By Marcello Ienca and David Shaw.
Italy and the UK arguably represent the two extremes of initial policy responses to the ongoing Coronavirus disease (COVID-19) outbreak. In the following we provide an overview of these response strategies and discuss what the rest of the world can learn from these two countries.
Chaotically draconian: The Italian coronavirus response
The containment measures enforced by the Italian government are probably the strictest response to the COVID-19 pandemic seen outside Asia so far. The Italian approach involved a rapid escalation of politically-enacted countermeasures aimed at delaying human-to-human transmission of SARS-CoV-2. These countermeasures involved syndromic surveillance, aggressive testing, isolation of positive cases and top-down enforcement of so-called “red zones”: geographic areas in which mandatory community-quarantine was enforced on the entire population.
On February 21, the first non-imported cases of coronavirus emerged in Lombardy. After having initially downplayed the contagion, the government decided to promptly lock down some of the affected municipalities and declare red zones. Amidst an increasing number of cases outside the red zones, on March 4, the government gave on social media the go-ahead for the closure of schools and universities throughout Italy. Four days later, a decree was issued to declare all of Lombardy and 14 other provinces an extended red zone. As an unofficial draft of the decree leaked to some newspapers on the evening before its enforcement, several people fled the affected regions raising concerns about propagating the contagion to the rest of the country.
Finally, only two days after the previous decree, the red zone was extended to the whole country, hence imposing a total lock-down and massive temporary restrictions of personal freedoms. Eventually, all non-essential factories were shut down.
These drastic measures appear ethically justified in light of the public health emergency faced by the country: over 70,000 cases (as of March 26) and a death toll significantly greater than any other country including China, where the virus originated. As intensive care units across the country (and especially in Lombardy) are dramatically close to the saturation point, reducing peak incidence and deaths is an ethical imperative. The positive effect of these containment measures is starting to be noticeable at the country-level, while the curve has already flattened significantly in some local municipalities where the outbreak began.
The outbreak hit Italy harder than other country partly due to unavoidable factors such as time and an older-than-average population, which may partly explain the exceptionally high case-fatality rate. However, preventable errors such as information leakage and issuing several different orders within a short time (rather than outlining one clear and consistent strategy) also played a negative role. In total, the government gradually issued seven containment-related decrees, three of them within only four days. As the most recent decrees typically replaced the previous ones, the population was repeatedly asked to comply with rapidly changing orders. This might have weakened the enforcement of these orders and reduced compliance. In particular, the choice of initially restricting the lockdown only to specific regions might have spurred panic-driven exodus to other regions.
Prima facie, the Italian approach can be reasonably defined as “proactive” since all containment measures described above were enacted before any other Western country and even, with the exception of the factory shut-down, before the WHO declared COVID-19 a pandemic (March 11). However, when it comes to pandemics, responsiveness is an absolute, not a comparative value. At a closer look, these measures were rather reacting to the exponential increase in the number of cases, which, in turn, could have been predicted and anticipated more effectively based on data coming from China, South Korea, Taiwan and Singapore. If any of the aforementioned measures were taken one or two weeks ahead, hundreds —possibly thousands—of lives could have been saved. This insufficient proactivity was just the preview of a trend subsequently seen across all European countries, most of which are clearly following the same dramatic path.
Sound and fury, signifying nothing: The UK coronavirus response
Despite months of building evidence, the UK government has bungled the response to the novel coronavirus outbreak. Initially, the aim of the response was to “contain” the virus and prevent it spreading through the population. However, on the 5th of March the Chief Medical Officer for England said that the response had mainly shifted to the “delay” phase, where spread is viewed as inevitable and the aim shifts to reducing the load on the National Health Service at any one time. This may have been premature, as the UK government claimed, on March 12th, that containment was still the main focus of the response. The next day, the Chief Scientific Adviser Patrick Vallance mentioned that part of the delay response would be to achieve “herd immunity in the UK”. Commentators were quick to point out that this strategy would require sacrificing hundreds of thousands of lives, resulting in rapid denials that this had ever been the strategy and a move to more restrictive self-isolation advice on March 16 and the announcement of school closures on the 18th, but the damage was done.
The fact that the announcement about herd immunity was made on Friday the 13th is chillingly appropriate. Subsequent statements have suggested that the “science has changed”, but this seems implausible given that anyone with basic knowledge of arithmetic could have worked out the potential mortality (and morality) associated with pursuing a herd immunity strategy. And if herd immunity was ever part of government policy – even if only for a few days – then this is deeply unethical, for several reasons.
First, aiming for herd immunity involves a conscious policy decision to let perhaps half a million people die – mainly people over aged 70 who are much more likely to require intensive care beds and to die of the virus (the same group discriminated against in Italian guidelines on rationing intensive care provision). Second, there is very little evidence to support the hypothesis that herd immunity would work in this case – we are dealing with a very new virus and most evidence on herd immunity comes from the context of vaccination. Third, even if there were a chance that herd immunity would work as a strategy, the timing of it would have to perfect for it to work, which seems extremely unlikely given the lack of evidence. Finally, if this were a clustered clinical trial, no ethics committee on the planet would approve a design with such weak evidence and such high risks – yet the UK government is sadly not subject to ethics review.
The herd immunity approach may also have led to the UK’s otherwise inexplicable decision not to test widely for coronavirus, despite testing being a much more viable strategy. Fortunately that approach has now been abandoned, but it has been shown that delaying the introduction of measures designed to limit the spread of the virus by even one day can lead to a 40% increase in cases. It is thus likely that the prevarication for at least a week of the government and Prime Minister – who also felt it appropriate to call ventilator procurement “Project Last Gasp” – has led to thousands of people being infected unnecessarily, meaning that hundreds of people have died because of their incompetence. The UK’s coronavirus has been full of sound and fury, signifying nothing but careless – or callous – disregard for science and lives.
What can the world learn?
Italy was caught off guard, but rapidly imposed strict measures to attempt to contain the spread of the virus. The UK was not caught off guard, with the advantage of lessons from Italy as well as Asia, but still dithered, delayed and increased the number of avoidable deaths through temporary pursuit of a herd immunity policy, finally following Italy’s stricter model at least two weeks too late. The government bears great moral responsibility for its failure to develop clear policy and implement it swiftly. Italy did the right thing, though probably in the wrong way, while the UK was forewarned but not forearmed due to lack of a clearly thought through policy. If the lesson from Italy is “be vigilant”, the lesson from the UK is “be logical” – but only by being both can governments respond effectively to this crisis.
Authors: Marcello Ienca and David Shaw
MI: Senior Research Fellow,Health Ethics & Policy Lab, Department of Health Sciences & Technology (D-HEST), Swiss Federal Institute of Technology (ETH Zurich)
DS: Senior Research Fellow, Institute for Biomedical Ethics, University of Basel, and Assistant Professor, Care and Public Health Research Institute, Maastricht University
Competing Interests: MI is an Italian citizen and DS is British (and Swiss).
Social media: Twitter: @MarcelloIenca