Meanwhile in the US…
Limmy is a funny fucker.
CORONAVIRUS | INSIGHT
Coronavirus: 38 days when Britain sleepwalked into disaster
Boris Johnson skipped five Cobra meetings on the virus, calls to order protective gear were ignored and scientists’ warnings fell on deaf ears. Failings in February may have cost thousands of lives
Johnson joins a lunar new year dragon eyes ritual on the day of a Cobra meeting about the virus in January
BEN STANSALL/AFP
Insight |
,
and
Sunday April 19 2020, 12.01am BST, The Sunday Times
Share
Save
On the third Friday of January a silent and stealthy killer was creeping across the world. Passing from person to person and borne on ships and planes, the coronavirus was already leaving a trail of bodies.
The virus had spread from China to six countries and was almost certainly in many others. Sensing the coming danger, the British government briefly went into wartime mode that day, holding a meeting of Cobra, its national crisis committee.
But it took just an hour that January 24 lunchtime to brush aside the coronavirus threat. Matt Hancock, the health secretary, bounced out of Whitehall after chairing the meeting and breezily told reporters the risk to the UK public was “low”.
This was despite the publication that day of an alarming study by Chinese doctors in the medical journal The Lancet. It assessed the lethal potential of the virus, for the first time suggesting it was comparable to the 1918 Spanish flu pandemic, which killed up to 50 million people.
Unusually, Boris Johnson had been absent from Cobra. The committee — which includes ministers, intelligence chiefs and military generals — gathers at moments of great peril such as terrorist attacks, natural disasters and other threats to the nation and is normally chaired by the prime minister.
Johnson had found time that day, however, to join in a lunar-new-year dragon eyes ritual as part of Downing Street’s reception for the Chinese community, led by the country’s ambassador.
It was a big day for Johnson and there was a triumphal mood in Downing Street because the withdrawal treaty from the European Union was being signed in the late afternoon. It could have been the defining moment of his premiership — but that was before the world changed.
That afternoon his spokesman played down the looming threat from the east and reassured the nation that we were “well prepared for any new diseases”. The confident, almost nonchalant, attitude displayed that day in January would continue for more than a month.
Johnson went on to miss four further Cobra meetings on the virus. As Britain was hit by unprecedented flooding, he completed the EU withdrawal, reshuffled his cabinet and then went away to the grace-and-favour country retreat at Chevening where he spent most of the two weeks over half-term with his pregnant fiancée, Carrie Symonds.
Johnson with Symonds in a selfie posted on social media in February
It would not be until March 2 — five weeks later — that Johnson would attend a Cobra meeting about the coronavirus. But by then it was almost certainly too late. The virus had sneaked into our airports, our trains, our workplaces and our homes. Britain was on course for one of the worst infections of the most insidious virus to have hit the world in a century.
Last week a senior adviser to Downing Street broke ranks and blamed the weeks of complacency on a failure of leadership in cabinet. The prime minister was singled out.
“There’s no way you’re at war if your PM isn’t there,” the adviser said. “And what you learn about Boris was he didn’t chair any meetings. He liked his country breaks. He didn’t work weekends. It was like working for an old-fashioned chief executive in a local authority 20 years ago. There was a real sense that he didn’t do urgent crisis planning. It was exactly like people feared he would be.”
Inquiry ‘inevitable’
One day there will be an inquiry into the lack of preparations during those “lost” five weeks from January 24. There will be questions about when politicians understood the severity of the threat, what the scientists told them and why so little was done to equip the National Health Service for the coming crisis. It will be the politicians who will face the most intense scrutiny.
Among the key points likely to be explored are why it took so long to recognise an urgent need for a massive boost in supplies of personal protective equipment (PPE) for health workers; ventilators to treat acute respiratory symptoms; and tests to detect the infection.
Any inquiry may also ask whether the government’s failure to get to grips with the scale of the crisis in those early days had the knock-on effect of the national lockdown being introduced days or even weeks too late, causing many thousands more unnecessary deaths.
We have talked to scientists, academics, doctors, emergency planners, public officials and politicians about the root of the crisis and whether the government should have known sooner and acted more swiftly to kick-start the Whitehall machine and put the NHS onto a war footing.
They told us that, contrary to the official line, Britain was in a poor state of readiness for a pandemic. Emergency stockpiles of PPE had severely dwindled and gone out of date after becoming a low priority in the years of austerity cuts. The training to prepare key workers for a pandemic had been put on hold for two years while contingency planning was diverted to deal with a possible no-deal Brexit.
This made it doubly important that the government hit the ground running in late January and early February. Scientists said the threat from the coming storm was clear. Indeed, one of the government’s key advisory committees was given a dire warning a month earlier than has previously been admitted about the prospect of having to deal with mass casualties.
It was a message repeated throughout February, but the warnings appear to have fallen on deaf ears. The need, for example, to boost emergency supplies of protective masks and gowns for health workers was pressing, but little progress was made in obtaining the items from manufacturers, mainly in China.
Instead, the government sent supplies the other way — shipping 279,000 items of its depleted stockpile of protective equipment to China during this period in response to a request for help from the authorities there.
Impending danger
The prime minister had been sunning himself with his girlfriend in the millionaires’ Caribbean resort of Mustique when China alerted the World Health Organisation (WHO) on December 31 that several cases of an unusual pneumonia had been recorded in Wuhan, a city of 11 million people in Hubei province.
In the days that followed, China at first claimed the virus could not be transmitted from human to human, which should have been reassuring. But this did not ring true to Britain’s public health academics and epidemiologists, who were texting one another, eager for more information, in early January.
Devi Sridhar, professor of global public health at Edinburgh University, had predicted in a talk two years earlier that a virus might jump species from an animal in China and spread quickly to become a human pandemic. So the news from Wuhan set her on high alert.
“In early January a lot of my global health colleagues and I were kind of discussing ‘What’s going on?’” she recalled. “China still hadn’t confirmed the virus was human to human. A lot of us were suspecting it was because it was a respiratory pathogen and you wouldn’t see the numbers of cases that we were seeing out of China if it was not human to human. So that was disturbing.”
By as early as January 16 the professor was on Twitter calling for swift action to prepare for the virus. “Been asked by journalists how serious #WuhanPneumonia outbreak is,” she wrote. “My answer: take it seriously because of cross-border spread (planes means bugs travel far & fast), likely human-to-human transmission and previous outbreaks have taught overresponding is better than delaying action.”
Events were now moving fast. Four hundred miles away in London, on its campus next to the Royal Albert Hall, a team at Imperial College’s School of Public Health led by Professor Neil Ferguson produced its first modelling assessment of the impact of the virus. On Friday January 17 its report noted the “worrying” news that three cases of the virus had been discovered outside China — two in Thailand and one in Japan. While acknowledging many unknowns, researchers calculated that there could already be as many as 4,000 cases. The report warned: “The magnitude of these numbers suggests substantial human-to-human transmission cannot be ruled out. Heightened surveillance, prompt information-sharing and enhanced preparedness are recommended.”
By now the mystery bug had been identified as a type of coronavirus — a large family of viruses that can cause infections ranging from the common cold to severe acute respiratory syndrome (Sars). There had been two reported deaths from the virus and 41 patients had been taken ill.
The following Wednesday, January 22, the government convened the first meeting of its scientific advisory group for emergencies (Sage) to discuss the virus. Its membership is secret but it is usually chaired by the government’s chief scientific adviser, Sir Patrick Vallance, and chief medical adviser, Professor Chris Whitty. Downing Street advisers are also present.
There were new findings that day, with Chinese scientists warning that the virus had an unusually high infectivity rate of up to 3.0, which meant each person with the virus would typically infect up to three more people.
One of those present was Imperial’s Ferguson, who was already working on his own estimate — putting infectivity at 2.6 and possibly as high as 3.5 — which he sent to ministers and officials in a report on the day of the Cobra meeting on January 24. The Spanish flu had an estimated infectivity rate of between 2.0 and 3.0, whereas for most flu outbreaks it is about 1.3, so Ferguson’s finding was shocking.
The professor’s other bombshell in the report was that there needed to be a 60% cut in the transmission rate — which meant stopping contact between people. In layman’s terms it meant a lockdown, a move that would paralyse an economy already facing a battering from Brexit. At the time such a suggestion was unthinkable in the government and belonged to the world of post-apocalypse movies.
The growing alarm among scientists appears not to have been heard or heeded by policy-makers. After the January 25 Cobra meeting, the chorus of reassurance was not just from Hancock and the prime minister’s spokesman: Whitty was confident too.
In early February Hancock proudly told the Commons the UK was one of the first countries to develop a new test for the virus
STEFAN ROUSSEAU/PA
“Cobra met today to discuss the situation in Wuhan, China,” said Whitty. “We have global experts monitoring the situation around the clock and have a strong track record of managing new forms of infectious disease . . . there are no confirmed cases in the UK to date.”
However, by then there had been 1,000 cases worldwide and 41 deaths, mostly in Wuhan. A Lancet report that day presented a study of 41 coronavirus patients admitted to hospital in Wuhan, which found that more than half had severe breathing problems, a third required intensive care and six had died.
And there was now little doubt that the UK would be hit by the virus. A study by Southampton University has shown that 190,000 people flew into the UK from Wuhan and other high-risk Chinese cities between January and March. The researchers estimated that up to 1,900 of these passengers would have been infected with the coronavirus — almost guaranteeing the UK would become a centre of the subsequent pandemic.
Sure enough, five days later, on Wednesday January 29, the first coronavirus cases on British soil were found when two Chinese nationals from the same family fell ill at a hotel in York. The next day the government raised the threat level from low to moderate.
The pandemic plan
On January 31 — or Brexit day, as it had become known — there was a rousing 11pm speech by the prime minister promising that withdrawal from the European Union would be the dawn of a new era, unleashing the British people, who would “grow in confidence” month by month.
By this time there was good reason for the government’s top scientific advisers to feel creeping unease about the virus. The WHO had declared the coronavirus a global emergency just the previous day, and scientists at the London School of Hygiene and Tropical Medicine had confirmed to Whitty in a private meeting of the Nervtag advisory committee on respiratory illness that the virus’s infectivity could be as bad as Ferguson’s worst estimate several days earlier.
The official scientific advisers were willing to concede in public that there might be several cases of the coronavirus in the UK. But they had faith that the country’s plans for a pandemic would prove robust.
This was probably a big mistake. An adviser to Downing Street — speaking off the record — said their confidence in “the plan” was misplaced. While a possible pandemic had been listed as the No 1 threat to the nation for many years, the source said that in reality it had long since stopped being treated as such.
Several emergency planners and scientists said that the plans to protect the UK in a pandemic had once been a priority and had been well funded for the decade following the 9/11 terrorist attacks in 2001. But then austerity cuts struck. “We were the envy of the world,” the source said, “but pandemic planning became a casualty of the austerity years, when there were more pressing needs.”
The last rehearsal for a pandemic was a 2016 exercise codenamed Cygnus, which predicted the health service would collapse and highlighted a long list of shortcomings — including, presciently, a lack of PPE and intensive care ventilators.
An equally lengthy list of recommendations to address the deficiencies was never implemented. The source said preparations for a no-deal Brexit “sucked all the blood out of pandemic planning” in the following years.
In the year leading up to the coronavirus outbreak key government committee meetings on pandemic planning were repeatedly “bumped” off the diary to make way for discussions about more pressing issues such as the beds crisis in the NHS. Training for NHS staff with protective equipment and respirators was also neglected, the source alleges.
Members of the government advisory group on pandemics are said to have felt powerless. “They would joke between themselves, ‘Ha-ha, let’s hope we don’t get a pandemic’, because there wasn’t a single area of practice that was being nurtured in order for us to meet basic requirements for a pandemic, never mind do it well,” said the source.
“If you were with senior NHS managers at all during the last two years, you were aware that their biggest fear, their sweatiest nightmare, was a pandemic, because they weren’t prepared for it.”
It meant that the government had much catching-up to do as it became clear that this “nightmare” was turning into a distinct possibility in February. But the source said there was still little urgency. “Almost every plan we had was not activated in February. Almost every government department has failed to properly implement their own pandemic plans,” the source said.
One deviation from the plan, for example, was a failure to give an early warning to firms that there might be a lockdown so they could start contingency planning. “There was a duty to get them to start thinking about their cashflow and their business continuity arrangements,” the source said.
Superspreader
A central part of any pandemic plan is to identify anyone who becomes ill, vigorously pursue all their recent contacts and put them into quarantine. That involves testing, and the UK seemed to be ahead of the game. In early February Hancock proudly told the Commons the UK was one of the first countries to develop a new test for the coronavirus. “Testing worldwide is being done on equipment designed in Oxford,” he said.
So when Steve Walsh, a 53-year-old businessman from Hove, East Sussex, was identified as the source of the second UK outbreak on February 6, all his contacts were followed up with tests. Walsh’s case was a warning of the rampant infectivity of the virus: he is believed to have passed it to five people in the UK after returning from a conference in Singapore, as well as six overseas.
But Public Health England failed to take advantage of our early breakthroughs with tests and lost early opportunities to step up production to the levels that would later be needed.
This was in part because the government was planning for the virus using its blueprint for fighting the flu. Once a flu pandemic has found its way into the population and there is no vaccine, the virus is allowed to take its course until “herd immunity” is acquired. Such a plan does not require mass testing.
A senior politician told this newspaper: “I had conversations with Chris Whitty at the end of January, and they were absolutely focused on herd immunity. The reason is that with flu, herd immunity is the right response if you haven’t got a vaccine.
“All of our planning was for pandemic flu. There has basically been a divide between scientists in Asia, who saw this as a horrible, deadly disease on the lines of Sars, which requires immediate lockdown, and those in the West, particularly in the US and UK, who saw this as flu.”
The prime minister’s top adviser, Dominic Cummings, is said to have had initial enthusiasm for the herd immunity concept, which may have played a part in the government’s early approach to managing the virus. The Department of Health firmly denies that “herd immunity” was ever its aim and rejects suggestions that Whitty supported it. Cummings also denies backing the concept.
The failure to obtain large amounts of testing equipment was another big error of judgment, according to the Downing Street source. It would later be one of the big scandals of the coronavirus crisis that the considerable capacity of Britain’s private laboratories to mass-produce tests was not harnessed during those crucial weeks of February.
“We should have communicated with every commercial testing laboratory that might volunteer to become part of the government’s testing regime, but that didn’t happen,” said the source.
The lack of action was confirmed by Doris-Ann Williams, chief executive of the British In Vitro Diagnostics Association, which represents 110 companies that make up most of the UK’s testing sector. Amazingly, she said her organisation did not receive a meaningful approach from the government asking for help until April 1 — the night before Hancock bowed to pressure and announced a belated and ambitious target of 100,000 tests a day by the end of this month.
There was also a failure to replenish supplies of gowns and masks for health and care workers in the early weeks of February — despite NHS England declaring the virus its first “level 4 critical incident” at the end of January.
It was a key part of the pandemic plan — the NHS’s Operating Framework for Managing the Response to Pandemic Influenza, dated December 2017 — that the NHS would be able to draw on “just in case” stockpiles of PPE.
But many of the “just in case” stockpiles had dwindled, and equipment was out of date. As not enough money was being spent on replenishing stockpiles, this shortfall was supposed to be filled by activating “just in time” contracts, which had been arranged with equipment suppliers in recent years to deal with an emergency. The first order for equipment under the “just in time” protocol was made on January 30.
However, the source said that attempts to call in these “just in time” contracts immediately ran into difficulties in February because they were mostly with Chinese manufacturers, which were facing unprecedented demand from the country’s own health service and elsewhere.
This was another nail in the coffin for the pandemic plan. “It was a massive spider’s web of failing; every domino has fallen,” said the source.
The NHS could have contacted UK-based suppliers. The British Healthcare Trades Association (BHTA) was ready to help supply PPE in February — and throughout March — but it was only on April 1 that its offer of help was accepted. Dr Simon Festing, the organisation’s chief executive, said: “Orders undoubtedly went overseas instead of to the NHS because of the missed opportunities in the procurement process.”
Downing Street admitted on February 24 — just five days before NHS chiefs warned a lack of PPE left the health service facing a “nightmare” — that the UK government had supplied 1,800 pairs of goggles and 43,000 disposable gloves, 194,000 sanitising wipes, 37,500 medical gowns and 2,500 face masks to China.
A senior Department of Health insider described the sense of drift witnessed during those crucial weeks in February: “We missed the boat on testing and PPE . . . I remember being called into some of the meetings about this in February and thinking, ‘Well, it’s a good thing this isn’t the big one.’
“I had watched Wuhan but I assumed we must have not been worried because we did nothing. We just watched. A pandemic was always at the top of our national risk register — always — but when it came we just slowly watched. We could have been Germany, but instead we were doomed by our incompetence, our hubris and our austerity.”
In the Far East the threat was being treated more seriously in the early weeks of February. Martin Hibberd, a professor of emerging infectious diseases at the London School of Hygiene and Tropical Medicine, was in a unique position to compare the UK’s response with Singapore, where he had advised in the past.
“Singapore realised, as soon as Wuhan reported it, that cases were going to turn up in Singapore. And so they prepared for that. I looked at the UK and I can see a different strategy and approach.
“The interesting thing for me is, I’ve worked with Singapore in 2003 and 2009 and basically they copied the UK pandemic preparedness plan. But the difference is they actually implemented it.”
Working holiday
Towards the end of the second week of February, the prime minister was demob happy. After sacking five cabinet ministers and saying everyone “should be confident and calm” about Britain’s response to the virus, Johnson vacated Downing Street after the half-term recess began on February 13.
He headed to the country for a “working” holiday at Chevening with Symonds and would be out of the public eye for 12 days. His aides were thankful for the rest, as they had been working flat-out since the summer as the Brexit power struggle had played out.
The Sunday newspapers that weekend would not have made comfortable reading. The Sunday Times reported on a briefing from a risk specialist that said Public Health England would be overrun during a pandemic as it could test only 1,000 people a day.
Johnson may well have been distracted by matters in his personal life during his stay in the countryside. Aides were told to keep their briefing papers short and cut the number of memos in his red box if they wanted them to be read.
His family needed to be prepared for the announcement that Symonds, who turned 32 in March, was pregnant and that they had been secretly engaged for some time. Relations with his children had been fraught since his separation from his estranged wife Marina Wheeler and the rift had deepened when she received a cancer diagnosis last year.
The divorce also had to be finalised. Midway through the break it was announced in the High Court that the couple had reached a settlement, leaving Wheeler free to apply for divorce.
There were murmurings of frustration from some ministers and their aides at the time that Johnson was not taking more of a lead. But Johnson’s aides are understood to have felt relaxed: he was getting updates and they claim the scientists were saying everything was under control.
400,000 deaths
By the time Johnson departed for the countryside, however, there was mounting unease among scientists about the exceptional nature of the threat. Sir Jeremy Farrar, an infectious disease specialist who is a key government adviser, made this clear in a recent BBC interview.
“I think from the early days in February, if not in late January, it was obvious this infection was going to be very serious and it was going to affect more than just the region of Asia,” he said. “I think it was very clear that this was going to be an unprecedented event.”
By February 21 the virus had already infected 76,000 people, had caused 2,300 deaths in China and was taking a foothold in Europe, with Italy recording 51 cases and two deaths the following day. Nonetheless Nervtag, one of the key government advisory committees, decided to keep the threat level at “moderate”.
Its members may well regret that decision with hindsight, and it was certainly not unanimous. John Edmunds, one of the country’s top infectious disease modellers from the London School of Hygiene and Tropical Medicine, was participating in the meeting by video link, but his technology failed him at the crucial moment.
Edmunds wanted the threat level to be increased to high but could not make his view known as the link was glitchy. He sent an email later making his view clear. “JE believes that the risk to the UK population [in the PHE risk assessment] should be high, as there is evidence of ongoing transmission in Korea, Japan and Singapore, as well as in China,” the meeting’s minutes state. But the decision had already been taken.
Peter Openshaw, professor of experimental medicine at Imperial College, was in America at the time of the meeting but would also have recommended increasing the threat to high. Three days earlier he had given an address to a seminar in which he estimated that 60% of the world’s population would probably become infected if no action was taken and 400,000 people would die in the UK.
By February 26 there were 13 known cases in the UK. That day — almost four weeks before a full lockdown would be announced — ministers were warned through another advisory committee that the country was facing a catastrophic loss of life unless drastic action was taken. Having been thwarted from sounding the alarm, Edmunds and his team presented their latest “worst scenario” predictions to the scientific pandemic influenza group on modelling (SPI-M), which directly advises the country’s scientific decision-makers in Sage.
It warned that 27 million people could be infected and 220,000 intensive care beds would be needed if no action were taken to reduce infection rates. The predicted death toll was 380,000. Edmunds’s colleague Nick Davies, who led the research, says the report emphasised the urgent need for a lockdown almost four weeks before it was imposed.
The team modelled the effects of a 12-week lockdown involving school and work closures, shielding the elderly, social distancing and self-isolation. It estimated this would delay the impact of the pandemic but there still might be 280,000 deaths over the year.
Johnson returns
The previous night Johnson had returned to London for the Conservatives’ big fundraising ball, the Winter Party, at which one donor pledged £60,000 for the privilege of playing a game of tennis with him.
By this time the prime minister had missed five Cobra meetings on the preparations to combat the looming pandemic, which he left to be chaired by Hancock. Johnson was an easy target for the opposition when he returned to the Commons the following day: the Labour leader, Jeremy Corbyn, labelled him a “part-time” prime minister for his failure to lead on the virus crisis or visit the areas of the UK badly hit by floods.
By Friday February 28 the virus had taken root in the UK, with reported cases rising to 19, and the stock markets were plunging. It was finally time for Johnson to act. He summoned a TV reporter into Downing Street to say he was on top of the coronavirus crisis.
“The issue of coronavirus is something that is now the government’s top priority,” he said. “I have just had a meeting with the chief medical officer and secretary of state for health talking about the preparations that we need to make.”
It was finally announced that he would be attending a meeting of Cobra — after a weekend at Chequers with Symonds where the couple would publicly release news of the engagement and their baby.
On the Sunday there was a meeting between Sage committee members and officials from the Department of Health and the NHS that was a game-changer, according to a Whitehall source. The meeting was shown fresh modelling based on figures from Italy suggesting that 8% of infected people might need hospital treatment in a worst-case scenario. The previous estimate had been 4%-5%.
“The risk to the NHS had effectively doubled in an instant. It set alarm bells ringing across government,” said the Whitehall source. “I think that meeting focused minds. You realise it’s time to pull the trigger on the starting gun.”
Many NHS workers have been left without proper protection
At the Cobra meeting the next day, with Johnson in the chair, a full “battle plan” was finally signed off to contain, delay and mitigate the spread of the virus. This was on March 2 — five weeks after the first Cobra meeting on the virus.
The new push would have some positive benefits such as the creation of new Nightingale hospitals, which greatly increased the number of intensive care beds. But there was a further delay that month of nine days in introducing the lockdown as Johnson and his senior advisers debated what measures were required. Later the government would be left rudderless again after Johnson himself contracted the virus.
As the number of infections grew daily, some things were impossible to retrieve. There was a worldwide shortage of PPE, and the prime minister would have to personally ring manufacturers of ventilators and testing kits in a desperate effort to boost supplies.
The result was that the NHS and care home workers would be left without proper protection and insufficient numbers of tests to find out whether they had been infected. To date 50 doctors, nurses and NHS workers have died. More than 100,000 people have been confirmed as infected in Britain and 15,000 have died.
This weekend sources close to Hancock said that from late January he instituted a “prepare for the worst” approach to the virus, held daily meetings and started work on PPE supplies.
A Downing Street spokesman said: “Our response has ensured that the NHS has been given all the support it needs to ensure everyone requiring treatment has received it, as well as providing protection to businesses and reassurance to workers. The prime minister has been at the helm of the response to this, providing leadership during this hugely challenging period for the whole nation.”
596 deaths confirmed in UK hospitals.
Weekend figure is usually lower.
The virus gets lazy at weekends.
Anthony Costello
@globalhlthtwit
I cannot believe what I am hearing at the press conference. Deputy CMO Jenny Harries still believes that testing policy in the UK has been correct. And she doesn’t understand links between tests and #COVID death rates. Is this #CMO policy? If so, they should resign.
Good overview by Donald McNeil here.
Some bizarre societal apartheid could potentially be in the offing. Very good information about the vaccination trials process towards the bottom.
The coronavirus is spreading from America’s biggest cities to its suburbs, and has begun encroaching on the nation’s rural regions. The virus is believed to have infected millions of citizens and has killed more than 34,000.
Yet President Trump this week proposed guidelines for reopening the economy and suggested that a swath of the United States would soon resume something resembling normalcy. For weeks now, the administration’s view of the crisis and our future has been rosier than that of its own medical advisers, and of scientists generally.
In truth, it is not clear to anyone where this crisis is leading us. More than 20 experts in public health, medicine, epidemiology and history shared their thoughts on the future during in-depth interviews. When can we emerge from our homes? How long, realistically, before we have a treatment or vaccine? How will we keep the virus at bay?
Some felt that American ingenuity, once fully engaged, might well produce advances to ease the burdens. The path forward depends on factors that are certainly difficult but doable, they said: a carefully staggered approach to reopening, widespread testing and surveillance, a treatment that works, adequate resources for health care providers — and eventually an effective vaccine.
Still, it was impossible to avoid gloomy forecasts for the next year. The scenario that Mr. Trump has been unrolling at his daily press briefings — that the lockdowns will end soon, that a protective pill is almost at hand, that football stadiums and restaurants will soon be full — is a fantasy, most experts said.
“We face a doleful future,” said Dr. Harvey V. Fineberg, a former president of the National Academy of Medicine.
He and others foresaw an unhappy population trapped indoors for months, with the most vulnerable possibly quarantined for far longer. They worried that a vaccine would initially elude scientists, that weary citizens would abandon restrictions despite the risks, that the virus would be with us from now on.
“My optimistic side says the virus will ease off in the summer and a vaccine will arrive like the cavalry,” said Dr. William Schaffner, a preventive medicine specialist at Vanderbilt University medical school. “But I’m learning to guard against my essentially optimistic nature.”
Most experts believed that once the crisis was over, the nation and its economy would revive quickly. But there would be no escaping a period of intense pain.
Exactly how the pandemic will end depends in part on medical advances still to come. It will also depend on how individual Americans behave in the interim. If we scrupulously protect ourselves and our loved ones, more of us will live. If we underestimate the virus, it will find us.
More Americans may die than the White House admits.
Covid-19, the illness caused by the coronavirus, is arguably the leading cause of death in the United States right now. The virus has killed more than 1,800 Americans almost every day since April 7, and the official toll may be an undercount.
By comparison, heart disease typically kills 1,774 Americans a day, and cancer kills 1,641.
Yes, the coronavirus curves are plateauing. There are fewer hospital admissions in New York, the center of the epidemic, and fewer Covid-19 patients in I.C.U.s. The daily death toll is still grim, but no longer rising.
The epidemiological model often cited by the White House, which was produced by the University of Washington’s Institute for Health Metrics and Evaluation, originally predicted 100,000 to 240,000 deaths by midsummer. Now that figure is 60,000.
While this is encouraging news, it masks some significant concerns. The institute’s projection runs through Aug. 4, describing only the first wave of this epidemic. Without a vaccine, the virus is expected to circulate for years, and the death tally will rise over time.
The gains to date were achieved only by shutting down the country, a situation that cannot continue indefinitely. The White House’s “phased” plan for reopening will surely raise the death toll no matter how carefully it is executed. The best hope is that fatalities can be held to a minimum.
Reputable longer-term projections for how many Americans will die vary, but they are all grim. Various experts consulted by the Centers for Disease Control and Prevention in March predicted that the virus eventually could reach 48 percent to 65 percent of all Americans, with a fatality rate just under 1 percent, and would kill up to 1.7 million of them if nothing were done to stop the spread.
A model by researchers at Imperial College London cited by the president on March 30 predicted 2.2 million deaths in the United States by September under the same circumstances.
By comparison, about 420,000 Americans died in World War II.
The limited data from China are even more discouraging. Its epidemic has been halted — for the moment — and virtually everyone infected in its first wave has died or recovered.
China has officially reported about 83,000 cases and 4,632 deaths, which is a fatality rate of over 5 percent. The Trump administration has questioned the figures but has not produced more accurate ones.
Fatality rates depend heavily on how overwhelmed hospitals get and what percentage of cases are tested. China’s estimated death rate was 17 percent in the first week of January, when Wuhan was in chaos, according to a Center for Evidence-Based Medicine report, but only 0.7 percent by late February.
In this country, hospitals in several cities, including New York, came to the brink of chaos. Officials in both Wuhan and New York had to revise their death counts upward this week when they realized that many people had died at home of Covid-19, strokes, heart attacks or other causes, or because ambulances never came for them.
In fast-moving epidemics, far more victims pour into hospitals or die at home than doctors can test; at the same time, the mildly ill or asymptomatic never get tested. Those two factors distort the true fatality rate in opposite ways. If you don’t know how many people are infected, you don’t know how deadly a virus is.
Only when tens of thousands of antibody tests are done will we know how many silent carriers there may be in the United States. The C.D.C. has suggested it might be 25 percent of those who test positive. Researchers in Iceland said it might be double that.
China is also revising its own estimates. In February, a major study concluded that only 1 percent of cases in Wuhan were asymptomatic. New research says perhaps 60 percent were. Our knowledge gaps are still wide enough to make epidemiologists weep.
“All models are just models,” Dr. Anthony S. Fauci, science adviser to the White House coronavirus task force, has said. “When you get new data, you change them.”
There may be good news buried in this inconsistency: The virus may also be mutating to cause fewer symptoms. In the movies, viruses become more deadly. In reality, they usually become less so, because asymptomatic strains reach more hosts. Even the 1918 Spanish flu virus eventually faded into the seasonal H1N1 flu.
At the moment, however, we do not know exactly how transmissible or lethal the virus is. But refrigerated trucks parked outside hospitals tell us all we need to know: It is far worse than a bad flu season.
The lockdowns will end, but haltingly.
Commuters on the Staten Island Ferry.Credit…Misha Friedman for The New York Times
No one knows exactly what percentage of Americans have been infected so far — estimates have ranged from 3 percent to 10 percent — but it is likely a safe bet that at least 300 million of us are still vulnerable.
Until a vaccine or another protective measure emerges, there is no scenario, epidemiologists agreed, in which it is safe for that many people to suddenly come out of hiding. If Americans pour back out in force, all will appear quiet for perhaps three weeks.
Then the emergency rooms will get busy again.
“There’s this magical thinking saying, ‘We’re all going to hunker down for a while and then the vaccine we need will be available,’” said Dr. Peter J. Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine.
In his wildly popular March 19 article in Medium, “Coronavirus: The Hammer and the Dance,” Tomas Pueyo correctly predicted the national lockdown, which he called the hammer, and said it would lead to a new phase, which he called the dance, in which essential parts of the economy could reopen, including some schools and some factories with skeleton crews.
Every epidemiological model envisions something like the dance. Each assumes the virus will blossom every time too many hosts emerge and force another lockdown. Then the cycle repeats. On the models, the curves of rising and falling deaths resemble a row of shark teeth.
Surges are inevitable, the models predict, even when stadiums, churches, theaters, bars and restaurants remain closed, all travelers from abroad are quarantined for 14 days, and domestic travel is tightly restricted to prevent high-intensity areas from reinfecting low-intensity ones.
The tighter the restrictions, experts say, the fewer the deaths and the longer the periods between lockdowns. Most models assume states will eventually do widespread temperature checks, rapid testing and contact tracing, as is routine in Asia.
Even the “Opening Up America Again” guidelines Mr. Trump issued on Thursday have three levels of social distancing, and recommend that vulnerable Americans stay hidden. The plan endorses testing, isolation and contact tracing — but does not specify how these measures will be paid for, or how long it will take to put them in place.
On Friday, none of that stopped the president from contradicting his own message by sending out tweets encouraging protesters in Michigan, Minnesota and Virginia to fight their states’ shutdowns.
China did not allow Wuhan, Nanjing or other cities to reopen until intensive surveillance found zero new cases for 14 straight days, the virus’s incubation period. Compared with China or Italy, the United States is still a playground.
Americans can take domestic flights, drive where they want, and roam streets and parks. Despite restrictions, everyone seems to know someone discreetly arranging play dates for children, holding backyard barbecues or meeting people on dating apps.
Partly as a result, the country has seen up to 30,000 new case infections each day. “People need to realize that it’s not safe to play poker wearing bandannas,” Dr. Schaffner said.
Even with rigorous measures, Asian countries have had trouble keeping the virus under control.
China, which has reported about 100 new infections per day, recently closed all the country’s movie theaters again. Singapore has closed all schools and nonessential workplaces. Japan recently declared a state of emergency. (South Korea has struggled at times, too, but on Sunday reported only eight new cases, the first single-digit increase in two months.)
Resolve to Save Lives, a public health advocacy group run by Dr. Thomas R. Frieden, the former director of the C.D.C., has published detailed and strict criteria for when the economy can reopen and when it must be closed.
Reopening requires declining cases for 14 days, the tracing of 90 percent of contacts, an end to health care worker infections, recuperation places for mild cases and many other hard-to-reach goals.
“We need to reopen the faucet gradually, not allow the floodgates to reopen,” Dr. Frieden said. “This is a time to work to make that day come sooner.”
Immunity will become a societal advantage.
Imagine an America divided into two classes: those who have recovered from infection with the coronavirus and presumably have some immunity to it; and those who are still vulnerable.
“It will be a frightening schism,” Dr. David Nabarro, a World Health Organization special envoy on Covid-19, predicted. “Those with antibodies will be able to travel and work, and the rest will be discriminated against.”
Already, people with presumed immunity are very much in demand, asked to donate their blood for antibodies and doing risky medical jobs fearlessly.
Soon the government will have to invent a way to certify who is truly immune. A test for IgG antibodies, which are produced once immunity is established, would make sense, said Dr. Daniel R. Lucey, an expert on pandemics at Georgetown Law School. Many companies are working on them.
Dr. Fauci has said the White House was discussing certificates like those proposed in Germany. China uses cellphone QR codes linked to the owner’s personal details so others cannot borrow them.
The California adult-film industry pioneered a similar idea a decade ago. Actors use a cellphone app to prove they have tested H.I.V. negative in the last 14 days, and producers can verify the information on a password-protected website.
As Americans stuck in lockdown see their immune neighbors resuming their lives and perhaps even taking the jobs they lost, it is not hard to imagine the enormous temptation to join them through self-infection, experts predicted. Younger citizens in particular will calculate that risking a serious illness may still be better than impoverishment and isolation.
“My daughter, who is a Harvard economist, keeps telling me her age group needs to have Covid-19 parties to develop immunity and keep the economy going,” said Dr. Michele Barry, who directs the Center for Innovation in Global Health at Stanford University.
It has happened before. In the 1980s, Cuba successfully contained its small AIDS epidemic by brutally forcing everyone who tested positive into isolation camps. Inside, however, the residents had their own bungalows, food, medical care, salaries, theater troupes and art classes.
Dozens of Cuba’s homeless youths infected themselves through sex or blood injections to get in, said Dr. Jorge Pérez Ávila, an AIDS specialist who is Cuba’s version of Dr. Fauci. Many died before antiretroviral therapy was introduced.
It would be a gamble for American youth, too. The obese and immunocompromised are clearly at risk, but even slim, healthy young Americans have died of Covid-19.
The virus can be kept in check, but only with expanded resources.
The next two years will proceed in fits and starts, experts said. As more immune people get back to work, more of the economy will recover.
But if too many people get infected at once, new lockdowns will become inevitable. To avoid that, widespread testing will be imperative.
Dr. Fauci has said “the virus will tell us” when it’s safe. He means that once a national baseline of hundreds of thousands of daily tests is established across the nation, any viral spread can be spotted when the percentage of positive results rises.
Detecting rising fevers as they are mapped by Kinsa’s smart thermometers may give an earlier signal, Dr. Schaffner said.
But diagnostic testing has been troubled from the beginning. Despite assurances from the White House, doctors and patients continue to complain of delays and shortages.
To keep the virus in check, several experts insisted, the country also must start isolating all the ill — including mild cases.
In this country, patients who test positive are asked to stay in their homes but keep away from their families.
Television news has been filled with recuperating personalities like CNN’s Chris Cuomo, sweating alone in his basement while his wife left food atop the stairs, his children waved and the dogs hung back.
But even Mr. Cuomo ended up illustrating why the W.H.O. strongly opposes home isolation. On Wednesday, he revealed that his wife had the virus.
“If I was forced to select only one intervention, it would be the rapid isolation of all cases,” said Dr. Bruce Aylward, who led the W.H.O. observer team to China.
In China, anyone testing positive, no matter how mild their symptoms, was required to immediately enter an infirmary-style hospital — often set up in a gymnasium or community center outfitted with oxygen tanks and CT scanners.
There, they recuperated under the eyes of nurses. That reduced the risk to families, and being with other victims relieved some patients’ fears. Nurses even led dance and exercise classes to raise spirits, and help victims clear their lungs and keep their muscle tone.
Still, experts were divided on the idea of such wards. Dr. Fineberg co-wrote a New York Times Op-Ed article calling for mandatory but “humane quarantine processes.”
By contrast, Marc Lipsitch, an epidemiologist at the Harvard T.H. Chan School of Public Health, opposed the idea, saying: “I don’t trust our government to remove people from their families by force.”
Ultimately, suppressing a virus requires testing all the contacts of every known case. But the United States is far short of that goal.
Someone working in a restaurant or factory may have dozens or even hundreds of contacts. In China’s Sichuan Province, for example, each known case had an average of 45 contacts.
The C.D.C. has about 600 contact tracers and, until recently, state and local health departments employed about 1,600, mostly for tracing syphilis and tuberculosis cases.
China hired and trained 9,000 in Wuhan alone. Dr. Frieden recently estimated that the United States will need at least 300,000.
There will not be a vaccine soon.
Even though limited human trials of three candidates — two here and one in China — have already begun, Dr. Fauci has repeatedly said that any effort to make a vaccine will take at least a year to 18 months.
All the experts familiar with vaccine production agreed that even that timeline was optimistic. Dr. Paul Offit, a vaccinologist at the Children’s Hospital of Philadelphia, noted that the record is four years, for the mumps vaccine.
Researchers differed sharply over what should be done to speed the process. Modern biotechnology techniques using RNA or DNA platforms make it possible to develop candidate vaccines faster than ever before.
But clinical trials take time, in part because there is no way to rush the production of antibodies in the human body.
Also, for unclear reasons, some previous vaccine candidates against coronaviruses like SARS have triggered “antibody-dependent enhancement,” which makes recipients more susceptible to infection, rather than less. In the past, vaccines against H.I.V. and dengue have unexpectedly done the same.
A new vaccine is usually first tested in fewer than 100 young, healthy volunteers. If it appears safe and produces antibodies, thousands more volunteers — in this case, probably front-line workers at the highest risk — will get either it or a placebo in what is called a Phase 3 trial.
It is possible to speed up that process with “challenge trials.” Scientists vaccinate small numbers of volunteers, wait until they develop antibodies, and then “challenge” them with a deliberate infection to see if the vaccine protects them.
Challenge trials are used only when a disease is completely curable, such as malaria or typhoid fever. Normally, it is ethically unthinkable to challenge subjects with a disease with no cure, such as Covid-19.
But in these abnormal times, several experts argued that putting a few Americans at high risk for fast results could be more ethical than leaving millions at risk for years.
“Fewer get harmed if you do a challenge trial in a few people than if you do a Phase 3 trial in thousands,” said Dr. Lipsitch, who recently published a paper advocating challenge trials in the Journal of Infectious Diseases. Almost immediately, he said, he heard from volunteers.
Others were deeply uncomfortable with that idea. “I think it’s very unethical — but I can see how we might do it,” said Dr. Lucey.
The hidden danger of challenge trials, vaccinologists explained, is that they recruit too few volunteers to show whether a vaccine creates enhancement, since it may be a rare but dangerous problem.
“Challenge trials won’t give you an answer on safety,” said Michael T. Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy. “It may be a big problem.”
Dr. W. Ian Lipkin, a virologist at Columbia University’s Mailman School of Public Health, suggested an alternative strategy. Pick at least two vaccine candidates, briefly test them in humans and do challenge trials in monkeys. Start making the winner immediately, even while widening the human testing to look for hidden problems.
As arduous as testing a vaccine is, producing hundreds of millions of doses is even tougher, experts said.
Most American vaccine plants produce only about 5 million to 10 million doses a year, needed largely by the 4 million babies born and 4 million people who reach age 65 annually, said Dr. R. Gordon Douglas Jr., a former president of Merck’s vaccine division.
But if a vaccine is invented, the United States could need 300 million doses — or 600 million if two shots are required. And just as many syringes.
“People have to start thinking big,” Dr. Douglas said. “With that volume, you’ve got to start cranking it out pretty soon.”
Flu vaccine plants are large, but those that grow the vaccines in chicken eggs are not suitable for modern vaccines, which grow in cell broths, he said.
European countries have plants but will need them for their own citizens. China has a large vaccine industry, and may be able to expand it over the coming months. It might be able to make vaccines for the United States, experts said. But captive customers must pay whatever price the seller asks, and the safety and efficacy standards of some Chinese companies are imperfect.
India and Brazil also have large vaccine industries. If the virus moves rapidly through their crowded populations, they may lose millions of citizens but achieve widespread herd immunity well before the United States does. In that case, they might have spare vaccine plant capacity.
Alternatively, suggested Arthur M. Silverstein, a retired medical historian at the Johns Hopkins School of Medicine, the government might take over and sterilize existing liquor or beer plants, which have large fermentation vats.
“Any distillery could be converted,” he said.
Treatments are likely to arrive first.
In the short term, experts were more optimistic about treatments than vaccines. Several felt that so-called convalescent serum could work.
The basic technique has been used for over a century: Blood is drawn from people who have recovered from a disease, then filtered to remove everything but the antibodies. The antibody-rich immunoglobulin is injected into patients.
The obstacle is that there are now relatively few survivors to harvest blood from.
In the pre-vaccine era, antibodies were “farmed” in horses and sheep. But that process was hard to keep sterile, and animal proteins sometimes triggered allergic reactions.
The modern alternative is monoclonal antibodies. These treatment regimens, which recently came very close to conquering the Ebola epidemic in eastern Congo, are the most likely short-term game changer, experts said.
The most effective antibodies are chosen, and the genes that produce them are spliced into a benign virus that will grow in a cellular broth.
But, as with vaccines, growing and purifying monoclonal antibodies takes time. In theory, with enough production, they could be used not just to save lives but to protect front-line workers.
Antibodies can last for weeks before breaking down — how long depends on many factors, Dr. Silverstein noted — and they cannot kill virus that is already hidden inside cells.
Having a daily preventive pill would be an even better solution, because pills can be synthesized in factories far faster than vaccines or antibodies can be grown and purified.
But even if one were invented, production would have to ramp up until it was as ubiquitous as aspirin, so 300 million Americans could take it daily.
Mr. Trump has mentioned hydroxychloroquine and azithromycin so often that his news conferences sound like infomercials. But all the experts agreed with Dr. Fauci that no decision should be made until clinical trials are completed.
Some recalled that in the 1950s inadequate testing of thalidomide caused thousands of children to be born with malformed limbs. More than one hydroxychloroquine study has been halted after patients who got high doses developed abnormal heart rhythms.
“I doubt anyone will tolerate high doses, and there are vision issues if it accumulates,” Dr. Barry said. “But it would be interesting to see if it could work as a PrEP-like drug,” she added, referring to pills used to prevent H.I.V.
Others were harsher, especially about Mr. Trump’s idea of combining a chloroquine with azithromycin.
“It’s total nonsense,” said Dr. Luciana Borio, a former director of medical and biodefense preparedness at the National Security Council. “I told my family, if I get Covid, do not give me this combo.”
Chloroquine might protect patients hospitalized with pneumonia against lethal cytokine storms because it damps down immune reactions, several doctors said.
That does not, however, make it useful for preventing infections, as Mr. Trump has implied it would be, because it has no known antiviral properties.
Several antivirals, including remdesivir, favipiravir and baloxavir, are being tested against the coronavirus; the latter two are flu drugs.
Trials of various combinations in China are set to issue results by next month, but they will be small and possibly inconclusive because doctors there ran out of patients to test. End dates for most trials in the United States are not yet set.
Goodbye, ‘America First.’
Previously unthinkable societal changes have taken place already. Schools and business have closed in every state, and tens of millions have applied for unemployment. Taxes and mortgage payments are delayed, and foreclosures forbidden.
Stimulus checks, intended to offset the crisis, began landing in checking accounts this week, making much of America, temporarily, a welfare state. Food banks are opening across the country, and huge lines have formed.
A public health crisis of this magnitude requires international cooperation on a scale not seen in decades. Yet Mr. Trump is moving to defund the W.H.O., the only organization capable of coordinating such a response.
And he spent most of this year antagonizing China, which now has the world’s most powerful functioning economy and may become the dominant supplier of drugs and vaccines. China has used the pandemic to extend its global influence, and says it has sent medical gear and equipment to nearly 120 countries.
A major recipient is the United States, through Project Airbridge, an air-cargo operation overseen by Mr. Trump’s son-in-law, Jared Kushner.
This is not a world in which “America First” is a viable strategy, several experts noted.
“If President Trump cares about stepping up the public health efforts here, he should look for avenues to collaborate with China and stop the insults,” said Nicholas Mulder, an economic historian at Cornell University. He has called Mr. Kushner’s project “Lend-Lease in reverse,” a reference to American military aid to other countries during World War II.
Dr. Osterholm was even blunter. “If we alienate the Chinese with our rhetoric, I think it will come back to bite us,” he said.
“What if they come up with the first vaccine? They have a choice about who they sell it to. Are we top of the list? Why would we be?”
Once the pandemic has passed, the national recovery may be swift. The economy rebounded after both world wars, Dr. Mulder noted.
The psychological fallout will be harder to gauge. The isolation and poverty caused by a long shutdown may drive up rates of domestic abuse, depression and suicide.
Even political perspectives may shift. Initially, the virus heavily hit Democratic cities like Seattle, New York and Detroit. But as it spreads through the country, it will spare no one.
Even voters in Republican-leaning states who do not blame Mr. Trump for America’s lack of preparedness or for limiting access to health insurance may change their minds if they see friends and relatives die.
In one of the most provocative analyses in his follow-up article, “Coronavirus: Out of Many, One,” Mr. Pueyo analyzed Medicare and census data on age and obesity in states that recently resisted shutdowns and counties that voted Republican in 2016.
He calculated that those voters could be 30 percent more likely to die of the virus.
In the periods after both wars, Dr. Mulder noted, society and incomes became more equal. Funds created for veterans’ and widows’ pensions led to social safety nets, measures like the G.I. Bill and V.A. home loans were adopted, unions grew stronger, and tax benefits for the wealthy withered.
If a vaccine saves lives, many Americans may become less suspicious of conventional medicine and more accepting of science in general — including climate change, experts said.
The blue skies that have shone above American cities during this lockdown era could even become permanent.
You actually expect people to read all that?
1 Like
Sorry, could you type that again, I sort of trailed off out of disinterest before the end of your post.
“We have the best Q-tips”.
He’s just firing out random words and figures for the craic here
He’s playing more videos of people saying nice things.
He’s having the time of his life
It would be very appropriate if Trump would put his signature on the death certificates of the 40,000 plus people who have died of COVID-19 in the US.
OANN gets first question standing at the back again. He’s such a shameless cunt but he covered Fox by quoting Brett Baier reporting on a dem convention so he’s good.
Keep your voice down he shouts at a reporter.
‘Top of the FBI is scum’
Is that the same OANN bird in a different dress?
Murica is fucked.
The place is fucked. Their brains are so scrambled by the media they don’t know what way is up.
1 Like