Britain and Germany are not identical; we have slightly different cultures, different political systems, different demographics. But as countries go, we’re pretty similar. We’re both middle-sized-to-large countries — there are about 66 million of us, about 83 million of them. We are both western European democracies with temperate climates. They’re the 16th richest country in the world by GDP per capita; we’re the 21st. We both enjoy beer and football. It’s hardly comparing apples and oranges.

And yet, somehow, British people have been dying at six times the rate of German people, from a disease that both countries could see coming at the same time. I wanted to ask around a bit and find out why.

The short version is that there are several factors, of varying importance — but, probably, none of them is magic, or hidden, or mysterious. There’s no obvious need to posit “immunological dark matter” or illegible cultural factors. Germany was better prepared and reacted faster than Britain did, and in some ways got lucky, while making some mistakes of its own; it had a political system and, of course, politicians, which were better suited to the moment; and together, those factors added up to keeping several tens of thousand Germans alive.

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The key factors, in particular, appear to have been that they took measures earlier, and that they were better at protecting the most at-risk people. Those decisions came at significant cost, economically and to people’s lives – but, I think most of us would agree now, they were worth it.

Here’s the longer version.

First, the political system. Germany, unlike Britain, is very decentralised. It is a federal country of 16 states. Each state is itself broken down into smaller units, each with considerable autonomy over public health measures. The local health authorities all report into the centralised Robert Koch Institute, which is the main public health body, a bit like the US Centres for Disease Control, but often make decisions on their own.

According to Jens Spahn, the German health minister, speaking with Jeremy Hunt at a Policy Exchange event in July, this allowed more rapid responses at local level: “In this crisis, there are unforeseen things, and it means you have to handle things very pragmatically. It can help to have many different players who are self-organised.” If you have cases rising locally and the autonomy to do something about it, you don’t have to wait for central authority to order you to do so.

One direct example of this is the track, trace and isolate (TTI) system, which in Britain so far – I think I’m being fair in saying – has been an expensive failure. In Germany, the TTI system was always very obviously under the remit of the local public health authorities. “Doctors had to report a positive test to the public health authority; the authority had to report it to the Robert Koch Institute. Then there were manual forms that were given straight to the doctor, who had to get numbers and call everyone up, find out the symptoms, get them to isolate,” says one senior German public health expert I spoke to. There wasn’t a single central body trying to run a one-size-fits-all system across hundreds of disparate local authorities.

It also allowed different regions to try different things, which could then provide feedback on what works and what doesn’t. The public health expert told me that Jena, in eastern Germany, was the first “to implement a requirement to wear masks, which in Germany at the time was considered an infringement of personal freedom – silly when you think about it! – and they had much lower infections, so it led to it being implemented elsewhere”.

The health system had other advantages. Spahn pointed out to Hunt that Germany’s intensive care units (ICUs) had very high capacity by the standards of its peers, and – also important – most Covid-19 patients were not treated in hospital at all, but by community GPs. That prevented the hospitals getting overrun, and reduced hospital transmissions. 

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One huge advantage Germany had early on was testing. In January 2020, shortly after China made the SARS-Cov2 genome public, researchers at the Charité hospital in Berlin developed one of the very first Covid-19 tests; it was swiftly adopted by the WHO. By 1 February, all the passengers on a flight from Wuhan landing at Frankfurt international airport were tested, and two of them were found to be asymptomatic carriers of the disease. Being able to check at the border like this so early meant it was much easier to keep the disease out of the country.

Germany imposed widespread testing early on and continued – Britain, overwhelmed in the early months and following a pandemic flu plan which assumed that it would be impossible to continue testing all at-risk people, limited testing to hospitals and other high-risk areas in early March. By 1 April, Britain had performed around 150,000 tests in total; Germany, around a million. Germany was much better able to see where its outbreaks were.

It was also much more able to follow them, because its contact tracing system was largely in place via the localised public health authorities and the Robert Koch Institute, as we mentioned above.” I’m not sure if this authority had a lot to do for the last 20 years,” says my public health expert, “but in this moment it was crucial.” They also kept it well-staffed, recruiting medical students, firefighters and other groups to stop it from becoming overwhelmed. It also developed a functioning app much earlier. This means that it is now able to trace essentially every case of Covid-19; Britain, as yet, is not.

No doubt it was also helpful to have a scientifically engaged leader who led by example. Angela Merkel declared early in March that Covid-19 was the biggest threat since the Second World War – my public health expert said that “she never does that, she’s not a drama queen”. She was very involved in the Ebola crisis and is interested in public health and global health; this played to her strengths. She also led by example: “She goes to some European summit and the Italian PM tries to hug her and she veers away.” The public health expert drew a comparison with examples given British politicians – Boris Johnson proudly shaking hands; Dominic Cummings breaking lockdown rules. It’s only speculation, however, whether it had a major effect.

But there do appear to have been two really crucial steps that Germany took. The first was protecting the elderly and vulnerable – in quite a severe way. Britain’s great mistake, well documented now, was discharging patients from hospital straight into nursing homes, with no quarantine or testing. In Germany, this was not allowed – no patient could go into a nursing home from hospital unless they were able to be quarantined for 14 days first, or, later, until a test came back negative.

Spahn said that these measures were stringent: “We had some big incidents where too many care home inhabitants died in an outbreak, and we could see how brutal this virus was for very old people.” So they prevented all contact – “no visitors at all, even your partner – 50 years of marriage, but still not allowed to see each other for days or weeks”.

It came at huge cost to mental health and happiness. “It was a choice between the devil and the deep blue sea,” said Spahn. “The social consequences and health consequences that came with the distancing were hard. You have to balance between the harm of the virus and the social distancing, and we were on the side of being very cautious.”

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Schools were closed suddenly; nurseries too. Hospital visiting was limited to the point where fathers couldn’t attend their children’s birth. This was hard and painful – special-needs schools were shut down at short notice, support for parents of disabled children stopped coming with no warning. “It had a huge impact on mental health,” my health expert said. “There was a genuine attempt to protect vulnerable communities from superspreading events, but at the same time there was a lot of collateral damage on the health and happiness of everyone involved.” It was immensely controversial.

It seems, however, to have had a huge impact. Our World in Data reports that by late May, only 19% of Covid cases in Germany were among the over-70s, compared to 36% in Spain and 39% in Italy. And that meant that fewer people died: just 4.6% of those tested positive by May in Germany, compared to 14.1% and 12% in Spain and Italy respectively. Younger people are at much lower risk from the disease.

The other really key difference is that Germany simply acted faster than Britain did. Both countries were able to watch the progress of the disease in China, and then in Italy, at the same time. But as the virus started to arrive inside their own borders – more slowly in Germany, perhaps because of the more rapidly available testing system, perhaps because they imposed more stringent border controls earlier – Germany was ahead of Britain in every decision it took.

For instance, on 22 March 2020, a total of 252 people had died in this country, compared to 67 in Germany. But Germany introduced its own version of “lockdown” right then, on the 22nd; Britain didn’t enter full lockdown until the following day. According to an Oxford University index of how stringent government responses were – looking at measures such as school closures, stay-at-home orders, restrictions on gathering, and transport bans – Germany had stricter measures in place than the UK from late February right up until the 23 March lockdown, despite having a much more well-controlled outbreak. Britain, like the US, tried to avoid the economic consequences for as long as possible – Germany simply decided it would risk them, after seeing events in Italy and Spain. In hindsight, this appears to have been the wise decision, both from a public health point of view and an economic one.

We should note that “lockdown” in Germany meant something very different from what it meant here: Spahn said that it was closer to a Swedish model, where people were encouraged to remain home where possible and to avoid standing close to each other, than to a Spanish one, with troops in the streets and enforced curfews. But Germany did take measures earlier than its peers, and never needed to be as strict as some because its outbreak was always better-controlled.

Germany was also lucky in a lot of ways: the early outbreaks, for example, tended to be among healthy middle-aged people returning from skiing holidays in northern Italy. That meant the first patients tended to survive, and also avoided immediate outbreaks in the care system.

There may have been demographic advantages, too, – the epidemiologist Adam Kucharski of the London School of Hygiene and Tropical Medicine speculated to me that the smaller average household size in Germany may have been a factor, although likely only a small one.

Also, the fact that Germany was so well-set-up is partly the luck of the cultural draw. As the public health expert points out, the country has a proud tradition of public health, going all the way back to Robert Koch himself, the great 19th-century public health doctor and rival of Louis Pasteur. The strong pharma, epidemiology and virology landscape were all important, but the current German government can’t take a large fraction of the praise for them.

Finally, Spahn said, even the fact that Germany shut down when it did was, in part, luck. “We didn’t know back then if this is the right time,” he said. “If it’s too early, too late. But it seems to have been just the right moment to get it down before it could really spread.” He remembered a meeting with other health ministers shortly before lockdown, when Italy and France were the only ones having major problems. “Then Spain had to lock down, a week later. It was really a question of one, two, three weeks.” Small differences in time made a big difference in outcome, and, he says, Germany’s decision involved some good fortune.

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It should also be pointed out that not everything went well for Germany. As well as the backlash over the strict and heartbreaking rules around nursing homes and hospitals, there was a shortage of PPE for a long time, just as in Britain; and also, there was long-lasting resistance to wearing masks. 

But we don’t know whether this is the whole story, and I’m not sure we ever will. It’s not as though we can run the experiment again, randomly assigning different policies to Germany each time, and without that almost all of this is little better than informed speculation. Certainly, though, the factors listed above are probably a large part of why so many Germans are now alive, when so many Britons are not.

Britain’s facing a resurgence now – as I write, another 143 deaths have been announced, roughly as many as died on 25 March, two days after lockdown (although note that I’m comparing deaths announced today with deaths that actually took place on that date, so not quite the same thing). In Germany, meanwhile, numbers are much lower – while the UK has seen numbers like 60, 70, 80 over the last few days, Germany has had numbers like 10, 12, 16. It’s about the one-to-six ratio that we’ve seen for the entire pandemic.

Can we learn from Germany’s success? Acting fast, protecting vulnerable people, giving autonomy to local and regional authorities – these seem to have worked there, and perhaps they’ll work here. But perhaps we don’t have the deeper structural and political arrangements (and the political personnel) that allowed Germany to move so fast and be so agile. I hope it’s the former. 

*Usual caveats about the ways deaths are recorded apply. These are confirmed deaths, not excess, so it’s an underestimate in both cases, but I think we’re dealing on roughly the correct scale.

The dietary supplement industry knows this, but it wants you to buy its vitamins anyway. It can’t say “Buy our vitamins, they’ll make you healthier,” because that’s not true, and they can’t say “Buy our vitamins, you’ll piss them straight down the toilet,” because that’s not the most effective sales pitch. So they choose a third way: they make a true scientific statement which heavily implies, without ever quite saying, that the supplements will help.

For instance, they might say “iodine contributes to normal growth”, or “iron contributes to normal cognitive development”. Both of which are entirely true. But what they don’t say is “taking our iodine supplements will help your children grow”, because as long as your child is getting a healthy, varied diet, it won’t. Your child will essentially be acting as a middleman between Holland & Barrett and the sewage system. The supplement producers have not broken any advertising rules, but – I would argue – they have not been completely honest about their product’s effectiveness, either.

Recently, the Government agreed a £161 million deal with a British company called DnaNudge to provide 5.8 million Covid tests, as part of its “Moonshot” programme for mass testing of the population at the point of care. The CovidNudge test is “a rapid, accurate, portable and lab-free RT-PCR test that delivers results at the point of need and in just over an hour”, according to DnaNudge’s own promotional material. DnaNudge is a spinoff company of Imperial College London.

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The CovidNudge test is what is known as a lab-on-a-chip, or chip microfluidics: it carries out a PCR (DNA) test at small scale, using vanishingly tiny quantities of sample. “Chip microfluidics are exactly what they sound like,” a microfluidics academic who has his own spin-off company told me. “It’s the classical image of a scientist with a pipette doing mixing different mixtures, heating, cooling, running it in a big instrument, except it’s doing it all on a single chip the size of a matchbox.” 

CovidNudge, as I understand it, is a classical PCR test. Users take a swab sample from the mouth and test the mucus for the viral genome. There’s one difference – the SARS-Cov2 virus doesn’t have DNA, it has the related molecule RNA, so CovidNudge has to look for that instead. That means it has to include one more step that a normal PCR test doesn’t have, a reverse-transcription from DNA to RNA, so it’s called RT-PCR. None of this is new or revolutionary technology – it’s essentially next-generation sequencing, which has been around since at least the late 2000s – but it is solid. 

I am a little concerned, though, for several reasons. One, while I’m happy to accept that the test does indeed detect Covid, there is a shortage of good evidence that it’s as effective as we would like or need. Two, there are a few questions over its procurement — the timeline is a bit strange. And three, DnaNudge’s other, non-Covid-related products, and those of its founder Christofer Toumazou, seem to be advertised in a way that is somewhat reminiscent of those vitamin supplements I was just talking about.

Let’s look at these in order. First, the evidence. Because DnaNudge is a private company, it – understandably – doesn’t release all its research. That’s fine, but when a company is in receipt of £161 million in taxpayers’ money for its scientific products, some sort of evidence that those products work is probably in order.

Luckily, a study was published last month in the journal Microbe, a subsidiary journal of the Lancet. It took two samples from each of 386 patients. One sample from each patient was tested for Covid-19 in a laboratory; the other was tested by the CovidNudge kit. The results were then compared, to see if CovidNudge spotted all of the positive cases that the lab tests did.

Superficially, the results were quite promising: 71 of the 386 patients tested positive in the lab; CovidNudge detected 67 of them, suggesting that it was 94% as sensitive as the full laboratory test. And it had no false positives.

There are some concerns, though. First, this is already a small sample; an effective sample size of 71. I’d be pretty wary of placing a £161 million investment on the back of it. Second, 94% sounds pretty good, but it’s far from perfect. A biotech investor and former academic I spoke to said “If you take today’s numbers, we had about 6,000 new cases [when I spoke to him in late September]. That means this test would tell about 360 [infected] people that they’re fine and don’t need to isolate.”

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In their response, DnaNudge say that “symptomatic individuals should remain in isolation regardless of negative tests”. But NHS guidelines under the current testing regime say that if someone tests negative, then they don’t need to self-isolate unless they feel unwell (which is not the same as being symptomatic).

And there’s a more specific worry. The study validated its own work by not only checking for SARS-Cov2, the virus that causes Covid – it also looked for human RNA. If the test came back negative for that, then they decided that the sampling must have been ineffective. As well as the 386 valid samples, there were 32 invalid ones, 24 of which were being tested with CovidNudge. The other eight were samples tested in the lab.

That’s fine – sampling is imperfect. The concern is that those failed results were then excluded from the analysis. Of the 24 invalid CovidNudge tests, 22 had a corresponding lab test. Of those, apparently, “16/22 (73%) tested negative”. I take that to mean that six of them tested positive. If I’m right, that means that instead of CovidNudge detecting 67 out of 71, it detected 67 out of 77, reducing its sensitivity to about 87% rather than 94%. “I don’t know how it got through the Lancet, honestly,” the microfluidics expert told me, meaning Microbe, the subsidiary journal. DnaNudge say that the invalid tests can be redone, which, they say, would mean this is less of an issue. 

And just as important, this testing is under ideal situations, run (presumably) by highly qualified testing staff in a laboratory situation. If 5.8 million of these tests are built and rolled out, then the overwhelming majority of them will not be used by experts but by ordinary people after a few minutes’ training. It is hard to see the errors in the sampling process becoming less of a problem. “PCR is a very sensitive technique,” said the biotech investor. “Once you let it loose in the hands of people who are not well trained, that 94% will get lower.” DnaNudge suggested the best case for sensitivity was actually 98% and that this figure would not get lower as the test was simple to operate. 

None of this is devastating to CovidNudge, but – again – I’d want to ask a lot more questions before giving the company £161 million. DnaNudge say, in their response, that “CovidNudge is not being evaluated or deployed for community testing at this time,” which rather raises questions about what we’re spending all this money for.

Second, I mentioned concerns about the timeline of the procurement. According to the health minister Helen Whately, responding to a written parliamentary question from the shadow cabinet minister, Helen Hayes, the DnaNudge contract award was published in the Official Journal of the European Union on 31 July. Imperial College London announced it on 3 August.

Again, that’s fine, but I don’t know what the Government was basing its decision on. The Microbe paper – the only study so far carried out – wasn’t published until 17 September. It was published as a preprint on 15 August, but that’s still two weeks after the decision to award this contract was apparently finalised. It may well be that the Government had access to the data before it was made available publicly, but it’s hardly ideal, again with so much public money going into it. 

I put these serious questions about the timeline to DnaNudge, who confirmed they had awarded the contract prior to and in the absence of any peer review because “the study results [had] already been made available to the key groups using the CovidNudge test in clinical practice”. But they didn’t make it clear whether the Government had seen the data. If the Government had not, it is hard to see how the necessary due diligence could have been performed on such a significant contract. And even if they had seen it, the data would not have been peer-reviewed: the Government’s decision to avoid peer-review is questionable, given how important it is to the due diligence process.

None of this would be so much of a problem if the company had a track record in providing diagnostic PCR tests for viral illnesses – which, for instance, Oxford Nanopore, the other company granted money in the Moonshot programme, does. Nanopore was providing real-time PCR tests for the Ebola virus back in 2016. “If you wanted to drop the Moonshot budget on something,” says the microfluidics expert, “[Nanopore] have a longer track record and the technology they use is more precise.” 

The geneticist Adam Rutherford, who is on record expressing concerns about the contract award to DnaNudge, agrees: “[Nanopore] is tested in the wild, it’s a reputable and good company who do quick-turnaround DNA sequencing for scientists who use it.”

That is not true of DnaNudge, which Rutherford says on Twitter “tests the boundaries of where direct-to-consumer genetics meets snake oil”. Their main product is a DNA test (“NudgeBox”) that, they say, reveals  “your genetic predispositions and risk levels – red, amber or green – to a number of nutrition-related health traits”, and uses that to tell you what foods you should avoid. It comes with a wristband (“colour-customisable DnaBands”) that you can then wear to the supermarket, and use to scan the barcodes of food products. It will then “[flash] red or green to tell you if it’s a good match for your biology”.

Which brings us back to the vitamin stuff. It’s not that our DNA tells us nothing about our diets. When scientists carry out enormous genome-wide association studies (GWAS), looking at tens or hundreds of thousands of subjects, they often find statistically significant correlations between certain “single-nucleotide polymorphisms”, SNPs – that is, single letters of DNA somewhere on our genome – and, for instance, our ability to digest certain foods. But they’re the sort of correlation that requires a sample size of tens or hundreds of thousands to detect. 

“They work at a population level, not individual level,” says Rutherford. “So the identification of those variants might have literally no effect on the individual, but at population level might have some statistically significant role in processing sugars per carbohydrates or whatever.” 

So while the DnaNudge website shows examples of its NudgeBox saying that Heinz Baked Beans are suitable for someone’s DNA profile but that Heinz Organic Tomato Ketchup isn’t, it’s just not plausible that a DNA test could tell us that, at an individual level.

DnaNudge say, in response, that their NudgeBox uses “well-established genetic markers that relate to the genetic risks for obesity, Type 2 diabetes, hypertension, and blood cholesterol”, and that by helping users make better food choices, they can postpone those diseases. But, says Rutherford, “Any geneticist would tell you that there’s nothing that this test can tell you that’s more personalised than ‘eat less doughnuts and more lettuce, and do more exercise’.” 

DnaNudge also say that their product might recommend, for instance, that users replace “Paleo Foods Co. Honey & Pecan Grain-Free Granola” with “Essential Waitrose Porridge Oats with Wheatbran”, and that by doing so for a year, you would consume 135,200 fewer calories and expect to lose nearly 8lb in weight. But that would be true whatever your NudgeBox told you.

Toumazou, the founder, was previously the scientific adviser to another company called GENEU, now defunct. It had a similar idea – it would take a PCR test and use it to give personalised DNA information, except this time for cosmetics. They had a shop on New Bond Street in London and an “exclusive” deal with Selfridges; its creative director was the Duran Duran keyboardist Nick Rhodes.

The idea was that you would pay £200, do a DNA test, have a consultation, and then an hour later you’d get your genetic report and advice and your profile-matched skincare products. Again, this just isn’t something that DNA tests can reasonably do – or, at least, if your skin is greasy, you don’t need to know that you have some SNPs that make it more likely that your pores will overproduce sebum. You can already tell that your skin is greasy; the DNA test doesn’t add anything new.

Toumazou “is a great inventor”, the biotech investor I spoke to said. “The work he has done is groundbreaking and phenomenal on building models of human systems. He’s a world leader in that, no doubt.” But, he says, the problem is overhyping. “I’m a cheerleader for these technologies,” he says. “But I’m also the guy who feels I need to protect them from overhype. I’m in the business of investing for a long time, 10 years, and what we don’t want is that there’s a flash in the pan and everyone hates it and no one invests in the long run.” DnaNudge is “overstating what DNA can do for us”, he says.

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The microfluidics expert agrees: “It’s an example of using a technology that doesn’t really work but they’re very precise on what they claim. ‘This [SNP] has been shown to be involved in diabetes,’ yes, but so are a million other things.”

Another microfluidics scientist, who works in the private sector, is a bit more cautious, but essentially agrees. She says it’s “not rubbish science, it’s more like lipstick science. ‘This is what you need to eat for your genetics’ comes across as bull, but there is genuine science behind it. But you need to look at hundreds of thousands of people to get a proper signal.”

The scientists I spoke to also raised concerns about its scalability, wondering whether they have the facilities to build the millions of testing boxes needed – DnaNudge made a loss of £9 million last year, which isn’t unusual for a relatively new startup, but does, according to the biotech investor, raise questions about how they’ll be able to “raise the capital to build the hardware”. DnaNudge did point us to the fact they have announced two manufacturing agreements which they say will facilitate production at the required speed and scale. 

One scientist suggested that the use of point-of-care tests like CovidNudge are a strange way to go, when there are 150 or so laboratories around the country, in universities and testing facilities, that could perform the tests more rapidly if you can get the swabs to them quickly. “Ramp up the facilities, ramp up the testing,” he said. “I can get a McDonald’s in 10 minutes from Deliveroo, I can get those turnaround times down.” It’s not as sexy, it doesn’t have a beautifully designed box, but it would probably work. And then you’d have a testing infrastructure that would be in place for the next pandemic. The other scientists I spoke to all agreed.

Or if you do want to do point-of-care tests, then there are other companies that have been doing it for a long time. Oxford Nanopore is one; GeneDrive is another; the Cambridge researcher Helen Lee developed the “SAMBA” lab-on-a-chip years ago which tested for HIV in sub-Saharan Africa.

More important, though: the really key thing we need to sort out is track and trace. That’s “the cornerstone of fighting the pandemic,” according to Rutherford, and at the moment it doesn’t seem to be working. 

So what I think we need to know is how the Government knew CovidNudge would work — and agreed to spend vast sums of money on it — before anyone had even seen the data. It’s one thing to piss a fiver away on vitamin supplements, but pissing £161 million on a Covid test from a company with no track record in disease diagnostics is quite another thing.

But we do need to start coming out of it soon, or the cure will become worse than the disease. So we need a way of returning to a sort of normality, and allowing the economy to restart, while avoiding that second wave. 

“Test, trace and isolate” — finding infected people, tracking down the people they’ve been in contact with, and getting them all to isolate for a period — is the most promising avenue, and the government says that it has put in place a “world-beating” system. But their handling of the testing regime — full of self-congratulatory bluster and statistical malfeasance — has not instilled confidence; and while the first tranche of results from the system have been reasonably promising, it has been slow to be developed at all, so it is already fighting uphill. So: can it work?

Well, one interesting paper just published by researchers at University College London looks at the impact contact tracing will have on the economy relative to lockdown. I spoke to one of the authors, the policy researcher David Manheim, to find out whether test and trace could indeed work for the UK. 

Some caveats: modelling is inherently uncertain. Manheim says that the model is robust — the headline outcomes remain broadly consistent even if the assumptions and inputs are tweaked — but it’s just one paper, and so far not peer-reviewed. As the situation develops we can compare its scenarios with reality.

It is worth noting how bad the two extreme situations, “doing nothing” and “staying locked down”, are. The most widely used estimate for the infection fatality rate (IFR) of Covid-19 is about 1%, and that’s what the paper uses. (UnHerd has spoken to various people who think it’s lower than that, and I perhaps over-optimistically predicted a few weeks ago that it would be below that level, but that seems to be the standard estimate.)

So here’s the background situation. If we come out of lockdown entirely, without any attempt at tracing and isolation, the paper estimates that between 60% and 80% of the country would end up infected, and between about 250,000 and 550,000 people would die. People will correctly point out the average age of death is over 80, but nonetheless it is a brutal toll.

On the other hand, if we try to reduce spread by only using lockdown, with no testing or tracing, then “we are likely to need lockdown for three of every four months (or four of every six months)” until the development and availability of a vaccine or highly effective drug treatments. That represents an extraordinary hit to the economy — in the worst case, around £1.2 trillion GDP lost by May 2022, when their models ended. To put that in context, the UK’s GDP in 2019 was about £2.2 trillion. We are talking about roughly a quarter of the entire UK economy being mothballed, with all the knock-on effects to health, wellbeing and happiness that entails.

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What you need is some sort of way of targeting your interventions. “Think of it as a continuum,” he says. “How good is our ability to figure out if someone has Covid? If we have no ability, then it’s ‘shut everything down’. If we have some ability, then you can isolate people purely based on symptoms. That reduces spread significantly, but isn’t enough on its own.”

“If you add testing, it gets better, because testing has a lower false negative rate than symptoms, and it catches it little earlier. But tracing catches it much earlier: you isolate everyone who was in contact with this person for two weeks.”

What testing and contact tracing allows is for people to go about their lives in some fairly normal way, and for something like a fully functioning economy to get underway. But the question is whether the scale of the system needed to do that is 1) plausible and 2) available at a cost worth paying. If it would cost a trillion pounds to put one in place, then it wouldn’t really achieve anything over remaining in intermittent lockdown.

“What we model in the paper is: how many tracers would you need?” says Manheim. It’s not a small job: the paper assumes that it would take almost exactly a full week’s work (37 hours) for one contact tracer to follow up all the contacts of a single infected person, including interviews with the subject and their contacts, arranging testing, and doing follow-up monitoring calls. 

Still, the basic result, he says, is that when case counts are relatively low, it is possible to identify and track enough of them to keep the rate of transmission down, at a cost that is relatively manageable. But “when there are too many cases, the costs of tracing are completely out of hand”, he says. If you have millions of cases, then you need many millions of tracers, and it becomes implausible.

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By Tom Chivers

Eventually it becomes cheaper simply to test literally everybody once a week — which ends up being about 10 million people a day — and requiring people who get positive tests to self-isolate. And even that is cheaper and more manageable than the costs of lockdown — the paper estimates it would cost about £36 billion over the next two years to do that many tests, a fraction of the £700 billion hit to GDP (and the smaller but still huge hit to the public finances) that we would otherwise be facing.

Luckily, the UK is not in that situation. Despite the somewhat doom-and-gloomy atmosphere, case counts are down somewhere a bit more manageable. The paper includes several scenarios which loosen and re-impose lockdown on given “triggers” — when the number of daily cases goes above 40,000, it is reimposed, and when they fall below 10,000 it is relaxed. The daily number of lab-confirmed cases in the UK, as of Sunday 14 June, was 1,514; that’s probably a low number because the weekend interferes with data collection, but data from the KCL/Zoe Covid-tracker app suggests that there are fewer than 5,000 daily new cases at the moment. So we are in the “manageable with contact tracing” zone.

But is the testing and contact tracing system we actually have fit for purpose? The British government has been making very loud noises about meeting the targets it set itself, of 100,000 tests by the end of April and 200,000 by the end of May. But those numbers were largely nonsense: the 100,000 tests included tests put in the post but not carried out, and multiple tests being carried out on the same person; the 200,000 included those but also included antibody tests, which are good and important things but entirely different. (And both also referred to “capacity”, rather than actual tests carried out.) Radio 4’s magnificent More or Less team have been digging away at this dispiriting little bit of governmental misinformation for weeks. Sadly, the virus does not seem to be reading the Department for Health and Social Care’s press releases.

The actual, real number of individual people being tested is about 50,000 a day. That’s not negligible, but in the paper’s best-case scenario (which still involves many thousands more people dying than have already), we will need to test at least 75,000 people now, and about 300,000 people a day over the winter. That’s assuming that we have enough contact tracers in place – if I’m reading the paper right, somewhere around 80,000 “public health community officers”, ie recruits, and a smaller number of more senior people to manage them – to contact all the contacts of each person with a positive test result. 

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The system doesn’t have to be perfect. The paper assumes that 64% of the contacts are traced within a day, and then self-isolate; but there’s no guarantee they will do so; in Israel, where Manheim lives, there are legal sanctions — people who leave their home when expected to isolate are texted a warning and can be given a ticket or arrested — but that may not be feasible here. 

And, Manheim points out, we shouldn’t throw up our hands and say that the British Government’s difficulties with testing and tracing now mean that the whole enterprise is doomed: we can improve it. “The sooner we find out what does and doesn’t work, the better. You’re not going to have a perfect system on day one.” There have been reports of the contact tracers saying that they have signed up and not been given any work, which sounds bad, but “that’s like any new for-profit company building a new thing. The public sector isn’t going to magically do any better. The question isn’t whether it’s doing well on day one, but whether it’s doing OK on day 30, and doing well enough on day 60.”

That said, the Government has not covered itself in glory. “One big bottom line thing that I think is important is that this study should never have been needed,” says Manheim. “We’ve known we needed test-and-trace for a long time.”  They wrote it with the intention of showing policymakers what may and may not work. It may be, he says, that in two months we learn that the Governments’ systems that they already have in place could be scaled up fast, and will do the job. But even if they aren’t, it’s better to start now than to leave it. 

“What they absolutely can’t do, and is a danger in the interim, is print out giant ‘mission accomplished’ banners and declare they’ve got everything done.” It’s not easy for politicians to tell the population that we’re going to have a tough time for the next two years; you don’t get rewarded for that. So it’s easier, in the short term, to declare victory.

But in the end, the numbers of deaths and hospitalisations will be the yardstick of success, and they’re very hard to explain away. The temptation to soft-pedal, to pay lip service to test-and-trace but actually just quietly let lockdown dissolve, will be great, but then we could end up in the worst of all worlds — a huge economic hit due to the pointless 12 weeks of lockdown, and vast numbers of dead all the same.