It’s not clear where the infection came from. But after 102 consecutive days without a single locally transmitted coronavirus case, a household cluster of four cases was discovered in Auckland, New Zealand, on Tuesday. The government responded swiftly and decisively. A three-day lockdown was imposed on Auckland, while further testing and intensive contact tracing was conducted. Thirteen individuals linked to the initial household cluster have subsequently tested positive for the virus.
The emergence of these new cases is a sign of how difficult it is to eliminate Covid-19, even in a small, sparsely populated island nation with a border that has been mostly closed, and where people who enter the country are subject to rigorous testing and quarantine. The prime minister, Jacinda Ardern, voiced her disappointment, but many New Zealanders were likely relieved to observe the manner in which their health system quickly identified new infections and implemented actions that will likely prevent this cluster of cases from escalating into a major outbreak.
Although a test-and-trace system that rapidly detects coronavirus and prevents onward transmission may not eliminate the risk of new cases popping up, it can minimise the impact of the virus. New Zealand has only had 22 coronavirus deaths, compared with the UK’s more than 46,000. And with summer approaching in New Zealand, the country can reasonably look forward to more coronavirus-free days in the future.
There’s no such optimism in England. Unlike New Zealand, England’s approach is not to eliminate Covid-19 altogether, but to minimise its impact. Instead, there are good reasons to be worried about the approaching winter, when transmissibility of the virus will be greater and schools are expected to reopen. Crucially, the country’s overcentralised, fragmented and semi-privatised test-and-trace system has been costly and ineffective; despite the proclamations of Boris Johnson, a system based on outsourcing centralised contracts to Serco, which then outsourced contact-tracing jobs to call centre operatives, was never going to be “world-beating”. Although the government’s recent decision to outsource these call handlers to local teams may help improve the system overall, using remote call handlers with minimal experience and training was a poor approach from the outset. Meanwhile, Serco and Sitel are continuing to siphon off scarce resources that should be invested in local public health teams.
Thankfully, we seem to be evolving towards a more decentralised system with greater recognition of the importance of local action plans and local public health leadership. But much more needs to happen if England is to be ready for a potential second wave of coronavirus cases this winter. Testing capacity needs to continue expanding. It also needs to be quick, agile and linked to frontline health and social care workers, as well as people in the community, such as schoolteachers, who are critical for identifying new clusters of the virus.
A real-time information system that spans local health centres, regional public health teams and national levels of administration will be crucial to identify clusters and “super-spreading” events (there is some evidence that only 10% of those with the infection may be responsible for as much as 80% of transmission). The government also needs to ensure that people who test positive for coronavirus actually do isolate. No data is currently available showing whether people who are asked to isolate comply with the 14-day quarantine period, nor is there financial support available to insulate them from the consequences of doing so.
Nobody can tell for certain what will happen in the autumn and winter. There are so many variables, and our models are still compromised by an incomplete understanding of how the virus behaves. We don’t know for certain how much of a role children and adolescents play in spreading coronavirus. We don’t know exactly what proportion of the population are susceptible to infection, nor what proportion of that population are vulnerable to a clinically significant illness.
What we do know is that England will be entering autumn and winter under different circumstances. The country will be a quieter and less crowded place than in early March; there will be no densely packed trains and football stadiums, no indoor choir practices, no office Christmas parties. There won’t be thousands of people returning from high-transmission holiday destinations, and we should not be making the mistakes that led to hospital patients being discharged to care homes, where they unwittingly spread the virus.
Health authorities may not be able to stop the embers of the epidemic from continuing to flicker, but they should be able to prevent the full-blown conflagration we experienced in March and April. We’ve seen the damaging effects that indiscriminate, prolonged lockdowns have on young and vulnerable people, and on the economy as a whole. To avoid imposing draconian measures, the government must support people to behave responsibly and safely – not just give orders from above.
The former requires a well-informed public; rather than instructing people to “stay alert”, which could mean a number of things – and therefore means nothing – the government should provide them with clear guidance. Rebuilding public trust will be integral to preventing future outbreaks. To a great extent, we are all in this together – but we can’t brush over the fact that some people are affected far more than others, and that the trade-offs inherent in any set of chosen policies are fundamentally political and ethical in nature.
Ultimately, the government won’t be judged by the health effects of coronavirus alone. The fallout from the pandemic will be felt socially and economically, entrenching inequalities that already exist in our society. We must do all we can to prevent a surge of coronavirus deaths this winter. This won’t be easy, but if we’re going to live with the virus, we’ll need to treat it alongside the other risks and threats to our health and wellbeing.
• David McCoy is a professor of global public health and director of the Centre for Public Health at Queen Mary University of London