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17 May 2022

Did the UK perform better than thought on Covid-19?

The circumstances were unenviable but to shrug and say ministers “did their best” is to excuse the inexcusable.

By Philip Ball

In the end the UK has had a very middling pandemic. That is the apparent message of a recent report by the World Health Organisation (WHO) that provides new estimates of the numbers of Covid-related deaths in different countries. In terms of deaths per capita, the report ranks the UK 15th in the “best performing” list among itself and the 27 EU states. So has all the harsh criticism of the government’s response been unjust? “Now we know our ministers did OK against Covid, but I hear no apologies” read the headline of Matthew Syed’s column in the Sunday Times on 8 May. Syed added that such unwarranted opprobrium was a sign of “the shocking decline in the standard and probity of public discourse”.

I agree with Syed that the decline is real, and he’s right to suggest that those hysterically accusing the government of having pursued a “eugenic” Covid-19 strategy contribute towards it. But so do ministers who have misled us about, to give a few examples: the scientific basis for the pointless 10pm curfew; the role of Brexit in the vaccination programme; the level of knowledge about asymptomatic transmission before the fateful (and unlawful) decision not to isolate hospital patients discharged to care homes; the (also unlawful) awarding of PPE contracts; and the growing list of Downing Street parties held during lockdown. The pandemic has indeed revealed a decline in standards and probity, and there are more criteria for judging the government’s Covid performance than the awful death tally at what we can only hope is the tail-end of this global trauma.

The WHO figures might look enticingly like a league table, but that’s not the right way to use them at all. As Francois Balloux of the Genetics Institute at University College London (UCL) has said of the statistics: “A single number for each country is unlikely to capture the full complexity of vastly different socioeconomic situations and two years of often inconsistent policies.”

The study suggests that Covid deaths have been widely under-reported, largely because many countries lack the resources to identify every case. By looking at excess deaths above the normal rates in each country, the report concludes that about 15 million have died in the pandemic worldwide — almost three times the official number. In some countries the official figures seems to be a gross underestimate; in India, for example, the actual mortality rate may be ten times higher (although Indian authorities dispute that). For the UK, the estimated and official death rates match rather well.

Are the new figures reliable, though? The mortality rates are estimated relative to the baseline levels for each nation but this immediately prejudices the numbers. For one thing, the baseline depends on seasonal epidemics of flu and other respiratory conditions, which also kill many people, but such outbreaks were suppressed by lockdowns and social distancing, making the Covid-related excess mortality look smaller than it actually was. (If, say, it is estimated that normally 10,000 people die in a flu season and the WHO records 50,000 dying in that period during a Covid year, the excess — presumed Covid-related — deaths will be 40,000. But if pandemic restrictions meant there was no flu season to speak of, it’s likely that almost all of those 50,000 deaths were in fact Covid-related.)

Crucially, such underestimation will be greater in those countries, such as the UK, that have relatively high rates of pre-pandemic seasonal death from conditions such as flu. The UK’s baseline was high by European standards, says Christina Pagel, a specialist on healthcare statistics at UCL, because we have a relatively unhealthy population and a lot of health inequalities. So in effect, the WHO’s method of accounting “rewards” with apparently better outcomes those nations that have not managed health well in the past.

This said, the WHO statistics are unlikely to be very wide of the mark when it comes to painting a general picture. By the early autumn of last year it was fair to say that many wealthy nations had fared more poorly than might have been expected. In particular, Devi Sridhar, public health professor at Edinburgh University, writes in her book Preventable: “No one could have anticipated that the US and UK, consistently ranked by pandemic preparedness indices as the top two countries for capacity and readiness, would suffer as badly as they did.” Sridhar attributes part of that to the “poor leadership” of Donald Trump and Boris Johnson, but also to the mistaken idea that there was a trade-off between public and economic health.

The picture has changed somewhat as the Omicron coronavirus variant continues to do its lethal work. Death rates in some eastern European and South American countries have soared (or simply stayed high), in part because of poor vaccine protection. In Romania, for example, just 40 per cent or so of the population has received two shots. Widespread vaccine hesitancy there is attributed to distrust of authorities, misinformation and fears that government intervention could lead to a return of Communist-era social control. If western Europe no longer looks quite as bad, that’s not because its early mitigation policies were good but because it has benefited more from the vaccines than eastern Europe, which has been “hammered by low vaccination rates”, says Pagel.

And if the UK’s mortality rate is comparable with that of France, Spain and Germany, that doesn’t make it fine. None of those countries did well. “They all made different mistakes,” says Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine. The real story emerges not from a final tally but from the trajectories of the statistics over the course of the pandemic. These show that most of the UK’s deaths were incurred in the pre-vaccine period, and that almost half of the current total had been accumulated by May 2020.

For similar reasons, the WHO estimates don’t in themselves tell us much about the relative merits of different strategies. It was never very meaningful, for example, to compare the effectiveness of UK lockdowns with the laissez-faire approach of Sweden, which has a population density ten times lower. What’s more, the effectiveness of a lockdown depends on how it is implemented. If it comes too late — if the virus has already spread widely, as it had in the UK in both March and November 2020 — then locking down will do less to curb deaths. That point was plain from a study by McKee and others published in April in Plos One, which estimated that if the March 2020 lockdown had been introduced a week earlier (as many scientists were advocating), there would have been about 34,000 fewer deaths by June, and the time spent in lockdown, and consequent damage to the economy, livelihoods and health, could have been halved. Such estimates are of course tricky given the unknowns involved, but these figures are consistent with earlier studies. Perhaps, when weighed against a probable Covid-related death toll in the UK of 170,000-190,000, one might decide that a few more tens of thousands of preventable deaths owing to ministerial procrastination come out in the wash. Bereaved families are unlikely to see it that way.

All this aside, the idea that we should judge a nation’s policy response to the pandemic from a mortality league table is foolish. Sweden, for example, while incurring much higher deaths than Norway, fared better than the UK per capita; official statistics put the numbers at around 570 per million for Norway, 1,840 for Sweden and 2,640 for the UK. Yet a recent analysis of Sweden’s Covid policy concluded that it was woefully divorced from the science. It said: “Scientific methodology was not followed by the major figures in the acting authorities or the responsible politicians… resulting in arbitrary policy decisions… The Swedish people were kept in ignorance of basic facts.” How could anyone suppose that was OK?

How, then, did the UK government really do — aside, that is, from the parties, the lies, the missed Cobra meetings, the Durham road trips, the procurement scandals, the disastrous Test and Trace scheme, the Prime Minister’s alleged (and denied) readiness to “let the bodies pile high in their thousands”? No one can deny the tremendous challenges and pressures that policy-makers faced, and few proved equal to them anywhere in the world. When the government’s job was largely to step back and let the research or public health communities do their thing, the results could be excellent, such as the UK’s first-class surveillance capabilities (for example to sequence the virus in test samples), the vaccine programme, the Recovery trials that identified the antiviral dexamethasone, and indeed the Oxford-AstraZeneca vaccine itself. “The science was great,” says McKee, “and the people in the front line [of healthcare] did a great job.” But when it came to ministers formulating policies and taking decisions, it’s a very different story. Yes, the circumstances were unenviable, but to shrug and say “they did their best” is not only to excuse the inexcusable but to squander the opportunities to learn from the mistakes.

Perhaps instead we might heed the judgement of the Commons Science and Technology Select Committee — not known for leftist activism — which last October pronounced that “decisions on lockdowns and social distancing during the early weeks of the pandemic — and the advice that led to them — rank as one of the most important public health failures the United Kingdom has ever experienced”. Or we might look to the view of Jeremy Farrar, director of the Wellcome Trust and a member of Sage, the government’s scientific advisory committee, who calls the period of January-February 2021 “preventable carnage” and says that Johnson’s credence of the views of a minority of maverick scientists was “responsible for a number of unnecessary deaths”. Whether these assessments will be borne out by the public inquiry into the UK’s response to the pandemic remains to be seen, but I doubt that the WHO estimates will be considered particularly relevant for that reckoning.

[See also: What is monkeypox and how worried should we be?]

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