In June 2018, during an appearance at the Hay Festival, Devi Sridhar warned: “Our biggest health challenges are interconnected… The largest threat to the UK population is someone in China who’s been infected from an animal… and gets on a plane to the UK. What good is it for the UK just to be worried about what’s happening here?”
In 2020, after the UK has endured more than 45,000 deaths from Covid-19, the American scientist’s words have proved grimly prescient. Throughout the crisis, Sridhar, 36, who is professor and chair of global public health at the University of Edinburgh, has been a voice of bracing clarity and urgency.
“There’s been a muddling of health and economic imperatives,” she said when we recently spoke. “At the start the UK government delayed the lockdown because the idea was we had to save the economy and be minimal in our intervention. But if we look at economic performance over the first half of 2020, what becomes clear is that the places that went in hard, dealt with their public health problem and then released had a better economic recovery and more consumer confidence. Look at the East Asian countries, they look pretty much similar, which is remarkable.
“In the West, in general, we went into a late lockdown and therefore it was a long lockdown. We spent weeks debating whether testing mattered, then we got testing up and running but the test and trace system was still not fully functional. We’ve gone in circles over how serious the virus is. I don’t think those debates happened in the countries that really locked down.”
Sridhar, who has long studied infectious diseases, believes the West was slow to grasp the severity of Covid-19 because it is less lethal than viruses such as Sars, Ebola and Mers. “There’s no way you could have said to people: ‘10 per cent of you die.’ But because it’s on the border – a 1 per cent [fatality rate] – it leads to, ‘Could we get away with a flu strategy?’ The countries that dealt with Sars have done better.”
Though the choice facing governments is often framed as protecting lives or protecting the economy, the UK has suffered the worst of both worlds: it has recorded the highest excess death rate of any European country (more than 65,000 deaths) and endured the worst economic recession of any G7 member state.
“I don’t think it’s been through any deliberate decision not to protect lives or livelihoods,” Sridhar said. “It’s been a neither here nor there strategy, going back and forth. They’re trying to tread the middle path but the middle path leads you nowhere, unfortunately.”
Sridhar believes that the UK’s rising hospitalisation rate (currently 9,199 people) makes a circuit break lockdown “inevitable”.
“Hospitals are already filling up, delaying surgeries, we’re going back to the NHS being converted into a Covid health service to cope with those numbers. And if your strategy is relying on healthcare, you’re going to lose. It’s like leaving your goalie alone on the pitch… Infectious disease prevention is all about the layers you put in front so that someone never arrives at a hospital.”
She warned: “The longer we delay the decision to go into lockdown, the longer it is going to last. It’s your epidemic curve: the longer it takes to go up, the longer it will take to go down, and that’s why if you’re lower you get out faster. There are countries that entered and exited lockdown while we were still going into it because they basically went in hard.”
Devi Lalita Sridhar was born and raised in Miami, Florida, by an Indian family. After achieving a degree in biology from the University of Miami at the age of just 18, she became the youngest person in the US to be awarded a Rhodes Scholarship to the University of Oxford.
Sridhar’s devotion to public health stems from the loss of her father to cancer when she was 17. “Even as a teenager I could see that health was the definition of true wealth,” she recalled in an interview with the Lancet earlier this year.
“A lot of my friends were at parties, I was at the hospital or, when I was older, driving him back at 16 from chemotherapy. It really got to me that health is the basis of our existence. It doesn’t really matter how many cars you have or if you can travel in first class, it really matters being able to live your life in a fulfilling way.”
Her father, Dr Kasi Sridhar, who died of leukemia and lymphoma at 49, was a lung cancer specialist at the University of Miami. “You don’t take anything with you when you die,” his daughter told me. “All you take is your legacy of what good have you done in the world.”
Sridhar, who took up her Edinburgh post in 2014 after previously working at the University of Oxford, also serves as a member of the Scottish government’s Covid-19 advisory group. Does she believe that having Boris Johnson as prime minister has compounded the UK’s woes?
“I always get in trouble for these political comments! I think we need a certain type of leadership right now: calm, considered, risk-averse, scientifically based. And not based on public polling because people want direction, they want to be led.
“I think instead we’ve had such mixed messaging. We have a Prime Minister who wants to be popular and wants to be liked and wants to tell people things that will make them feel good. Unfortunately we’re in a crisis where we have to tell people hard truths and own up to how bad the crisis is.”
Sridhar derided those who argue that “herd immunity” and “shielding the vulnerable” – as advocated by the recent Great Barrington Declaration – is a viable strategy.
“We can’t shield the vulnerable, we tried that, it didn’t work, so a lot of people are going to die… It will put you into cycles of lockdown and release because of rising hospitalisation. Young people don’t die of this but they are hospitalised: those in their thirties, forties, fifties. And if your hospitals are full, all the other health stuff can’t run, which means you’re forced into a lockdown.
“Then you have long Covid, rising morbidity in young people. We’ve never used this approach to any infectious disease in the past, we’ve never let them spread, we’ve used control and elimination strategies… Focused protection doesn’t work. It’s unethical and unscientific, it’s telling people what they want to hear and giving it a veneer of scientific credibility.”
As countries contend with a second wave of the virus (or an unbroken first one), observers search for examples to emulate. Some cite New Zealand, where a swift lockdown led to only 25 coronavirus deaths and a landslide election victory for Jacinda Ardern’s Labour Party. Others point to Sweden, which recorded a high death toll but has so far avoided a significant second wave, or Germany, where mass testing allowed the country to escape the worst of the pandemic.
What does Sridhar believe the UK can learn from more successful countries? “We did a review for the Lancet; winning here is not just limiting Covid deaths, it’s your economy running, unemployment being low, schools being largely open, the health service functioning.
“There were three things: the first was a robust test and trace system. Testing is so essential in terms of the volume of people you test and then how you manage quarantine and contacts.
“The second was really good guidance: saying to people, ‘Nobody wants this infection, it’s one you don’t want to have. It’s a dangerous virus, you don’t want to get it and you don’t want to pass it on. Don’t go to crowded spaces, wear face coverings, ventilation is key.’
“The third thing, and this is where Europe struggles the most, is around border controls. You don’t want to keep importing chains of infection, once you’ve crunched the curve it’s easier to seal off. That doesn’t mean you’re sealed off for ever but you solve your domestic problem first and then you set up your travel bubbles. This is what East Asian countries have done: Hong Kong and Singapore have a travel bubble, South Korea started one. New Zealand and Australia have a travel bubble.”
“One of the things that wealthier countries, especially, can do is barricade their populations, protect them and let them return to some semblance of normality. Get back to big rugby games, clubs open, live music, arts, all of the things that make life worth living, but in return you can’t travel very easily. That’s the trade-off East Asian and Pacific countries have accepted. In Europe they wanted it all.”
Though Sridhar is hopeful that a successful vaccine will be developed by the spring of 2021, she warned: “It isn’t going to be perfect or a silver bullet. It’s a component like testing or better apps and better treatments. It’s not going to be the fairytale ending people are hoping for.”
The absence of a vaccine, combined with harsher weather, she added, meant “the next four months are going to be really rough”.
“This is going to last a long time but we will have relief from March as the days get longer and as we head into summer with a new chance to be able to get this right before the next winter.”
Covid-19 has been a disease of deprivation: it has interacted with pre-existing medical and social ills to lethal effect (Richard Horton, the editor of the Lancet, has spoken of the UK suffering a “syndemic”: a synthesis of epidemics). It is no coincidence that Liverpool, the fourth most deprived local authority in England, was the first area to be classified as “very high risk” under the government’s new system.
For Sridhar, success will be measured not only by whether the UK defeats Covid-19 but by whether it redresses its profound inequalities.
“Covid-19 has revealed from all sides how unequal our society is. During lockdown, whether you could escape to country estates and enjoy it, or whether you were working class, stuck at home with children or having to go to work every day. You’re much more likely to die if you’re from a deprived background and this is because of occupational risk and housing risk. My hope for the future is that we can have a renewed sense of community and tackle these inequalities.”