It is the kind of scene that is now a distant memory in the UK. Some 6,000 miles away, Taipei’s Pawnshop club is crammed every Friday and Saturday evening with sweaty crowds dancing under wreaths of smoke, and jostling each other at the bar for drinks. Here, the only reminders of coronavirus are on the door, where punters have their temperatures checked and scan a QR code to enter their contact details.
Taiwan’s strict coronavirus controls means only citizens, long-term residents and travellers with business visas are allowed in, and anyone coming from abroad must spend two weeks in a quarantine hotel. Once that time is up, they emerge into a normality unimaginable in much of the rest of the world. As of 24 September, only 507 Covid-19 cases and seven deaths have been reported in the country; there hasn’t been a single domestic transmission since 8 April. So far at least, there has been no sign of a second wave, not even a ripple. Clubbers heading to Pawnshop rub shoulders with fitness devotees going for a workout at a 24-hour gym. Down the road at the Tonghua night market, groups of friends and families sit elbow to elbow, sharing plates of fried tofu, barbecued meats and spring onion pancakes. There are some reminders of the pandemic woven into daily life. Masks are required on public transport, and temperatures are taken on entry to most buildings. But early and effective action by Taiwanese authorities means that people can largely relax. They are watching the tragedies unfolding in so many other places with horror and incomprehension. “It’s painful for me to hear these stories from the UK and the US,” says Popcorn, a drag queen whose eclectic act at the Cafe Dalida bar involves the type of audience interaction that would be impossible even in performance venues attempting to reopen in the UK. “Knowing what’s possible, and seeing what’s actually happening… it’s sad.” Back in April – when Taiwan had its last case, and China, where the virus almost certainly originated, was also getting the disease under control – Boris Johnson believed that what those countries had achieved was possible in Britain too. The corner was being turned. Soon after his own brush with Covid-19 in early spring, the prime minister was full of optimism and combative talk. On 27 April he told the nation it would not be long: “If this virus were a physical assailant, an unexpected and invisible mugger – which I can tell you from personal experience, it is – then this is the moment when we have begun together to wrestle it to the floor... the moment we can press home our advantage.” On 1 June, the health secretary, Matt Hancock, also believed the virus was in retreat. “The data show we are winning the battle against coronavirus. Today we are therefore able to make some cautious changes to the lockdown rules, carefully and safely,” he said. Last Tuesday, however, the UK went backwards, tightening restrictions again. Suddenly cases were doubling every seven days, increasing at rates not seen since March. Scientists had warned in the summer that easing off too soon and too fast in response to pressure from Covid-doubting Tory MPs and businesses could allow the virus to return, and it has done just that – with a vengeance. The public was bemused at this latest U-turn, as was much of the normally Tory-supporting media. The Daily Mail, which appears to be selling shares in Johnson as fast as Covid-19 infections are rising again, was scathing in an editorial. It was furious not only that new lockdowns loomed but that Johnson’s government was failing to take the people, or even MPs, with it. “Depressingly, this authoritarian nightmare is likely to drag on for another six months,” it said.
It also articulated the key debate which now splits the Conservative party, the cabinet and the country – and over which No 10 appears completely undecided itself. “Does the PM really want Britain to oscillate interminably in and out of lockdown to try to avoid even a single casualty? Or do we accept the contagion in our midst, protect the vulnerable and get on with the business of living?” The mix of anger and confusion was unsurprising. It was, after all, less than three weeks since Johnson had been enthusiastically urging people to return to work; three weeks since schools had reopened because ministers had insisted they were safe. And the hugely popular and successful “eat out to help out” scheme had ended as recently as 1 September, having brought the hospitality sector back to life and coaxed people out of their homes to spend again. Government advice had chopped and changed often in the previous six months, but this was the sharpest readjustment of all. “I think we are going down the Swanee,” said a despairing Labour MP last week as he pondered the multiple disasters of Covid-19, the switches in government policy towards it, and the Brexit internal market bill which Johnson had brought to the Commons to allow him to break international law. “We are supposed to be a great country but we are an embarrassment,” said the shadow minister. “We can’t deal with this bloody virus and our government trashes the law. And I just despair.” MPs knew they would face the wrath of constituents when they returned home this weekend. Pubs and restaurants, which had only just got used to serving under Covid safety requirements – measures that had cost them dearly to introduce – would have to close at 10pm and begin turfing out drinkers well before. “It is tragic for them,” said a senior Tory. “They have hung on so far. I really fear this will be their death knell.” Johnson also announced new £10,000 fines for people who refused to self-isolate. Advice on working from home was again turned on its head and people who could were told that they should. Businesses that were not Covid-safe would be closed. There was talk – which is gaining ground among panicked Conservative MPs – of using the army to help enforce rules and control the swelling second wave.
The restrictions would remain for six months, the PM said, through Christmas and beyond. Far from being wrestled to the ground, the virus was alive and kicking. Any optimism had drained away. In the Commons last Wednesday, the Labour leader Sir Keir Starmer – conscious that the country was back in full crisis mode and needed some wartime togetherness – backed the strict new rules but laid the blame for the second wave at the door of the government, citing its continued failure to set up an efficient, locally responsive test and trace system. “When is the prime minister going to act?” Starmer asked as MPs from all parties demanded to know why the UK, whose health service is still admired across the world, was so helpless in the face of the coronavirus pandemic. Lessons from abroad Covid-19 is in many ways still a mystery enemy. Neither governments nor scientists fully understand how it spreads – authorities in the US are still debating the role of airborne transmission – and why the death toll in badly affected areas varies so widely. In the Brazilian city of Manaus this spring, the death toll was so high that bodies piled up in the streets and were stacked three-deep in mass graves, in scenes that could have been lifted from a medieval plague diary. In war-torn Afghanistan, with a battered health system and most people unable to afford social distancing, millions of people are thought to have contracted the disease. In the capital, Kabul, nearly half of children have been infected, the government estimates. But while Afghanistan’s gravediggers, coffin-makers and others who serve the bereaved have reported an increase in burials, the country has not been overwhelmed by death as Manaus was. There have also been countries, from India to South Africa, which have seen infections soar after they came out of lockdown but mortality rates rise much more slowly. South Africa now has approaching 700,000 confirmed infections, but under 17,000 deaths – nearly 60% more total cases than the UK but less than half the number of deaths. Some fatalities may go uncounted in places with weak record-keeping, but it is hard to cover up catastrophe on the scale that hit Manaus. Scientists are still arguing over the reasons some countries seem to have been spared heavy death tolls even as the infection spreads. A relatively young population may be less vulnerable than in fast-ageing western disease hotspots. People living in overcrowded conditions may have stronger immune systems, fortified by fighting off many past infections. But if it is hard to predict how Covid epidemics will develop, it is much easier to see what keeps the disease at bay. The few countries that have managed to effectively eliminate coronavirus range from authoritarian China to liberal democracies such as Taiwan and New Zealand. The clue to their success is not in their style of government but in several key steps they have taken to control the virus. All have sealed their borders, slowing new arrivals to a trickle, and brought in strict quarantine – two weeks in sealed-off hotels – for the few who are allowed in. They also have rapid testing and effective tracing systems that are activated on the few occasions that community spread of the virus is identified. And there is also a second group of countries that have used similar tactics to keep the epidemic under relative control, even if the disease cannot be stamped out. Deaths are in the hundreds, or still kept to double figures. They range from Uruguay to Vietnam and Senegal. Even Italy, one of the first places outside China where health systems were overrun by the disease, now seems to be managing far better than other western countries. Cases are rising, but only slowly: people are still enjoying restaurants, bars and beach trips; children are back at school.
The exact policies adopted by these second group of governments have differed, but they share many common factors. Those that do not enforce quarantine for arrivals in the country require negative coronavirus tests shortly before travel. Test and trace functions effectively in all of them, so that when a new outbreak emerges, it can be halted as soon as possible. In many – though not all – mask wearing in public places has become not just routine, but expected. In contrast – although the British government has partially accepted that without proper testing, isolation of the sick and protective equipment for healthcare staff in the early stages, the virus spreads with devastating ease – UK authorities did not prepare failsafe systems to provide these essentials. The scale of the problem is reflected in the UK’s record in staving off Covid-19 and preventing deaths, as shown by data that is both disastrous and highly incriminating. To date, Covid-19 death rates for the UK have reached 616 per million people. This figure is only slightly below the rates experienced in nations acknowledged to have had the worst responses to the pandemic, such as the US and Brazil, where Covid death rates were, respectively, 626 and 657 per million according to Johns Hopkins University on Saturday. By contrast, Sweden – where shops, restaurants, schools and bars remained open and which has taken the lightest of touches in dealing with the pandemic – still has a death rate below the UK’s: 581 per million. On the other hand, Germany – which reacted rapidly and forcibly to the arrival of Covid-19 – has kept its death rate to 114 per million. Back in the UK And now the figures show the virus biting back in the UK and spreading at alarming rates, putting huge new pressure on the NHS. As of Friday, hospital admissions in England were at their highest level in more than three months as infections continued to rise. As of 9am on Saturday there had been a further 6,042 lab-confirmed cases UK-wide, after Friday’s highest single-day figure. The government confirmed that new lockdown restrictions would be introduced in Wigan, Stockport, Blackpool and Leeds from midday on Saturday adding to those in place in large parts of the country. Residents in these areas were told they would no longer be allowed to mix with people outside their household or “bubble” in private. And thousands of students are in effective lockdown, just days after starting their courses in the face of union warnings that colleges were unprepared to deal with the likely spread of Covid. Hundreds of students in Manchester were told to self-isolate on Friday after 127 of them tested positive for Covid-19, as cases spread to more than 20 universities across the UK. And hundreds of thousands of students in Scotland have been banned from socialising and going to bars. An outbreak of more than 100 confirmed cases at the University of Glasgow led to at least 600 students being told to self-isolate on Wednesday night. So why – in so far as we can find answers – are we back in such a mess? Many scientists believe that, having got numbers down in the summer, we failed to finish the job off and reduce them to a low enough level before easing restrictions. We moved too fast, too early. And when the restrictions were removed, there is a consensus emerging that the easing was done unsystematically, instead of individual restrictions being lifted one by one at different times. The result was that the impact of single, specific withdrawals could not be assessed. “We didn’t keep on the pressure to maintain a reduction in [the R rate] over the summer and people have gone back to normal behaviours too quickly,” said Anne Johnson, professor of epidemiology at University College London. “We are now paying the price.” Joshua Moon, of Sussex University’s science policy research unit, pointed to “the narrow cadre of experts” who have given advice on Covid to the UK government as a problem. “The composition of Sage [the government’s Scientific Advisory Group for Emergencies] consisted of virologists, modellers and behaviourists, rather than experts in public or global health, primary care, emergency medicine, or nursing,” he said. In particular there was a lack of support – financial, practical and psychological – for those being asked to isolate, Moon said. “If you live alone, across the country far from family or friends, how can you gain access to food or medicine? What is needed is increased direct support for those isolating.”
The Dominic Cummings affair also had a clear impact, said psychologist Professor Dame Til Wykes of King’s College London about the antics of the prime minister’s chief adviser, leading the public to lose faith in government and authority. “He wasn’t admonished and he wasn’t sorry. That really broke the community’s trust in any government messaging.” That messaging has become increasingly confused, Wykes believes. “You can’t go to a football match but you can go grouse shooting. That just accentuates the class divide and says we are not all in this together.” On the ground, however, health experts, NHS workers, people working for local councils all know it is the failure to get a proper, locally responsive, test-and-trace system operating that has been the key problem since the spring and summer. Prof Christina Pagel, professor of clinical operational research at University College London, explains the importance of such a programme: “If you have infected people, and lots of non-infected people, you’re trying to stop the infected people mixing. We know that quite a lot of transmission is by people who either never have symptoms, or in the two days before they get symptoms. So you have to find those people and stop them mixing. And the only way to do that is by contact tracing.” But during the summer, England’s contact tracing system was not able to pinpoint those asymptomatic carriers. NHS Test and Trace failed to reach its target of 80% of close contacts of people who tested positive and in some areas tracers only reached half the contacts provided. The testing programme did at least reveal Covid hotspots, Pagel said, which allowed local health teams to act. Yet demand for tests spiked four weeks ago, despite steady increases to capacity, creating a backlog of tests, and many people were unable to be tested at all. “When testing has fallen over to the point that you actually can’t be sure where the hotspots are, because there are places you cannot get a test, then all you have left is to try and stop the whole population mixing,” Pagel added. “It’s a really blunt instrument, but that’s where we are.” So the absence of adequate test-and-tracing equals new lockdowns. NHS trusts are also concerned. Saffron Cordery, the deputy chief executive of NHS Providers, said: “We’ve been really dismayed by the political response to the challenges and breakdown in implementation of test and trace.” Instead of chasing a target of 500,000 tests for political reasons, it would be more helpful for ministers to acknowledge the issues around capacity, she said.
“To get the NHS back up and running and restoring the whole range of services, we need a way of keeping staff safe and keeping patients safe, and one of those factors is test and trace. We are teetering on the edge of a second wave and it’s very likely that we will fall in. “Restoring services is absolutely fundamental, because we’re coming into winter. Winter often leads to staff shortages because of illness anyway – it’s absolutely critical that teachers and healthcare and care staff are prioritised.” As winter approaches, most scientists are now becoming increasingly worried that the colder weather will force people to spend more time indoors and so trigger rises in Covid infections, while flu and other seasonal illnesses could have further grim impacts. The UK will then have to rely on its much-criticised test-and-trace service as its main disease defence. At the same time, MPs, including many Tories, are increasingly angry that their government is introducing new restrictions without consulting them and allowing them to vote on them in parliament first. This week, on Wednesday, Johnson faces a huge Tory revolt that may force him to ask his MPs for their backing before imposing new rules unilaterally. “He should realise that unless MPs are bound in to his decisions they will not feel they have to support them and promote them to the public,” said a senior member of the influential Conservative backbench 1922 Committee. “That has been a big problem.” The public is losing faith in the government’s ability to manage the crisis, and in Johnson, as the Observer’s Opinium poll, which gives Labour a three-point lead, shows. On a practical level, one suggestion to improve efficiency has been put forward by Prof Rowland Kao of Edinburgh University. “Bulk testing – where more than one sample is tested at the same time then retested separately if a positive result is obtained – has been implemented in many other countries,” he told the Observer. That would give capacity a vital boost, he added. A looming crisis The NHS is now facing a winter crisis like no other. It has been trying to catch up on thousands of cases of cancer, heart disease and other illnesses left untreated during lockdown. And researchers are now becoming aware that Covid’s long-term impact on patients will add further strains on the health service. “It is now thought that 10% to 20% may suffer from ‘Long-Covid’ – a wide range of disabling and life-changing chronic symptoms that affect the young, the old, those that had mild symptoms as well as those with severe symptoms,” said the immunologist Prof Daniel Altmann of Imperial College London. “We need to get to grips with this. It may have unforeseen consequences for quality of life, employment, NHS provision for years to come.” In addition, the threat to the nation’s mental status is now a key concern, added Wykes. “The continuing uncertainty has increased the mental health problems in those who already had problems and it has produced new cases. We need more mental health research and more research on how to gain and maintain community trust.” On the other hand, scientists have learned a great deal about the Covid-19 virus over the past six months and that knowledge should help us over the next six, said Prof Sarah Harper, founding director of the Oxford Institute of Population Ageing. “From surveys we now have good information on the public-health reaction of the British population,” she said. “People have taken on board health information, so long as it is clear and well communicated. Public health information should now be tailored towards individuals, and those who will need specific shielding should be informed directly from their healthcare practice. On the other hand, a blanket shutdown of care homes will lead to unnecessary suffering for older residents. They need better support.” A short-term future of lockdowns and restrictions looks inevitable, added Jeffrey Barrett of the Wellcome Sanger Institute. “We’re all exhausted, but there are no other options for the next few months. However, at some point, maybe early next year, we will come out of this wave, and then I think we will reach a turning point. Most importantly, we may have vaccines that are proven to be effective.” On Tuesday, Johnson ended his televised address by saying: “The fight against Covid is by no means over … There are great days ahead. But now is the time for us all to summon the discipline, and the resolve, and the spirit of togetherness that will carry us through.” It sounded a familiar refrain. But, strikingly, it was delivered by the man in charge of running the country, setting himself the task of “defeating” Covid-19 with less conviction, and confidence, than before.