UK response to Coronavirus — why I think it’s appropriate
Edit 28 September 2020 — I was musing over what I wrote early on in the pandemic, and this blog came to mind.
It’s pretty clear that the UK should have locked down earlier, and indeed we now know from released SAGE minutes that they did advise the UK government to do exactly that.
So, for example, when I wrote here “I didn’t vote for Boris Johnson, but to be fair to him, he’s stepping aside and letting the experts do the talking.”, then I’d like to clarify that I was indeed wrong to say that. In the interests of mea culpa type territory, I also stated elsewhere that the NHS would definitely be overwhelmed. It was not overwhelmed, though clearly a conversation with any NHS staff member would highlight the incredible strain it was under.
And just to provide further clarity lest anyone mendacious be looking in and twist my words — yes of course a lockdown was essential. Many discussion points around when best for the start and end of a lockdown, but of course one was necessary.
And this ends the 28 Sept edit, everything below is as was written at the time.
(So, I originally published this just on google drive on 13 March 2020, at http://bit.ly/covid19headm . But it’s got a few thousand views now, so am reposting it at a more permanent home on here too. From below, it is exactly the same as the google drive version)
Personal thoughts of Michael Head, University of Southampton, around the UK response.
13 March 2020 (written about 2pm, who knows by the evening things might have shifted around a fair bit…)
I have a background in infectious disease epidemiology and public health research, and have been commenting on COVID-19 to the media and general public. Here’s some thoughts on, in particular, the UK response right now. I use the phrase ‘evidence base’ a lot, and also refer to ‘local context’. They’re unsexy but important aspects around guiding an outbreak response.
Usual disclaimers around they’re not intended to be representative of employer or anyone else. You can tweet me on @michaelghead (life is a little bit manic right now, so apologies in advance if I don’t respond).
Do you think the UK response is appropriate?
At this precise point in time, yes
The evidence base
The evidence base used to make the UK decisions draws on the international evidence base, but importantly has a specific focus on the UK context. There are good reasons for that.
Do not underestimate the impact of social and behavioural responses in infectious disease outbreaks. Really, the epidemiology is a little easier. Judging how people will respond individually and en masse is much harder, and unlike epidemiology, social science doesn’t have a straightforward ‘number’ or easily digestible soundbite result for people to assess. Thus, in my view, behavioural scientists are the most underrated people around, and are often mocked because they provide perceived soft wavy answers where soundbites demand things like death rates and p values.
So, the evidence base around how people respond in urgent situations is difficult to assess. Here in the UK, it’s partly focused on 2009 swine flu pandemic (since we as a country don’t have many opportunities for real live practice) though it is regularly reviewed in between outbreaks. Much of it is open-access, though I think a plain English summary from the Department of Health around decision-making and the evidence it is using would be helpful in guiding public understanding.
See the evidence base review around government pandemic planning -
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/215666/dh_125333.pdf
Other links worth looking at include https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/213717/dh_131040.pdf
Here’s some links around behavioural response during influenza outbreaks,
https://www.ncbi.nlm.nih.gov/pubmed/20630124
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2812%2970206-2/fulltext
These are of course not meant to be comprehensive, but illustrative of the sort of data that is considered around outbreak responses, and the thinking that goes into it. The behavioural and social science side is really important research. And to quote from the Lancet paper — “There were wide differences in the adoption of preventive behaviours between countries…”
That sort of aspect is important when considering “why are we not doing the same as some other places…”. We don’t all react the same, at individual level or across larger populations.
Compliance over long-term disruptions
The UK population by and large have significant control over their daily life. You choose when to pop out for a pint of milk, or if you’re off to the concert. Significant disruptions greatly reduce that control and thus need high population acceptance and compliance. You won’t get that over a long period of time. As a taster for what’s to come, people already can’t be trusted to buy toilet-roll properly, so how about long-term compliance when significant levels of freedom and control are removed, when fun is temporarily cancelled and there’s a need to stay indoors for long periods of time? How will compliance be then? The evidence base, as we have it right now, suggests it will decline.
Thus, when do you introduce shutdown measures? Not too early. We are still very early in the outbreak. So, for as short a time as possible, at some point in the coming weeks. But not right now.
Counter-intuitive?
It’s understandable if the perceived lack of a response to appear to be counter-intuitive, when there’s opportunities to “DO SOMETHING BIGGER!”. But, counter-intuitive means its harder to get your head around, not that it’s wrong.
Other countries are shutting down stuff…
So for example, other European countries policies, are they
a) evidence-driven in their own local context
or b) politically (and thus knee-jerk) driven.
I genuinely don’t know the answer to that. What evidence are Norway, Ireland, Italy and the others using? I’ve cited some of the UK –focused research further up. It’s quite hard to find (it shouldn’t be). So, what is being considered elsewhere, and is it specific to their context, and why would it be relevant in the UK context?
If anyone knows the literature being used to inform decision-making elsewhere, then seriously, do highlight them to me, I’d be keen to receive them.
But what we can say is –
The UK approach is driven by evidence that is appropriate for the local context. And what other countries are doing with their populations, with subtle or markedly different cultural and social expectations and habits, does not mean the UK is doing the wrong thing. “They’re-doing-something-different” is in itself not a good reason for doing the same here. Decision-making has to be more nuanced than that.
I think Jeremy Hunt highlighted Thailand as an example of a country who is doing better than us (correct me if that’s wrong). Thailand are charging people for testing, up to hundreds of dollars a time, and (anecdotally) thousands of dollars for some international visitors (even if they’ve been in Thailand since before the start of the outbreak, so clearly therefore not a new imported case). Plus plenty of anecdotal evidence that Thai public health services are poorly prepared and not receiving anywhere near appropriate levels of funding or support.
So people aren’t being tested. They can’t afford it. That skews the picture. Thailand may well be representative of many resource-poor countries (and a global concern for how those countries can and will respond), but is not a good case study if comparing to the UK
Context-specific evidence. That’s what we need. We are certainly not China, or Iran. We’re not even Italy or Ireland. We can all learn from each other, but don’t be surprised by the presence of locally-driven responses that are quite different.
Are other countries looking at us wishing they had what we had?
Like free healthcare, and free tests? Not charging patients for getting tested? Sure, they are, many countries would like that.
And do you really want Donald Trump overseeing your outbreak? I didn’t vote for Boris Johnson, but to be fair to him, he’s stepping aside and letting the experts do the talking. Boris knows nothing about coronavirus. Experts know something. Thus, the conversation here is as smooth as it can be. For the record, I really don’t defend Boris Johnson very often. So this is unusual.
So, it’s not all bad here in the UK, you know. Grass is not always greener, and all that.
We are still early in the outbreak…
In the same way that if in the first ten cases, 5 die, we shouldn’t then infer it’s a 50% mortality rate. That’s easy to understand, too early, not necessarily representative.
Here, the global response, and UK response, it’s still early. It may not seem like it, it might seem COVID-19 has been around forever. But, we’ve got a minimum of months of this left yet. However this pans out, you’ll need to get used to it.
Infections can come in waves
Yes, often the flu season comes in waves, and it greatly increases pressures on the health service at specific times. All those graphs on social media that indicate how nice it would be for smoother progress towards the peak and out the other side? It’s harder to do that, with case numbers arriving in waves and multiple peaks. So fewer mini peaks and bumps in that graph, makes it easier to plan healthcare. And that means great care over when you put in place those shutdowns
In conclusion
More stringent interventions (shutdowns etc) will come, potentially very soon. We know that. We’ve been told that. But, even though it might be counter-intuitive, going-gung-ho right now does not appear to be the best response. Many people are vocal, saying gung-ho should be the UK response. The usual justification that comes with that is “because they’re doing it over there”.
That’s not providing the evidence base that supports those views. So if you disagree with the UK response then, as we sometimes say, ‘citations required’.
Decision-making is an imperfect art, using imperfect evidence and so requiring pragmatic views. The evidence base as it stands tells us to manage the increases in cases carefully with a variety of factors (including self-isolation, the potential emergence of herd immunity etc) influencing a smoother path forward that might otherwise be the case.
Here’s one final thought — decision making here in the UK is very overseen by the Chief Medical Officer (and other senior colleagues and advisors of course), who is a supremely intelligent experienced and thoughtful individual, backed up by an excellent team of analysts, researchers, policymakers etc. Just because he is pragmatic and softly-spoken, and not shouting as loudly as the next person, why assume he is wrong?
