A personal view and insights gathered from various sources up to 20 April 2020. Purpose is not to be biased or pass judgment but rather to invite reflection -- we live in unique and challenging times. -------------------------- Extract from Page 1 -------------------------- The UK, Italy and France surely have lessons to learn from Germany and South Korea. The aim here is to understand, not judge, criticise or blame This slide show records facts that merit attention in the UK - UK plans - UK response - Conclusions - Numbers - Political and moral dilemmas

1. UK Response to
COVID-19
A point of view (as of 20 April 2020)

2. Contents
UK Plans01
UK Response02
Conclusions03
Numbers04
Political and Moral Dilemmas05

3. UK Plans
“the virus will inevitably spread”
UK Influenza Pandemic Preparedness Strategy

4. UK’s flu
virus risk
management
• Risk identification
• The risk is well-known and quantifiable
• Every year, c17,000 die of flu in England
alone
• https://www.thetimes.co.uk/article/how-
does-the-coronavirus-death-rate-compare-
with-flu-and-how-long-will-the-outbreak-
last-tlpnwxg89
• Risk mitigation
• Every autumn, the UK vaccinate older
people against flu.
• Risk containment
• Little or nothing is done to contain the flu
virus when it happens.

5. UK
pandemic
risk
management
• Risk identification
• A flu-like pandemic has been number 1 in
the UK National Risk Register since 2008.
• Risk mitigation
• The government had stock piles (to be
discussed)
• Like most other countries, they might have
done more to prepare (to be discussed).
• Risk containment
• The government followed closely the “well-
laid plan” set out in the UK Influenza
• Pandemic Preparedness Strategy

6. UK planning for a pandemic was informed by
Use the hyperlinks to find them
• 2003: WHO report on SARS (the first coronavirus)
• 2008: UK national risk register (pandemic is number 1 risk)
• 2011: UK Influenza Pandemic Preparedness Strategy
• 2016: Exercise Cygnus: a simulation to estimate the impact of a flu pandemic.
• 2018: The WHO checklist for pandemic preparation

7. 2003: WHO concensus report on SARS
(I’m not blaming WHO)
• The first coronavirus
• “striking progress had been made in [understanding] the coronavirus1 that is itscause”.
• transmission can be prevented by adherence to basic measures.
• inc. rapid case detection, case isolation, contact tracing and good infection control.
inc hand. washing and the use of personal protective equipment (PPE).”
• This must have encouraged scientists to think “containment” could work.
The report did not mention mass testing or lock down.

8. COVID-19 differs from SARS
• COVID-19 is harder to contain and more symptomless than SARS
• Wikipedia says SARS reproduction number was 2 to 5.
• “Transmission efficiency [of SARS] appears greatest from severely ill patients [in]
the second week of illness.”
• Wikipedia says COVID-19 reproduction number is 1.4 to
3.9. But many are *symptomless* when transmitting the
virus

9. 2008: UK national risk register
• Published “to inform the public more fully of the risks that we face”
• A pandemic is the number 1 risk

10. 2011: UK Influenza Pandemic Preparedness
Strategy
• “the virus will inevitably spread… local measures taken to disrupt or reduce the spread are likely to have very limited or
partial success”.
• ”“Pandemic-specific vaccine is likely … available within four to six months.”
• Restrictions on public gatherings and public transport
• 4.21 There is very limited evidence that restrictions on mass gatherings will have any significant effect on influenza
virus transmission.
• Large public gatherings or crowded events where people may be in close proximity are an important indicator of ‘normality’
and may help maintain public morale during a pandemic.
• The social and economic consequences of advising cancellation or postponement of large gatherings are likely to be
considerable for event organisers, contributors and participants.
• There is also a lack of scientific evidence on the impact of internal travel restrictions on transmission and attempts to impose
such restrictions would have wide-reaching implications for business and welfare.”

11. COVID-19 differs from flu
• “Many of us have been surprised by the speed, and also the aggression of thevirus.”
• WHO’s European spokesman April15th
• “Britain was following closely a well-laid plan to fight a flu pandemic - not thisdeadlier disease.” Reuters
• A copy of the “UK Influenza Pandemic Preparedness Strategy 2011,” which aspokesman
• said was still relevant, stated the
• “working presumption will be that Government will not impose any suchrestrictions.
• The emphasis will instead be on encouraging all those who have symptoms to follow the advice to stay at home and
avoid spreading their illness.”Reuters

12. 2016: Exercise Cygnus
• “The exercise, which simulated a deadly outbreak of so-called “swan flu”, is believed to have
shown that in the event of a deadly pandemic the NHS would be overwhelmed by a shortage of
critical care beds and vital equipment.” Guardian
• After the exercise, the Chief Medical Officer said serious problems were a lack of medical
ventilators and the logistics of disposal of dead bodies.
• It turns out, today, the NHS is not overwhelmed, there are enough beds and ventilators,and
disposal of dead bodies has not been a problem.
• But PPE supplies are not enough for the 16,000 care homes

13. 2018: WHO checklist for pandemic
preparation (I’m not blaming WHO)
• 40 pages of extensive, worthy, but somewhat bland guidelines. E.g. prepare for xxx Each country
interprets the guidelines its own way.
• On lock down: “voluntary or enforced quarantine” is discussed in terms of isolating individuals - taking ethical concerns
and personal freedoms into consideration. I’ve seen no reference to a nationwide lockdown.
• On resources: “Identify needs for trained staff, equipment (including PPE and reagents).” UK had more health
service resources and stock piles than most countries WHO oversee.
• On testing: “Develop surge plans to manage increased demand for testing”.
• This doesn’t seem to imply mass testing in advance on the scale of Germany or South Korea.

14. Hmm…
• Politicians like to follow (and therefore if
necessary blame) experts if they can.
• UK Influenza Pandemic Preparedness
Strategy didn’t anticipate the impact on policy and
human behavior of a virus that is much more life-
threatening than flu.
• Perhaps the government’s scientific advisors were
too wedded to their strategy.
• The strategy seems to have underestimated
• The willingness of Britons to stay home when
faced with a life-threatening virus.
• Mass testing and resources needed for it
• The needs of care homes as well as hospitals
• Having said, that the plan does seem to be
meeting its objective of protecting the abilityof
the NHS to treat people who need it.

15. Must-read articles on the 2020 virus
crisis
• October 2019, The Global Health Security Index from the Johns Hopkins Center for Health Security and the Economist
Intelligence Unit released ranked the USA and UK 1st and 2nd in preparedness for a disease outbreak.
• This expert talks about the USA’s national plan; note the supply chain remarks.
• This Reuters investigation explains why following the UK Influenza Pandemic Preparedness Strategy
was problematic.
• Some use the virus crisis to bash their government, or the whole of westerndemocracy, some with a utopian vision of the
future. Read Mathew Syed’s excellent article.

16. UK Response
“Britain was following closely a well-laid plan.”
Reuters investigation

17. UK –
January
2020 – Low
threat
• Dec 31: WHO was informed of pneumonia cases
(unknown cause) inChina.
• Jan 7: The Chinese identified the new virus.
• Jan 13: WHO reported China report “no evidence of
significant human to human transmission”
• “UK scientists agreed the risk to the UK population was
“very low.”Reuters
• Jan 20: WHO announced the virus outbreak to the world.
• Jan 30: WHO said “There is no need for travel and trade
restrictions”
• First case in the UK. “The [UK] government raised the
threat level to “moderate”. Reuters

18. UK –
February –
Moderate
threat - hope
for
containment
• “minutes and interviews show Britain was following closely
a well-laid plan to fight a flu pandemic.” Reuters
• The plan’s “Containment” phase appeared to be working.
• Feb 13: UK chief medical officer “A UK outbreak is
still an “if, not a when,”Reuters Feb 28: First non-
traceable case in the UK
• WHO repeatedly refused to call the virus outbreak a
pandemic.
• “Britain missed a deadline to participate in a common
purchase scheme for ventilators,to which it was invited.
Johnson’s spokesman blamed an administrative error.” Reuters

19. March 3rd:
Science-
led policy
From the start, the UK government took its
direction from scientists and NHS experts.
• March 3, two days before UK’s first virus death
• “Our country remains extremely well prepared,”
Johnson said as Italy reached 79 deaths.
• “We already have a fantastic NHS,” the
national public health service, “fantastic testing
systems and fantastic surveillance of the
spread of disease.” Reuters
• It turned out the testing and surveillance wasn’t
as good as Boris has been led to believe.

20. UK –
March –
move to
High Risk
and Lock
Down
• March 4: The government published their plan to help the NHS by
"flattening the curve”.
• March 5: First death in the UK.
• March 9: “The government’s Scientific Advisory Group for
Emergencies recommended that the UK reject a China-style lockdown…
Tougher measures could create a “large second epidemic wave once the
measures were lifted.”Reuters
• March 11: WHO declared a pandemic.
https://www.statnews.com/2020/03/11/who-declares-the-coronavirus-
outbreak-a-pandemic/
• In retrospect, WHO should have said, a month earlier: “This may not
yet meet our academic definition of a pandemic, but it looks certain
to become one. Every nation’s government should now be acting on
the basis it will become one very soon”.
• March 12 The chief medical officer announced the threat to UK had
moved to“high.”
• March 16: The government urged voluntary social
distancing, stay at homeetc. March 23: Enforced lock
down.

21. Direction set
by UK
scientists in
February and
March
"for more than two months, the scientists whose advice
guided Downing Street did not clearly signal their
worsening fears to the public or the government.
Until March 12, the risk level, set by the government's top
medical advisers on the recommendation of the
scientists, remained at "moderate", suggesting only the
possibility of a wider outbreak." Reuters
“the scientific committees that advised Johnson didn’t
study, until mid-March, the option of the kind of stringent
lockdown adopted early on in China, and then followed
by much of Europe.
The scientists’ reasoning: Britons, many of them
assumed, simply wouldn’t accept such restrictions.”
Reuters
It seems they underestimated the impact on policy and
human behavior of a virus that is much more life-
threatening than flu

22. The
resources
needed?
(status at
April 15th)
• UK Influenza Pandemic Preparedness Strategy
• “The UK will continue to maintain stockpiles
and distribution arrangements for antiviral
medicines and antibiotics sufficient for a
widespread and severe pandemic.”
• No antiviral medicines fit COVID-19
• “The Government already has in place stockpiles
of facemasks and respirators for health and
social care workers.”
• A projected peak ventilator need was 18,000. The
UK has about 10,000 and more have been ordered.
However, Mercedes F1 engineers have produced
10,000 less invasive CPAP breathing aids. Early
data suggest at least half the patients otherwise put
on a ventilator will not need one.

23. From this Guardian report
“the bulk of pandemic stockpiles consist of PPE,
including masks, gloves and aprons. Stockpiled goods
have shelf lives and so require frequent replenishment.
However, supply chain difficulties seem to have been
underestimated. Not only c1,000 hospitals but c16,000
care homes.

24. I can find no mention of it in UK Influenza Pandemic
Preparedness Strategy
In 2020: “Minutes of technical committees indicate that almost no
attention was paid to preparing a programme of mass testing.”
Reuters
NHS planning was too centralised; it was hoped a few (8?) central
laboratories would up to the job. Belatedly, they are engaging
another (40?) distributed laboratories and private sector ones.
The UK doesn’t have the chemical industry resources of
Germany, and didn’t build up enough stocks of tests ahead of
global demand for them..
Mass testing?

25. It appears the global supply chain logistics
were underestimated up to March.
In the daily briefings, the politician is always
flanked by people such virologists,
epidemiologists, the chief scientist, the chief
medical officer, etc.
Why isn’t the politician flanked by supply
chain logistics experts?
Global supply
chain logistics

26. Political strategy
This virus crisis has challenged what we
normally value in the UK - restrained
government and policing by consensus.
The Swedish strategy (keep things working,
keep old people at home) is interesting.
More totalitarian/authoritarian regimes were
quicker to impose draconian measures. And
some Asian countries were sensitized by
earlier epidemics.

27. About the South
Korean response
UK pandemic plans presumed a flu virus that could not be contained
By contrast, South Korea not only suffered SARS and MERS, they had
contained them.
So, they had already developed people tracking and warning measures
And when COVID-19 emerged, they started out determined to make
containment work. They told 4 laboratories to develop a test, and now
have 100 able to make it.
If a significant minority of the population had rejected surveillance of
them, then SK could not have contained the virus.
https://www.wired.co.uk/article/south-korea-coronavirus

28. About the Taiwanese
response (from the Telegraph)
Like SK, Taiwan was sensitized by SARS and
MERS.
“Taiwan is not a WHO member but its national
pandemic plan could have been written after the
current outbreak rather than seven years before it.
Stockpiles of personal protective equipment, the
capacity for mass testing, and plan for
a nationwide quarantine and devices to keep the
economy running are all there.”

29. Exit strategy?
It seems there no certainty about
this – anywhere in the world
Lock downs will be removed
gradually, tentatively, and perhaps
re-imposed
We won’t know for many months
what the outcome of different
strategies will be.

30. Conclusions
Nobody expected a virus so highly deadly to the old.
Timelines & Personal Thoughts

31. UK – January 2020
(Low Threat)
Dec 31: WHO was informed of pneumonia cases (unknown
cause) in China.
Jan 7: The Chinese identified the new virus.
Jan 13: WHO reported China report “no evidence of
significant human to human transmission”
“UK scientists agreed the risk to the UK population was “very
low.” Reuters
Jan 20: WHO announced the virus outbreak to the world.
Jan 30: WHO said “There is no need for travel and trade
restrictions”
First case in the UK. “The [UK] government raised the threat
level to “moderate”. Reuters

32. Recap: Risk identification and planning?
A pandemic has been the
number 1 risk in the UK’s
National Risk Register
since 2008.
So, the UK’s NHS and
scientists have been
modelling and planning
for a flu-like pandemic for
more than decade.
But it turns out COVID-19
is unlike flu, we are
having to react to the
data as it arrives.
Did the scientists
assume from WHO report
on SARS that a
coronavirus could be
suppressed?
Did the scientists
underestimate the impact
of a virus more
transmissable and deadly
than flu?
Nobody expected a virus
so highly deadly to the
old.

33. Recap:
Risk
mitigation?
There was a stock pile of PPE and ventilators enough for
while, but…
In March, Jenny Harries (Deputy Chief Medical Officer) well-
nigh admitted that they underestimated supply chain
logistics issues.
Not only within the NHS to c1,000 hospitals but also to
c16,000 care homes.
More than 8 billion PPE items delivered so far.
Nobody expected a virus so highly deadly to the old

34. Recap: risk containment?
Some containment actions have been speedy and successful
But it appears planned containment actions did not include
mass testing or lock down.
Presuming the virus cannot be stopped, the plan was to ensure
everybody who needs hospital care will get it.
The strategy has always been to protect the NHS first and
foremost.
As late as March 9th, when the risk was still rated as moderate,
SAGE recommended not locking down.
It seems planners underestimated the need to find and use
resources outside the NHS.
Nobody expected a virus so highly deadly to the old.

35. Conclusions A more
personal
viewUK’s national health service may not be the best in the world,
but it has some of the best virologists and epidemiologists in
the world, and it does do central planning.
For sure, UK gov and scientists could have done better.
But I don’t blame anybody in particular.
Sticking too closely to the long-prepared strategy may be
seen as a system failing.
And centralised “big up front design” tends to inhibit agility
when events happen.
I doubt any UK government would have over-ruled the plan or
scientific advice they have been given since the start of the
outbreak.
Reuters suggest the need for a wider pool of experts, and
wider discussion of their plans.

36. Numbers
Comparing UK with its most comparable neighbours
Observations & Personal Thoughts

37. Different countries
- different demographics
It seems the virus spreads faster and
wider in countries/areas which have
• More highly urbanized populations
(Belgium and UK for example)
• Larger cities with larger mass transport
systems
• London is very much larger than
any other city in comparable EU
countries
• New York (mass transport) has
fared far worse than Los Angeles
(private transport).
• Much travel between cities
• A higher proportion of older people
(Germany the exception to most rules)
https://en.wikipedia.org/wiki/European_countries_by_percentage_of_urban_population
Italy
(North)
Spain France
UK
(London)
Germany
Proportion in urban
areas
70%
(94%)
80% 80%
83%
(100%)
77%
Millions in cities
over 1 million
3 4 2 10 8
Proportion over 65 22% 19% 19% 18% 21%

38. Different countries
- different data capture approaches
Comparing cases is hopeless; comparing deaths is better, but still unreliable
https://towardsdatascience.com/dont-believe-any-numbers-on-coronavirus-
9c5d6a971bef
Some publish only deaths in hospital, others include care home deaths.
Ascribing a cause of death to the virus often difficult.
Some countries record only deaths certainly ascribable to coronavirus,
Some record all deaths of people diagnosed with coronavirus
Some perform post-mortem tests on people not diagnosed with it.

39. Italy and UK
compared
Charts aligned at 50th
death date.
Note they enforced locked down at same point
on the curve (UK urged voluntary measures a
week earlier)
Italy Spain France UK Germany
1st death
Feb
22
Mar 3 Feb 14
Mar
5
Mar 9
50th death Mar 2 Mar 11 Mar 12
Mar
16
Mar 20
Lockdown Mar 9 Mar 10 Mar 17
Mar
23
Mar 22

40. France
include past care home deaths
Germany
much lower death per day rate
How do deaths per day compare?
Charts aligned at 50th death date.
UKSpain
similar - but smaller population
Italy Spain France UK Germany
1st death Feb 22 Mar 3 Feb 14 Mar 5 Mar 9
50th death Mar 2 Mar 11 Mar 12 Mar 16 Mar 20
Lockdown Mar 9 Mar 10 Mar 17 Mar 23 Mar 22

41. Projections?
Despite data capture discrepancies, my charts suggest Italy, Spain and France are
following remarkably similar trajectories.
With UK following a week or two behind.
The charts show all three comparators are slow to get their daily death rate below 500.
Can they do much contain future outbreaks until the rate drops much further?

42. USA?
New York has about half USA virus deaths.
(New York and London are far larger than other cities in Europe).
“America’s national-level response [is] hampered by its federalist system.
The federal government [has] narrow authorities at the U.S. border.
Early, Trump banned the entry of foreign nationals and closed borders with both Mexico and Canada.
But the primary authority for ordering major public-health interventions lies with U.S. states.
Congress has exclusive power to regulate interstate commerce and travel, but the president cannot.
The Department of Health and Human Services [has some] authority to issue quarantines, but not to ban interstate travel.”
https://www.theatlantic.com/ideas/archive/2020/03/why-theres-no-national-lockdown/609127/

43. Last Words...
Political and Moral Dilemmas
Final Thoughts

44. Note on self interest (after Hayek)
Capitalism is based on the idea that allowing sellers (in
competition) and customers to trade in their own self-
interest is more efficient and effective than central planning.
Self-interest includes an individual’s interest in helping their
family, friends and community to thrive.
That principle underpins the evolution of social animals, of
which human society is an especially flexible and volatile
kind.
The challenge arises when you have to make choices
between who (individuals or groups) you help, and when.
Politics is the art of compromise; leaders make decisions by
trading off the pros and cons of different options.

45. Trade offs (cf. the
Trolley problem in
Wikipedia)
Anything of interest may be valued for different qualities, by
different stakeholders and different observers of those
stakeholders. And a value may change in retrospect.
The value of something crystalizes when you have to make
a choice between options.
E.g. the value of a trade solidifies when a seller and
customer agree a price.
And this virus crisis may force people make decisions that
compare:
1) The value of life to those old and young (does Sweden's
strategy favour the old?).
2) The value of saving life now and later
3) The value of individual freedom and civil rights against
public health
4) The value of global trade against national security
5) The value of reducing population against global
warming

46. 2. Saving life now and later
It has been estimated that 80,000 died of flu in the USA in 2017.
Each year, flu must kill tens of thousands in Russia and perhaps over 100,000 in China.
Imagine you are the president of the USA or China.
You know, when the flu seasons arrives, it will kill tens of thousands of people.
You have the power (Trump doesn't in reality) to prevent most of those deaths, by isolating every
household and stopping productive work/trade.
But you know that will later increase deaths from poverty/illness.
What do you do?

47. 3. Individual freedom
against public health
This virus crisis may lead to
countries/societies/cultures to be more authoritarian.
You will carry an identity card and a mobile device that
the government monitors.
The government may monitor (and sometime direct)
your individual movements.
And as in China's new social credit system, you will be
penalized if you waste money on non-essentials or
behave “badly”?
https://www.vox.com/the-
goods/2018/11/2/18057450/china-social-credit-score-
spend-frivolously-video-games

48. 5. Reducing
population growth
against global
warming
This brilliant 4 minute video shows the last 200 years
have seen astonishing improvements across the globe
in public health, wealth and education.
https://www.youtube.com/watch?v=jbkSRLYSojo
The video that follows it shows the impact of natural
disasters has been greatly reduced.
By contrast, our long-term ecological and
environmental problems are expressions of one
problem: over population.
The most effective tool we have for reducing
population growth is increased GDP per head
But that increases ecological challenges such as
global warming.

49. THANK YOU
#staysafe #stayconnected #staycalm