On a cold, wintry, Saturday morning in 2003 I was on the Northern line for an hour long journey from Elephant and Castle, northbound. Several times I fell asleep, and once awoke, startled and disorientated in Burnt Oak, one stop beyond my destination. For during many weekends that winter I was on shift at the Centre for Infections at Public Health England in Colindale. After my hour long journey, I would pass though security and go to the post room to collect a stack of manila envelopes. These were taken up to the category 2 containment lab, where I started pipetting snot. Each vial of viscous yellow liquid was a nose and throat swab from a patient with suspected influenza.
During my PhD I saw first hand the mundane, grinding, reality of virus testing. Early starts, lack of sleep, shut in a windowless room for much of the day, Magic FM on the radio. It is this testing that everyone is now talking about, as the UK moves into the delay phase of the pandemic.
Should schools close or stay open? What about football matches and festivals? Gyms, clubs, bars? Should all flights be cancelled, or just from some countries? Should everyone with symptoms be tested or only those with a confirmed contact? Should you self isolate, or be forced to stay at home in quarantine?
Every government in the world is now making these decisions, or preparing to make them, and is charting their own slightly distinct course. In the UK, a Prime Minister with a reputed dislike of experts is now flanked not only by the Chief Medical Officer, but the Chief Scientific Officer too. Their announcement “based on modelling”, is hotly discussed for what it didn’t include. No school closures, no cancellation of large events, no mandatory testing for everyone with a prolonged cough or fever. Instead, self isolation for those with symptoms, however mild. And more advice to wash hands early and often.
My virologist friends, both in the UK and overseas, are almost uniformly calling for the most drastic measures to be taken. The editor of the Lancet and a former regional director of Public Health England castigate the government for inaction. A letter from New York’s virologists calling for school closures circulates on social media. I know many of them, and respect them all.
Is the UK decision based on scientific evidence? And should economics play any part in health decision making?
The schools question seems the biggest divergent policy of the UK government. Ireland, which famously shares a border with the UK, has closed all schools, but the UK has not. The research so far says that children are neither super spreaders of SARS-CoV-2 (as with influenza) or severely affected (as with RSV). I have many colleagues who live in fear of school closures, as they will then be unable to work. Doctors, nurses, and carers have children too - who will look after us when they are at home with their children? Will grandparents, at the highest risk of severe infection, take on child care responsibilities for working parents? There is a clear social cost to school closures, which should form part of the decision, along with the science.
As for large events, it seems that government policy is almost an irrelevance, as events cancel themselves and ticket holders stay away.
Should economics form part of the discussion? At a recent careers panel at a US conference, a hospital doctor and fellow panellist advised the audience to study economics - because it affects every decision taken in hospital. The biggest predictor of your life expectancy is not your genetics or biology, but your income. It is absolutely right for economic well-being to be considered when making decisions, such as closing concert halls, restaurants, schools or airports, that may lead to lost earnings and financial hardship.
We do not know how long this outbreak will last but it is reasonable to think that in the UK, cases will fall as we approach even our own wet version of summer. Influenza spreads year-round in the tropics, and in the southern hemisphere during winter, which is approaching. SARS-CoV-2 will likely return to the UK in the autumn, regardless of any government policy.
By then, we either need anti-virals, vaccines, or herd immunity. Some coronaviruses don’t provide great immunity, but an infection this year may mean protection from infection, or from severe illness next year. This annual cycle may continue indefinitely, as with influenza, RSV, and the 200+ common cold viruses (including several other types of coronavirus) that bother us each winter.
The UK’s approach is one of the few, along with Taiwan (which has been hugely successful) and some others, which assumes that the virus is here to stay for the long term. If we make this reasonable assumption, then the response to COVID-19 is a marathon not a sprint. As Angela Merkel (a trained scientist herself) said, up to two thirds of us could become infected. For healthy adults and children, the goal is not to prevent infection, but to delay it. For the elderly, where the mortality rate could be as high as 10%, prevention is paramount. Any delay also allows the development of antivirals (some existing antivirals may help) and life saving vaccines, especially for those at greatest risk.
We do not know whether the UK’s long-term approach will be effective. But we do know that social distancing and hand washing are proven to work. Closing all schools now will seem much less effective if the virus returns each winter. The government needs to prepare for more drastic measures, but for the moment, a long term approach is not unjustified. It is just not what most countries, inevitably focused on the short term, are doing.
Image credit: James Gathany, CDC