s Spain, France and Germany start to struggle with rising Covid-19 cases, alarm bells are ringing again in the UK. Over the weekend, 3,000 new people tested positive for Covid-19 in a 24-hour period, and dozens of schools in England and Wales have reported outbreaks. While the number of hospitalisations is still low, the trajectory of the US, France and Spain suggest that hospitalisations tend to follow increased case numbers by several weeks. It’s impossible to have a high number of infections and community transmission and not have vulnerable or elderly individuals hospitalised. They live with and among all of us. It’s worth remembering that case numbers now aren’t comparable to those in March. Before, tests were only done on people who had been admitted to hospital. Now, symptomatic people are being tested outside of hospitals and in the community, along with their contacts. This means that we’re picking up infections and positive cases that we weren’t previously testing for. Nonetheless, after enduring the considerable pain of a prolonged lockdown, nobody wants to see the UK going backwards on the progress it has made. As numbers rise, ministers face difficult decisions about how to get on top of this situation and ensure schools remain open. If the government doesn’t do anything and lets the virus spread, hospitalisations will increase, deaths will follow and ministers will be blamed for not doing enough to suppress the virus. The economy will continue to take a hit and schools will probably have to move back to blended or fully online learning. This kind of situation is already playing out in Brazil, as well as some states in the US. A survey of parents across the US by the New York Times revealed that only one in seven children are attending school in person. Even Sweden closed upper secondary schools and universities on March 17 as its case numbers increased. But if the government moves early to limit the spread of the virus and lower the number of cases, ministers will then be blamed for overreacting and unnecessarily hurting the economy. This is a classic paradox in public health: prevent illness from occurring and then get blamed afterwards for enacting the measures that saved lives. Public health is about preventing illness, while medicine is about treating it. This also explains why governments often delay acting until public opinion has shifted or until health services are already strained. Several steps are necessary to manage the current situation. The government should commit to what’s often referred to as maximum suppression (“zero Covid” or “elimination strategy”), aiming to stop community transmission and keep the number of cases as low as possible. To support this, we all need clear, daily messaging from the UK government on the number of daily cases and tests (both the number of people testing positive and the number of people tested), and on how many cases are arising from hotspots, such as factory outbreaks. We need transparency on the underlying data, and blunt honesty from our leaders about the difficult position we’re in. Scotland’s first minister, Nicola Sturgeon, has not taken a holiday this summer, and continues to host a daily coronavirus briefing. She consistently provides much of this information to the public and explains the reasoning behind different measures. Some have suggested that letting young people become infected might help boost immunity in the population. But young people can also become seriously ill (particularly those with underlying conditions, which they might not even know about) and can pass on the virus to elderly and vulnerable individuals they come into contact with. We have a collective responsibility to watch out for these members of our community and make them feel valued and supported by following the guidance and changing our behaviour to avoid risky situations. Once cases arise, the testing and tracing system needs to be ready to put out fires. Testing needs to be accessible and available to individuals with results returned within 24 hours in order to be useful for tracing contacts. The system in England is not up to scratch. People are having to travel hundreds of miles in order to receive a test. Scotland struggled with increased demand for tests from children and young people in the first two weeks after schools reopened. Demand for tests will only increase in the coming weeks as people catch other winter viruses that cause similar symptoms to Covid and schools and offices reopen. “Super-spreading events” such as large house parties, religious gatherings and nightclubs can result in dozens of people becoming infected quickly. When these occur, the testing and tracing system can become strained as chains of infection move faster than tracers can identify contacts. At this point, local restrictions limiting visits to certain indoor places – whether these be clubs, pubs or indoor house visits – for a length of time might be necessary to give time for the NHS testing and tracing teams to do their work. These local restrictions should be introduced in a proportionate, and data-driven way and sectors that suffer as a result should receive targeted economic packages. It seems unlikely that the UK will have another national lockdown if these mechanisms are in place. For those feeling hopeless in the face of this pandemic, science is giving us reason for cautious optimism on a weekly basis. We already have three treatments that mean survival from Covid-19 is improving. Several promising vaccines are in phase 3 trials and mass, rapid, saliva-based tests are already being used in universities in the United States. Mass testing, or a vaccine, will eventually get us back to a more “normal” version of daily life, but these require time to deliver. And right now, as much as we would like to forget it, we are in the midst of a major global pandemic. No country in the world looks the same now as it did pre-coronavirus. Each government is making hard choices, and their populations are having to live with their consequences. • Prof Devi Sridhar is chair of global public health at the University of Edinburgh