To Contain the Pandemic in the U.K, 'We Have to Do Things Differently'

With some 350,000 cases and 40,000 deaths, the U.K. is second only to the United States in its total confirmed death toll from the COVID-19 pandemic.

The British government, led by Prime Minister Boris Johnson - who was himself hospitalized with the disease - is working to reopen the economy and allow people to return to work, even as millions lose their jobs or placed on a "furlough" scheme where the government temporarily covers most of their salary.

There's been criticism of the government's halt of its testing strategy on March 12 and for delays to the "track and trace" app that would enable those people with symptoms to be isolated and for those they have come into contact with to be identified and tested. The U.K. has the capacity to test over 100,000 people-a-day but is still in lockdown.

With the recent sunny weather drawing thousands of people to parks and beaches, though, the danger of a second spike threatens. How close is the world to a vaccine? And what lessons can the U.K. learn from looking at how President Donald Trump and the U.S. have handled the pandemic?

Professor Sir Robert Lechler of King's College, London (where he also serves as Vice-Principal), is one of the world's leading experts on immunology. His expertise puts him right at the heart of the U.K.'s - and the world's - response to the COVID-19 pandemic.

He is also Executive Director of King's Health Partners Academic Health Sciences Centre, which includes hospitals like Guys and St. Thomas Hospital in London, which treated Prime Minister Johnson in intensive care.

He is also president of the Academy of Medical Sciences and has recently been appointed special advisor to the House of Lords Select Committee for the response to COVID-19. He is in the forefront of research and understanding of this novel coronavirus.

In short, Professor Sir Robert Lechler is one of the best people in the world to discuss the next steps in the COVID-19 pandemic, the health implications of the lockdown and how realistic the hopes for a vaccine might be.

Newsweek spoke with him earlier this week.

NEWSWEEK: Is it fair to say that COVID-19 could be wiped out in London in a few weeks?

Professor Sir Robert Lechler: The R-value [reproductive rate] is the key. The most important thing is that the R-value stays less than one, as we've heard being repeated as the mantra from [chief scientific adviser to the U.K. government] Patrick Vallance and company. The lower the R number, the faster the virus will decline.

Australia shut themselves off from any international entrants as soon as this virus became known. And they've had a very small epidemic in Australia and Western Australia is talking about eradicating the virus. That means that they're going to need some sort of passport to travel within Australia from areas that are virus-positive, to areas that are virus-negative.

I think London, it'll be a while. A long while. It's a bit premature to think otherwise.

Is this the right time to start reopening the U.K?

The health impacts of this pandemic fall into four buckets.

The first and obvious are the effects of the virus, which is what everybody is focused on at the moment, quite appropriately. But that may turn out to be the least consequential.

That's because the second is the displacement of routine clinical activity that this has caused. It is quite extraordinary. If you go around U.K. hospitals, you find lots of empty beds because they have been repurposed to be COVID hospitals and the NHS [National Health Service] has expanded up their intensive care capacity.

If you talk to GPs [General Practitioners], they'll say they're not seeing patients unless they've got a cough because patients are scared to go to the surgery in case they're going to get infected. It doesn't mean people aren't developing cancers and disease and diabetes and everything else.

There's a big backlog accumulating and, if that backlog [remains] as winter pressures start emerging, that's going to be challenging.

A third impact is the economic downturn. We know that poverty is bad for your health and we know that we've got some considerable health inequalities in this country.

For the first time in human history--I think I'm right in saying that--we've seen a slight decline in life expectancy in the most socially, economically deprived sectors of our society. And that is probably linked to the austerity phase that we went through.

And we're going to have another austerity phase. There is a fear that this is going to exaggerate, temporarily at least, health inequalities.

The fourth impact is the mental health consequences of this pandemic, which come in various shapes and sizes ranging from the impacts on frontline workers in a very stressful working situation and this concept of moral injury.

This is a battlefield concept where you find yourself taking decisions that offend your moral principles. Northern Italy would have had this in spades because they got overwhelmed. We never got overwhelmed. But nonetheless, there would have had to be prioritization decisions, which are very difficult.

And then you've got the impacts on the elderly who have been deliberately isolated. You try to avoid isolation with elderly people because that exaggerates depression. And here we are telling them they've got to isolate it. Then you've got the impact on the young generation, particularly adolescents, who are having to socially isolate at a crucial developmental phase.

The long term mental health impact will be considerable.

I'm very glad I'm not prime minister at the moment because he has got some very tough balancing acts to perform and he's balancing one impact against the other.

If you say, 'Right, we're going to be really, really cautious' and we are going to keep the lockdown in place considerably longer, then the economic downturns can be more severe, political activity returning to normal is going to be more difficult and the mental health impacts can be greater.

If you ease the lockdown too soon, well, you can see the equation. It's a very tough one.

I think Boris has probably got it right, in so far as anything's 'right,' but the key will be really efficient and effective monitoring.

Detecting infections, contact tracing, and isolating cases, particularly around vulnerable people as we begin to relax, are all key.

We'll have to learn as we go. What I anticipate happening is there will be pockets of trouble and if adequate screening is in place, you'll say 'Right, in X, we've got trouble,' so you act locally to respond to what you detect locally.

If I was asked to give a critical evaluation of the way the U.K. has performed, I think it's there's been too much central command and control. I think local management and local solutions are, in general, a better way to handle this.

There's so much we don't know about children's likelihood to spread the virus. Do you think it's premature to open schools?

Hard facts are thin on the ground here. But the interesting claims are that, number one, it's a very benign illness in the large majority of kids. There are catastrophic cases but that's a rare event. But it's obviously a nasty event. It's normally a very benign or even asymptomatic illness.

Secondly, it appears that primary school-aged children transmit less. I don't know why that is. It's almost counterintuitive because if you've had the experience of having young kids, you go to nursery, they come back, they've always got a snotty nose and they're a sort of viral vector. You're living with this the whole time. So why are primary age kids transmitting less? I really don't know, but I'm sure those claims have some basis for them.

When Johnson spoke, he said that primary schools might be the first to open in early June. And that seems to me reasonably sensible.

But that comes with the caveat that primary-school-age kids very often have living grandparents and even great grandparents. And that's the vulnerable sector of society.

So all of this must be coupled with a really efficient, easily accessible, rapid turnaround testing system in the community so that we can identify people quickly when they are infected and then do contact tracing.

One of the unknowns is, what fraction of people have an asymptomatic illness. There might be 24 new cases in London but that's 24 cases that you know about. How many cases are there that you don't know about?

All the government announcements early on were about a cough and fever and a bit of breathlessness and that was COVID. Now, actually, the symptomatology is much more varied than that.

Colleague James Spector developed a symptom tracking app and he's put together about 14 symptoms. That can be manifestations, including abdominals symptoms, which are quite prominent, and in some people, that's more than cough. There's loss of taste, headache, fatigue. It's really an unusually varied illness, much more so than any other viral illness that I've ever come across.

And then so when people say they're asymptomatic, they may mean 'I haven't had a cough or fever,' but they may have had one of these other things or they may have no symptoms at all.

That's particularly likely to be true in kids. That's why this antibody test is of such interest.

If you're going to get a symptomatic illness, you're transmitting the virus two or three days before you get any symptoms.

I think any sense of security or over-optimism about London is premature. But the good news is the peak of the pandemic in the U.K. seems to be at about the beginning of April. And it's just steadily declined. Now it's a bit of a plateau. It's way, way down in terms of the numbers of people reporting symptoms from where it was but there's still a trickle of cases happening.

With Kawasaki syndrome now manifesting in some children, how worried should we be about a link between these two conditions?

It's a new and unrecognized phenomenon. The syndrome is a bit like toxic shock. It's a bit like when someone's septic so they have fever, they've got a lot of inflammation, sometimes manifesting as a skin rash, sometimes serious or severe enough to compromise cardiac function. And the Kawasaki syndrome describes that.

The unusual thing is that the sporadic outbreak of cases coincides with a pandemic of COVID-19. It's a correlation and it's tempting to think it has a causative link.

Is there a causative link? A number of kids who have this syndrome tested negative for the virus.

But it's beginning to emerge that 50 percent are known to have had the virus and it appears to lag a few weeks behind having had an infection with Cov-2. So it looks like an over-exuberant immune response. Quite often, deaths from virus infections occur because of the immune response getting overexcited and its collateral damage.

In the so-called Spanish flu in 1918, the majority of those who died were young people, rather than old people, because young people's immune systems were more active and caused collateral damage.

This looks like a late immune-inflammatory response, consequent on an earlier encounter with this virus. But why it happens is completely unknown at the moment.

Is this going to be a widespread concern?

I think it's going to be a very small percentage. If you accept the statement that the peak of this infection in the U.K., in London, was at the beginning of April and that this Kawasaki syndrome happens in two or three weeks after you've been infected, probably the highest number of kids infected with this virus was in early April.

I can't see any reason why you'd expect that a great big wave of this is yet to come. There will be more cases, I'm sure. But no, I think all the evidence that I'm aware of says this is a very rare but nasty complication.

There are a very small number of fatalities. Most of those affected do recover. Most don't need intensive care and ventilation; only a minority do. That said, the secretary of state for health is right to say he's worried about it because it's a very nasty thing.

Prime Minister Johnson has said that four percent of people have had the new coronavirus, and some estimates have been as high as 25 percent. What do you think the infection rate is?

Based on the best information we've got, and the antibody testing which is imperfect and not terribly sensitive, my guess would be that around 20 percent of people living in London have had COVID-19.

If London is ahead of the rest of the country by at least by a couple of weeks, do you expect those numbers to be replicated across the country?

I'm not quite sure what a reasonable guess would be. The hope would be that London will be unique.

It had a rapidly expanding number of infections early on, partly because of the density of the population, partly because a lot of travelers were coming into London, so there were a lot of transmitters, more than in the rest of the country.

The lockdown happened simultaneously [as cases in London spiked].

One would hope that the prevalence of infection in Aberdeen will be considerably lower than it ever has been in London because the lockdown happened before there had been a lot of infected people. I think there'll be geographic variation like in Australia, where Melbourne has a significant number of cases, Perth has very few.

Do you think we are prepared for an end to lockdown? Is contact tracing up to scratch and have all the causes of criticism around a lack of preparation been fixed?

I think they are being fixed.

Where we've been found wanting in the U.K. has been largely around logistics in relation to testing and PPE. The way the NHS has responded has been amazing, brilliant.

And the fact that we weren't overwhelmed just demonstrates the capacity of the NHS to flex in response to a crisis. And I think that's been really impressive. And the weekly claps have been deserved. Everybody's done a fantastic job.

The NHS has always been one of the most-loved institutions. Do you think those claps and goodwill will turn into something more long term and more meaningful--that turns into policy, helping increase funding to the NHS?

We should do a piece of work on how science and technology can help to create a sustainable health and care system. It was very striking in the run-up to the last election that all the parties were trying to beat the other parties in terms of 'I'm going to put more in.... I'm going to put more into the NHS', et cetera. And it's just unsustainable.

If you look at the increased fraction of the public purse that's going into the NHS, it just can't go on indefinitely. So my argument is, we have to do things differently.

And technology may allow us to do things differently. And I'm talking about the very obvious. And again, I think it's another dividend of this pandemic because there's been an awful lot more online consultations. And I may be about to start doing some work with [online primary care provider] Babylon Health.

You download the app and you get a checkbox and you tell them what you're feeling and they all say you should go and see your GP or you should go and have a hot toddy or whatever.

I think they [the NHS] are thinking really intelligently about how to not to waste a good crisis, as it were, and use this disruption to accelerate some very sensible things: reconfiguring specialist services, consolidation, getting the right distribution of critical care beds around the capital and thinking about more uses of AI and online consultation.

Support for the NHS from the public will quite possibly be even warmer. That's true. But I don't think that should mean we just go on pouring money into the NHS.

It means we've got to say, okay, how are we going to do things differently and what can we learn from this?

The reason I said logistics was an issue---take testing for example.

We have this bizarre and rather frustrating situation that we had a lot more capacity than was being used. So that was true even on my local patch, putting my Kings Health Partners hat on. We had, just in the NHS diagnostic labs, capacity to do three thousand tests a day and we were doing a few hundred.

With the university, we worked to expand that capacity by bringing some of the research labs into work in partnership with the NHS. We can now do seven thousand a day and we're doing way less than that with another £750,000 investment. We can get up to 13,000 a day.

That's just in Kings Health Partners. You can replicate that around the country in academic medical centres and large diagnostic facilities. It's a very large capacity on top of that, of course. Instead, you've got these testing factories set up in Milton Keynes, Alderley Edge and Glasgow.

It's a moot point as to whether that was the right approach but the problem has been a logistics one. You've seen these photographs of NHS workers on their day off, feeling rough, driving to an IKEA car park and giving four hours to get swabbed. It doesn't look like state of the art, 21st-century logistics.

What we're testing now, in care homes in South East London, is whether people can self-swab. It looks as though it probably does work quite well so then you can just post the swab through the letterbox.

Pretty much everybody in the population could do this if they feel unwell in any way: self-swab, then a Deliveroo, CitySprint, Uber delivery driver comes around and picks up the swabbing, takes it to the lab. That's the sort of logistics we need for rapid access, testing capacities and then contact tracing.

We need to know how this NHSx app performed in the Isle of Wight. But if we got something like that rolled out to rapidly identify the contacts, to test them and then isolate people, we'd be in a much better position.

Should everyone be tested?

I'm not sure that's necessary. Most adults do get symptoms if they get it so testing anybody who's symptomatic, even if the symptoms aren't entirely classical, along with contact tracing and testing contacts, is very, very deliverable.

Antibody testing will be very useful to assess the level of herd immunity. But there are still unknowns here. What fraction of people who have the virus develop an antibody response? That's question number one.

Question number two is, if you have an antibody response, does that mean that you are immune? Number three is, how long does that immunity last?

On the first of those questions, we've looked at patients who've been through our hospitals and therefore, by definition, have been sick.

And 95 percent at least develop an antibody. 'Seroconversion' is the language we use.

I don't know the answer to whether this is true for patients who have a mild illness that just went to bed for a couple of days at home and had a cup of hot toddies and got better, or even kids who had an asymptomatic illness.

What fraction of those people develop an antibody response that you can measure?

I don't know of any convincing evidence that people get reinfected. There are a number of claims that have come up in the press. There was some data I saw from South Korea where it was claimed that some people had been reinfected.

But actually they've revised that now, saying there were some false positives.

Is there a scientific split between people who think there is immunity and people who think there isn't?

There are some people who had SARs who got reinfected. That is probably the strongest argument for saying, look, don't be too confident that if you had COV-2, even if you got an antibody response, you're really protected.

But the reinfection was a much milder illness than the first infection. One of the striking features of the immune system is that it does have a memory.

Even if the immune response you've had is not quite sufficient to prevent a second infection, it will certainly--or highly, highly likely--get very rapidly into gear to clear the infection faster than the first one.

So if you've got a neutralizing antibody against spike proteins [like the ones seen in COVID-19], I would expect you to be pretty safe from infection.

I know you're working on trials primarily based on treatment rather than cures. How much do we know about how to treat COVID-19?

The treatments on trial fall into three categories.

Firstly, there are the antiinflammatory interventions that are trying to address this collateral damage. In a cytokines storm, hormone-like chemicals are released by immune cells. If you have too much of it, it causes trouble like tissue inflammation or damage and organ failure.

Small amounts of them are absolutely crucial to immune response. So the fact it's called a "cytokine storm" implies we've got a hell of a lot. There are some trials of inhibitors and other anti-inflammatories to reduce that pneumonia risk that can be life-threatening in the most severely ill.

The second category is repurposing existing drugs. [Anti-viral drug] Remdesivir is the one that's had the most attention. It looks as though it reduces your length of stay and reduces virus severity in some people.

The third category is this convalescent plasma approach, which essentially borrows an immune response that a recovered person has made by transferring it into a patient who might benefit in helping them to clear the virus faster.

There may be others, but those are three categories of current trial.

I think we should reflect quite carefully on how you can recreate the sort of intensity of focus and collaborative effort. It's very striking that the groups have been collaborating more than conventionally is the case to address this challenge.

Is the end of this crisis a vaccine? And is there any clue to when that might be?

The two U.K. vaccines that are into trials now are the [University of] Oxford vaccine and the Imperial [College, London] vaccine.

The Oxford one has taken a vaccine that they developed for MERS, which was a Middle East Respiratory Syndrome, a very nasty coronavirus. So they made a vaccine using this technology against MERS and that proved to be very promising.

They've taken the Cov-2 sequence, a spike protein sequence, and replaced the MERS sequence. And that's the basis of the vaccine.

And so I certainly give it a 50/50 chance of success.

From first principles, I would say there is a good chance of getting an effective vaccine. I'd say better than 50/50. We should know a fair bit about the efficacy of the Oxford vaccine in humans by September.

Then you've got the challenge of manufacturers scaling up. And you know, [you've got] Bill Gates in the wings offering to fund that and some of the pharmaceutical companies prepared to turn some of their infrastructure to do that. So I think that will happen with unprecedented haste.

But amidst all this, it's really, really important to celebrate the extraordinary progress, not just the pace of progress. The first case of COVID-19 was the 12th of December last year. The virus was sequenced by the 2nd of February this year. The fact that there's a vaccine being tested within four or five months of this thing starting is absolutely remarkable and I don't think people should lose sight of that.

It's quite possible that there will be a vaccine for use in early next year. The question then is, what would you do with your vaccine?

I was expecting problems in some low or middle-income countries in Africa.

They've got no health system organized across those countries, the underlying health is poor and they're poorly nourished. And so they're just sitting ducks to something like this.

I thought: as soon as the virus gets into Africa, we'll see what happened.

But it hasn't happened yet. I can't explain that. But if it does happen, you could say that the priority for the vaccine is for the most vulnerable populations on the planet because otherwise they'll go on spreading to the rest of the world.

Or you could say, we will vaccinate the elderly and diabetics in the U.K. first.

That is an interesting problem I don't have a ready-made answer for.

When it comes to those vulnerable people, there is a stark difference between fatality rates of black, Asian and minority ethnic populations compared to white people. Do you have any idea about why that might be?

It sounds genetic. The bottom line from our own analysis is that the main difference is that the average age of the people who get sick in the BAME [Black, Asian, minority ethnic] population is significantly lower than the average age of the Caucasian population who get it.

But time will tell. There's obviously a lot of genetics work going on because we simply don't understand why some people get a very mild illness and some people get really sick.

I suspect there is a genetic propensity in how the immune system varies between individuals but this has still to be determined.

How real is the risk of a second COVID-19 wave happening? Does that change across the world or is it a global problem?

There absolutely must be a risk but it depends very heavily on two things: It depends on the prevalence of infection and it depends on the R values of the prevalence of infection that we badly need to know. I'm sure data is being gathered as we speak.

We badly need really good testing and contact tracing. But if we do start to see spikes in particular geographies, provided we can detect those quickly and say, 'Okay, right, well we actually need to close X' and all those people self isolate and quarantine themselves and trace the contacts, then I think we won't get a second wave.

We'll just get spikes in localities. But if we don't do what I've just said, then clearly there is a risk of a second wave.

The second wave would be very tough because I would be worried about how people would respond to being told to go back into their burrows. There's a risk of social unrest if we had to re-lockdown when people were beginning to breathe again. There is also the concern of next winter. What do we need to do to avoid a crisis in the winter? The nightmare scenario would be a second wave of COVID-19 coinciding with winter flu.

Is that likely?

No, I think it's absolutely not likely just if you're thinking about worst case scenarios, I'd say it's the worst-case scenario.

I think that it'll be crucial that we have a really, really vigorous flu vaccine campaign more than ever before. But it depends on containing the numbers, testing, contact tracing and people cooperating and then behaving appropriately if they test positive.

How very different is Trump's response in the U.S. and how has the U.K. learned from that?

What has been concerning to watch is the inconsistency in messaging of how serious an illness this is. In the early days, it was very much played down, then it became a crisis, then inconsistency about what is and is not safe in terms of when to relax rules.

I think the biggest difference will be exaggerating health inequalities and the impacts of the economic downturn. I heard that one in four Americans could be unemployed. I can't believe that I'm surprised to hear that. The absence of a safety net in the U.S. has always been a vulnerability of the U.S., I think, but it is really graphically exposed under these circumstances.

The negative impacts of this on population health will be much more severe, I suggest, than the impact of this virus itself.

Correction 05/22 11.00 EDT: A previous version of this article incorrectly referred to "Seroconversion" as "Zero conversion". This has been corrected.