This is how America and Britain are maximising coronavirus deaths

Only radical action and social distancing can avert a bloodbath

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If you search on the web for the term ‘coronavirus bloodbath’ (which I did after I noticed the term occurring repeatedly in the press), you’ll notice that the headlines are not about the mass deaths of vulnerable people that are inevitable on the sort of bungling business-as-usual trajectory adopted by the likes of President Donald Trump and Prime Minister Boris Johnson.

The headlines are about stocks. Shares. Wall Street. The economy. Oil. Growth. Business. Banks. Finance.

Screenshot from Google web search on 11th March 2020

Sections of the media, incumbent political elites, Wall Street and City of London investors are obsessed with the ‘bloodbath’ that is taking down the economy.

But this is not fundamentally an economic crisis. It’s a public health crisis. While global economic growth in its current form is structurally beyond salvage — the lives of human beings at risk from the spread of the novel coronavirus are not.

This piece sets out in stark terms what is at stake. I’ve used the available data and trends to extrapolate a series of ‘business-as-usual’ projections which convey the scale of what could happen without urgent ‘delay’ and ‘mitigation’ efforts being implemented right now. These are not forecasts, but thought-experiments — derived however from reasonably plausible worst-case assumptions — to scope the scale of the risk.

A worst-case scenario could see up to 1.5 million deaths in the UK, and up to 7.6 million deaths in the United States, based on assuming the highest estimated fatality rate. These scenarios are entirely avoidable. I do not believe they will happen at this full-scale: as crisis deepens, it will likely trigger more draconian measures which will have a dampening effect. But the longer that stronger social distancing measures are postponed, the greater the trend toward worst-case outcomes and higher likelihood of more intense (but belated) draconian actions. In this way, my concern is that current US and UK government strategies make higher fatality rates more likely by failing to slow the infection spread and thus rapidly overwhelming healthcare facilities early on.

If you’re reading this, specifically if you’re in a position of power as a national government official, a parliamentarian, a local authority manager, business leader, nonprofit pioneer, entrepreneur, media professional, community leader, headteacher, company manager, or whatever, it’s long past time to get on board for the sake of humanity and life itself.

Simple maths and scientific evidence prove unequivocally that without significant early efforts to slow and delay the spread of the virus through radical social distancing, mass deaths become more and more likely the longer such measures are postponed. Further, the only way to minimise the societal dislocation caused by radical social distancing is for the system to shift away from elevating narrow self-interest toward maximum mutual, networked support, particularly for the most vulnerable.

In coming weeks and months, the coronavirus will continue to spread exponentially, will overwhelm national healthcare facilities, and will lead to mass deaths. But it is not yet too late to mitigate these impacts.

Behind the curve

The American and British governments are responsible for flawed decisions which have endangered our populations.

Both have pursued courses of action that have accelerated the spread of infection, making the deaths of many vulnerable elderly and ill people inevitable.

In the United States, President Donald Trump is about to preside over one of the most colossal public health disasters ever.

Not only did the US government’s inexplicably incompetent response end up facilitating the spread of the virus in the homeland, Trump has gone to pains to downplay the risk of the virus — more concerned about maintaining the stock markets. His decision to ban all flights from Europe to the US comes late in the day and will fail to contain the exponential spread of the virus within the US, already well underway.

Whether due to lack of funding or political will in the White House, the Centers for Disease Control failed to manufacture sufficient test kits. As a result, tests are not only unavailable around the country for the growing number of ordinary citizens falling ill, due to the scarcity of test kits healthcare workers who have fallen ill are being denied testing too.

The result is that large numbers of people getting infected with the coronavirus across the United States are not being detected — and the number of official coronavirus confirmations in the US is therefore artificially low.

Across the pond, the British government is failing in a different manner.

During a television interview on 5th March with Philip Schofield and Holly Willoughby on This Morning, Prime Minister Boris Johnson made reference to one ‘theory’ which his government was attempting to balance against other priorities. He explained the theory as follows:

“One of the theories is, that perhaps you could take it on the chin, take it all in one go and allow the disease, as it were, to move through the population, without taking as many draconian measures. I think we need to strike a balance, I think it is very important.”

He went on to say that he did not prefer this theory:

“But I think it would be better if we take all the measures that we can now to stop the peak of the disease being as difficult for the NHS as it might be. I think there are things that we may be able to do.”

But the government’s position has been at odds with itself for months.

Johnson indicated that the government recognises the need to reduce and delay the peak of the epidemic in order to reduce the burden on the National Health Service — and thereby reduce the fatality rate. This is the standard approach recommended by medical experts, grounded in the scientific data. They call it ‘flattening the curve’.

Yet what Johnson also inadvertantly revealed is that someone in his government was bandying about another ‘theory’: the extraordinary notion that the government should do nothing and allow the virus to infect nearly everyone sooner rather than later.

Although the Prime Minister indicated that this was not what he believed to be the “better” option, this isn’t a real scientific theory at all. It has no foundation in medical science, and is unsupported by the data. But someone in his government has debated this theory.

While Johnson said that he wanted to pursue measures that would reduce the burden on the NHS, the government had still refused for a whole month to move out of the containment phase (tracking infected people and who they could have potentially infected and moving them into self-isolation or quarantine) into the ‘delay’ phase which would implement more stringent social distancing measures necessary to do so.

Yet the failure of this approach is unmistakable. On 11th March, UK Health Minister Nadine Dorries tested positive for coronavirus. The government had no idea how she became infected. She had met and potentially put at risk hundreds of people, including Cabinet officials and other members of Parliament. The implication is undeniable: the spread of this novel coronavirus is out of control to the point that a senior government minister is infected and the authorities are incapable of identifying how this happened.

Nadine Dorries is stark proof that the coronavirus is well on the way to becoming endemic. This is the direct result of the government’s irresponsible decision to postpone meaningful delay actions through social distancing for several weeks.

The question, then, is who inside Boris Johnson’s government promulgated the ‘theory’ of allowing the virus to ripple through the population?

According to ITV’s Robert Peston, this is the active strategy of the British government, which prefers not to slow down the spread of the virus too efficiently, but only at a ‘much delayed’ speed. Specifically, Peston reports that the strategy is the brainchild of Boris Johnson, Dominic Cummings and Matt Hancock:

“The strategy of the British government in minimising the impact of Covid-19 is to allow the virus to pass through the entire population so that we acquire herd immunity, but at a much delayed speed so that those who suffer the most acute symptoms are able to receive the medical support they need, and such that the health service is not overwhelmed and crushed by the sheer number of cases it has to treat at any one time.”

Peston says that the government is reluctant to implement large-scale, systematic, top-down social distancing measures, but to focus instead on guidance for individual behavioural changes.

This approach is premised on the idea that since the spread of the virus is unstoppable around the world, it poses an indefinite ever-present threat to the UK, and that as soon as any restrictions are lifted the virus will simply resurface. Peston’s account suggests that the government has made up its mind — since coronavirus is here to stay, rather than slowing it down too much, we should slow it down a bit, but otherwise allow it to pass through the population to do what needs to be done.

As Ed Yong has reported for The Atlantic, it turns out that ‘herd immunity’ was not necessarily the ‘goal’ of the UK government as such — but that the government’s advisors believed that as the outbreak would in the longer term be uncontrollable, achieving ‘herd immunity’ could be a potential side-effect of large numbers of Britons being infected. This could explain why the UK government did not choose to act earlier — and it now turns out that the scientific modelling used to justify not pursuing early social distancing measures was wrong and will “likely result in hundreds of thousands of deaths.”

Either way, then, the UK government approach simply did not follow automatically from the science. It was based on a particular political interpretation of the science. For instance, Peston claims that the reason for not closing schools is that it would reduce manpower at hospitals and care homes, making them vulnerable to failure. But as we see below, this overlooks the definitive science proving that drastic measures like school closures can prevent the healthcare system from being overwhelmed by dramatically slowing the spread of the virus in the first place.’

Perhaps the biggest hole in the ‘herd immunity’ aspiration is that in order for it to work, a vast majority of the population would need to acquire the virus and become immune to it — but there is no decisive scientific evidence yet that acquiring the virus leads to immunity. Although some scientists see eventual herd immunity as likely, no one knows how long immunity will last, whether it would be permanent, or last only for a few months. Cases of the reinfection of recovered patients have been confirmed in Japan and China. Zhan Qingyuan, director of pneumonia prevention and treatment at the China-Japan Friendship Hospital, warned in a briefing on 31st January: “For those patients who have been cured, there is a likelihood of a relapse. The antibody will be generated; however, in certain individuals, the antibody cannot last that long.”

Take Sir Patrick Vallance’s belief that some after 60 percent of Britons would be infected with coronavirus, this could create ‘herd immunity’, and compare them with this sobering observation from Prof Samuel McConkey, deputy dean at the Royal College of Surgeons in Ireland. He told the Irish Times that he “already expected that [Covid-19] would reinfect people because that is what happens with the previous coronaviruses”.

“The worry is that Covid-19 could spread around the world in a devastating way in March, April and May, and then three months later it could spread around the world again because we are not protected by immunity after the first infection. That’s the worry, that if there’s no acquired immunity it will circulate around for years or until we find a technology to control it.”

This means that based on the current scientific evidence, it is entirely possible that people people do not develop permanent natural immunity. In this case, the only prospect for herd immunity would be for a vaccine to be developed and for the majority of the population to become inoculated which won’t happen for another year to 18 months:

The reality is that without more comprehensive social distancing policies in place as early as possible, the fatality rate will be dramatically higher. By refusing to shift to such measures, the government guarantees higher death rates.

This has now been corroborated by the publication of a report by Imperial College COVID-19 Response Team — which is advising the UK government — which concludes that the previous UK ‘mitigation’ strategy which has avoided wider social distancing policies would “likely result in hundreds of thousands of deaths and health systems (most notably intensive care units) being overwhelmed many times over”. Amazingly, despite warnings from countless experts and scientists, this conclusion was “only reached in the last few days”, says the report.

A projected worst-case scenario for Britain

All the data indicates very clearly that during the period in which governments refused to move to the ‘delay’ phase, the coronavirus has been circulating rapidly across communities in the US, UK and Europe, and is on track for exponential growth.

The British government’s planning for a worst-case scenario appears to severely underestimate the potential risk.

As I show below, the application of this ‘theory’ would lead to something like 70 percent of the British population becoming rapidly infected, potentially leading to the deaths of between 400,000 and 1.5 million people — most of them elderly and ill.

This and the other projections discussed below are not forecasts, but worst-case projections based on do-nothing scenarios derived from very specific assumptions to illustrate the severe risks of inaction. Running through the thought-experiments of these scenarios throws light on what could happen and how difficult it will be to avoid.

The government’s announcement of mild new social distancing measures may mildy mitigate such worst-case scenarios but they come too little, too late. By postponing these and more extensive measures, the government has guaranteed that they will be less effective, and has increased the early burden on the NHS — which will lead to a greater number of deaths that could have been avoided.

We can begin by collating data on the number of confirmed cases in the UK. Below is a graph based on the number of daily confirmed cases of coronavirus in the UK up to 11th March:

Data source: John Hopkins University Coronavirus Resource Center

The vertical axis indicates the number of cases. The blue line indicates the number of new confirmed each day, while the red line plots the cumulative total number of confirmed cases overall.

As you can see, as Britain has been rolling out test-kits around the country, we have only begun to catch-up with the number of cases that exist. The number of new confirmed cases coming in each day (blue) is on a fluctuating upward trend. But the red line is the one that’s key — it shows that the number of confirmed coronavirus cases is growing exponentially.

On average, it has been doubling every 2–3 days. UPDATE: As of 13th March, this projected exponential trajectory has been corroborated by the fact that the new confirmed cases have more than doubled over that 2–3 day period.

The underlying reason cases are growing exponentially is simple — it’s due to the basic reproduction number (RO), which indicates how many people a single infected person infects. The available data is still evolving, but so far it shows that the RO is at least 2 and potentially higher depending on the context (different conditions appear to decrease or increase the risk of infection).

In order to explore what we can expect if the current rate of growth in daily confirmed coronavirus cases in the UK continues in this way, I applied the same rate of growth to these numbers and projected it forward. It produces this:

This corroborates what we have already heard from government officials, that the cases will “start to peak” in April. This scenario assumes that no or minimal delay or mitigation efforts are put in place. It shows that under that scenario, the infection rate accelerates around mid-to-late April and continues through to the end of that month at which point, given that rate of growth, a total of 42,074,112 Britons would be infected: some 64 percent of the entire UK population.

The government’s belated new measures will mitigate slightly against a worst-case outcome. But to a significant extent, some of this exponential growth in spread is now locked in due to the failure to move earlier to stronger social distancing measures.

This particular scenario is already devastating, but it might also be a conservative scenario — because the true number of infected people is many multiples higher than the number of confirmed cases.

One way of extrapolating how many multiples — again conservatively — is the case of Washington state, where epidemiologists estimated that the number of infected people was at least ten times higher than the number of confirmed cases at that time, at the end of February. Elsewhere, this ratio is twice if not three times as high. But using that very conservative baseline, we can generate some plausible conservative estimates of the minimum number of infected people in the UK.

Now if we take those estimates and project them forward using the RO of 2 (so each of those infected people would infect two more — once again keeping it conservative), the projected scenario is much faster.

Epidemiological studies based on confirmed cases indicate a doubling rate every six days. But this is an artifact of the extent to which a virus’s spread is tracked by authorities. As Tomas Peuyo has shown, the true number of cases growing is actually much faster than confirmed cases.

Therefore, for this thought-experiment projection I’ve assumed that over a period of 6 days — based on the RO of 2 and an estimated average 5-day incubation period — each of those individuals would be able to infect two more, with each of those infecting two more. This of course also assumes no, minimal, or ineffective social distancing measures.

The grey line indicates the estimated minimum number of people probably infected, as compared to the red line indicating confirmed cases. The gap between the two widens, as the actual number of infections spreads, with confirmed cases tracking well below the real epidemic.

The graph indicates that the number of people who may actually get infected in a no-mitigation scenario could reach 45,875,200 people as early as 18th April, 69 percent of the entire population.

How many deaths might we then see in this scenario? There is a best and worst case, based solely on the estimated fatality rate, which could be as low as about 1 percent (still 10 times worse than the common flu); and potentially as high as 3.4 per cent, the figure touted by the World Health Organisation looking at global cases. In reality, this rate would be variable according to the local and national context, healthcare systems, social stratification and many other factors (see UPDATE note two paragraphs below for further discussion of the fatality rate).

Under this absolute worst-case scenario we’d see a minimum of 458,752 deaths, and a maximum of 1,559,757 deaths. This is because, without comprehensive social distancing measures to slow the spread, the rising number of cases would rapidly overwhelm healthcare facilities as is happening in Italy.

Epidemiologists and virologists largely agree that this scale of death is a plausible worst-case scenario. Dr Jeremy Rossman, Honorary Senior Lecturer in Virology at the University of Kent, has argued that the UK government’s ‘herd immunity’ strategy “could result in the deaths of more than a million people with a further eight million severe infections requiring critical care.”