Covid-19 - So how are we doing? Lessons from USA, UK and France and how to move forward
Rob Hnatuk, Ben Deaville and Jon Bastow*
As lifelong friends resident in the USA, UK and France respectively we have been speaking weekly as the Covid-19 pandemic has unfolded. We all have an interest in healthcare and have been comparing progress in our respective countries and speculating on different strategies and how they will impact.
Below we share data and discuss the varying approaches to distancing, mask-wearing and contact tracing. The views expressed are our own and no offense or criticism is intended ;we simply wish to stimulate open thinking on how best to tackle the pandemic globally.
Deaths per capita (mortality) show the highest levels in the UK, then USA then France. This usually lags the cases so USA is likely to increase significantly in the coming weeks, but could also be influenced by hospital capacity which is stretched in the Northern half of France Is the high mortality in the UK due to less strict prevention behaviours, is this connected to individualistic behaviour or more about leadership strength? What more can the three countries do to better reduce the mortality?
Turning to cases per million inhabitants, of our three countries, the USA is highest, followed by the UK and then France. France shows a reassuring trend and did enforce a strict lockdown from mid March until the 11th May, only allowing people to leave their homes for selected reasons such as going to work if not able to work from home e.g. health workers, shopping for essential supplies, and exercise for up to 1 hour a day within 1km of residence. Jon only visited Supermarkets, Pharmacies and Doctors during this lockdown and still only leaves home for ‘approved’ reasons. Restaurants and bars remain closed and schools are just starting to open up. Masks have been made available, coordinated by the French government and we received an email from our local supermarket asking us to collect our allocation of 50 masks at a fixed low price ( although higher end masks are being sold at much higher prices). Contact tracing is available through a government App ‘STOP COVID’. There has been a national survey of residences asking about willingness to use an app using decentralised data.
Finally, testing rates are highest in the USA and have increased impressively in the UK and USA recently. France has chosen to only test self reporting symptomatic people, whereas UK and USA are doing screening programs which will provide a more complete picture, but will it also influence the transmission and death rates? Time will tell.
The UK is doing the worst of the three countries, largely as a result of a delay in implementing the lockdown, according to recent modelling by the University of Edinburgh:
The process of removing the lockdown is being backed by the government’s contact Tracing system. The National Health Service in the UK has developed its own smartphone app which relies on centralised data collection, as opposed to the Google/Apple app which retains the data locally on the phone. Amnesty International has expressed concern over this approach stating; “to date the health secretary has failed to present any evidence as to why the current proposal for a centralised database is necessary and lawful”.
In order for the app to be effective at least 60% of the population must have it. Allowing for those who don’t have a smartphone, this means that 75% of smartphone users must have the app running on their phones. This very high uptake will only be possible if the public buy into the idea and are willing to trust the government with their data.
Recent issues have brought into question the public’s willingness to trust the government’s motives, this may have a significant impact on the uptake of the app. The last week of May was dominated by a scandal involving the Prime Minister’s most senior advisor, who appeared to break lockdown rules. The issue of trust in the government is therefore very relevant in the UK context. The UK app has been plagued with issues and the government has set up a working party to examine the idea of switching to the Google / Apple app instead. Meanwhile the UK government has launched its contact tracing initiative without a working app.
The US is approaching this very differently than France and the UK. There is no national stay at home order. It is up to each state to impose its own policy. Montgomery County, Pennsylvania with a population of 831,000 was the first to lock down it’s residents on March 13th. Currently it is seeing an ongoing infection rate of about 100 cases a day with a total of 6500 cases over the pandemic.It did not see the large scale cases that were seen in New York City (March 22nd) and Northern New Jersey (March21st). This eerily mirrors the 1918 Spanish Flu Pandemic when the Philadelphia lock down took longer than St Louis with significant impact on deaths:
Now the question is when to open up. Do it too early and there is a wave 2 of the outbreak . Do it too late and the economy suffers unnecessarily. Here are the scenarios for one county.
This is why most states are going for a track and trace program that will employ thousands of people across the country. In most cases, individual States are leaving it up to local governments to have this in place before reopening. At a later date the States will use the MITRE’s Sara Alert system to help track individuals. The Sara Alert is a Secure tracking system to enroll persons at risk and potentially exposed individuals. Apple recently unveiled their new 13.5 iOS for iPhone 6S and above in the US. It does not contain an opt-in or opt-out feature.
Although prevention behaviours are also influenced by many other factors such personality type, travel habits, etc there are distinct differences culturally, and in leadership style across the three countries.
France seems to generally be ‘staying at home’ and the French government has made it clear that this is expected, and employers are less individualistic culturally ( France is dominated by larger employers who traditionally are more ‘paternalistic towards their staff) Most people are wearing masks and observing the 1 metre distancing. All utility bills were waived/ put on hold to help people financially and other initiatives such as 50 euro vouchers to repair bicycles to encourage cycling to work have been put into place to encourage ‘socially distanced travel’ and reduce the demand/density on buses and trains. The financial impact seems less in the media but is certainly of concern for most people. From the 27th May the case rate has gone up so it is possible that France has eased confinement too soon and may need to tighten up again or leverage the contact tracing App to get the cases back down - thankfully there is no increase in mortality so far. The 22nd June is a key date for France to decide on mass gatherings and whether to modify any of the deconfinement measures.
The US is also facing many challenges. Unemployment checks are not coming to all and are not on time for most. Students who just graduated are not seeing any federal aid at all. Lines for food banks free food are long with most running out before everyone gets food. As for adhering to the CDC’s guidelines: Very few wear a mask or gloves out in public. Large group gatherings are happening everywhere despite public health officials' recommendations that they should be limited. Here is an image of a beach community two week apart.
Of the states that have reopened 16 are showing increased cases of COVID 19 and they still remain open. Will this cavalier nature hurt us in the long run? We are sure to find out.
Overall then France seems to have done well on cases and mortality with a strict confinement early on. There are alarming signs of a potential second wave as cases have kicked back up recently following deconfinement measures, and the French government may well modify the deconfinement accordingly.
The UK has seen impressive falls in cases in the last 2 weeks and is testing widely, however the death rate is the worst of the three, perhaps due to a combination of a late and ineffective lockdown and poor hospital/nursing home care and capacity.
The US has by far the worst level of cases of COVID-19 but the mortality remains below the UK and the testing rates are the highest.
Moving forward things need to loosen up very carefully based on strong science and modelLing and strong leadership coupled with civil society solidarity will be significant factors in finding the correct balance between saving lives and minimising the effect on the economy. A connected global community that continues to cooperate and learn from each other will be key.
Rob Hnatuk is a lifelong resident of Montgomery County, Pennsylvania. He has over 20 years of genomics experience. During his time at a fortune 500 Company he ran Global Public Health sales working through two large outbreaks (Ebola (2014) and Zika(2016)). He was a member of the 4th International Meeting on the control of Neglected Zoonotic Diseases at the WHO.
Ben Deaville is a Physics teacher living near Derby, UK. Who has been tracking and modelling data on the development of the pandemic in the UK.
Jon Bastow helps organisations accelerate innovation across R & D and Access in healthcare. He lives in France and is helping various diagnostic, treatment and vaccine approaches to COVID-19.
The authors take all legal responsibility for use of all charts and graphics.