Since its death toll surpassed Italy’s on May 5th to become the highest in Europe, the United Kingdom has earned the title of the ‘worst’ affected European country by the coronavirus. Two months ago, it looked unlikely that deaths in the UK would rival those in the worst-hit countries at the time, such as Italy and Spain, but currently, the UK’s official death toll is second only to the United States'. Understanding the reasons why the UK’s death toll is now exceeding those of its western European neighbours is probably the key to stalling both the present health crisis and preventing future pandemics.

Border

The first contributory factor to the climb in the UK’s death toll is the country’s loose border controls throughout the pandemic. Only as the UK begins to emerge from lockdown has a two-week quarantine period on arrivals been suggested for future implementation. In contrast, most countries globally have imposed a mandatory two-week quarantine period on all arrivals since mid-March. Instead, the UK has relied on the fast drop in passenger numbers to minimise the risk of imported cases. The UK’s divergence from the global trend has caused speculation that the country’s suffering has been worsened as a result of imported cases. Genomics of the virus will reveal whether this has been the case, or if the fall in international travel alone was enough to keep the UK from an influx of foreign cases.

Lockdown

A further factor considered significant in reducing the effect of the virus is the point in time that a country was put into lockdown. The UK government implemented a nationwide lockdown on March 23rd and, at the point of overtaking Italy’s death toll, had recorded over 32,000 deaths. Spain and Italy, who both implemented a countrywide lockdown at least one week prior to the UK, have both managed to keep their total deaths lower than the UK. While this could suggest that the earlier implementation of lockdown measures may be associated with a lower death toll, this does not stand in all cases. Germany, who imposed their lockdown only a day earlier than the UK, has managed to keep its death toll below 10,000 so far. This would suggest that the point at which the UK entered lockdown may not have been the instrumental factor in itself that has led to the highest death toll in Europe.

Test, Track, Trace

The extent to which a country has employed the ‘test, track and trace’ policy is also considered influential on its relative success against the virus. Now amongst the countries performing the most tests daily, the UK was slow to increase its testing capacity at the beginning of the pandemic. To put this into perspective, Germany had conducted approximately 1.3 million tests by April 4th whereas the UK had only conducted 300,000 by April 10th. Extensive testing at the beginning of the pandemic may have given countries such as Germany greater knowledge of how the virus was spreading through its population, allowing the government to isolate cases earlier to prevent further spread.

Demographics

Characteristics of the UK’s demographic may also have leant themselves to worsening the effect of the virus. Preliminary research indicates that the virus is highly contagious, on average infecting three people from one host, and then affecting the individuals’ respiratory system. With one of the highest population densities in Europe and an ageing population with naturally weaker respiratory systems, the British may be more susceptible to the virus than other nationalities. As knowledge of the virus grows, other characteristics of the UK’s population, such as high levels of urbanisation, a high level of adult obesity and specific cultural norms, may also point to vulnerability to the virus.

Reactive Policy

Since the beginning of the pandemic, the UK policy has appeared reactive, to date changing direction twice to maintain public support. Initially, a strategy designed to achieve herd immunity was employed. This assumed the general population would develop its own protection from the virus once a significant proportion had been exposed to the virus and so developed resistance. The anticipated resultant reduction in transmission would reduce the virulence to what the government assumed to be an acceptably low mortality rate. However, pushback from the population, perhaps affected by panic-instilling media reports of overrun hospitals in Italy forced the UK government to change course for the first time, to a tactical emphasis on preventing the health service being overwhelmed, something that was achievable, unlike a low death toll.

This short-term focus resulted in a nationwide lockdown to lower the transmission rate and so delay the impact of the virus on the health service. Government policy has now changed once more, driven by the imperative to resume commercial life, albeit in a measured release to avoid uncontrolled infection rates again. This latest phase may well benefit from the original objective of achieving some sensible level of herd immunity. Overall policy has remained flexible and adaptive to the demands of the public and the greater health crisis, but it is too early to judge the effects of these policy changes on the death toll in the UK.

Underreporting

At the present, when contrasting current death tolls, declaring the UK the ‘worst’ affected country in Europe is a logical observation, but it is a sweeping statement that overlooks nonequivalent comparisons. Differences in reporting standards and the extent of testing mean it is likely that there is currently under-reporting ongoing in many European countries (including the UK). While the UK includes deaths with positive COVID-19 tests in hospitals, care homes and at home, it also counts suspected cases of COVID-19 that were not tested, unlike Spain. While there is not a universal standard of measurement, fully conclusive comparisons cannot be made.

Furthermore, labelling the UK the ‘worst’ affected country in Europe is valid while information on the virus and its long-term effects are scarce, but as these subsequent realities become clearer, only focusing on a headline death toll will be a limited perspective. If the death toll in relation to population size were examined, Belgium would be performing ‘worst’ in Europe, recording 700 deaths per one million of its population, compared to the UK, who has recorded 400. If the extent to which civil liberties have been sacrificed in relation to the death toll was measurable, countries such as France and Spain, who have been temporarily living under a police state, could appear ‘worst’ affected. Furthermore, the cost of the future economic consequences of the virus, which eventually will reduce living standards and life expectancy, will likely be missed from the death toll of this pandemic. Therefore, the perspective from which one assesses the ‘worst’ affected country in Europe is likely to change over time, as the greater impacts from the pandemic become clearer.

The current consensus on the reasons driving the UK having the highest death toll in Europe, is that it is still too early to know for sure. However, without a clear universal measurement, the ability to make this conclusion is limited. Nonetheless, at this stage it appears that the UK has suffered as a result of demographic characteristics that may have hindered the effectiveness of government strategy. While time will pass before solid conclusions can be formed on which European country is in fact worst affected by the virus, and most importantly why, it remains important to continue learning from the varying strategies adopted by governments to prevent further loss of life.