Article Published April 1st, 2020

“Getting it done” was the buzz phrase that helped Johnson win the last election, in those days when the world was different. There were promises about trying to level up the poorer regions of the country, whose votes were “borrowed” by the Conservatives from Labour. And some of this resulted in a muddled discussion about HS2 and joining the North up with the rest of the country. And then came Covid-19, at first barely noticed. Then a triumvirate of the Prime Minister, the head of Public Health England and the Chief Scientific advisor to the government emerged at press conferences to spread comforting balm about the progress of the disease, the counter measures being adopted, and the hope that by all pulling together we shall overcome. The main thing being to “flatten the curve”, to “save” the NHS. Not a word about the patients it should be noted. And then, more recently the realization that stronger medicine was needed, and the withdrawal of civil liberties began, in the name of slowing down the spread of Covid-19.

Cut to a scene of staff in a front line hospital somewhere close to you, if you live in London. One hears a harassed doctor or nurse explain how they are trying to hold back a deluge of Covid-19 cases, with no testing equipment, no personal protection, no vaccine, and no respirators. Odd, one might think, given that the world has been observing for months, from a distance, how the Chinese authorities have grappled with the Hubei outbreak, and in particular the epidemic in Wuhan, a city larger than London. When questioned about when these crucial pieces of equipment were due to be delivered, the triumvirate waved their hands, declared that quantities have been ordered, and all will be well – for the professional staff of the NHS it should be stressed, in the unspecified near future. Perhaps useful to note at this stage that German doctors are not allowed to administer tests or provide treatment without a special respiratory mask and protective clothing. Could this help to explain the markedly lower death rates from Covid-19 in Germany than in the UK?  In Germany the death rate (to March 25th) was 0.48% of confirmed cases, compared with 5.2% in the UK. We don’t yet know the full picture of course – the data is not yet fully available.

And in the almost exclusively nationally based coverage on the media, are we looking at how the situation in the UK inter-reacts with events elsewhere, particularly in Europe?  So, could the difficulties in getting hold of protective equipment for the NHS have something to do with a ban of the export of protective masks announced by Germany a while back? Are we also aware that Germany, doubtless along with other EU countries, are sending delegations from the Bundewehr out across the world to buy up every bit of protective equipment, masks, and presumably respirators they can lay their hands on? Perhaps our brand new aircraft carriers could be put to some Covid-19 prevention use?

Slow federal response

Not that it is all sweetness and light across the Channel. The federal EU’s overall response has been slow. It is only now that the EU has closed the Schengen borders to outsiders, something doubtless adding to border frictions, and slowing down the delivery of crucial equipment. Generously, the EU made an exception for Britain, and by implication Ireland, since neither are in Schengen, and only one of them is still, technically, in the EU.

Despite the successes scored by its medical system, the response to Covid-19 by the federal republic of Germany has also been slow and clunky. This is partly attributable to the federal system of government in both Germany and across the EU. There are 16 Bundesländer, all of whom have stronger interests in health policy than has the federal government in Berlin. Something similar can be said for the EU with 27 member states, all of whom have sovereign rights about governing their own health services and in deciding on policies to deal with Covid-19. And this may account for the much faster spread of the disease in the EU, and particularly in France, Spain, Italy and Germany. They are all several weeks ahead of the UK in terms of the spread of the disease. The actual gap may of course be less than this, owing to downward biases in UK statistics. There are no incentives to report Covid-19 cases since patients generally don’t get medical treatment, they’re simply asked to stay at home in quarantine. These cases, and any related deaths are currently not recorded in the official British statistics.

The current figures also show that death rates in France, Italy, Spain and the UK are all considerably higher than in Germany, and in China.  This in turn raises another question. Why is it that the performance of most Asian countries, including China, has been better than that achieved by Europe/EU countries? Judging by the figures published by Johns Hopkins University, the Asian countries have been much more successful in both restricting the spread of the disease, and in reducing death rates.

Other medical inequalities

Analysing the state of different health systems presents a confusing picture. Thus Sweden and the UK have similar number of hospital beds per capita, yet Swedish death rates from Covid-19 are much lower than in the UK. Could this be related to the fact there are twice as many doctors per capita in Sweden than in the UK?

Asian countries spend similar amounts per capita on health care to Europe, have been much more successful in containing the spread of the disease. Do we understand why is this so? Could it be that measures of social control are at least as important as medical measures in restricting the spread of the disease, and that the Asian countries have been better at the social control part of Covid-19?

Spanish Lessons

In earlier studies of the last major pandemic, the Spanish influenza outbreak in 1918, some experts concluded that it was ultimately social, and not medical measures, that eventually brought the epidemic under control. And it is beginning to look as if this may be the case with Covid-19 as well. The Asian countries, and China in particular, have shown that stringent limits on social mobility, controls over social distancing, combined with effective enforcement measures have greatly contributed to better outcomes. The provision of testing equipment and personal protective gear for the medics has also made a huge difference. If you can conclusively identify who has, and who does not have the disease, it becomes a lot easier to direct counter measures more effectively. Yet even though these lessons were there to be seen and observed, it has taken the Europeans rather too long to react. The result being that there are now more Covid-19 cases in Europe than in China, and the disease is spreading very widely, while continuing to kill more of the elderly and the medically challenged.

Are there any lessons that we can still learn from the 1918 pandemic? Is this a model for Covid-19?

It is estimated that some 25% of the global population caught the Spanish flu, leading to 450 million cases in 1918. If the same were to happen today, this would suggest a total number of cases of 1.9 billion cases, a huge increase.

Estimates of the number of fatalities from the Spanish flu vary between a minimum of 17 million, through to 50 million and an upper estimate of 100 million deaths. If those numbers appear implausible then it should be realized that the low 17 million estimate converts into a fatality rate of 0.94%. The medium and upper estimates convert into fatalities rates of 2.8% and 5.6% respectively. According to our data, by March 25th 2020 the fatality rate on confirmed Covid-19 cases was 4.46% globally, ranging from 9.8% in Italy, to as little as 0.48% for Germany. The death rates for the Spanish influenza do not appear out of line with those being experienced with Covid-19. And it should be borne in mind that there are further variations by age group. The major difference thus far between Spanish flu and Covid-19 is that Spanish flu was highly lethal for young adults, which is not the case with Covid-19.

This analysis underscores the importance of keeping the overall number of cases to a minimum. The danger is that, unlike with SARS, Covid-19 has already spread much further and is infecting a larger part of the population. This has troubling implications for the future.

Spanish flu took some time to cover the world. The outbreak is considered to have started in January 1918, and ended in the western countries around November/December 1918. The outbreak continued in other parts of the world until 1920, and its effects on some of the smaller nations was dreadful, with death rates of up to 10% of the population in some small Pacific nations.

Today it is hoped that scientists will develop a vaccine in the next 12 to 18 months, if we are lucky earlier. This will then hasten a return to normality, as social contacts are restored and many service industries can pick up their business where they left off.

The experience of Covid-19 suggests that different national approaches do have different outcomes. Chinese authorities have taken a more authoritarian approach, restricting civil liberties and deploying the army more quickly than in Europe. Although it took longer, pictures from Lombardy now look very similar to earlier pictures from Wuhan, with similarly stringent social control measures.

UK systemic weaknesses contribute to higher death rates

Closer examination of the UK raises issues about NHS deployment, and its resilience to a pandemic crisis. It is plausible that the UK’s relatively high Covid-19 death rate is partly due to low levels of equipment and staffing. This can be seen by the following indicators, all per hundred thousand people. Hospital beds 2.7, doctors 2.6, intensive care beds 6.6, all much less than in other countries. The comparable figures for intensive care beds are France (11.6), the US (34.7) and Germany (29.2).

There are even more striking differences in the levels of equipment available in different national health systems. The UK has 7.2 MRI scanners per million population, compared with 34.7 in Germany, and 15.4 for the whole of the EU. The performance in CT scanners is even more unfavourable. The UK can muster 9.5 per million population, to Germany’s 35, and the EU average of 21.4.

Given that the overall UK levels of health spending (after recent changes in methodology) are similar to many other countries, the issue appears to be on how the funds are distributed and spent within the NHS. These are fundamentally political decisions, and have been made by a series of Conservative governments and senior NHS management. These decisions have left the NHS in a more vulnerable position, making it less resilient than other health systems, and this is contributing to the higher observed death rates from Covid-19.

One of the main lessons for the government and NHS is that there has to be more spare capacity and higher levels of equipment to improve resilience to serious epidemics in the future. Since at the moment, “getting it done” is more up to Covid-19 than to NHS management. And that reflects poorly on the government of the day.