One of my favourite aphorisms concerns two archetypal doctors – one a surgeon, the other a physician – confronted by a patient with a life-threatening emergency. “Don’t just stand there, do something!” shouts the surgeon. “Don’t just do something, stand there,” the physician replies.
Originally a humorous encapsulation of the different character traits typifying these two very different branches of medicine – surgeons, decisive people of action; physicians, cerebral theorists – it strikes me the aphorism could be repurposed to describe the divergence in the management of the coronavirus pandemic emerging between the UK and the rest of the world.
Numerous other countries, many with far fewer confirmed cases than us, are imposing restrictions on the gathering and daily movement of their people, as well as banning immigration. The UK did have its own case-based containment phase, but last week it officially shifted to a delay phase. At present this consists largely in voluntary efforts: self-isolation in the event of respiratory symptoms; good hygiene practices; and a degree of social distancing and home-working.
This approach has received widespread criticism, including from professor John Ashton, a former regional director of public health, and from senior figures in the World Health Organisation. These are not voices to be dismissed lightly. And faced with a serious public health threat, it does feel unnerving not to be employing stringent counter-measures. Surely we should be closing schools and universities, limiting travel and public events? (A ban on mass gatherings is expected from next week.) Shouldn’t everyone with a temperature or cough be being tested? That would feel like we were doing something. And in some countries, such as China, South Korea, and Singapore, these kinds of approaches have brought new case numbers down impressively.
Dealing with this pandemic is going to be a marathon, however, not a sprint. Underpinning UK strategy is the conviction that the virus is not eradicable by containment. Covid-19 is a perfect storm of a pathogen. It causes minor enough illness in most patients to make it hard to detect and therefore isolate every case, meaning it spreads itself very effectively. Once strict population-based containment measures – which severely curtail normal life and are not sustainable long-term – are lifted and people start travelling and mixing again, it won’t be long before coronavirus resurges.
Superimposed on this is the tendency for viral infections to come in waves, typically peaking in winter months. And unlike the 2009 pandemic of swine flu, which had an exceptionally low mortality rate (around 0.02 per cent), Covid-19 has the capacity to send at least 5 per cent of affected people into intensive care, many of whom won’t survive. The accounts coming out of Italy this past week are a chilling demonstration of what happens to a health system hit by a sudden surge of critical cases – it has been utterly overwhelmed.
If coronavirus can’t be eradicated by containment, and if, unchecked, it will completely outstrip our capacity to care for serious cases, then the best way of managing it is to gain some control over the timing and rate of the inevitable infections. This is the UK’s ambitious strategy – to flatten and draw out the first wave.
Think of coronavirus cases as water flowing through a hose. Population-based containment would be like pinching the pipe so hard that you shut it off completely, but the force required can’t be maintained forever; soon muscles fatigue and cramp, and the water starts up again. What the UK is attempting is to regulate the flow. At present the water pressure (new case numbers) is low, so relatively little force is needed to limit the flow rate – these are our current low-key tactics. As water pressure rises, the hose needs to be squeezed harder to keep the flow rate controlled – these will be the institutional closures, event cancellations, and travel restrictions we’re told may come.
If successful, the UK will reach next winter with a substantial proportion of the population immune to Covid-19, while having maintained the capacity to care for severely affected patients in intensive care units along the way. The anticipated second wave next winter will be dramatically attenuated.
But there are huge uncertainties. No country has ever tried to regulate the rate of a pandemic in this way before. And assumptions about acquired immunity may be upturned should Covid-19 – the biology of which is still largely unknown – prove itself capable of mutating to evade the immune system as influenza routinely does.
When we look back, I suspect we will see our rigid initial case definition – based purely on travel history or known contact with a confirmed case – and attendant restriction on testing as having fatally undermined our case-based attempt at containment. But given where we are now, our strategy of trying to control what is inevitably approaching strikes me as both bold and intelligent. It is not without risk, though, and only in time will we know whether it was the right choice.