Britain’s perfect coronavirus storm: Why were we hit so hard?

On Maundy Thursday, the day before the Easter weekend, Andy Street made an urgent call to as many business leaders as he could make contact with across the West Midlands.

Alone in his deserted headquarters, the Mayor of the West Midlands phoned them for help with sourcing extra supplies of PPE for key staff working in the region’s local authorities.

Last week, Street told Reaction why he was so determined to get equipment as fast as he could. “The NHS hospital trusts were not running short of PPE although there were some problems with frequency and reliability. But I wanted to be sure that we had enough protective gear for all key workers in care homes and those working on the front-line in the local authorities, transport staff and refuse collectors, for example. We wanted to be ahead of the game.”

He did not have to wait long for a response from business. Three working days after the Easter break, the feedback came pouring in: 367 local companies pitched in with offers to help make new equipment.

The offers for extra PPE supplies came from 57 existing manufacturers and suppliers in the district, and 15 new ones. Jaguar Land Rover and Cadbury’s, two of the region’s biggest employers, were among those offering to help.

The former John Lewis boss was astonished at the speed, and generosity of spirit from local business. “The reaction was brilliant. Everyone came together, with the Birmingham Chamber of Commerce pulling out the stops.”

They could see the disaster unfolding in the hospitals around them as the numbers of people dying with Covid-19 mounted by the day. As in Greater London, Birmingham and the West Midlands region has suffered cruelly from the virus outbreak. Taken together, the number of those who have died in London and the West Midlands with Covid-19 represents about 45% of the national toll.

Sadly, the number of deaths in Birmingham, Britain’s second biggest city with one million people, and the West Midlands as a whole, with three million people, came as little surprise. As Street says: “Birmingham is a highly mobile and well-connected city with thousands of people travelling in and out of the city on trains and buses every day. They were doing so until the lockdown.”

“People were flying into the airport from all over the world, everyone was moving around right up until those last few days. This extraordinary mobility is one of the many reasons why we were the second city leading into the pandemic, and why we have been hit by the disease so badly. We also have areas of dense housing with inter-generational families living together in small spaces, and many people who are in poor health.”

So marked are the regional disparities – and even the disparities within urban areas – in the pattern of deaths now emerging in the UK that many public health experts are asking whether Britain was an accident waiting to happen.

The question is whether the lop-sided and skewed state of Britain created a perfect storm for the coronavirus to have such a devastating impact.

There are five elements peculiar to the UK which combined may have led to this storm being so ferocious.

They are:

1) Over-centralisation around London, south east and the Midlands, and four international airports with huge traffic flows.

2) Sharp health inequalities between the North and South, as well as within urban conurbations such as London and Birmingham.

3) A high proportion of Britain’s population are of mixed heritage: 14% of people in the UK are from ethnic minorities. This makes significant parts of the population more vulnerable to the disease than others because of underlying health conditions associated with specific genetic and social factors.

4) The UK’s NHS – and its supply chains – are highly centralised while the medical establishment is cautious in its treatment of public health.

5) Finally, there is the UK’s fragile social care system with 410,000 elderly persons people living in homes, making efforts to shield the most vulnerable particularly difficult.

Add these factors together and you can see why public health experts are not surprised that Britain is on a comparable trajectory to Italy, which is still the hardest hit country in the world, in terms of the number of deaths. As of last night, the death toll in the UK hit 28,734 while the mortality numbers in Italy were 28,884.

While Britain is tracking Italy’s death rate, it’s only fair to say that the actual number of deaths in Italy, France and Spain may well be much higher than current totals as these countries have not included all deaths in homes or care homes and may be widely under-estimated.

Packed Britain

The UK is the most populous country in Western Europe after Germany with a population of 66 million. Beyond the sheer numbers, what may turn out to be most relevant is that most people are concentrated in the south-east, in London and upwards in a banana shape across the West Midlands up to the North West, another area to be badly affected by the virus.

Germany has recorded relatively low death rates compared to its continental neighbours. Why so? For starters, Berlin has a population of only 3.6 million compared to London with 8.9 million. The population of Germany is also far less concentrated than the UK, with several big cities spread around its vast land mass. Germany’s healthcare system is decentralised and devolved.

Cities with dense populations and high use of public transport – especially the underground – have all experienced a higher number of infections and death rates because of this mobility factor amplifying transmission rates of the disease.

Like in London, other populous cities with extensive tube networks such as Milan, Madrid, home to 6.6 million people, and Moscow (nearly 12 million), have also reported far higher infection rates and deaths.

Exacerbating this mobility flow within our cities is the fact that Britain has four international airports – Heathrow, Gatwick, Luton and Stansted. Until the more severe travel restrictions imposed a few weeks ago, these airports were heaving with millions upon millions of travellers right up until the airlines stopped flying all but the most essential flights.

We know too that millions of holiday makers and skiers were travelling to and from hotspots such as northern Italy – and indeed from China – through until March. Only recently did the government demand that passengers arriving into the UK should isolate.

Britain’s airports are also among the busiest in the world. The most recent figures showed the UK had 268 million people travelling in and out of the country in 2016, and numbers were rising.

The UK’s huge mobility and inter-connectedness is why its so unhelpful when some observers compare the UK to countries such as New Zealand or Norway, which both have small populations of around five million who are spread around a big land mass. You might even say superficial.

The North South divide keeps getting bigger. Health inequalities in the UK are deep, with an astonishing number of people who live with multiple comorbidities such as obesity, heart disease and diabetes for a big chunk of their lives making them far more susceptible to fatal diseases such as Covid-19.

Being fat, or just living in what is being called an “obesogenic” environments in which it is easy to access fast food and processed foods, for example, has been shown to drive obesity. And being overweight is believed to trigger a “troublesome” immune response to Covid-19, with NHS data now showing that three quarters of those in intensive care with the disease carry extra weight, particularly men.

There is no polite way of saying this but Britain is a nation of fatties, and the fattest in Europe. A report from Organisation for Economic Cooperation and Development in 2017 showed that 26.9% of the UK population had a body mass index of 30 and above, the official definition of obesity. Another UK report showed that on top of those defined obese, another third were overweight suggesting that two thirds of the public are either obese or overweight.

The OECD report also showed that obesity had increased in the UK by 92% since the 1990s, thus demonstrating once again the spectacular failure of well-intentioned various public schemes to improve diet, nutrition and exercise.

Only five of the other OECD’s member states had higher levels of obesity: four outside the continent and one in Eastern Europe. At the present pace, the report predicted that half the UK population will be obese by 2050.

Yet it is a simple truth: those who live in a leafy part of London or the southern suburbs can expect on average to live up to ten years longer than someone in Walsall or Wolverhampton – where liver disease is prevalent – or on a deprived estate in Manchester and Middlesbrough.

No wonder then that public health experts in the North are not shocked by last Friday’s figures from the Office of National Statistics which showed that Covid-19 related deaths in the most deprived regions were 55 deaths per 100,000 people, compared with 25 deaths in the wealthiest areas.

Over the last few days, the North West, including the cities of Liverpool and Manchester, has overtaken London as the epicentre of the disease while the North East has emerged as another hotspot in the outbreak.

Even within London – the epicentre of Britain’s outbreak – there are huge disparities in outcomes.  London has the highest mortality rate, with 85.7 deaths per 100,000 people – more than double the national average of 36.2 fatalities. The  poorest boroughs of Newham, Brent and Hackney are the three worst-hit regions in all of the country, suffering 144, 142 and 127 deaths per 100,000 respectively.

Compare those numbers to Hastings, in affluent East Sussex, and Norwich, which had the lowest COVID-19 death rates – suffering six and five deaths per 100,000, respectively.The Hastings figures are interesting because the town itself is one of the country’s most deprived yet the surrounding district is relatively well-off.

Professor John Wright, clinician and epidemiologist, has been working throughout the crisis on the front line at the Bradford Teaching Hospital, where he also advises on public health policy.

Wright agrees there are structural issues within Britain which may have led to the pattern emerging. Where you live, and how you live, matters.

“What is interesting is that Covid-19 is proving to be a multi-demic rather than a pandemic,” he says. “We can see the disease is affecting different areas and different demographics. Where you live and how you live has a direct impact on health. In many cases, BAME means deprivation.”

Yet as Professor Hunter points out, these health inequalities are not new – but few in Westminster or Whitehall have wanted to hear just how bad.

Only a few months ago, a report published by  the King’s Fund confirmed how stark the gap is in healthy life expectancy from birth between fellow Brits. Based on research conducted between 2015 and 2017, the report showed that those who lived in the least deprived areas could expect to live roughly 19 more years in good health than those in the most deprived areas. Yes, 19 years difference, twice the time spent in ill-health by those in the least deprived areas.

The current life expectancy for the UK is  81.40 years in 2020, a tiny rise on 2019. However, this average age depends hugely on where you live. For example, the area for the lowest healthy life expectancy for females was in Nottingham, at 53.5 years, while men living in Blackpool had the lowest life expectancy, at 54.7 years.

Recent Public Health England data for 2014- 2016 shows that between the most and least deprived areas of England, the gap in life expectancy was 9.3 years for males and 7.3 years for females.

Another report by the Global Burden of Diseases, Injuries and Risk Factors found the health gap between rich and poor has hardly changed in 25 years. If the healthiest region of England – the south-east, were a country it would top the league of 25 industrialised nations. But if the North West were a separate country it would be in the bottom five.

The discrepancies are shocking, although they help explain political developments in the last decade. What the numbers put into context yet again is why so many people in these areas voted for Brexit, and indeed, why the so-called Red Wall voters opted for Boris at the last election. Those voters wanted to be heard and they wanted investment.

Responding is complex but it does not need to cost much. In the long-term, improving overall health outcomes would actually cost less as fewer people would mean less spent on costly NHS treatments and pills. It would also improve people’s well-being and productivity.

Recent research by the North’s six great universities, Health for Wealth: Building a Healthier Northern Powerhouse for UK Productivity, estimates that by improving health in the North, the £4 gap in productivity per-person per-hour between the Northern Powerhouse and the rest of England could be cut by 30% or £1.20 per-person per-hour.

Does BAME means deprivation?

Another facet is the country’s high proportion of people of mixed heritage, many of whom are more vulnerable to illnesses such as diabetes and cardiovascular disease because of specific genetic factors. Doctors are looking at whether those underlying conditions may have left those of mixed race background – combined with other social factors – more exposed to Covid-19.

Early evidence from NHS England for the first 12,600 deaths in English hospitals showed just how sharp the differences in mortality rates were between different ethnic groups. Black Britons account for 3.4% of the population, but they make up 6.4% of the deaths so far.

Hospital death rates from the virus per 100,000 population were 23 for white British, 27 for Asians, 43 for black people and 69 for those of Caribbean heritage. But it does not apply for all ethnicities: the mortality rate for Bangladeshis is, to date, 20 per 100,000.

These differences can be seen at the regional level. Birmingham City Council’s data shows that more than a third of those living in Wolverhampton are from a BAME background, with 16 per cent of the population born outside the UK.

It has been noted that nearly one in four confirmed cases of Covid-19 in the four Black Country boroughs, Birmingham and Staffordshire have resulted in deaths. Compare that to the one in seven nationally. Yet in Staffordshire, where the death rate is far lower, the figure for people from BAME backgrounds is just 6.4 per cent.

Indeed, so worried is Public Health England by the differences in infection rates and deaths that it has launched its own investigation into the matter.

Centralised system

The NHS and Public Health England are locked into one of the most centralised health care systems in the world which may have led to logistical issues over supply rather than real shortages of equipment.

Both Wright and Hunter saw first hand how the central command structure of the NHS’s supply chains – through PHE – have been a problem, if not a bottleneck on supplies.

Wright, whose Bradford hospital went out to source its own PPE, says: “If there are lessons, it is that local areas should be more adaptive in the future rather than relying on central NHS for supplies.”

“We had to go out to the local community for help, to get local procurement. We had a fantastic response. I describe it as a Dunkirk type exercise with lots of small flotillas coming to the rescue as we have been clinging to the bone for the next lot of aprons. The top down approach does not seem to be working.”

In the North East, the Northumbria Healthcare NHS Foundation Trust, with other NHS organisations, has swung into action and brought in Wingrove Motor company in Cramlington to transform the factory into a production line to make 7,500 protective gowns for frontline NHS workers.

Hunter says: “That’s just the sort of pro-active action we need to see more of. Our procurement system is over-centralised and sub-optimal. We should look at how the Germans manage their system.”

“I don’t like to criticise Public Health England but there are questions to be answered as it appears they have been wrong footed on several occasions.”

Something else we’ll need to consider when we emerge from this crisis is the question of whether Britain’s medical establishment is so conservative and cautious by nature that clinicians were less likely to experiment early on in the pandemic with new treatments until they had been rigorously tested by the regulators and the ethics authorities.

For example, the UK’s ethics approval rates are estimated to be more than five times slower than in the US, and twice as slow as in Poland, the centre of many international clinical trials.

That’s no bad thing by any means, in most circumstances.  But there are a growing number of reports that doctors in Spain and France were more prepared to experiment early on in March with lesser known and less tested treatments for the virus, including using the anti-malarial drug, hydroxychloroquine, the antibiotic azithromycin as well as cocktails of vitamins to treat patients.

That does not mean the NHS is not now at the cutting edge of drug treatment. Quite the reverse. But the NHS’s over-centralised chain of command  works more cautiously than other health care systems, such as Germany where the federal states are far more experimental. It was only on April 3 that the NHS launched its new, and exciting, randomised RECOVERY trial of more than 30 different treatments across the country’s Covid-19 patients.

Social care concerns

The fragile fabric of the UK’s social care for the elderly is a factor too: around 410,000 of Britain’s elderly live in 11,300 care homes, managed by 5,500 different providers, making shielding the elderly difficult at the best of times.

Professor Hunter says: “We were far too late shielding the elderly in their care homes, and at home. The time lag was too great. Second, we don’t take any pride in social care. Churn is enormous, people last on average a year. There are so many different reports on how to reform this, but we must sort it. Health and social care belong together.”

Britain’s political parties have been arguing for more than a decade about reforming social care, but still there is no proper plan.

What lessons can be learned?

Looking back over the last few weeks when the outbreak first hit his city so hard, Andy Street says there are lessons to be learned from this catastrophe for future policy.

“What is sure is that we will look at the inequalities in our region with much sharper focus. Having more devolution, and power to the regions – will help achieve this across the country.”

Wright, who spent time in Sierra Leone working during the Ebola outbreak, has two thoughts: timing and chains of command. “I saw first hand in Sierra Leone that timing is everything when you are fighting a pandemic. We made mistakes about the lockdown, it should have been earlier and there should have been tracking and tracing much earlier.”

Longer term, he says the UK needs to improve overall public health to make the population more resilient.

Professor Hunter agrees. He prays that the debate about the future of the NHS after the crisis has subsided will not just be about more hospital beds and ICU units.

“What we definitely don’t want is that investing in public health becomes sacrificed on the altar of opening more intensive care beds, buildings or beds. The paradox now is of course that we have loads of spare beds, ICU units and ventilators. That’s not what we want, although having a stockpile must be good.”

“Rather, we need to rebuild our public services so they are more resilient and better able to cope with the unexpected and unforeseen. For too many of its 70 years the NHS has suffered from being viewed as a service for the sick rather than a health service.”

Perhaps the NHS should be renamed the National Wellness Service, to concentrate minds.

On the other side of this crisis there will have to be a sober rethink.  A long-running series of public policy failures seem to have combined to give Britain a particularly bad dose of Coronavirus.