A parcel arrived in the post last week. It was from Taiwan, from a good friend who had spent a few years studying in Edinburgh. She is very fond of Taiwanese tea, and this is what I expected, but it contained face masks, a kind gesture. I had just finished calculating the national death rates around the world for this article and had noted that while, in Scotland, we have so far recorded a mortality of nearly 80 per 100,000 in the population, in Taiwan it is 0.03 per 100,000. In their population of 23.8 million, they have recorded 491 cases of COVID-19 with only seven deaths; in ours of 5.45 million we have recorded 44,000 cases and 4,330 deaths. I understood how anxious she must feel for us.
Over 10 months have passed since we first heard of the arrival of this new virus in Wuhan and learnt that it threatened to become a bad epidemic or even a pandemic. There was some initial encouragement from the fact that China got control quickly with what appeared drastic measures and their scientists were fast to work out and publish the genetics of the virus. It became clear that it was very easily transmitted and, worryingly, that it could pass from an infected but symptomless person to others, something that meant that control would be exceptionally difficult. The mortality associated with infection was high but not as high as in some other recent viral outbreaks such as SARS and Ebola. Scientists in laboratories worldwide started working on development of vaccines and clinical doctors started taking part in huge multi-centre trials of possible treatments, including novel anti-viral drugs, well-known drugs for other diseases, and passive immunotherapy with antibodies.
Perhaps we were complacent, having avoided previous outbreaks and become used to managing influenza. Certainly, our public health systems had been purposely downgraded in the name of business efficiency and centralised control. But we had good scientists, experienced from helping in earlier outbreaks in Africa and elsewhere, and we had a lot of epidemiologists and virologists, and great experience in vaccine development. Many people continued to holiday abroad and life went on for a while.
Reality struck when it reached northern Italy in February and we saw the horror in Europe of overwhelmed health services, desperate doctors and nurses struggling in intensive care. By early March it was here, and people were dying as we scrambled to get protective equipment and respirators. The NHS came close to collapse but avoided it by clearing patients to the care sector which in turn was ill-equipped and suffered appalling mortality. We were horrified to learn how our governments had neglected to prepare for an epidemic despite plenty of warning by its advisors and had run down local public health capacity, turning its attention away from infectious disease.
Lockdown ensued and afforded us a chance to control the epidemic and by late June the numbers of new infections and deaths had fallen to manageable levels. What was required at that point was highly efficient testing, with contact tracing and isolation to keep control. Huge resources, literally billions of pounds, were reportedly invested in this, outsourced and subcontracted to multiple private organisations, few if any with experience of public health. The whole system was put in charge of a Conservative baroness with a previous career in telecoms, and it failed dismally at the critical time it could have been a game changer. And now the cases and deaths are rising again and further lockdown seems inevitable to protect the NHS from being overwhelmed.
A glance at the facts of the pandemic to date tell the story. Worldwide, cases are still occurring at a rate of around 400,000 daily and 7,000-8,000 are dying each day. Deaths, however, have been stable for some months which suggests better diagnosis of early cases and probably more successful management. Comparisons between countries are staggering. Mortality is probably the best comparator, despite some reservations that I have discussed before (
20 May). A total of 1.11 million have died worldwide so far.
In the Far East, for example China at 0.34 per 100,000 and Japan at 1.31 per 100,000, the mortality is generally rather low. Rates per 100,000 in Europe sit uncomfortably top of the world range, with the UK at 86.6 and Scotland 79.6, accompanied by Belgium (90.1), Spain (71.5), Sweden (57.5) and France (49.5). Germany (11.7), Norway (5.2), Denmark (11.6) and Finland (5.2) have done much better. Russia, appropriately, sits between Europe and the Far East (16.6).
In the Americas, rates are comparable to Europe's so far: USA (66.4), Mexico (67.5) and Brazil (72.8), but they include some successes such as Uruguay (1.5) which has a population comparable to Ireland where 37.5 deaths per 100,000 have been recorded.
The greatest surprise, for those like me who thought that we would be better able to cope with epidemics than poorer countries, is Africa. The second most populous country, Nigeria, has a death rate of 0.57 per 100,000. South Africa stands out (31.86) but consider Kenya (1.6), Ghana (1.04) and Zimbabwe (1.6). They have much younger, therefore less susceptible, populations and no doubt there is under-reporting of deaths (remember we also under-reported ours initially). Nevertheless, the figures are startling until you consider that these countries are used to such deadly infectious disease outbreaks and almost certainly are using efficient human-based systems of tracking and isolating contacts. One might suggest that their people and politicians take outbreaks more seriously than we do. Paradoxically, their lack of money to fritter away on private companies seems to have been to their advantage.
There are clearly lessons to learn from these facts. It seems in colonialist terms that the child has indeed turned out to be father to the man, despite Gerard Manley Hopkins' humorous defence of the contrary view. The words are not wild. When our scientists realised how unprepared we were for the pandemic and looked ahead with their models, they must have been in despair at the obduracy of the government. When they saw the opportunity to catch the virus as numbers of cases declined after lockdown, they must have gasped as the Prime Minister put billions into US companies and consultants that could have been distributed to boost local public health responses, and compounded the error by encouraging people to go to pubs and restaurants rather than encouraging outdoor infrastructure work. This was ideology gone mad.
Where are we now? Heading back fast to where we were before. Is there room for optimism? Some, but that is for next week when we shall see if the current restrictions in Scotland are beginning to work. Whether they are depends critically on our common good sense.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own
