Richard North, 10/03/2020  
 


Talking on morning television yesterday, the prime minister was blandly discussing the range of options open to him to deal with the Covid-19 epidemic.

"One of the theories", he said, "is perhaps you could take it on the chin, take it all in one go and allow coronavirus to move through the population without really taking as many draconian measures". And, without ruling that out, he airily opined: "I think we need to strike a balance".

In terms of managing an epidemic, however, the "take it on the chin" option would seem to be valid only if the NHS has the capacity to deal with the burden of illness that results. Otherwise, patients will not get the treatment they need, resulting in avoidable deaths.

The "balance" Johnson is talking about, therefore, could end up with him determining the rate at which people will become infected. If the rate exceeds the capacity of the health system to treat them effectively, he will also be deciding that some people who might otherwise have survived will die.

What that capacity might be is very difficult for someone outside the system to determine, and even health professionals within the system will often only be able to estimate requirements. But we do know that there are approximately 30,000 general adult critical care beds in England and Wales, distributed between 214 units.

During the winter peak, utilisation rates might reach 99 percent, so numbers are no real guide to what is known as the "surge" capacity – the amount that can be squeezed out of the system in an emergency. That might run to between 10-20 percent of capacity, so we could be looking at a maximum of about 6,000 beds, assuming there are staff available to service them.

It was the Chief Medical Officer, Chris Whitty, though, who offered the worse case scenario of 80 percent of people becoming infected, with 95 percent of all cases occurring within a nine-week period. Of those, between 15-20 percent might need hospital care, with ten percent of the total case load requiring a period in a critical care bed.

Averaged out over a nine-week period – which ignores the likelihood of peaks that will be multiples of the average value – that gives us 60,000 people a day entering the system who will require critical care – something like ten times the maximum theoretical capacity. And many of those people will require more than a day so, as the treatment cycles extend, the number of people requiring care on any one day multiply.

Thus, while there are many who are warning that we are short of critical care resources, no one seems to be keen to point out the scale of the deficiency. And nor has it been pointed out that adoption of the "take it on the chin" option would lead directly to hundreds of thousands of avoidable deaths.

And yet, after another COBRA meeting yesterday, Johnson attended a press conference, reflected in a lobby briefing. From this, in summary, it is clear that there is to be no new government advice and/or action enacted at this stage in the epidemic. There are to be no movement restrictions and older people not advised to do anything special (other than hand washing).

All that we have to look forward to in terms of additional controls is that anyone with a cough or cold will soon be told to self-isolate for a week, and pensioners will be advised to limit their social contact. This, by any measure, is looking uncannily like Johnson's "take it on the chin" option.

What appears to be an extraordinarily complacent approach belies the Italian experience. Only eleven days ago, the country had reported about 600 cases but is now at a level just over 9,000 – increasing at a rate of 2,000 a day – with 463 deaths. But only now has movement throughout the country been restricted, while public gatherings, including weddings, funerals and sports matches, have been banned.

Currently, the number of cases in the UK stands at 319 – including five deaths. In effect, we are just a fortnight behind Italy, if we are on the same epidemic trajectory.

Interestingly, Rory Stewart - now London mayor candidate – took exception to the inertia, arguing that the government had made a "serious mistake", and should have acted much more aggressively.

He was immediately slapped down on Twitter by a number of commentators, who asserted that the government was simply acting on "scientific advice". Stewart, on the other hand, maintained that the scientists themselves were saying that the current stance is a political decision.

He is, actually, quite right. No matter how much Johnson might hide behind his medical and scientific advisors, at this level the management of an epidemic is largely an exercise in practical politics. Thus, whether to go soft on controls, and take the hit in rising disease incidence, is entirely a political issue.

Where, of course, Johnson is trapped, is that he has little option but to bluff it out. The alternative, much touted by some pundits, is – as Stewart would prefer – to set up tough control measures in the hope that the rate of increase is slowed. The theory then is not so much that overall case numbers are reduced, but the illness is spread over a longer period, with lower daily peaks (illustrated).

This is explained by William Hanage, an epidemiologist at the Center for Disease Dynamics at the Harvard TH Chan School of Public Health in Boston. He says, that by taking avoidance measures: "The most important thing is that even if it won't protect you entirely, it will delay you getting infected. And if we can 'flatten the curve' we will avoid the worst consequences for healthcare services".

Hanage wants as many people as possible to work at home, something the government is not yet prepared to endorse. Supposedly, if enough people do this, the illness peak will never exceed the capacity of the NHS to deliver treatment.

That, however, is unrealistically optimistic. The total population at risk is so high, and the capacity of the NHS so low, that it is inevitable that treatment centres will be swamped, no matter what action is taken.

Should Johnson have chosen the delay option, therefore – going for draconian controls on the promise that they would reduce the death rate – the lack of NHS provision would find him out. This way, we take the deaths while delaying the necessary controls.

The other option, of course, would be for Johnson to come clean. Instead of patronising us with his embarrassing hand-washing nostrums, he could point out that, despite constant warnings that we were unprepared for the next pandemic, no effective action has been taken by successive governments.

Short of mobilising the resources of the nation on a wartime scale, therefore, he should admit that it was not possible for the government to manage this epidemic, should it develop to a worse case scenario, without substantial loss of life.

Even now, it might just be possible to turn things round, but the only sensible option is rapidly to increase the availability of critical care beds – and even then, that will require heroic measures and huge expenditure.

But then there is the risk that our worst fears might not materialise, and money spent might be regarded as wasted. To an extent, that puts government in an invidious position: it is damned if it doesn't plan for the worst, and damned if it does.

By presenting the people with a clear statement of the options, though, much of the downside risk could be avoided. The people, having been consulted, would then be closer to owning the decision, whatever it might be, neutralising any political fallout – especially when the opposition is so weak.

But "coming clean" is not this government's style, and it is certainly not anything Johnson would be at home with, as we have seen with Brexit. He would sooner indulge in mushroom management and have us dying in ignorance.






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