As Andy Burnham delivered a potentially fatal blow to the Government's coronavirus strategy on Thursday evening, his casual attire stood in contrast to the foreboding municipal building behind him.
Elected Mayor of Greater Manchester in 2017 on the back of rhetoric condemning “London-centric” politics, Mr Burnham lost no time in returning to the north-south divide.
“They are willing to sacrifice jobs and businesses here to try and save them elsewhere,” he declared. “Greater Manchester, the Liverpool city region and Lancashire are being set up as the canaries in the coal mine for an experimental regional lockdown strategy”.
It took 24 hours for the Prime Minister to hit back, essentially telling Mr Burnham that unless his position shifted he personally would be responsible for a surge in Mancunian Covid hospitalisations and deaths.
“I must stress that the situation in greater Manchester is grave,” Boris Johnson warned. “Each day that passes without action means more people will go to hospital, more people will end up in intensive care and tragically more people will die.
“So I urge the Mayor to reconsider and to engage constructively.”
The dispute marks a week in which any sense of “one nation” cooperation in the battle against Covid-19 was stamped out - possibly for good.
Scotland, Wales and Northern Ireland have all gone their own ways, each announcing their own versions of “circuit breakers” this week.
Now England itself - home to roughly 85 per cent of the UK’s 66 million strong population - appeared to be fracturing in the face of a second viral wave.
And a fearsome wave it is. Sir Patrick Vallance, the Chief Scientific Adviser, set his expression firmly to smirkless as he ran through data that showed his Covid “non-prediction” from almost four weeks ago had come to pass.
Quoting three sources of official data, he showed slides estimating that new cases were now running at anywhere between 22,700 and 74,000 a day. Split the difference and you arrive almost exactly at 50,000 - the number he and the Chief Medical Officer Prof Chris Whitty alighted on at their joint press conference of September 21.
Oh how they must wish their political masters could manage even the most basic of maths (2 x 2 = 4; 2 x 4 = 8; 2 x 8 = 16 etc)
Yet scientists, too, are split - if not on numbers - then on strategy.
The grandly titled Great Barrington Declaration of two weeks ago, which proposes that the World Health Organization’s suppression strategy be replaced with a “herd immunity” approach, was met with the John Snow Memorandum, another lofty document which demands we double down on “restrictions” until a vaccine or effective treatment comes along.
Both “lack rigour, humility and empathy,” said the independently minded geneticist Prof Francois Balloux. “They whip up fervour in the convinced, but neither even attempts to engage with anyone outside the 'true believers'. I find them both unhelpful.”
Surfers know that when the swell starts to rise you must either get to shore quickly or double down and paddle out to sea to avoid being crushed by the approaching breakers. What you must never do (although it is always the temptation) is dither in the impact zone.
Yet this is where the UK appeared to be this weekend; a nation too divided and fatigued to paddle in either direction, even as the seas around us were rising.
It raises the question, alluded to by the Prime Minister in June when he urged us not to throw away the sacrifices of April and March: is Britain’s Covid response going to bring with it all of the considerable costs but none of the benefits?
Winners and losers
The UK strategy is one of suppression, to hold the virus down at levels low enough to prevent the NHS and other services from being overwhelmed until a vaccine or a cure comes along.
Its costs are counted in vast capital investment, lost economic output and a good deal of collateral human and social damage. The hoped for benefits include the avoidance of overflowing mortuaries, maintenance of essential services and minimisation of long term economic and social scarring.
It is the same strategy as is being pursued across much of the rest of the world, with varying degrees of success.
In countries which acted early, like Singapore, Taiwan and South Korea, life has almost returned to normal but for an almost complete ban on international travel.
Their early investments in pandemic preparedness have paid off. Large scale deaths have been avoided, and economic losses, while significant, remain small in the great scheme of things. They are the surfers who got quickly to shore at the first signs of the impending storm.
In Europe things are very different. Few countries, if any, were properly prepared in advance and most have had a much greater incidence of the virus to deal with as a result.
Those that have done best, as measured by excess mortality, include Bulgaria, Slovakia, Czechia, Hungary, Poland, Norway, Denmark and Finland and Germany. At the other end of the scale sit the UK, Spain, Italy, Belgium, Sweden and Holland.
A paper in Nature this week said the varying outcomes were best explained by “differences in how well countries have managed the pandemic and the resilience and preparedness of the health and social care systems”.
Today in Europe, only Norway and Finland look like they have got safely to shore. The second wave of the virus is crashing across the rest of the continent and governments are urgently tightening social distancing measures to avoid the crest of the approaching break.
Chancellor Angela Merkel warned on Wednesday that Germany, which only weeks ago appeared to have escaped the second wave, could be heading for “disaster” unless drastic action is taken.
Children have been told to take blankets to school so the windows can be kept open and Mrs Merkel is fighting a battle with regional authorities to institute an internal travel ban.
“We don’t expect the numbers to fall tomorrow. They will continue to rise,” Helge Braun, Merkel’s chief of staff, said on Friday. “We are at the beginning of a really big second wave. Things are significantly more serious than they were in the spring.”
But as others paddled out for protection, the UK - or England at least - was still dithering in what may yet turn out to be a rerun of early March.
Jeremy Farrar, Director of the Wellcome Trust and a member of Sage, told the BBC: “I think we're in the worst of all worlds here.
“I think we've got to come together as a country. This fragmentation and frankly making this either a north-south or a party political issue - that's a very dangerous route to go down.”
Professor Susan Michie, Director of UCL Centre for Behaviour Change, is one of many calling for a two to three week “circuit breaker”, the major plank of which would be - not a full lockdown - but a nationwide ban on households mixing inside or out.
“A circuit breaker is needed immediately to get the transmission rate down,” she told The Telegraph. “The current situation of continued uncertainty, mixed messaging and divisive policies undermines trust, a sense of national purpose and motivation to adhere to restrictions”.
Prof Michie added that, as per the strategy set out by Independent Sage on Friday, such an approach should include the strengthening of the “public health scaffold” - especially a major overhaul of the faltering test, trace and isolate system - to emphasis a localised approach, rather than a centralised system overly reliant on the private sector.
For most, the debate this week was focused on timing and the backroom financing deals that have proved necessary to get local authorities to implement the new three tier system, which the Government announced on Monday.
But others were still debating the suppression strategy itself.
On Friday, the former Conservative Party leader Iain Duncan Smith attacked Sage for falling victim to a “form of groupthink that focuses exclusively on a drive to push down the infection rate to the exclusion of all else”. He urged ministers to focus on the “prescribing of anti-virals... to the most vulnerable members of our society” instead.
In doing so he channeled the spirit of the Barrington Declaration, which argues that the cure of widespread social distancing does more damage than the disease.
“The most compassionate approach that balances the risks and benefits of reaching herd immunity, is to allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk. We call this Focused Protection”, say the authors.
The trouble with this strategy is that it either requires difficult and detailed measures to be put in place to protect large numbers of vulnerable people (perhaps as many as 17 million in the UK) or to accept a much higher death toll - one that would need to dealt with largely through palliative care at home so hospitals don’t become overwhelmed.
Talking to the Telegraph, Sunetra Gupta, professor of theoretical epidemiology at the department of zoology, Oxford, and a co-author of the Declaration, said she was firmly focused on the “protection of lives”. The Barrington strategy was premised on saving more lives overall - direct and indirect - she said.
“I want to do it by minimising the numbers of deaths. We can protect a very large segment of those [vulnerable] people, not by locking them up in their homes but through infection control in care homes and the wider community”.
If that was not possible because shielding, once tested, could not be made to work would she think again?
“That's a very, very good question”, Prof Gupta said. “If shielding really doesn't work at all then we have to think about what those [mortality] numbers actually are... We would need to sit around the table like grownups… factoring in all the collateral damage as well as direct deaths”.
Ultimately Prof Gupa believes we will need a new “social contract” in which society accepts a certain number of Covid deaths as the price for maintaining vital economic and social freedoms and protecting the healthy.
We accept around 26,000 road traffic deaths and serious injuries in the UK each year as the price for keeping the country moving, for example.
But the Conservative MP Neil O’Brien, a former special adviser to Theresa May, calculates that a herd immunity strategy would lead to between 90,000 and 175,000 deaths even if you assume the NHS does not become overwhelmed, cutting off care to the healthy.
“Having crunched the numbers, I conclude the Declaration isn’t a viable solution”, he writes in today’s Telegraph. “The countries that are doing best have followed completely different approaches. We should learn from them, rather than embark on a route which would see the NHS overwhelmed and would be likely to lead to hundreds of thousands of unnecessary deaths”.
The difficulty with shielding was further highlighted by new evidence from clinical trials.
Even as Mr Duncan Smith was calling for antivirals to replace social distancing, a vast new global study looking at Remdesivir, the only antiviral so far licenced for use against Covid-19, concluded it “has little or no effect” on survival.
“This idea is barking mad, it needs to be put to bed”, said Martin McKee, professor of European Public Health at the London School of Hygiene and Tropical Medicine, of the herd immunity approach.
“It’s nonsense on stilts”.
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