itself, but now set to dominate the year. It was unsure of the status of the virus within the country yet was confident the horrific scenes emerging from Italy were some way off. The plan was coming together, and there was still time to prepare. In 16 days a new report would result in a policy the Government had not yet contemplated. The initiation of such, being an indictment of one of the assumptions behind February’s extensive planning, being found severely wrong: timing.
The calculation was this: how far behind Italy was the UK. For a virus where cases were going undetected and up to possibly 40% of people were asymptomatic, this was incredibly difficult. Covid-19 was an enemy that could not be seen. Its impact only realised when it was too late. Italy was a warning to the rest of Europe. But it was up to each country to judge how close that future was. This decision would shape the size and progress of the epidemic in the UK. As the month progressed, previous estimates of the virus’ spread were being ripped up. By the end of March, Covid-19 was spreading at a faster rate than had been anticipated. The virus still maintained many unknowns.
The UK Government held its first Press Conference on Covid-19 on the 3rd March. The Prime Minister was flanked by Chris Whitty and Patrick Vallance. These two relatively unknown scientists would soon become daily features of all our lives. After months of work behind the scenes, this was their first major public appearance.
Boris Johnson used the briefing to announce the Government’s ‘Coronavirus Action Plan’, which was divided into four stages: contain, delay, research, and mitigate. The main aim of the plan was to ‘slow spread and reduce infection’ whilst ‘minimising potential impact on society and the economy’. For now, the UK remained in the contain phase, where response focussed on contact tracing and preventing mass transmission. The PM stated that next would be the delay phase when ‘population distancing measures’ would be needed to slow the spread of the disease. Yet if ‘transmission of the virus became established in the population’ the UK would enter the mitigation phase when the chief focus would be to ‘provide essential services’. Johnson ended his speech stressing that ‘for the vast majority of people we should be going about our business as usual’.
Underlining the plan was a confidence that the UK wasn’t at a stage in its battle against the virus, to warrant any more serious public health measures. In response to a question by the BBC’s Political Editor Laura Kuennsberg, Patrick Vallance stated that the key point is about timing. There are a ‘number of measures that could be used to reduce the peak but if we implement them too early’ lots of societal disruption will be caused for little gain. A ‘12 week period is going to be needed once’ they are implemented.
The plan had been outlined. The public should continue as normal but with an added focus on handwashing. Tuesday 3rd March thus also started the moment when happy birthday could be heard mumbled in toilets across the country.
Earlier in the day, SAGE had discussed a paper published by the London School of Hygiene and Tropical Medicine that outlined the impact several policies could have on deaths and peak demand in England. Based on the worst-case scenario of a fatality rate of 1% and an R rate of 2.4, the group concluded that if unmitigated, Covid-19 would result in 570,000 deaths in England.
The closure of schools was judged as the least effective policy, with the isolation of the elderly estimated to still result in possibly 420,000 deaths. Similar to findings in February, the best response would be a combination of all measures, which would reduce the demand for hospital beds by 75% and reduce deaths by almost half.
SPI-B however cautioned SAGE against the implementation of such a combination. It stated that although ‘a combination is expected to have a greater impact, implementing a subset of measures which would have a more moderate impact’ would be preferred, because it would avoid ‘a second wave’. It questioned whether the stringent measures Hong Kong had introduced, including remote working and the extension of school holidays’ could be sustained. Hong Kong had however successfully reduced ‘illness rates’.
The issue of timing was not only about when to implement the measures but was also crucial in the tension between creating a plan that would avoid serious ramifications later in the year. Concerns over creating a second wave were felt very early on.
SAGE concluded that ‘sustained transmission of Covid-19 in the UK’ is highly likely and on the 5th March, Chris Whitty reported the first death from coronavirus in the UK. It was believed the individual ‘had contracted the virus’ within the country.
That very day the Prime Minister was interviewed on ITV’s This Morning by Phillip Schofield and Holly Willoughby. Asked ‘at what point do I tell my Mum to stay in’ Johnson said, ‘at this stage, the single best thing is to wash your hands’. Notably, in the interview a more nuanced approach was hinted at, undermining the view that the PM was a firm believer in outright herd immunity: ‘one theory is perhaps you could take it on the chin and allow the disease to move through the population. I think we need to find a balance. It’d be better to take measures and stop peak from being so difficult for the NHS’.
The presenters asked Johnson, how close we were to measures having to be introduced. ‘Today SAGE is meeting, these guys are brilliant, and we are going to see what they say’.
Whilst the PM reassured the nation, SAGE met at 10 Victoria Street to discuss several papers that had been published on when to trigger social distancing measures. A notable attendee at the meeting was Dominic Cummings. A consensus emerged from all the papers that were discussed. Each argued that should the response be ‘a short sharp shock’ then this should start later in the epidemic. If on the other hand a ‘gentler but prolonged intervention’ was preferred, then this should begin early and be scaled up over time.
LSHTM said that this would have many advantages allowing room for ‘policy modification’ and may help avoid a ‘larger epidemic after the summer’. Imperial College laid out how such an approach might look with case isolation and social distancing of those over 65 being implemented first. Then followed by the ‘closure of schools’. Although ‘general social distancing may have the largest impact’ again concerns were raised this may lead to ‘a second wave when the policy is lifted’.
It was judged that cases were not yet high enough to ‘move away from containment efforts’, despite surveillance data in ICU’s reporting Covid-19 cases not contracted overseas. SAGE concluded that ‘within 1-2 weeks’ isolation of households with a positive case should be implemented. ‘Roughly 2 weeks later, social isolation of those over 65 or with underlying medical conditions’ would be enforced. The assumption was that these measures were being introduced early in the epidemic. Instead, two weeks from now marked the day before the closure of pubs was announced.
Already SPI-B was concerned that stories from abroad were worrying the British public. The Department of Health found that over 60% of all age groups supported the closure of mass gatherings. On the 4th March the UK announced its largest one day increase to date as 34 new cases brought the total to 87, and in Italy schools and universities were closed after the highest increase in daily deaths – 28.
On Sunday 8th March, the NHS released data that showed calls to 111 had increased by more than a third compared to the same period last year. This came as the Government outlined measures that would be included in the upcoming Covid-19 Emergency Bill. Over the last week, two COBRA meetings had been held. The UK was about to move to the ‘delay’ phase.
The following Monday the Prime Minister in his second Covid-19 Press Conference, said ‘our scientists think containment is extremely unlikely to work on its own and we are making extensive preparations for a move to the delay phase’. Chris Whitty warned that soon members of the public will be ‘asked to do things differently’ and that it was crucial to catch the virus before cases ‘suddenly’ increased ‘quite fast’. But warned that measures being introduced too early would lead to public ‘fatigue’, after SPI-B had reported in Japan there was growing discontent around the closure of schools. The group also worried that the isolation of entire households following a positive case would create an ‘unequal burden’ and thus a more socially acceptable measure would be to isolate only symptomatic cases and at-risk members of the public.
The next day SAGE held a further meeting when PHE reported that from a study in China, children ‘appear to be less affected by the current outbreak’ but were ‘just as likely to be infected as adults’. It appeared that children were mainly asymptomatic or had only mild symptoms and that ‘family clusters’ were common.
Produced at the meeting was a more detailed plan, where the timing of triggering certain policies was agreed upon. It was reported that the UK is currently likely to have ‘thousands of cases – as many as 5,000 to 10,000’ which are geographically spread, and that transmission is underway in hospitals and in the community. Thus it was believed that the UK was 4-5 weeks behind Italy or 6-8 weeks if interventions were applied. Modelling showed that the country was 10-14 weeks from its ‘peak’ in the absence of interventions.
That day a total of 851 cases were confirmed. SAGE concluded that social distancing measures for the vulnerable should be applied to all those over 70 and agreed that social distancing could adopt a tiered approach. Concerns however, were raised over how compliant individuals would be, and scientists noted a tiered approach might reduce the overall efficacy of the policy. Under consideration was when to implement the isolation of positive cases, social distancing of more vulnerable groups, and forcing whole households to isolate should they live with a proven case. The agreed timing of when to trigger these are detailed below. SAGE was planning for a gradual approach, with more stringent measures being implemented as time went on.
As the Chancellor Rishi Sunak delivered his first budget statement on the 11th March, the picture outside the UK was getting bleaker. Only a day after a junior health minister Nadine Dorries became the first politician to test positive, hundreds of MPs sat crammed inside the chamber. In stark contrast, the United States announced it was to block travel from all European countries apart from the UK and the WHO declared Covid-19 a ‘pandemic’. The following day FTSE 100 experienced its worst day since 1987, dropping more than 10%. In the US automatic suspension of trading occurred for the second time that week, and NASDAQ ended 9.4% lower. In France and Germany, indexes crashed more than 12%.
This was despite the collective efforts of the Federal Reserve and the European Central Bank. Across the world economists and scientists were finding the disease and its impacts to be outpacing their response. Covid-19 was accelerating at an ‘alarming rate’. There were now more than 118,000 cases and 4,291 deaths across the world.
On the 12th March, it was clear that Boris Johnson was worried. On reaching the podium, the Prime Minister looked nervously to each side, mumbling ‘Patrick’, ‘Chris’, as if wishing to reassure himself that his most senior scientists were there. A deep breath followed as the PM announced that the UK was now moving from containment to the delay phase.
‘The true number of cases is higher than the number of cases confirmed. I’ve got to be clear, we’ve all got to be clear, this is the worst public health crisis for a generation. I must level with you, level with the British public, many more families are going to lose loved ones before their time’.
It was then announced that ‘from tomorrow’ those with coronavirus symptoms should isolate at home for ‘at least seven days’ and individuals over 70 or with serious medical conditions should not go on cruises. International school trips were cancelled. Testing was now being prioritised for those in hospital, and not individuals suffering from symptoms at home. The Department of Health’s Jo Churchill told the House of Commons that capacity is being ‘extended to NHS staff’.
Yet now was still not the time to trigger the policy interventions SAGE had discussed. Boris Johnson said that ‘in the next few weeks we are likely to go further’ and introduce household isolation on a positive case. The stopping of large public gatherings was being considered but the scientific advice remained that ‘banning such events will have little effect on the spread’. The previous evening, 3,000 Atletico Madrid fans had travelled to Anfield for the second leg of their Champions League tie against Liverpool. In Madrid there were already more than 1,000 cases and, on the 12th March, it was announced that the ‘La Liga’ would be suspended after the country had recorded more than 2,000 cases.
Explaining the government’s strategy, with it becoming increasingly distinct from actions being taken elsewhere, Patrick Vallance said that the UK remained ‘4 weeks behind Italy and other European countries’. Pointing to the graph that showed the shape of an unmitigated epidemic, he said the UK was ‘still at the flat part, with 590 reported cases and more than 20 people in intensive care. Vallance said it was likely that 5,000 to 10,000 people were currently infected. ‘Timing is crucial’ in successfully delaying and pushing down the peak.
Vallance referred to the strategy of herd immunity, that government sources were beginning to brief to the press. ‘It is not possible to stop everybody from getting it, also not desirable as we need some immunity to protect ourselves in the future’. On the following morning’s Today Programme, Vallance advocated building up some degree of herd immunity, because ‘the vast majority of people will get a mild illness’.
Asked by Kuennsberg over whether ‘holding back from some of the more drastic measures is the right’ approach, Boris Johnson said ‘we are guided by the science on everything we do’. The science at this stage recommended a different approach to that being taken elsewhere. The Prime Minister followed this advice. History will judge whether the reluctance to challenge it was his greatest mistake.
Whilst the press conference was taking place, the London School of Hygiene and Tropical Medicine was completing a paper that would shake the assumptions on which the British Government had based their plan upon. That very plan they were currently justifying to the public. They concluded that ‘by the time a single death occurs, hundreds to thousands of cases are likely to be present in that population’.
This meant the virus may have gone unnoticed for weeks. At their meeting on the 13th March, SAGE ‘now’ believed there were more ‘cases in the UK than previously expected, and we may therefore be further ahead on the epidemic curve. The science suggests that household isolation and social distancing of the elderly should be implemented soon’. Accepting that data being used for their modelling suffered from a 5-7 day lag, concerns were heightened that the UK’s assessment of its epidemic was now beginning to unravel.
It was at this point that community testing was ended. The moment scientists had planned for since February, when testing capacity was exceeded and community transmission was at a scale too great. Har arrived. Instead, testing was to be focussed on healthcare settings. Officially the UK had 2,121 cases.
Modelling was being done on the impact individual and household isolation, along with social distancing, would have on the epidemic. SAGE informed the Government that ‘household isolation is modelled to have the biggest effect of the three interventions currently planned’ and therefore there is ‘scientific evidence to support this being implemented as soon as practically possible.
LSHTM had informed SAGE that banning the attendance of sporting events ‘has an imperceptible impact on the epidemic’. They calculated that on average in the UK an individual makes 10.9 contacts per day, 3.7 of these defined as ‘other’ which included those made at sporting events and during leisure activities. Assuming an individual makes 5 contacts per sporting event then banning them would reduce other by 0.41%. In contrast, reducing ‘leisure’ contacts by 75% would reduce other contacts by 36.2%.
As a result, it was predicted that along with shielding of people aged over 65, and case isolation, the banning of leisure activities would reduce the total number of people needing intensive care by 112,000. It was a ‘modest impact’ on the overall epidemic and helped lead SAGE to conclude that ‘current proposed measures will not reduce demand enough’ for the NHS to cope.
SPI-M were tasked to investigate what kind of interventions could be implemented to resolve this. Despite such a conclusion, the idea of lockdown was not mentioned. In part because of data from Singapore that showed that once measures were lifted ‘new cases had appeared’. SAGE was ‘unanimous that measures seeking to completely suppress Covid-19 will cause a second peak’.
Concerns from SPI-B were raised over what may happen should public gatherings be stopped. The group worried that it may create dangerous ‘displacement activity’ whilst SPI-M found that ‘family gatherings, bars, and nightclubs’ were higher risk events. This thinking was backed by NERVTAG, which found that ‘risk’ of contracting the virus ‘increases with duration of exposure’.
They detailed that exposure for 30minutes at a distance of less than 1 metre was the ‘strongest risk factor’. Consequently, 2 metres for 15 minutes remained the definition of close contact. Social distancing however was met with challenge from some behavioural analysis, with concern that it would be hard to comply with over a long period.
Yet when discussing such behavioural analysis, scientists frequently found there was ‘no strong evidence for public compliance rates changing during a major emergency’. Indeed evidence from April of exceptionally high public compliance undermines many of these suggestions.
Nevertheless, as the UK media and public saw more stringent measures being adopted elsewhere, SPI-B warned the Government that such divergence needs to be explained properly or UK actions would be seen as ‘incompetent’. There was a risk of ‘not meeting expectations’ with YouGov finding that 36% of the public believed large public gatherings should be cancelled. In a Department of Health survey, 73% of people agreed that people ‘should stay away from crowded places’.
As the week came to a close, the UK began to enter the world of Covid-19. On Saturday 14th March there was no professional football played. Whilst SAGE debated the impact sporting events would have on the epidemic, the Premier League took the decision to postpone all fixtures for at least two weeks. In 14 days some hoped that stadiums would once again be filled with fans. Instead, grounds would remain closed, silence fill the air, and football consigned to the garden. In the local park, you would be fined for daring to kick a ball.
The sport that encapsulates community, identity, and the thrill of social events, had been stopped by Covid-19. The country that it reflects was about to experience the same fate.
The Imperial Paper
There are moments when the history of a nation is determined by a singular act, behaviour or decision. It’s an instance when the individual wrestles control from the forces of economies, cultures, and grand narratives. The micro can set in motion changes that alter the course of an entire population.
One of those rare moments was Monday 16th March. It was the day Neil Ferguson and Imperial College London published a paper that shook the British Government to its core. It modelled what would happen if the UK followed its strategy of mitigation, where cases were isolated, households entered quarantine if they had a positive case, and there was social distancing of those most at risk. The conclusion was startling.
In the absence of any measures, an uncontrolled Covid-19 epidemic would result in ‘81% of the UK population’ being infected and ‘510,000 deaths’. If the planned interventions were implemented, they would reduce peak healthcare demand by two-thirds and deaths by 50%. This however would not be enough to prevent the NHS from being overwhelmed. It ‘would still result in 8-fold higher peak demand on critical care beds over and above the available surge capacity’. The model estimated that 255,000 people would die.
As a result, Ferguson and his team recommended a policy of ‘suppression’, which entailed social distancing ‘of the entire population, home isolation of cases, and household quarantine of their family members’ along with possibly school closures. To be effective though, this would need to be in place until a ‘vaccine becomes available (potentially eighteen months)’ because ‘transmission will quickly rebound if interventions are relaxed’. Such a policy would need to be implemented ‘before Covid-19 admissions to ICUs exceeded 200 per week’ and would result in a peak 2-3 weeks after being enforced.
Whilst accepting the unprecedented nature of what they advocated – ‘no public health initiative with such disruptive effects on society had been attempted for such a long duration of time before and it’s unclear how populations will respond’ – the team at ICL calculated ‘suppression is the only viable strategy’. Suppression meant lockdown. But why did it take seven days for it to be enforced after the publication of this model?
SAGE suddenly changed their advice ‘regarding the speed of implementing additional interventions’. There was now ‘clear evidence to support additional social distancing measures being introduced as soon as possible’ and that ‘school closures may also be required’. Only then ‘may’ it ‘be possible to keep cases below the NHS’ critical care capacity. It was agreed that further analysis of the impact of school closures should be conducted immediately, as well as work to significantly increase ‘testing and the availability of real-time data flows’ to fully assess the impact of the proposed measures.
Coupled with the predictions from ICL of mitigation causing a possible 255,000 deaths, and failing in its strategy to protect NHS capacity, were two more studies that undermined the very basis of herd immunity itself.
S Riley at ICL showed how a strategy of herd immunity would not be possible to achieve in the UK because at the moment critical care capacity was exceeded, people’s behaviour would be to stay indoors and reduce contacts. At this stage, not enough people will have been infected with the disease to achieve herd immunity. Thus leaving the country with a broken healthcare system and no immunity amongst the population. ‘Critical care facilities would be saturated quickly and if populations spontaneously reduce transmission when this occurs any possible benefits of attempting mitigation are lost’.
The model predicted a scenario when in the absence of critical care facilities, the infection fatality rate could increase to 5%. In regions of northern Italy when critical care capacity was overwhelmed this resulted in ‘geographical quarantine’, thus isolating the virus to certain areas. Analysing people’s behaviour in these regions, and evidence from SARS, MERS, and Ebola outbreaks, the paper concluded ‘it is extremely unlikely that the average number of contacts will not be reduced substantially prior to the saturation of critical care’. Any economic benefits of avoiding lockdown would be lost at this point too, as people become scared of leaving their homes.
If in the UK this change in people’s behaviour occurred at ‘1x critical care capacity’, then ‘16,900,000’ individuals would be infected – only ‘51%’ of the ‘33million’ estimated to be required for herd immunity.
To avoid this situation, LSHTM modelled whether multiple lockdowns triggered ‘when ICU services are stretched’ would achieve herd immunity whilst protecting the NHS. One of the problems with a population gaining herd immunity is that there is ‘overshoot’ – when more people than are required contract the virus. This is because at the point herd immunity is reached – the peak – ‘there is still a very large number of infectious individuals’.
LSHTM modelled a situation where the UK shielded the vulnerable whilst isolating infected individuals for 7 months. The country would then enforce an ‘aggressive 3-week lockdown’ when ICU capacity is close to being exceeded. During a lockdown, all contacts outside the household would be reduced by 90%. Overall the epidemic is not allowed to overshoot and the total number of cases is reduced ‘appreciably’. Yet this would involve significant disruption to the economy and daily lives, that would undermine any perceived benefits from avoiding lockdown. It would also continue for ‘perhaps a year or more’.
An emergency COBRA meeting was held and afterwards, Matt Hancock appeared in front of an uneasy but full House of Commons. The Health Secretary announced that anyone with coronavirus symptoms should stay at home and he advised ‘people against all unnecessary social contact with others and all unnecessary travel’. ‘We need people to start working from home’ to ‘steer clear of pubs and restaurants. Shielding of the most vulnerable was scheduled to begin ‘in a few day’s time’ We should only use the NHS when we really need to. We will fight this virus with everything we’ve got’.
At 5.30 pm the Prime Minister explained to the nation that we were ‘now approaching the fast growth part of the upward curve’. There was an extra emphasis on the people of London, which was according to SAGE experiencing the ‘greatest proportion of the UK outbreak’ and was ahead of the rest of the country.
Responding to a question on care homes, Johnson advised against ‘people unnecessarily visiting care homes’. In the previous week care groups, Barchester and HC-One stopped non-essential visits, and Scottish care advised the same on 11th March. On the 13th the Government had advised care home providers to not allow visits from people feeling ‘generally unwell’ or who have ‘suspected Covid-19’. Between 25th February and 16th March, there had been 14 deaths and 30 outbreaks in England’s 150,000 care homes.
Sharing the grave tone Hancock used to speak to the Commons, Johnson said these measures were necessary to ‘give our NHS the chance to cope’.
Although these measures marked a seismic escalation in the UK’s response to Covid-19 they were not equal to the lockdown that was only a week away. This was because of a calculation being conducted at the heart of Government. In SAGE, COBRA, and Number 10, all eyes were on how fast cases of Covid-19 were doubling in the country.
At SAGE, it was believed the doubling time in the UK was between ‘every 5-6 days’, something the Prime Minister repeated in that evening’s Press Conference. This was almost twice as long as the estimate made in Italy, in early March, when cases were doubling every 3-4 days, and deaths every 2-3 days. Undermining this estimate further was that large numbers of cases at this stage in the UK were going undetected.
By the 20th March SPI-M-O concluded that the doubling time in Intensive Care units was between 3 to 5 days, and that the reproduction rate was higher than the 2.4 many of the models had been based on. A lack of testing meant the UK believed the virus was further away than it was. In the crucial seven days between the ICL paper and lockdown, this was one of the main reasons for the delay.
On the 17th March, France recorded 1,097 new cases and a total of 175 deaths. President Macron announced a nationwide lockdown, that only allowed people to go outside for fresh air. This meant Spain, Italy, and France were all now under national lockdowns. In the UK a total of 1,950 cases had been reported, with 112 deaths. Meanwhile, the European Union barred most travellers from outside the bloc for 30 days and Rishi Sunak unveiled £330billion worth of government-backed loans, and more than £20billion in tax cuts and grants for companies threatened with collapse. It was the biggest package of emergency state support for businesses since the 2008 financial crash.
Attention was turning to the fate of schools and on the 18th March SAGE met to discuss the evidence available. SPI-M-O had informed the meeting that despite the measures introduced on the 16th March, ‘in the absence of school closures NHS critical care capacity is likely or highly likely to be breached in short to medium term’. LSHTM predicted that closing schools ‘is likely to reduce deaths by around 9%’. Whereas they believed it made little difference between closing them now or after the Easter holidays, MRC and Imperial said that waiting until after Easter ‘risks exceeding ICU surge capacity’.
There were concerns that the closing of schools could result in children being cared for by vulnerable grandparents. LSHTM stated that even if their closure resulted in 50% of children having one additional daily contact with an elderly individual, the measures would still reduce deaths from around 290,000 to 282,000.
Their conclusion though was stark. Even with the measures that had been introduced, LSHTM warned the Government that the ‘UK is likely to experience a large epidemic which will result in overwhelming demand for health services’.
As the Government convened another COBRA meeting, SAGE advised that ‘modelling now supports school closures on a national level and that the effect would be greatest if instituted early’. It also said that if schools were to be kept open for key workers’ children, this would not have a significant enough ‘effect to offset the measure’. Closure was expected to last ‘several months’, whilst the impact of shutting Universities was ‘expected to be relatively small because students’ make up only a small proportion of the UK’s population.
That evening the Prime Minister announced schools will ‘shut their gates from Friday afternoon and will remain closed for the vast majority of pupils until further notice’. This was the first instance when the Government was using its powers to enforce domestic restrictions rather than just advising against certain behaviours. As it had done with leisure, social distancing, and working from home.
Yet it was because of recent announcements only being advise that serious concerns were mounting about NHS capacity being overwhelmed. Sky News’ Political Editor Beth Rigby asked the Prime Minister ‘when will we see wider enforcement to shut down London properly. London is not listening to your advice’.
At their meeting on the 18th March, SAGE discussed the possibility of locking down the capital. The Cabinet Office asked the Department of Health and SAGE to ‘provide health and behavioural science in respect of a ‘lockdown’ of London’. Members noted London was ‘possibly 1-2 weeks ahead’ of other places in the UK and cases there were ‘doubling every 5-7 days’ . Although this meant London will ‘experience serious capacity issues in 2-3 weeks’, no outright backing of the plan was given.
Of the 87 individuals in intensive care with Covid-19, 62 were in London. Concerns ‘were raised’ however, over whether’ locking down the capital would cause people to travel and ‘seed the virus in other places’. It was also mentioned that infections were rising in areas outside of London, with the Midlands having a ‘proportion of ITU cases relative to the population equivalent to London’.
For those gathered at the meeting, it was agreed that nationally ‘additional measures will be needed if compliance rates are low’ regarding the interventions announced on the 16th. The problem was that ‘reliable data on the health impacts of existing interventions’ would not be available in time.
This was a moment when data could not provide the answer. Modelling would be unable to analyse the impact of previous interventions ‘with great precision’. It was time for politicians to decide.
SAGE told the Government that interventions on places of leisure and indoor workplaces could be required. If they were, ‘it would be better to act early’. On Thursday 19th March, Boris Johnson told the country ‘we can turn the tide’ on this virus ‘within the next 12 weeks’. In Parliament, the Coronavirus Bill was introduced, which gave emergency powers to shut airports, hold people on public health grounds, and protection for tenants from eviction. It passed the following Monday.
On Friday 20th March, Chancellor Rishi Sunak appeared alongside Boris Johnson and announced the furlough scheme, where the Government would pay up to 80% of wages for workers who were unable to work. In a speech that helped make him the nation’s most popular Chancellor in 15 years, Sunak declared ‘To those anxious about the day’s ahead. I say this. You will not face this alone’.
The Prime Minister told the country that ‘we are strengthening the measures announced on Monday. We are collectively telling cafes, pubs, bars, restaurants to close tonight and not to open tomorrow’. The leisure and hospitality industry had been closed by the Government. ‘The sad thing is that today, at least physically, we need to keep people apart. Stay at home, protect our NHS and save lives’.
The previous weekend, football had been cancelled. Within a week the country had been transformed. In the past seven days 278 new deaths from Covid-19 had been announced and cases had increased by over 268%. On Saturday 21st March, silence stretched into pubs, stadiums, and schools across the country. Each empty building standing as a symbol of the pre-Covid world. A world that had suddenly been taken away.
On Sunday evening children weren’t preparing for school the next day. People were advised to no longer visit friends and family. On Mother’s Day, thousands stayed apart and rung their loved ones from home.
There was an uneasy sense of anticipation on Monday 23rd March. The previous day the Prime Minister had hinted at tougher measures: ‘take this advice seriously’ because ‘we will bring forward further measures if we think it is necessary’. All could look across Europe and see what those further measures were.
Germany had announced its lockdown on Sunday 22nd, and across the continent state of emergencies were being declared. The morning papers warned what was to come. The Daily Telegraph claimed the UK had ’24 hours to avoid complete lockdown’, the Daily Mail told readers to ‘Obey the virus – or else’ whilst the Daily Mirror labelled scenes of busy high streets as ‘Madness’. According to YouGov only 50% of Brits were ‘avoiding crowded public places’. It was not enough.
Monday 23rd marked the eighteenth SAGE meeting since the crisis began. At 10 Victoria Street London, the group was informed of two significant problems.
The first, was that although ‘adherence to social distancing’ had ‘increased’, there was still room for it ‘to be increased further’. SPI-B reported that for those under 70 and without a medical condition, ‘52% had stopped seeing members of family’ they don’t live with, ‘53% using public transport’ and ‘87% going to their place of work’. City Mapper data showed that on Saturday 21st March, usage was only 23% of average in London. Data collected by Google however, showed significant regional differences.
Glasgow’s ‘morning rush’ remained ‘83% of usual activity’ and people in the South East had stopped visiting hospitality far sooner than those in the North West. The group reported that ‘a substantial number of people still do not feel sufficiently personally threatened’. Thus it was recommended that ‘hard-hitting emotional messaging’ should be employed to increase the perceived threat, as well as the use of legislative measures. Despite earlier fears, ‘some countries have introduced mandatory self-isolation without evidence of major public unrest’. Later that evening YouGov reported 93% of Brits supported lockdown.
More worryingly was what SPI-M-O informed the meeting. It was now suggested that the doubling time of cases in Intensive Care Units was between ‘3-5 days’. This was dramatically shorter than the 5-7 days estimated only a week ago. As a result, it was ‘very likely that we will see ICU capacity in London breached by the end of the month’. This concern was not only consigned to London. The ‘rapid increase in ICU admissions is consistent with a higher reproduction number than previously’ thought. Rather than an R of 2.4, it was now thought to be higher than 3. Covid-19 was advancing sooner and at a quicker rate in the UK than had been predicted, and crucially than the models had assumed.
There was also worry about ‘significant spread’ of the virus in ‘hospitals’, which would be harder to stop by any social distancing measures amongst the public. SAGE was warning the Government that ICU capacity was likely to be breached. The NHS looked as though it might be overwhelmed.
Public Health England informed SAGE, that in Italy lockdown was successful in reducing growth rates of the virus. Lockdown had not been modelled by the group. Initially the plan was for a gradual implementation of measures.
SAGE judged that with a higher R rate than ‘previously anticipated’, more compliance with ‘social distancing will be needed’. Otherwise ‘case numbers in London could exceed NHS capacity within the next 10 days’. Due to the nature of the disease and a lack of community testing, there was ‘significant uncertainty concerning the impact of interventions brought in thus far’. To help measure their effect, SAGE advocated for increased ‘community testing’, saying it would be ‘invaluable’.
Following SPI-B’s assessment of public behaviour, the group agreed that further improvement was needed in ‘reducing’ peoples ‘contact with friends and family’, as well as ‘contact in shops’. Footfall in London’s parks had ‘trebled on average’ since social distancing measures had been introduced.
The conclusion was stark. SAGE informed the Government that the virus was spreading at a faster rate than had been anticipated. Without tougher measures, it was likely the NHS would be overwhelmed.
The Prime Minister called a COBRA meeting later that day, and at 6pm the BBC’s Laura Kuennsberg reported a ‘statement would be made to the country from Boris Johnson at 8.30pm’.
Three months after the virus had first been discussed within the walls of Whitehall, much remained unknown. The UK was about to embark on a policy never tried before. Across Europe, many countries were experimenting with something that was once seen as foreign and alien as Covid-19 itself. The economic and social impacts had not been modelled. The UK had gone from having no plan, to its newly created plan being ripped up by the accelerating spread of the disease.
At 8.30 pm on 23rd March 2020, Prime Minister Boris Johnson told the country that ‘you must stay at home’. ‘In this fight we can be in no doubt that each and every one of us is directly enlisted. I know that as they have in the past so many times, the people of this country will rise to that challenge. And we will come through it stronger than ever. We will beat the coronavirus and we will beat it together. I urge you at this moment of national emergency to stay at home, protect our NHS and save lives. Thank you’.
Globally there were now over 332,000 confirmed cases and 14,509 deaths. 8,742 of these had been in Europe, where Italy had now confirmed over 5,476 deaths. In the UK, 48 new deaths had been reported along with 669 new cases. A total of 5,687 Covid-19 cases had been confirmed and a total of 281 people had died. The United Kingdom entered lockdown.
Erik Green September 2020 erikgreen.co.uk