The failures of 2020: why didn’t the UK ‘Act Fast and Isolate’?

An examination of the UK 2020 pandemic response by Prof Anthony Costello

Four years on from the UK pandemic lockdown many people, understandably, want to move on. But we can’t move on without learning from what happened - there are many viruses out there with the potential to start a new pandemic (e.g. bird flu) and we need to be prepared. The latest estimates of global deaths published in the Lancet show that around 16 million people died from Covid in 2020 and 2021, and that global life expectancy fell by 1.6 years. Many of these deaths were avoidable – and some countries did avoid them. What can we learn from the UK pandemic response in 2020?

At the end of January 2020, when cases and deaths soared in China, the World Health Organization emphasised the two points of acting fast and focusing on isolation to break transmission rates. A comparison of Covid deaths between East Asian states who moved fast to suppress their epidemics when prevalence was low, and the lethargic Western countries who didn’t, shows a huge difference in death rates. Essentially their populations not exposed until vaccinated. The UK was among the worst in that first year.

Why did these differences arise? Some western observers have casually dismissed them as the consequence of submissive populations, or forged data (true in China) or autocratic governments. Yet countries like Australia, Japan, South Korea and Thailand cannot be dismissed; they have lively democracies, reliable data systems and high incomes like the UK.

Certainly, mistakes were still made in the East Asian countries. China suppressed Covid data and deaths for a full month up until 21January  2020. Japan was slow to develop a test. Hong Kong initially banned the use of masks. But once the pandemic exploded in Wuhan in late January, East Asian nations shared a broadly common approach: scientific unanimity that their coronavirus epidemics could be suppressed (unlike influenza), that speed was of the essence, the need to focus on hotspot areas, to mobilise large numbers of community health workers to identify cases and contacts, and to provide immediate financial and material support for households asked to isolate for 14 days.

Some countries like south Korea also used simple ‘quick and dirty apps' to support a social contract whereby GPS data would monitor patient isolation in return for tracking of symptom deterioration. In Wuhan and the surrounding Hubei province the Chinese government imposed a strict household lockdown lasting for 76 days. In the rest of the country, provinces had more autonomy but implemented a Stay at Home policy for a month. Then they tested for cases aggressively and used local restrictions and isolation to snuff out local outbreaks, a process that continued for the next two years until the population was vaccinated.

But the UK frittered away the opportunity to suppress the virus with scientific failure and political hubris. In the UK the newly appointed Scientific Advisory Group of Experts (SAGE) met on January 28. There was no independent or international public health specialist on the advisory group. By then, we knew the pandemic was the big one. People were dying in the streets in Wuhan. Papers in the Lancet confirmed the reproductive rate (R0) of the new coronavirus virus (later called SARsCo-V2) infection was around three, similar to its cousin SARsCo-V1. The case fatality rates of the new respiratory coronavirus were high. We knew that the proportion of cases presenting with symptoms had a 10-20% risk of hospitalisation and a 3-5% risk of death (the case fatality rate, CFR).  This CFR was lower than for SARs1 (up to 15% CFR) but 300-500 times higher than for the 2009 H1N1 influenza outbreak which only killed 1 in 10,000 people infected. 

The factors that make an infectious disease outbreak controllable were described clearly in a 2004 paper from Imperial. They looked at two moderately transmissible viruses, severe acute respiratory syndrome coronavirus (SARS1) and HIV, and two highly transmissible viruses, smallpox and pandemic influenza. The Figure from their paper shows severe acute respiratory syndrome (like SARS 1 and 2 ) and smallpox are much easier to control using these simple public health measures whereas influenza (too transmissible and too short an incubation period) and HIV (too many carriers without symptoms) cannot be controlled.

Black lines correspond to isolating symptomatic individuals only. Coloured lines correspond to the addition of immediate tracing and quarantining of all contacts of isolated symptomatic individuals with varying degrees of success.

Another WHO-led paper also concluded that coronavirus epidemics are very different than influenza and can be controlled through speed in findings cases and contacts and effective isolation. Indeed three members of SAGE had been authors on these papers. Yet, inexplicably, SAGE decided unanimously on January 28 to plan the pandemic response along influenza lines.

In East Asia epidemic control was surprisingly rapid. The Report of the WHO-China Joint Mission on Coronavirus Disease published on Feb 24 2020 (after a ten day investigation by international observers), and launched at a global media conference, having been shared with chief medical officers of major nations two days earlier, stated “China has rolled out perhaps the most ambitious, agile and aggressive disease containment effort in history...Specific containment measures were adjusted to the provincial, county and even community context, the capacity of the setting, and the nature of novel coronavirus transmission there”. 

It went on “A particularly compelling statistic is that on the first day of the advance team’s work (early February) there were 2478 newly confirmed cases of COVID-19 reported in China. Two weeks later, on the final day of this Mission, China reported 409 newly confirmed cases. This decline in COVID-19 cases across China is real…. Several sources of data support this conclusion, including the steep decline in fever clinic visits, the opening up of treatment beds as cured patients are discharged, and the challenges to recruiting new patients for clinical trials.”

Yet this crucial Report does not appear in any SAGE minutes. I’m told by a person present at the Feb 22 WHO meeting with CMOs that our own CMO strongly contested the Report’s findings.

It’s important to note that many Western nations including the UK had a four to six week advantage because  the pandemic took time to spread, rippling out across East Asia to Iran, Italy and onwards to Western Europe and the Western seaboard of the USA. WHO continued to emphasise the importance of breaking routes of transmission, but noted in their China Report on February 24 that “Much of the global community is not yet ready, in mindset and materially, to implement the measures that have been employed to contain COVID-19 in China”. The UK simply ignored the Report.

So the UK strategy continued as if this was pandemic influenza. No serious attempt was made to increase testing, to mobilise community workers at district level in our hotspot areas like parts of north London and the West Midlands, nor to advise the government to pay generously to enable people to isolate for 14 days. The UK had the lowest sick pay rates among OECD countries. Expenditure on sick pay in 2020 and 2021 was tiny at £54 million in 2020/21, and just £72 million in 2021/22. Isolation rates were dismal with only 43% people staying at home for the required period.

The consequence was prolonged national lockdowns to tackle an out of control epidemic, an ineffective test, trace and isolate programme, and the largest collapse in our national GDP for 300 years, a massive 11%,. The failure to provide sick pay and effective isolation, and suppress the epidemic in that first year, contributed to massive expenditure on furlough, budget support and ‘VIP procurement’ of a staggering £409 billion, with a further £450 billion spent by the Bank of England on quantitative easing.

By contrast East Asian states had their epidemics under control within 6-8 weeks, with no recurrence or need for prolonged lockdowns because of effective policies to bring new outbreaks under speedy control. They provided generous and reliable support for isolation, and suffered no overall negative impact on GDP in 2020, apart from Japan that saw a fall of 4%.

In the UK, our medical and scientific establishment remain in denial about the importance of speed in reacting to a coronavirus epidemic and of ensuring effective isolation of cases and contacts through devolved public health teams. The recent lengthy UK four nation CMO’s Report makes no mention of their failure of strategy nor the criticism made by the Health Select Committee chair in Parliament that failure to learn from East Asian countries from the outset represented “one of the biggest failures of scientific advice to Ministers in our lifetime”.

There is an assumption in the CMO report that the UK strategy of ‘contain, delay, research, mitigate’ was correct, and no discussion can be found on the failures to support isolation, nor the crazy decision to set up a find, test, trace and isolate programme in the private sector with no links to primary care or NHS databases, nor the importance of senior advisers speaking independently of political masters.

In the UK the Public Inquiry is ongoing but risks getting bogged down in internecine battles between politicians and civil servants. We don’t need to wait for a Public Inquiry lasting up to five years or more to address key failures in infection control. Public health strengthening and changes to our advisory structures should have started long ago, with important implications for the massive future public health challenges from worsening climate change. The UK has lost over 235,000 people to Covid to date. Had we replicated the death rates of South Korea, 180,000 people might still be alive.