Coronavirus: in for the long haul

14/05/2020

In mid-February of this year, the Los Angeles Times published a piece about the original 2003 SARS outbreak. "SARS killed hundreds and then disappeared", it wrote, asking: "Could this coronavirus die out?"

Ominously, towards the end of the piece, it cited Brittany Kmush, a public health researcher at Syracuse University's Falk College. "Viruses spread most", she said, "when they are very contagious and not that deadly". "If a virus is very lethal, patients often die before they can transmit the illness to many other people".

That is precisely the point I made at the back end of March, when I described the Covid-19 virus as "the killer with a benign face" - hardly surprising as it was nothing more than basic epidemiology.

But the point had been reinforced by Kmush, who added that Covid-19's mortality rate compared with SARS may actually hinder prevention efforts. "If [the original] SARS had similar characteristics to this coronavirus, it would still be circulating", she observed.

Now, we're getting official confirmation that we're in for the long haul. Soumya Swaminathan, the WHO's chief scientist, yesterday told an online conference that it could be "four or five years" before Covid-19 is under control, with many difficulties lying ahead.

Not least of this comes with the findings of large-scale antibody screening in Spain for SARS-Cov-2, with samples taken from over 60,000 participants. Yet, despite the terrible toll Covid-19 has taken, only five percent of those sampled demonstrated a positive response. Even in Madrid and surrounds, where the illness was more intense, only a 10-14 percent response was noted.

In a country with the second-largest number of cases after the United States, this indicates that we might be a very long way from securing anything approaching herd immunity.

Nevertheless, Swaminathan's comments came on the back of earlier comments by Mike Ryan, the organisation's emergencies expert, who has been warning for some time that the SARS-Cov-2 virus may become just another endemic organism in our communities, and may never go away.

Back in February, shortly after the LA Times had made its observations, Ryan fielded the question of what to do if the organism became endemic. With that status, he noted that some countries took the view that there was no point trying to put the effort into containing or contact tracing. "We should just accept and try and save lives and develop a vaccine and use the vaccine", or so the theory went.

At the time, of course, the disease was breaking out as a pandemic and Ryan was unequivocal about the need for a robust response. As regards the question of containment or mitigation, he said, containment worked. Success, he averred, was "about being ready, it is about a robust and aggressive response very, very quickly".

Needless to say, the UK knew better, having already adopted a mitigation policy. As deputy chief medical officer Jenny Harries famously said, the World Health Organisation "is addressing all countries across the world with entirely different health infrastructures and particularly public health infrastructures". We, she boasted, "have an extremely well-developed public health system in this country and in fact our public health teams actually train others abroad".

After hubris, of course, comes nemesis, in the form of what Keir Starmer claimed yesterday was "the highest death total in Europe and the second highest in the world".

Quite how far off the wall Harries really was has yet to be established – and may never be if we have a public inquiry which is about as useless as all the others in living memory have been. But, as I continue to trawl round the subject, I came across this article in the Guardian dated 2 January 2014.

Its headline was "UK 'unprepared for flu epidemic'", but this was no forerunner to Exercise Cygnus, which detected holes in our readiness. This was a review of a report by the think-tank, Centre for Health and the Public Interest (CHPI).

Asking the question, "Is the new NHS ready for Pandemic Flu?", this spoke to much more fundamental defects in the system, where disruption caused by the most recent NHS reorganisation had severely impacted on the UK's public health system.

In a [flu] pandemic, the think-tank said, when there will need to be clear lines of communication and responsibility, with the centre having capacity to direct personnel and healthcare resources towards areas of greatest need, "there is instead fragmentation and a lack of clarity within the newly-created organisational structures about who does what and how the system is co-ordinated".

The potential problems, it added, "stretch from the top, with an ill-defined role expected of the Chief Medical Officer, through confusing multiple and parallel structures embracing the NHS, Public Health England and local government, right down to the front line with its increasing number of private providers".

From all accounts, very little has changed in the last eight years, as indicated most recently by a tweet from Lancet editor Richard Horton.

He had been "in conversation" with someone whom he described as having "a ringside seat for many years" in the public health system, and had noted that "the dysfunctional relationship of bitter rivalry between Public Health England, NHS England, academia, and the private sector was a major cause of England's failed response to this pandemic".

Thus, while yesterday we had Starmer quizzing the prime minister about the recent treatment of care homes, the bigger and – in the scheme of things - more pressing issue goes by default.

As I wrote yesterday, echoing the comments of WHO officials, without a vaccine to give us long-term protection, the suppression process is not a one-off task. Case numbers, I averred, can be brought down to "acceptable" levels (that being a movable feast), so that the disease is brought down from its current epidemic level to become endemic – a background, fairly static level.

Then, as I noted from the Independent Sage Group's comments, we needed a system "which has long term sustainability" … "incorporating locality-based integration (integrated Care Systems) including local government and social care, and crucially with community participation".

For the government, I added, this presents it with a considerable political dilemma. It must recognise that the progressive centralisation of public health services over the last decades has not worked and that the system, as presently structured, is not fit for purpose. It must thus reverse the tide of centralisation and restore local structures, powers and responsibilities.

No sooner said, though, when we learn that the Cabinet Office has announced that five ministerial-led task forces will be established to determine how to re-open pubs, beauty salons, places of worship and leisure centres, as well as re-boot the aviation sector.