The Lost MarchHow the UK Government's COVID-19 Strategy Fell Apart
Alex Andreou‘s forensic analysis shows how Boris Johnson’s administration underestimated the speed of the Coronavirus pandemic and have been flying blind ever since
“We have taken the right steps at the right time based on the best scientific advice”. This is the standard ministerial response to any insinuation the UK may have been slow to act during the early stages of the Coronavirus outbreak. And since we’re not allowed to see that scientific advice in any detail, the argument is circular.
The trouble is, even on the available evidence, the claim falls apart at the slightest interrogation. At each step of this process, the Government’s timing appears to have been anything but right.
Rewatching those early COVID-19 briefings in late-February to early-March, one is instantly hit by a palpable sense of exceptionalism. The rhetoric was Trumpian. “We have a fantastic NHS, fantastic testing, and fantastic surveillance of the spread of the disease… Our country remains extremely well prepared,” the Prime Minister insisted on 3 March.
There was hubris, too. “I was at a hospital the other night, where I think there were actually a few Coronavirus patients, and I shook hands with everybody, you’ll be pleased to know”, boasted Johnson that day. On 12 March, when asked what steps were taken to shield him from the virus and whether any plans were in place in case he became incapacitated, he chuckled at the suggestion and replied “I’m just washing my hands.” This was two days after a minister had tested positive for COVID-19.
This Government didn’t “follow the science”. It cornered the science. Bullied it into sounding certain, on a subject with no certainty
The press briefing room was tightly packed with several dozen journalists on both occasions. The three lecterns were less than a metre from each other. A situation that persisted, incredibly, until 22 March. This did not look like a group of people who fully understood the gravity of the situation. As Johnson left the 12 March briefing, with chief medical officer Chris Witty, chief scientific advisor Patrick Vallance and health secretary Matt Hancock, they were huddled closely together.
Within a fortnight, three of the four were isolating with COVID-19 symptoms. A few days after that, Boris Johnson was in intensive care.
What Happened to the “Delay Phase”?
What could explain such casual disregard? The answer is simple. They thought they had a lot more time.
There was universal agreement that timing was crucial in a pandemic setting. “The timing is critical and that is true across all of the interventions we have looked at,” Vallance said on 12 March. Talking about their plan of action and how people may lose interest if asked to sustain measures too long, Whitty added: “We do need to do it at the last point it is reasonable.”
It was also made clear that the Government was considering and had modelled most possible interventions. Johnson was explicit: “Whatever is happening in other countries, whatever measures are being urged upon us, be in no doubt we are considering absolutely all of them and, in due time, they may, of course, become necessary.”
The most urgent question, therefore, became what might the UK curve look like and where we were along it. “In terms of the things that could be done … we need to understand where we are in the epidemic,” Vallance explained on 9 March. “We’re expecting the numbers to increase, initially slowly, but really quite fast after a while and we have to catch it before the upswing begins,” Whitty added.
“The most dangerous period is not now, but some weeks away,” Johnson said in the 12 March briefing. Cheltenham Festival was at that point on its second day. The Government had still not implemented any of its suite of measures announced on 3rd March, other than hand-washing.
“You can think of it as roughly two to three months from an outbreak of sustained person-to-person transmission up to the peak and two to three months for the peak to decline again,” Vallance explained on 3 March. Asked about his working assumption nine days later, he gave specifics: “We think that the peak may be something like ten to 14 weeks away. Could be a bit longer.”
This seems a catastrophic miscalculation. Britain was, in fact, three to six weeks away from the peak. It is a matter of record that hospital admissions peaked in the first week of April and daily deaths in the third.
In the Shade of the Sombrero
It is, of course, entirely reasonable to say that it was the measures that altered the timing of the peak. But the Government’s intervention only affected the decline of the numbers. What matters here is the beginning of the peak, the point at which the curve enters that much faster ascent, described by Vallance and Whitty as “the upswing” or “the inflection”.
“If implemented in combination as modelled, this set of measures is understood to most effectively delay and modify the epidemic peak, and reduce mortality,” the SAGE meeting minutes of 5 March state.
The Government’s action plan explicitly aimed to “delay the peak” and “stretch the peak”, according to Johnson. He was echoed by both scientists. Whitty explained how they aimed to “push the peak to late spring, early summer”. Vallance asserted that one of the reasons the delay phase was important was because “it pushes [the peak] out into summer months when the NHS is less busy”. On 9 March, Johnson was still hopeful their actions would “delay the peak of the spread to the summer”. He was echoed by Vallance.
This notion persisted, until at least the 16 March briefing. “Our objective is to delay and flatten the peak” the Prime Minister emphasised in his opening remarks. Talking about London, Vallance explained very clearly that by implementing measures just as you’re “reaching that inflection point” you might be able to aim measures “to completely suppress [the curve] and therefore the peak goes much further out.” He even ventured that they were implementing measures “a little bit earlier than other countries”, given where he thought we were. It is clear, in retrospect, that we were tragically late.
This is the slide that accompanied those early March briefings. It resulted in Johnson’s glib “squashing the sombrero” remark. It clearly reflects their rhetoric, at the time, of pushing the peak into the summer and their estimated timing. They expected to smooth the rise of the peak and push the start of it — with their “proposed action” — into late May.
We may not know the numbers on that slide’s “new cases” y-axis. But we do know the timing and shape of the curve that the Government predicted its “proposed action” would result in. And we know that what we got, looks nothing like it, neither in terms of shape nor timing.
We got a steep sharp rise, not that dissimilar to Italy’s, a higher peak and a much longer plateau (note the upper limit in the Italian chart is 6,000 cases, while in the UK one 8,000). The sharpest increase in cases is almost all within March. The Government’s delay strategy manifestly did not work.
Scientific objections as to the validity or prudence of such a delay strategy, or even whether it could have worked at a basic level, are important, but not the purview of this piece. This is merely an assessment of results against clearly stated aims.
By March 20 the slide disappeared and all talk of pushing the peak into the summer ceased. The delay phase was instead repackaged as “delaying the spread” and pretty soon became “the mitigation phase”.
More evidence from that period hints at the Government’s muddled thinking on how far along the curve of infection the UK was.
“We are maybe four weeks or so behind [Italy] in terms of the scale of the outbreak,” Vallance said in the 12 March briefing. “You’d expect it to follow a similar trajectory, in terms of the numbers – not in terms of the response. That’s why the measures come into place today. To see if we can deflect that and get that into a different trajectory.” In fact, Vallance was being conservative. The SAGE minutes from two days earlier claim “the UK is considered to be 4-5 weeks behind Italy but on a similar curve (6-8 weeks behind if interventions are applied).”
By 16 March, Vallance had begun to sound less sure: “the new numbers suggest maybe more like three weeks.” At the SAGE meeting two days later this had evolved into “the UK is two to four weeks behind Italy in terms of the epidemic curve.”
Former health secretary Jeremy Hunt questioned the timing in parliament on 23 March. “A week ago, the Government said we were four weeks behind Italy. That then changed to three weeks behind Italy, and today our mortality rates are just two weeks behind Italy. Our hospitals, especially in London, are filling up.”
Bizarrely, despite all evidence that the UK curve was speeding up exponentially, this notion — that we were four weeks behind Italy and our results would not be as bad – persisted until as late as the 7 April briefing. Total deaths in Italy that day were 17,000. Questioned about whether he expected to see those “sorts of numbers” in the UK, Vallance replied: “We are probably three or four weeks behind Italy, in terms of the outbreak, that doesn’t mean we end up with the same numbers.”
At that moment, we weren’t “three or four weeks” behind those Italian numbers, in fact, but fewer than two weeks.
Hospital only deaths exceeded 17,000 on April 20. We now know from ONS data, that by the week ending April 17, a total of 19,112 deaths involving COVID-19-19 were registered – and that was in England and Wales alone. By either figure, this is not a rounding error. It is a significant mistake.
Shifting Trigger Points
The second strong indication of how much more rapidly things were progressing, than the Government had initially thought, is in the speed of measure implementation.
On 9 March, Vallance explained in detail that there was a specific sequencing to the steps they could take. Social distancing measures, then stricter isolation, then protecting the elderly and vulnerable, somewhere in there possibly schools, then closing pubs or churches, which brought us closer to a full lockdown. “Even to cover the peak you’re talking about trying to make sure those sorts of measures are in place for 13 to 14 weeks or so,” he expanded three days later. Clearly envisaging a gradual process of restriction, then easing seven or so weeks before and after the peak.
Whitty was also very specific on the 9 March when asked when vulnerable groups would be asked to isolate. “That advice is going to be the next stage. At this point the thing we’re going to be moving on to in the next ten to 14 days is asking people who have got symptoms, however mild, to stay at home for seven days.”
This sequencing is reflected in the table, included with the 10 March SAGE minutes:
In fact, the Government asked people with mild symptoms to isolate, not ten to 14 days later, but three days later. They asked vulnerable groups to isolate, four days after that, on the 16th, at which point they also advised people to avoid pubs, clubs, theatres etc. They closed such establishments on the 20th. Finally, they put the country into lockdown on the 23rd. Several weeks of gradual measures had been compressed into eleven days. This was noticed and was described widely as a change of course.
In his 16 March address there was some acknowledgement by the Prime Minister that all may not be quite right, especially in London. “It’s now clear that the peak of the epidemic is coming faster in some parts of the country than in others,” he said. In response to a journalist observing we seemed to be “shifting through the gears rapidly”, Vallance said: “Importantly, it looks like we’re on the fast upswing or just about to get there and that’s the reason to want to come in quite quickly with these measures.”
The SAGE minutes of 13 March reflect this: “SAGE now believes there are more cases in the UK than SAGE previously expected at this point, and we may therefore be further ahead on the epidemic curve.”
By 20 March, the Government was being openly challenged. “What has changed?” was the very first question in that briefing. “It was becoming clear that in order to drive the curve down”, Johnson said, they had to accelerate the measures “to have an impact”. SAGE minutes from that same day concur: “UK case accumulation to date suggests a higher reproduction number than previously anticipated.”
Johnson later added “it’s perfectly obvious, when you look at the gradient of the disease, that we have a real threat now to our country, to the ability of our NHS to manage it and, unless we get this right, we are going to see thousands of lives lost.”
Two factors compounded these devastating miscalculations.
The first was the Government’s decision to throw a cloak of secrecy over the scientific advice it was receiving: the precise modelling, the assumptions underlying it, even the composition of the team of experts advising it were unknown until recently.
It required a fundamental shift in thinking to accept that the close examination, peer review and criticism that politics is programmed to avoid, are actually necessary preconditions for good science. It was a shift that never happened.
This move served to shield the Government from scrutiny — it was merely “following the science”. And the science could not be criticised, because it was secret.
Many asked for the workings to be made public. As a team of experts wrote in The Lancet on March 17, “different scientists can reach different conclusions based on the same evidence, and small differences in assumptions can lead to large differences in model predictions”. Professor Roberto Trotta warned that “the scientific basis for such decisions ought to be open to public scrutiny, both to check its soundness and for the sake of transparency and accountability.”
Plenty expressed surprise, even without seeing the workings. “We are told that the peak number of infections may be three months away,” Dr Milan Dagli wrote to the Guardian. “This astounds me considering that in China, the centre of the infection, confirmed cases peaked well within this timeframe.”
And when some of the advice was published, many wondered why the Government had focused on such a narrow selection. “The guidance seems to lean heavily on a single model of the outbreak – which some scientists suggest contains systematic errors,” warned The New Scientist.
The second, and perhaps most significant, factor was the calamitous policy decision on March 12 – as the World Health Organisation was advising “test, test, test” – to stop testing in the community and restrict it to people who presented symptoms in a hospital setting. “It is no longer needed for us to identify every case,” said Whitty.
“I think it is incredibly surprising that testing and contact tracing is overlooked,” remarked Edinburgh University’s Devi Sridhar. “Outbreaks begin and end with testing.”
World Health Organisation director-general Tedros Adhanom Ghebreyesus agreed. “You can’t fight a virus if you don’t know where it is. Find, isolate, test and treat every case, to break the chains of transmission. Every case we find and treat limits the expansion of the disease.”
From that moment on the Government was flying blind. It had its erroneous assumptions, about how the curve was behaving and how far away the peak was, and no way to check against those assumptions so it could course-correct. Maybe this was down to testing capacity. But if Hancock could drive capacity from 10,000 to 100,000 within April, he could have done so in February or March, had the decision been made.
The only indicators the Government now had were external – hospital admissions, hospital testing, deaths, numbers in Italy and other countries. But in a disease with such a large percentage of asymptomatic or mildly symptomatic carriers and a median incubation period of 5.1 days, such indicators can’t tell you what is happening in the community at any given point. You are merely looking at the recent past, through a keyhole.
When the lockdown came on March 23, it seemed a rushed reversal of policy and went against the messaging which preceded it. Only days before, Downing Street was briefing that there was “zero prospect” of a lockdown that would limit people’s movement.
One possible explanation, of course, could be that the public did not respond to the earlier measures. But we know the opposite to be true. Both the Government and its scientific advisors have consistently said that public response, our compliance with measures, was actually above what they had expected. A leading figure remarked that “we have seen even larger reductions in normal behaviour, contact, than we would have dared hope”.
Three events stand out to explain this sudden change. On 16 March the Imperial College London’s model predicted significantly higher numbers. Although the model has been heavily criticised since it may in time come to be seen as the vital alarm bell that saved many lives. On 20 March the first hospital in London declared a “critical incident” because it had run out of intensive care beds. On 21 March, Italy broke the 6,000-new-case barrier. This would actually turn out to be its absolute peak of new cases.
We may never know conclusively, but it’s a reasonable assumption that this was a decisive week for Government thinking. It seems around this time that it realised the assumptions it had made — about the UK curve, how it would behave, when it would peak, how far behind Italy it was — had been wholly wrong.
But it was, in many ways, already too late. The scientists had kept emphasising, in the early briefings, how crucial to their “delay stage” it was to catch this thing exactly right “on the inflection”, as they put it. How often they repeated that the spread would go slow for ages and then suddenly very fast and how crucial it was “to catch it before the upswing begins”.
Rewatching all those early briefings sequentially, I was left in little doubt that in the days leading up to the 23rd, when lockdown was introduced, this was a Government in panic. It was behind its own schedule in implementing its own plan. It had missed that elusive point of the inflection before the upswing began.
Was this down to a wrong assumption, bad advice, miscommunication? Was it simply what Johnson’s former director of communications Guto Harri describes as his libertarian tendency “to set the bar quite high to justify the state getting involved in people’s everyday lives” that proved a critical drag on the timing of measures being adopted? We may never know.
So many things hang from this mistiming. Everything from the lack of earlier mobilisation to acquire everything from ventilators to PPE, the delay in expanding testing capacity, the empty Nightingale hospitals, which were still opening weeks after the peak, even as others stood empty or were closing. And of course the awful death toll. Researchers now claim the death toll in the UK could have been similar to Germany’s if it had acted earlier. Everything was geared towards being optimal, at the wrong time.
Nothing has Changed
As a former market investigator, specialising in pharmaceutical and medical markets, my job was to sit across the table from experts, employed to prove conclusively what suited their client and assess the internal consistency of their model and the assumptions that go into them. I know modelling is imprecise and pliable.
I publish the results of my investigation not to attack the scientists, epidemiologists, mathematicians and modellers for making mistakes. The science of prediction, especially when it comes to something so novel, is inexact, full of pitfalls. It is building a house of cards on quicksand.
I publish this retrospective to shed light on the “system errors” former WHO official Anthony Costello speaks of that “led us to have probably the highest death rates in Europe.” To criticise the fact that the scientific process, in this case, has been infected by politics.
Not only was the advisory body infiltrated by political appointees, who were more than mere observers, we now know. But the scientists were publicly co-opted by the politicians, from the start. They were put on podia, either side, given rope. They had to sound sure back then —it was conducive to public confidence. Little room for nuance or scientific doubt. Their function was to calm people, to look like they knew precisely what they were doing.
This Government didn’t “follow the science”. It cornered the science. Bullied it into sounding certain, on a subject with no certainty. We deserve the honesty of scientific doubt.
And now they have no option but to repeat the Prime Minister’s mantra: “We have taken the right steps at the right time.” Plainly, that isn’t true. To insist so is either denial or deception. Neither helps to restore failing public trust.
Meanwhile, the Government approach remains mired in the same problems now that beset it in March. The same cornered scientists are made to say with equal confidence what the R rate is —when the margin of error is huge. The same Government that failed to procure PPE for nurses, is urging teachers to trust it.
The SAGE processes and advice still lack transparency. Contact tracer recruitment and training is, at the very least, problematic. We have seen no results from the tracing app trial on the Isle of Wight. We know it will be delayed until June and rumours are the Government may even be preparing to ditch it.
This is a time when confidence in the Government’s actions could not be more important. As we emerge from lockdown, we need to be able to trust the information we are given, trust what the science says unspun, trust that the necessary safety precautions are in place, trust that assumptions are not left unchecked and decisions unchallenged.
The Government adopting ‘a delay strategy’ was neither orthodox nor uncontroversial and was noticed, even internationally. “One European nation has stood apart”, remarked Fortune. “Prime Minister Boris Johnson moved the country to phase two, in which measures are taken to try to delay the peak of the outbreak. His actions have divided health experts, with several prominent experts criticizing the Government for doing too little, too late.”
Effectively, most other nations fell into one of two camps. Countries like China, Italy, and – to a lesser extent – France, Spain and Belgium that did not have much warning, had to go pretty much straight into mitigation measures. Then there are countries like South Korea, Slovakia, or Greece that implemented draconian containment measures proactively, perhaps even precipitously, to pause the pandemic and give themselves time.
Our Government was alone in having a distinct ‘delay stage’. And so, I think it is not unreasonable to ask whether it succeeded. Britain stood quite solitary in believing that, in a swirl of unknowns, it could be so precise, to intervene so surgically, it could manipulate the ascending curve and push the peak weeks or months to the future. Our Government was alone in believing it could be so clever as to allow just enough transmission, but not too much.
“If we can’t see the workings, it’s hard to assess if something is justified or not,” the former Conservative leader in Scotland, Ruth Davidson complained about the Scottish Government recently to Sky News. “You want to do things differently? Fine. But if that has consequences, then you have to answer for them.”