Martin McKee: The questions we need to answer before easing lockdown

British ministers and their advisers were in an unenviable position when it became clear that covid-19 had reached the UK. This was a new virus, with characteristics that were still largely unknown, that was spreading rapidly. They could see how better equipped health services in other countries were being overwhelmed, and even if unwilling to admit it, we can assume that they were reflecting on the ability of a public health system weakened by a botched reorganisation in 2012 and a decade of austerity to cope. Decisions had to be made quickly, even if, as now seems clear, not quickly enough. Were the measures adopted sufficient? The restrictions were much less stringent than in countries such as Spain or Italy. Why did guidance say that infections in care homes were unlikely, given everything we know about what are termed “institutional amplifiers” of infection—places where people are confined in often crowded conditions—despite the evidence on television screens of spread in another type of amplifier, cruise liners? These are all questions for the inevitable inquiry.

Now, as they contemplate exiting the lockdown, even if only partially, they have the benefit of time. They also have a lot more information. But nothing like enough. There are three areas where we need clear statements of what is known and, as importantly, what is not known and what the government is doing to fill any remaining gaps in our knowledge.

The first is a list of remaining questions about the epidemiology of this disease and how they will be answered. Ministers are fond of telling us that we cannot make comparisons with other countries. Of course we need to take account of context and make appropriate adjustments where this is possible. But there are many other areas where we have no such qualms, despite major problems. Take basic economic indicators, such as GDP, widely used as a measure of progress. Over 50 years ago Robert Kennedy set out why it “measures everything … except that which makes life worthwhile”. There will always be problems with attributing deaths to a particular cause, especially in older people. But the initial decision to count only those who died in hospital after being tested positive was never justifiable. Monitoring age and seasonally adjusted excess deaths from all causes may not be perfect, but it is better than what the government reports each day. Of course some of those excess deaths will not be due to covid-19, but the response should be to try to find out what is causing them, not simply to put the question in the “too difficult” tray. We also need much more clarity on testing. Testing must be to answer questions. Ministerial reluctance to break down the 100,000 target into categories answering different questions, such as what the prevalence is in the population, how many contacts are being infected by a case, and so on, raises questions about whether they know.

The second is the nature of what we now realise is a complex multi-system disease and not the classic viral pneumonia that we first suspected. There is a wealth of research emerging almost every day, providing insights on the effects of the virus on the blood vessels, kidneys, nervous system, and other parts of the body. This is offering new insights into possible opportunities for prevention and treatment, from reducing the risk of infection to stabilising the lining of the blood vessels and managing the often fatal inflammatory storm. The UK’s Recovery trial, ensuring that candidate treatments are evaluated rigorously, is an exemplar of what can be done, but it is difficult to avoid the conclusion that too many of the discussions are taking place in clinical silos. The sheer volume of evidence can seem overwhelming, and of course until it is peer reviewed it must be treated with caution. The last thing we need is a repeat of US President Donald Trump’s endorsement of hydroxychloroquine. What we do need is a clear mechanism to ensure that a wide range of front line clinical and basic science expertise is brought together, something that is not obvious at present.

Finally, what system will be put in place to get us out of the lockdown? Commentators accept that much more will be needed than organisations to manage testing or contact tracing. But what? So far, the government’s approach has been to rely on centralised initiatives, handing testing to an accountancy firm and now, it is rumoured, contact tracing to an outsourcing company. This is the approach that has been tried and has failed over many decades in poorer countries. Accounts of the failures of the testing programme should have been no surprise. But this is not all that we can learn from poorer countries, especially those that have confronted Ebola. Despite their lack of resources, some, such as Rwanda, seem to be responding effectively to the pandemic as they have well trained local infection control teams in place, embedded in and with the trust of the communities they serve. Trust is too often undervalued. It is not encouraged by giving contracts to companies mired in controversy. The least the government can do is to provide a diagram setting out all the functions needed to implement a test, trace, and isolate strategy and then overlay it with every organisation necessary to make it happen, with clear lines of communication and accountability. If this does not include a strong role for local government and, especially, its public and environmental health departments, it will fail. 

Martin McKee is Professor of European Public Health at the London School of Hygiene & Tropical Medicine and a member of the Independent SAGE convened by Sir David King. He writes in a personal capacity.