Why Keir Starmer is Wrong about Tracing and Testing…for Now.

Why Keir Starmer is Wrong about Tracing and Testing…for Now.

Keir Starmer is wrong.  Despite what he said in PMQS on Thursday. Tracking and tracing of COVID-19 was not critical over the last 10 weeks. It made perfect mathematical sense to stop testing during the middle phase of the epidemic and here’s why.

“Tracing is critical” Sir Keir said. No, Sir Keir, it’s not critical under all circumstances. The fact is, in peak pandemic, tracing would make almost no difference.

The government is coming under criticism for tracking and tracing cases early on, and then abandoning this, only to be looking at  restarting again in the near future. This isn’t a policy failure, it’s smart, and it’s entirely in-line with the mathematics. It is probably also still somewhat too early to return to that approach, although there will come a time when it is highly appropriate.

Why? The answer lies in the immutable mathematics of the pandemic.

We need to recognise two key facts:

  1. That a proper “trace and test” system will be small scale by its nature.
  2. It’s crucial to deploy that system at points in a pandemic where it actually makes a difference.

Let’s look at those two points:

A Test and trace system will be small scale by it’s nature

The reality is that close contact tracing is going to be enormously labour intensive. It’s not simply about doing a vast number of tests, it’s about doing those tests on the right people. It’s about identifying everyone  that an infected person has been in contact with in the previous 14 days and testing all of them. Doing 100 targeted tests in that way is clearly a vastly more difficult and labour intensive undertaking than doing  1000 tests on people at random.

Therefore, the reality is, that no system of that nature is going to be able to really test vast numbers of the right people. Sure, you can tests lots of people, but testing lots of the wrong people, or even the right people at the wrong time is pointless.

The timing is crucial. It’s not good enough to simply contact everyone who has been in contact with an infected person in the last 14 days and test them all at once as soon as possible after the diagnosis of the initial person.

You will get a whole bunch of negative tests this way. This is because the window of time during which those people will have a positive test will be different depending whether they had contact with the infected person just yesterday, or 14 days ago, or on multiple times through the previous 14 days. And they need testing at times which reflect the incubation time.

For example, there’s no point testing someone who only came into contact with the infected person yesterday. They won’t be positive yet. You need to wait and test them in a few days time. And probably several times over the next 14 days to spot if they become positive.

You also have to keep in mind that if you test someone who came into contact with the infected person 14 days ago, they might well test negative, but they might have already gone from a negative test, to a positive test, infected a bunch of other people, and gone back to negative, all in the last 14 days. Thus, for that person, even if you test them and they are negative, you probably still need to trace and test all of their contacts. Whereas, for the person who only had contact with the infected person just this morning, you don’t need to – but you do need to tell them to self isolate for the next 14 days.

It should be apparent that doing this properly is incredibly detailed work, which requires highly trained public health workers who understand exactly what they are doing, communicate well with each individual involved to extract the relevant information, and then have superlative detective skills to round up all these contacts.

Yes, electronic apps on phones will help, but they are an only a tool to help assist this work if it’s being done properly.

And there’s very little point at all in doing this work with 90% effectiveness. If 10% of cases are slipping through your trace and test system, you will achieve very little at all, due to the exponential growth potential of the virus.

This is why pointing at other countries and saying “look they’ve done lots more tests than us” means virtually nothing without really understanding what those tests are intended to achieve.

You should also consider this: There is a world of difference running this kind of thing while a country is lock-down  compared to when it is functioning normally.

While all the pubs, bars and cafes are shut, yes, you might get away with a trace and test system which is sub-par and still find it is workable. However, when you suddenly find you have to trace and test everyone who went to a busy pub on a Friday night a week previously – the level of complexity rises rapidly.

The conclusion is this: Real trace and test systems are, by their nature, going to be small scale affairs if you are seriously looking at trying to identify and isolate every last case. You won’t be able to apply when there are large numbers of cases circulating.

It’s crucial to deploy trace and test at points in the pandemic where it makes a difference

Consider this graph:

Bellcurve4

As discussed above, our test and trace capacity allows us to eliminate a small number of highly selected cases. This is represented by the red line.

The first point is an obvious one to make, which is that, as a proportion of the total number of cases, that trace and test capacity obviously becomes a near meaningless drop in the ocean if it is deployed near the pandemic peak (notice the blue line demonstrating the cases in excess to capacity of the trace and test capacity).

On the other hand, that red bar is a much bigger proportion (virtually all) of the total number of cases when deployed very early on.

However the real point of this isn’t the effect on the total number of cases (the Y axis of the graph), it’s the effect on the timing of the graph (the X axis).

The difference in impact you can make on the X axis is very clear. Look at the regions labeled “1” and “2” . Deploying your trace and test tactic early on can significantly delay the time to peak, where as,when you move into the exponential growth phase of the graph, it makes very little difference to this at all. (Green line 1 is much longer than green line 2).

In fact, this visual demonstration vastly under-estimates this difference, because you can’t easily fit the massive exponential growth phase accurately onto a graph, but it gives you the visual idea, that the first green line is clearly longer than the second. You just have to bear in mind that the graph under-estimates that difference.

This is why the British Government chose to undertake trace and test early on, and abandoned it as the pandemic progressed. 

It made perfect sense, in February and March, to try and push the peak of the pandemic back into the summer, and hence, using that period of time denoted by that green line labelled “1” to delay things was sensible, but there was no sense in expending time, money and effort on trace and test policies in the midst of the epidemic peak. It simply makes no beneficial difference.

Why are the Government looking at re-introducing “trace and test” now?

Why then, are the government now looking at introducing trace and test going forward?

To understand this we need to understand something about the nature of entropy. Entropy has a specific meaning within physics, but is also a general principle of the world around us: Things tend towards states of stability. It is very difficult to maintain any system in a highly unstable state. It will always want to collapse into its most stable configuration.  Consider the diagram below

balls

You can probably spot instantly that the ball on the left is in an unstable configuration, while the ball on the right is in a stable configuration. A slight nudge on the ball on the left will cause it to roll down the hill,  and it will continue to accelerate from an initial push, while that on the right, if given a slight nudge it will tend to slow, and eventually come back to its current position.

What is true of the ball is true, in an analogous sense, of viral epidemics. Essentially all viral epidemics are about the virus  reaching a stable state within its host population.

If you have a population which is mostly not immune to the virus, then it is very much like the ball on the left – unstable. The smallest “nudge” by increasing the of number of infections will cascade into exponential growth. An initial impetus of infection leads to ever increasing acceleration of viral growth.

However, in a population which is immune, you can give much bigger “nudges” and not get the same effect.  More like nudging the ball on the right. The virus may infect a few people, spread a bit, but as it is constantly bumping into people who are already immune, the cascade effect of exponential growth is no longer possible. It will tend to self-limit to smaller, regional outbreaks.

The fact is, as the UK comes down off the slope side of its epidemic peak, we are now in a much more stable configuration with respect to COVID-19 than we were beforehand. How stable, depends a lot on exactly how many people have already had COVID-19 and how much herd immunity there is. and how long that herd immunity lasts. (Which is admittedly something of an unknown.) In this sense, the more infections there have already been, the better. According to the University of Manchester over 25% of the UK population may well have already had COVID-19.

Now, at this point, it again, makes sense to start tracking and tracing COVID-19. Under these circumstances, we aren’t anticipating another huge peak, so limiting small numbers of cases could make an outbreak of what might have been 100 cases into an outbreak of just 10. That’s clearly worth doing  because we are back to the scenario of being able to make a difference to the number of individual lives that can be saved. If you can do tracing and testing at a a rate which can “keep up” with the epidemic then that’s worth doing. And if you are a a situation of stability, then your tracing and testing can keep up with the outbreak.

Why are the Government not rushing back to trace and test?

While government are again looking at introducing an intensive trace and test system, they don’t appear to be rushing to do so. This was what Sir Keir Starmer was criticizing in PMQs.

The reason for this is because there is a fair degree of uncertainty about how much herd immunity we now have in the UK population.

We have a fairly unusual “hybrid” situation with COVID-19. Some countries slammed the door shut on COVID-19 before it ever really took off. They have populations who are massively susceptible to COVID-19 going forward. They are still very much in the situation like the ball on the left hand side diagram. Some countries like Sweden have not really gone the full lock down route. They are much nearer the ball in the right hand side diagram, metaphorically speaking.

The UK picture is a mixture of the two. If you imagine New Zealand as being like the Ball on the left, and Sweden as being the ball on the right, the UK is somewhere in between. The exact curvature of the landscape on which our “ball” is rested is not really clear.

This is because it’s very difficult to tell to what degree our numbers of current cases have dropped off because of the natural peak of the first wave and herd immunity, and to what degree this is due to the lock-down suppressing infections reaching their natural peak.

If it is primarily the latter, then our state with regards COVID-19 is still unstable. Our “ball” is still sat on an unstable and bumpy landscape. We are prone to another large outbreak. Now, if that’s true, it actually may well not be smart to suppress that at this point, because all this will do is delay that second peak (remember back to the green lines). If we suppress the second peak towards autumn and winter, the impact of it will be far greater than allowing it to come through the summer.

Unfortunately a really good test for immunity is still not widely available. There is a reason why Prof Chris Whitty has maintained since very early on that we need  immunity testing, and why he has always seemed rather ambivalent about testing for active infections. We are seeing that reason come to the fore now.

As we don’t have that test widely available, the way we will tell the difference is by closely monitoring the number of cases that we see as lock down lifts.

Effectively lifting lock-down gradually is like giving the “ball” a series of little “nudges” and seeing what happens, to try and “feel out” what kind of landscape the ball is sitting on. Is it on a hill, or in a valley? We will watch how the ball moves, that is, how the case numbers respond, to try and assess this.

And here, things are rather counter intuitive:

If case numbers stay low then we can assume it is because there is widespread herd immunity: Which means it is sensible to go ahead and establish  trace and test procedures.

If numbers seem to pick up very rapidly as lock down lifts, we can assume there is still a marked “second wave” to come. If that is the case, then, unfortunately, there is a strong argument for letting that wave move through the country over the course of the summer months. If we use test and trace and heavy lock-down measures to restrain it, we run a severe risk of simply pushing it back to  the winter of 2020, which could be far worse.

However, this presents the government with the awkward position of seeing numbers rise, and yet appearing to “do nothing”. Which may prove politically untenable, all the more so, if Sir Keir is breathing down Boris’s neck about testing.

This is the real danger in the current climate: I believe Sir Keir has good intentions, but pressing the government to make moves which seem like a good idea when in fact they are not scientifically sound, could ultimately cost lives. Sir Keir is astute enough to realise this, and this is why he has, for the most part, been very careful in his approach during this crisis, and not gone after the government like a rabid dog over every policy, as many on his side have wanted him to do.  He has, for the most part, shown commendable restraint in his approach to this crisis. He ought to make sure he is well apprised of the dilemmas involved in trace and test.

The two views on COVID-19

It’s worth closing this article by just reminding readers of one of the great answered questions about COVID-19.

Most theorising about what is the best way to deal with COVID-19 hangs on a central difference of opinion on the nature of the problem we have before us which emerged early on in this epidemic:

Virologists in many other parts of the world, looked at the virology of COVID-19 and said “It’s a coronavirus, SARS and MERS were coronaviruses, it will behave like SARS and MERS.”

Epidemiologists in the UK looked at the behaviour of COVID-19 and said “It’s an airborne droplet spread illness, often mild or asymptomatic (unlike SARS and MERS), but occasionally serious. It’s therefore more like a flu.  It’s epidemiology will follow that of flu”.

Both sides have got at least part of this wrong:

Those  in the first group probably thought COVID-19 would be limited by restrictive measures. They were basically wrong. SARS and MERS topped out at a few thousand cases and died out. At five million confirmed infections world wide and counting, COVID-19 has not proved to be containable in the same manner.

The UK approach to think of it as flu led to some some errors of judgement about who was at risk. The initial assumptions was that it would be those who are most at risk of flu (mostly those with respiratory diseases). This turned out to be at least partially wrong. It turns out that things which are risk factors for heart disease  are probably more relevant for COVID-19 risk: Old age, Obesity, diabetes, ethnicity, male sex. (Which is not to say there is no increased risk from having pre-existing respiratory diseases)

However, the big question remains about who is right about the long term future of COVID-19.

If the approach of many other parts of the world is right, then, at some point, COVID-19 will still die out like SARS and MERS.

If the UK view is right, then we are looking at COVID-19 eventually becoming  a disease like measles, chicken pox or flu, where you got occasional pockets of  disease break out, and it never really goes away.

An awful lot of what seems confusing about government strategy is to do with hedging our bets between those two outcomes, because no one really knows, although the UK experts seem to lean towards the second view.

So if it all seems confusing at times, it’s because it is. There cannot be “clear advice” on a situation which is far from clear. However, it doesn’t follow that “if the situation is far from clear then we should play safe and stay in lock down and trace and test everybody”, because if the UK epidemiologist’s view is right, then that will actually make things worse in the long run.

That, is the true answer to Sir Keir Starmer’s question at PMQs. The problem is, there’ simply no way to reduce it to a three part soundbite slogan for the Prime Minister to quote from a podium – and thus Sir Keir, and the wider population, will likely go on being confused.

Unlocking the SAGE files: What DID the Experts Tell the Government About COVID19?

Unlocking the SAGE files: What DID the Experts Tell the Government About COVID19?

There is an enormous amount of speculation about whether the Government is following the advice of SAGE – The Government’s science advisory group. Yet there is very little clear commentary on what SAGE have actually been advising Government. So let’s actually have a look at officially released SAGE documents:

We start with a graph published in this document from SAGE to Government on 9th March.

SAGEgraph1

Lock down is the green line.

See the problem? Yes, lock down now produces a near flat line of case numbers through spring and summer…but look at Winter.

A massive second peak – right in the midst of winter, when it would pose all sorts of additional problems.

On the 9th of March, just 2 weeks before we entered lock down on 23rd March, SAGE were offering Government no options for COVID-19 which did not feature at least some pretty significant peak, and the harshest lock down they were modelling for suggested probably the worst of all scenarios – a massive winter peak.

This is what Government were being told by their scientists on 9th March. What would you have done with this if you were Boris?

What led them to this conclusion? For that we need to to look at another SAGE document from 2nd of March which is viewable here

I’m going to pick a few notable quotes:

First, the big one:

“5. If a reproduction number in the region of 2 – 3 occurred in the UK it would correspond to
around 80% of the population becoming infected. Not all of them would be symptomatic”

On the 2nd of March, SAGE were advising Government that 80% of the population were going to get COVID-19.

But wait, surely they were going to advise Government to take measures to stop that horrible event happening?

Well…no.

“8. Measures which reduced contact rates would be expected to flatten the peak of a UK
epidemic and extend it to some extent. They are unlikely to greatly reduce the overall clinical attack rate.”

“Measures which reduced contact rates” means lock-down, social distancing etc. “The attack rate” is the number of people in a population who contract a virus.

This is a crucial point: The advice being given here is that measures which reduce contact rates ultimately will not change the attack rate. 80% of people in the UK are still going to contract this virus according to SAGE – with or without a lock-down.

“9. More stringent measures, or a combination of measures would be expected to have a greater impact. Were they to have such a large impact on transmission that the reproduction number could be reduced to somewhere in the region of 1, a large increase in cases would be expected once they were lifted.”

So this is the scenario we actually have is it not? Lock-down is a combination of stringent measures. The SAGE advice admits this may achieve an R “somewhere in the region of 1”. i.e. they think it possible the epidemic can be pushed into remission, but, they still believe there will be a “large increase in cases” when those measures are lifted.

Which sounds to me awfully like they aren’t budging from the idea that 80% of the population are going to contract this virus pretty much whatever you do.

What about School Closures? Will that do it?

“10. Analysis of the epidemic pattern in Wuhan is inconsistent with no transmission from/to children, i.e. children are likely an important group in the epidemic even if they directly experience little disease. Consequently, school closures are likely to impact transmission, although significantly less than with flu. If it were similar to that of influenza, for R0 around range 1.9 – 2.3 and school closures of 6 – 12 weeks, different models estimate that peak incidence could be reduced by 7.5% – 25%. Mass school closures are unlikely to reduce the final size of the epidemic and are unlikely to delay the peak by more than 3 weeks.”

Nope, again, SAGE are entirely pessimistic. You can move the peak, and spread it out, but you cannot change the total size of the epidemic.

What were SAGE advising Government about screening then to try and restrict the virus spread?

“22. The long incubation period means isolation of contacts of cases would need to be lengthy and that entry screening is likely to be ineffective.”

So that’s a “no” from SAGE on that one too then…if you’re not screening people on entry to the country, why would you be screening them anywhere else?

And what exactly were SAGE expecting in terms of mortality then? Let’s remind ourselves that SAGE had advised Government that 80% of the population were going to contract this virus whatever measures were taken.

“16. Our best estimate of the infection fatality rate is in the range of 0.5% to 1%, ranging from 0.01% in the under 20s to 8% in the over 80s.”

Taken together with SAGE’s assertion of 80% of people being infected, SAGE just told Government that 250,000 to 500,000 people will die. Yet SAGE gave Government not a single option or intervention which would change that figure, at least, not in this document, as far as I can see.

There are further comments of note in this sage document from 4th March worth noting:

9. Modelling suggests that the stringent interventions introduced in Wuhan from 23 January (quarantine and movement restrictions) may have reduced the reproduction number to below one.

However,there are differing views across the scientific community about whether other factors were involved in this. There is also speculation that the approach taken in Wuhan, to apply stringent regulations which have been rapidly lifted, may result in a second larger peak.

It’s worth viewing a graph of where China was at, at the time this statement was made on 4th March:

chinacovid

We can see in retrospect that, if you believe the Chinese data, they had beaten the virus back with their measures and have not yet (writing in early-mid May 2020) had a second surge. Yet clearly, at the point we were launched onto our current COVID-19 trajectory, SAGE believed that was a distinct possibility.

And “being launched on a trajectory” is the correct way to think of this. Our strategy was essentially like launching a rocket. We put it on a launch pad and let it go by early March at the latest, and a lot of what we are seeing playing out since then is the mathematics of those initial decisions taking effect. So we really have to judge the whole thing on what Government were being advised at that point.

And, at that point, SAGE still believed in second surges of COVID-19, including in China, which has not had one to time of writing. They believed it so strongly, they made this statement:

“9. A combination of these measures is expected to have a greater impact: implementing a subset of measures would be ideal. Whilst this would have a more moderate impact it would be much less likely to result in a second wave. In comparison combining stringent social distancing measures, school closures and quarantining cases, as a long-term policy, may have a similar impact to that seen in Hong Kong or Singapore, but this could result in a large second epidemic wave once the measures were lifted.”

SAGE were absolutely obsessed, it seems, by the possibility of a second wave, and insisted that over-suppression of COVID-19 initially would make this worse.

Yet, just a few paragraphs later, we read this:

“14. It should be noted that whatever the reduction in peak NHS bed demand achieved by these interventions, in the reasonable worst-case scenario demand will still greatly exceed supply.”

Think about what SAGE have just said. They have, on the one hand, advised Government to not take every available suppressive measure to avoid a massive second peak. On the other hand, they have advised Government that even taking every possible measure, demand on beds in the NHS will still greatly outstrip supply.

Very much leaving the Government between a rock and a hard place, you might say.

This, dear reader, was what Government was being given as expert advice a couple of weeks before they took us into lock down: A quarter of a million people are going to die – and you must not do everything you can to try and save them, because if you do it could be even worse.

And notice all the things people talk about now which were notable by their absence from the SAGE advice: Contact tracing? Running around trying to pin down every last case of COVID-19 and eradicate it? Vast numbers of mass testing to pick up cases?

Nope. None of that. Why? because SAGE were resolute that the epidemic is going to happen – and nothing you can do will change it.

No wonder Government seem paralysed to act in early to mid March. They must have been petrified.

Did SAGE start advising differently after lock-down? No. Not really. Let’s look at what SAGE were saying on 25th March. (Bear in mind the China graph above is showing near eradication of COVID-19 by this time). In this document, SAGE were considering an “optimistic” and “pessimistic” scenario for how things might pan out, and make this statement:

“3. The fewer cases that happen as a result of the policies enacted, the larger subsequent waves are expected to be when policies are lifted. As we cannot predict how policies will change, the terms “Reasonable Worst Case” and “Optimistic Scenario” are only in relation to the number of deaths seen in a first wave.”

Again, even after the UK had entered lock-down, SAGE continue to be obsessed with a second wave. To the degree they are only prepared to model scenarios for the first wave, and caveat that, the better the first wave, the worse the second wave will be. (Thus surely making all such modelling essentially a moot point?)

The document goes on to tell us that:

“Imperial’s and Warwick’s models both gave around 10,000 deaths in the first wave of an optimistic scenario”

Well, clearly they were optimistic….

I’d love to tell you what they modeled as their pessimistic scenario but…weirdly… that is not included in this document.

However, in a sense, it seems irrelevant. SAGE were still advising that “less deaths now means more deaths later”

This was shortly after entering lock-down. However, since entering lock-down there also appears to be a lock-down on information from SAGE.

The only additional document perhaps of interest that I could find as of today, is a document from 1st April  speculating on how lock-down measures might be lifted or modified.

There are a number of interesting quotes here, such as this one:

“We are unclear what the evidence base is that the targeted behaviours are a substantial contribution to disease transmission, particularly given the high adherence rates currently observed in the community. Is there evidence, for example, that exercise conducted more than 1km away from the house leads to higher rates of transmission than exercise conducted within 1km of the house? Indeed, for this option, there is a risk that reducing the ability of people to apply some flexibility in choosing where to exercise will increase risk by preventing people from spreading out in nearby open space.”

So while some have maintained that the UK lock-down was not strict enough, SAGE were actually showing concern that it was unnecessarily tough. 

Another quote is extremely telling:

“There is robust theory and evidence that adherence is likely to be high as long as (i) perceptions of the risk of Covid-19 to self and others are high, (ii) the perceived effectiveness of restricting activity is high”

Essentially, they advise that the public must receive the message “COVID-19 is extremely dangerous but the lock-down measures will make you safe” – There is an emphasis that the part before and after the “but” are both extremely important.

But wait…hadn’t SAGE also been saying before that nothing we could do would ultimately change the the attack rate of the virus? It rather seems they were. So in what sense should the public  be convinced that the “effectiveness” of restricting activity is high?

“Stay Home. Protect the NHS. Save Lives.” is a great message. It has the mark of Dominic Cummings marketing genius about it. It’s rather more catchy and inspiring than “Stay Home. Protect the NHS. 250,000 of you are going to die whatever we do, but we might keep it below half a million” 

According to the government page where SAGE documents are listed there are no new further updates.

As far as I can see, all the SAGE modelling and warnings regarding a second wave remain current thinking – unless there are newer documents which are simply not currently available online.

I’m afraid I can draw only two possible conclusions on this:

A. SAGE got it fundamentally wrong on the “second wave” question. The data from China and South Korea resolutely refuses to support any evidence of a second wave. This is frankly bizzare. It defies nearly every epidemiological assumption and pre-existing belief about what is possible in disease control. Yet, for all my misgivings there may be a point where we have to believe the data. Maybe there just isn’t going to be a second wave after all. However, I’m faced with a genuine dilemma on that, because my instinct is that it is just not possible, and yet, at some point, I’ll have to admit that I, and the esteemed minds of SAGE, were wrong on this one. We ought, under those circumstances, surely recognize that Government cannot be at fault for acting in line with SAGE advice however?

B. SAGE are still going to be right about a second wave  SAGE were advising from the start that 80% of the population were going to contract COVID-19 and the only real question was “when”. This goes right to the heart of all sorts of questions about planning. It goes to the heart of the question about testing for example. (Which is interestingly absent from most of these documents as being any part of SAGE’s thinking). If 80% of the population are going to get this whatever you do, there is really very little point testing people. In fact, it’s clearly detrimental to spend enormous amounts of time and money on testing people for a virus that basically everyone is going to get.

It even, to a point, goes to the questions about PPE supply in some circumstances once you accept that, at some point basically everyone is going to get this disease. If SAGE had got this right, then testing would have been a massive waste of time and precious resources better spent on hardening the countries infrastructure to cope with an inevitable  quarter of a million predicted deaths – whether in one wave or two. The only question is about controlling the rate at which that tidal wave comes at us.

At this point in time, I think you can still back either conclusion, but there are a final few thoughts to make on this:

In March SAGE were giving Government no option that had an outcome of less than a quarter of a million deaths in the total epidemic. Our death toll currently stands at a tragic 32,000 and the press are all over the Government for their failures. 

If we finish up anywhere even remotely near our current death toll,  then we have come out of the other side of this with a result which is borderline miraculous…and would have appeared too good to be true in early March.

Dunkirk is often referred to as a Miracle. Government were told to expect the near obliteration of the the British Army. Instead 338,226 soldiers were evacuated from the beaches. What is often forgotten is that around 40,000 British and a further 40,000 French soldiers were left behind and spent the war as Prisoners of War of the Nazis in terrible conditions, and many did not survive to see liberation.

Yet, we record Dunkirk as a historical “success”.

So, it seems to me there are two options. (We must bear in mind this based on not having any  further SAGE reports to go on to update us on their initial “second wave” theory”)

Either there is no second wave – in which case we should, in the long run, view this as the epidemiological equivalent of Dunkirk, and be thankful that our epidemiologists gave Government frankly terrible advice and yet somehow we still muddled our way through it at well below the mortality rate initially predicted.

Or else, there will be a sizable second wave – in which case nearly everything that people have been criticizing the government for with regards to “not enough testing” etc will prove to be utterly irrelevant in the long run, and the Government strategy may prove to be essentially on point. That’s the good news. The bad news, on that view,  is that over a quarter of a million of us are still on course to die.

I really don’t envy the Prime Minister his job either way to be honest.

 

 

Unintended Consequences of Lock-down for COVID-19?

Unintended Consequences of Lock-down for COVID-19?

Here is a graph….

flugraphedit

This is a graph demonstrating the first wave of COVID-19. It shows how we suppressed it – that first peak on the left. Then it shows how, if we release “lock down” we then get a massive second wave surge.

It shows why it would be so dangerous to lift lock down too early. It shows how COVID-19 has responded to our interventions. It shows how it will respond to our failures…

Except…it’s not that at all….

It’s a graph of the 1918 flu pandemic. Here it is in full.

flugraph

 

Now here’s an important point: Europe was rather too busy during 1918 to have a full lock down. (There was a war on). Recreational facilities such as music halls and theatres closed, but then everything was in war-time mode in 1918 anyway. Crowded munitions factories kept working as normal.

Which is not to say there were not some public health measures suggested: People were encouraged to take “brisk walks in fresh air”, and encouraged to smoke…thought of as being healthy for the lungs at the time.

So maybe that dip in the first peak is due to the government health interventions of the time?  All those fresh air walks and cigarettes? Ok, probably not.

Sir Arthur Newsholme of the Royal Society of Medicine wrote a memorandum that advised people to stay at home if sick and avoid public gatherings, but the government chose not to promote it. The advice, largely due to the war was to “carry on”.

And yet..there was a small first peak which subsided. It’s well noted that the second peak happened because of the combination of the mass movement of soldiers at the end of the war and the arrival of winter. However, what is less commented on is why the first peak subsided when it did.

The answer is that there isn’t really a clear cut reason why that first peak subsided. Certainly not one attributable to a deliberate government intervention or public behaviour change. It happened probably largely spontaneously.

The laws of large numbers are odd. On the one hand, we expect randomness in small events, and consistency in large ones: If you roll a dice once, you may get a one, or a six. You can’t tell which. If you roll a dice 600 times, though, you will get, pretty consistently about 100 ones and 100 sixes.

However, the effect of large numbers cannot be relied upon to give you consistent outcomes when there is something called sensitive dependence on initial conditions. This is where despite starting from seemingly very similar initial conditions, and despite initially seeming to track along a similar path and respond predictably at first, wildly varying and unpredictable results emerge over a longer time frame. This is the basis of chaos theory.

This may be a partial explanation of why the first wave of the 1918 pandemic died down. The randomness of complexity. If we replayed history, with the same conditions, the initial wave may have continued into a much bigger peak.

In fact, people have already started looking at fractal modelling of the COVID-19 outbreak. Broadly speaking, what this shows is that during the initial phase of exponential doubling of the virus, interventions have a fairly predictable effect. Thus, it was predictable that lock down would initially reduce R0 – the reproduction rate of the virus. This is why there was good sense in the initial month or so of lock down. However, as the situation develops beyond that phase, the effects of an intervention like lock-down become much more unpredictable. Obviously the non-virus effects of lock down become more unpredictable over time (effects on mental health, other aspects of physical health, the economy, etc), but it’s probable that even the effects on the virus of lock down become increasingly unpredictable over time. More on that later, but for the moment let’s go back to that 1918 flu graph:

Had this been the graph we saw in the COVID-19 outbreak as I suggested at the start of the post, we would all be tempted to say that the first peak of the graph fell due to lock-down measures, would we not?

There is a very great temptation when looking at data to attribute cause and effect where none exists. We believe in cause and effect when it suits. We ignore it when it doesn’t.

When a pattern doesn’t suit the cause-effect story we want to tell, we are able to come up readily with half a dozen reasons why that might be.

However, when it does fit the cause-effect story we want to tell, we simply ignore those alternative explanations as awkward unnecessary complications.

This selective appeal to cause-effect narratives is an incredibly universal human trait: For example, we all know we are apt to attribute our failures to bad luck but, we attribute our successes to our skill.

What this all means for COVID-19 is that we cannot expect a simple cause-effect relationship between lock down and what happens to the rates of the virus going forward. It does not follow that, because the lock-down measures were right at the start to suppress the initial exponential growth, that they remain the right measure now.

The reason for this is because, as the graph of viral growth deviates further from the standard exponential growth phase that we saw at the start, the more unpredictable the results of lock down are likely to become.

Let’s look at specific example of the sort of unpredictable effect that might emerge by using a thought experiment:

A Tale of Two Rats

I want you to imagine a lab-rat experiment.

We start with a group of  500 genetically identical rats in a large cage and infect a couple at random with a virus.

We will call this first cage the white cage.

Rats are not allowed to mix too freely  in this cage. They are only allowed fairly limited interaction with each other. A few rats at a time, but nonetheless, all milling about to some degree.

The virus starts to spread and rats start to get sick. When a rat gets sick we classify it as either “mild” or “severe”.

Our first rat, when he gets sick, has  mild illness, we take him out the main group and put him on his own so he can’t spread his disease to any other rats. In a solitary isolation pen. We will  call these individual isolation cages  the green cages.

Our first few rats who get sick are similar, with mild illness, and each gets transferred to an individual solitary isolation green cage. However, after a while, we get a rat who is much more significantly unwell. He’s really poorly. He has severe disease. We take this rat and we put him in a smaller pen called the red pen, in which there is a small population of around a dozen healthy rats which all mix quite freely within the smaller tighter confines of the red pen

The healthy rats in this pen are transferred back and forth twice a day between the main white pen and the red pen, while the really sick rat stays in the red pen throughout his illness.

Soon, some of those other red pen rats start to get sick with the more severe disease that they caught from our rat in the red pen.

If they become sick with mild disease – again, we put them to the green isolation pens, but if they get sick with the more severe version of the illness, they get transferred to the red pen, until they either recover or die.

What we notice is that they get the severe version slightly more often than initially. That’s no surprise, because they caught their illness from the rat with the more severe illness. Even so, some will still get a more mild illness, but they get excluded to the green pens.

Because these rats have been moving back and forth between the red and white pens until becoming symptomatic, they will, of course, have circulated the disease back into the white pen.

As new rats, both those from the general white pen population, and those transiting back and forth between the white and red pens, develop the severe strain, we keep transferring them to the red pen, and excluding ones with mild disease to the green pens.

What we find is that, while the total rate of infection is initially low (because of the restrictions on movement) the infections which do occur, are proportionately increasingly of the severe strain, while the mild strain of the virus appears to die out. Moreover, the infectiousness of the strain starts to go up. What will happen is that the white pen population start getting infected more and more easily with the severe strain. This could happen gradually, but could happen all of a sudden.

You could suddenly have a white pen so full of very sick rats you have no space for them in the red pen.

What have we done here?

We have just created a breeding ground for selectively breeding a super-deadly strain of the virus, which is both super-deadly and spreads very easily.

The virus does not stay the same. It mutates. Some of those mutations will make the virus more deadly. Some will make it more mild. Each time it moves from rat to rat, it will change slightly.

In the experiment design above, every time the virus produces it’s “mild” form, it gets “punished” by being put in isolation in the green cages and denied the chance to spread any further. We are eliminating from the population those strains of the virus which cause mild disease.

However, every time it produces its most deadly form, it gets “rewarded” – by being moved to the red pen where it can spread easily to a new population of rats. Having infected all the healthy rats there, it then gets to circulate back into the main population to repeat the cycle.

The fact the population in the main pen don’t mix completely freely but only have limited contact puts a selective pressure on the virus to become even more contagious, because its chances to spread are so limited.

Pretty soon the virus is going to “learn” by evolutionary natural selection  1) It must make its rat-host sick enough to get into the red pen, 2) It must be infectious enough to exploit the limited opportunities for spread in the white pen where there is limited interaction between rats.

Essentially, it’s going to need to become a really really nasty super-bug.

I suspect you may have guessed by now where I’m going with this:

The white pen is Britain in lock-down

The green pen is people self-isolating at home with mild illness

The red pen is NHS Hospitals receiving the most sick

The non-infected rats in the red pen who move between the red and white pens twice a day are the healthcare workers going to and fro work.

So it turns out, on the experimental model above, once initial exponential spread is suppressed, continuation of lock down potentially turns into a breeding ground for the nastiest possible variant of COVID-19.

Now, I want to point out a few flaws in the model, but also post counters to them:

  1. We are not all genetically identical, unlike the rats. Therefore, differences in how sick we get are less likely to be just due to what strain of the virus we have, but our own attributes (age,gender, ethnicity, other illnesses). This is true, but I would counter this by saying that we know there were at least 11 sub-types of SARS-COV-2 before it even got out of Wuhan, (although thought to be insignificantly different from each other) and goodness knows how many genetic mutations of it are floating around the globe now. This, after all, is a virus which has pretty recently just pulled off the trick of mutating itself to leap from animal to human. This suggests its a virus with a fair degree of mutative capability.  Odds are that sooner or later there will be significant sub-strain mutations in COVID-19. Also, the variations in the human genetics and their subsequent interactions with different strains of COVID-19 only serve to make this more complex, not less complex.
  2. We do not perfectly self-isolate the mildly sick, while letting the seriously sick spread randomly in hospitals. It’s true, this presented as a “perfect” isolation in the lab-rat model, but my betting is that when someone gets mildly sick with COVID-19 and self isolates as they should, their contact is limited to a pretty small number of people. With the best will in the world, hospitals are busy places. The person who gets really sick with COVID-19 and goes to hospital comes into contact with doctors, nurses, porters, radiographers, HCAs,, catering staff…the list goes on and on. Importantly, those individuals come into contact with each other. While healthcare professionals take every care with PPE with patients, in most hospitals the social distancing between staff is sub-optimal.
  3. It could be argued the other form of virus that does very well in this environment would be one that is asymptomatic and spreads very easily. Theoretically that’s true, but this is an iterative process. the more mild strains are being eliminated and not allowed to spread, which stops you getting progressive iterations towards a totally asymptomatic strain, unless you get there in a single evolutionary leap. Where as, the more severe the virus gets, the more iterations it gets to experience looping between the red and white pens, potentially getting nastier each time.

Am I saying this is what the UK Lock down measures will do to COVID-19?

No. that’s not what I’m saying. The last of the three points I gave above demonstrates the problem. It is quite possible, that, by random variation of the virus, in the experiment I gave above, you could get a very infectious but virtually asymptomatic variant of the virus pop up early on in the experiment – which would do enormously well and eliminate all other strains. You would then quickly see the infection die out completely.

But emergence of that strain would be an essentially random event, and lies at the extremity of the probability window. However, it’s an excellent demonstration of how the small variation of initial conditions (in this case, exactly what strain of virus you have) could have enormous and essentially unpredictable effects on the overall outcome.

Essentially, how this experiment pans out will depend largely on what random mutations the virus throws up, and in what order they occur. However, the path that I lay out to a super-deadly strain is a perfectly plausible one

Think about how this would appear if you were looking at a graph, like the flu pandemic one at the top of the post. What you would see is an initial peak,. then a fall after imposition of lock down. You would congratulate yourself that all was going well with the lock down, and then, suddenly, just as you are about to pop the champagne corks, seemingly out of nowhere, despite lock down, a second peak of an even more deadly variant pops up.

Unforeseen consequences of Lock-down

The point I’m really making is that we should be wary of unforeseen consequences.

We should be extremely wary of being too dogmatic about what we think Lock-down will or won’t achieve.

Unfortunately Lock-down  acts on so many variables in so many different ways at the same time, that the true outcome of lock-down is going to be incredibly hard to predict. It could easily wander into territory where chaos theory mathematics applies, and highly unpredictable outcomes arise…even when considering just the effect on COVID-19 itself, let alone collateral effects of lock-down.

Human beings have been responding to viral infections for millennia. By the very fact we are still here, that demonstrates we are actually enormously resilient to new viral infections. That is likely due to our individual immune systems, but also due to our innate group behaviours during an illness.

One innate group behaviour is that, while we are mildly sick, we tend to still be social and interact, but when we become really unwell, we tend to automatically self isolate.

It’s obvious why the second of these behaviours gives us an evolutionary advantage in fighting off pandemics, but we should be wary of ignoring the value of the first.

It is very likely the fact that we share mild strains of infections, allowing them preferential spread over the more aggressive variants  is actually part of how, as a species, we have historically fought off pandemics.

Yet due to lock-down we are effectively trying to exclude that mechanism

(This, by the way, doesn’t amount to an argument for simply letting nature take it’s course in all cases. It is not an argument against vaccination for example. The difference here is that lock-down is an enormously blunt instrument, compared to the precision tool of vaccination. Although vaccination acts on a whole population, it acts through a very narrow and well defined intervention where we can exclude a lot of chaotic possibilities. Vaccinations target antigens which arise from parts of viral genomes which are highly stable and not prone to mutation, thus eliminating the possibility of viral evolution around the vaccine.)

We are entering a point in the COVID-19 scenario, worldwide generally, and particularly in the UK, where virtually all mathematical modelling is going to break down. We do not have a simple idealised logarithmic curve which we are flattening. World wide, we are quickly moving to an erratic, saw-wave, which is likely to throw up new exponential peaks somewhat haphazardly.

People will want to blame governments and public health policies. They will want to argue that “If we had done X then Y would have happened.” They are almost certainly wrong.  In the absence of a highly reliable and definitive intervention like a vaccine, the behaviour of COVID-19, at the macro-scale from this point out is going to be a roller coaster ride of randomness.

At the micro-level of individuals and small groups, people ought to continue to be careful about shielding the vulnerable,  hand washing, social distancing, and PPE protocols in certain settings, but unless we clearly see the emergence again of idealized exponential growth, the idea that we will get predictable responses to large scale lock down interventions is likely to break down rapidly, and, as the lab-rat though experiment shows, could be extremely harmful indeed

Dr Rosena Allin-Khan’s “Tone” on COVID19 Testing

Dr Rosena Allin-Khan’s “Tone” on COVID19 Testing

An exchange between the Member of Parliament for Tooting and the Health Secretary stirred up a social media storm, a fairly mediocre exchange becoming inflated into the Newspaper headline “A&E doctor MP furious after Matt Hancock tells her to watch her tone”

Numerous people on social media have misquoted Matt Hancock as having told her to “Watch her tone”. He did not say this. Neither did he mean this. And I strongly suspect that Rosena Allin-Kahn knows he didn’t.

I rather suspect that many will have simply made up their minds what they want to believe about this exchange in advance – but let’s walk through it anyway.

We should try to figure out exactly what went on here, because what actually happened matters. The truth matters. When you are speaking in the context of the human tragedy deaths of 30,000 people, that doesn’t give you a free pass to be extra-emotional and take liberties with the facts. Quite the opposite, it means you need to carefully restrict yourself to the facts with as little emotion as possible. Your comments get held in greater scrutiny, not less.

First, I want to make a point about Allin-Kahn being an A&E doctor and referring to herself in the first person “Front line workers, like me” : This should be irrelevant when she is standing on the floor of the House of Commons. Ms Allin-Kahn, in the Chamber, you are speaking as the Member of Parliament for Tooting, not as a “Front line worker”.

Referencing her own role, as a doctor, to lend weight to her point is extremely poor form.

Anyone who has sat on public panels, or committees, or a jury, or any other similar role knows the importance of this: You must not conflict and confuse your roles in other spheres of your life to generate inappropriate influence.

It is also incredibly lazy to reference yourself as an authority. If you are making a good point well in the House of Commons, it shouldn’t need the attachment of your personal authority. The point should stand on its own. The MP speaks as the collective voice of the people of Tooting, not as an in-house lobbying group for doctors.

It is at least questionable to me whether practicing as a doctor while simultaneously being an MP is appropriate, but if they are to be combined, it would seem to me the mark of good practice on both counts to draw a very clear dividing line between the two roles and not blur that line.

Allin-Kahn blurs that line, and that is where the problem starts. Let’s go through what she said:

“Front line workers like me, have had to watch families break into pieces as we deliver the very worst of news to them that the ones they love most in this world have died.”

This is true. However, it should be said it’s true in every hospital every day of the year all the time. Why is Allin-Kahn telling us this? Having a loved one die is traumatic and tragic? Yes. Nearly everyone, sadly, already knows that.

These opening comments do absolutely nothing to make a point, only to try and frame the point in the maximally emotive context, and then to laden further emotion onto it by personalizing it to herself with the “like me” comment.

“The testing strategy has been non-existent. Community testing was scrapped. Mass testing was slow to roll out, and testing figures are now being manipulated.”

Does this have anything to do with her previous comment? Not really. The previous comment was only there to set emotive mood for this comment. We will return to the question of testing itself momentarily. Simply here, I would make the point that the comments she made previous to this have no logical connection to her point about testing – only an emotional one.

“Does the secretary of state commit to a minimum of 100,000 tests each day going forward…”

Ah..the actual question! If this is what she wanted to know – why didn’t she simply ask this? Again, we will address shortly the significance of 100,000 tests a day.

“and does the secretary of state acknowledge that many front line workers feel that the government’s lack of testing has cost lives and is responsible for many families being unnecessarily torn apart in grief?”

Is this not obviously emotionally manipulative? Her question is rather mundane one about testing numbers. How does she make the leap from a question about testing numbers to “families being unnecessarily torn apart in grief”? That’s quite a leap. Why cranking up the emotional dial to 11 on a question about testing?

The way it has been reported that Matt Hancock told her to “watch her tone” makes it sound like an adult telling a child not to be petulant, suggesting a tone of deference to him should have been taken.

But what, actually, was his response?

“No I don’t Mr. Speaker. I welcome the honourable lady to her post as part of the shadow health’s team.”

An entirely polite and civil opening…

“I think she might do well to take a leaf out of the shadow secretary of state’s book in terms of tone.”

Note, the “shadow secretary of state” is also a Labour MP. So he’s actually here giving a compliment to other Labour MP’s tone. I commented in a previous article  that Keir Starmer’s tone has been restrained and appropriate. I believe the MP he is referring to here would be Jonathan Ashworth.

Can it really be said that his concern about her tone is the amount of due deference that she showed to him? Surely not. Surely it makes more sense that he is referring to her “tone” of heavily emotive language about grief  when talking about the data on the amount of tests?

Even if you disagree with him about whether that tone was appropriate, it’s clearly not that he’s being condescending to her. He’s not calling her tone petulant towards him, he’s calling it manipulative of the public.

“I am afraid, what she said is not true. There has been a rapid acceleration of testing over the last few months in this country, including getting to 100,000 tests a day. We have been entirely transparent on the way that has been measured throughout, and I have confidence that the rate will continue to rise. Currently capacity is 108,000 a day and we are working to build that higher.”

Matt Hancock goes on to give a rather mediocre answer about testing.

So much for talking about the tedious subject of “Tone”. We can surely conclude:

  • Matt Hancock did not tell Dr. Allin-Kahn to “watch her tone”
  • He was not criticising her tone for lacking respect to him, but for being overly emotive and manipulating the emotions of the bereaved.
  • Dr. Allin-Kahn was speaking as a politician. Not a doctor. And Hancock, not unreasonably, replied in kind

However, let’s talk for a bit about the testing which Dr Allin-Kahn got so emotive about.

The testing she refers to is the PCR throat swab test which tells us whether someone has Coronavirus at the time of the test.

There are three things worth noting about this test:

  1. The Test is exceptionally unreliable.

This Oxford paper quotes swab tests as only being positive in around 60 to 70% of cases

This means the test is so unreliable, that even if the swab test is negative, if a patient’s symptoms appear to be COVID-19 then doctors will still treat the patient as COVID-19, and if they die, may well still record “COVID-19” as the cause of death.

The test has its uses. I’m not saying we don’t need to test at all. At a widespread population level, the PCR test is somewhat useful in giving Public Health England some kind of sense of the number of active cases floating about in the community, but as a test for individuals, it has very little utility due to its inaccuracy.

Indeed, doing vast numbers of tests on the community is potentially dangerous. 30% of people who are actually positive could end up being falsely reassured that they are negative when, in fact, they are actively infectious.

At this point, everyone is supposed to be socially shielding and acting as if they might be positive anyway to a large degree. What could be worse in that context than falsely reassuring someone that they are negative, when in fact they are positive?

2. The Testing Process may propagate COVID-19

The test is a throat and nasal swab. Either patients self-swab, which worsens the problem above, because self swabs are even less likely to pick up a good quality sample that gives a positive test.

Or, the patient attends a mass testing facility and a healthcare worker swabs them.

That is – a healthcare worker who is doing nothing all day but swabbing person after person with potential COVID-19 symptoms in a big long queue.

It doesn’t take a genius to figure out that COVID-19 testing stations could effectively be COVID-19 spreading stations.

3. It doesn’t change what actually happens.

There are six categories of people:

Significantly Unwell – Positive test  Test outcome: Admit to hospital.

Significantly Unwell – Negative test Test outcome: admit to hospital

Mildly Unwell – Positive test – Go home self isolate.

Mildly unwell – negative test – Go home, still self isolate because the test result might be wrong

Completely well – Positive Test  –self isolate , don’t go out at all.

Completely Well – Negative test. – Don’t self isolate – but still socially distance yourself 2 metres from others, work from home if you possibly can, don’t go out apart from exercise or essential work.

Now, for the top two categories I listed, knowing whether a patient is positive or negative will obviously be helpful to some degree in their in-hospital management, but all hospital in patients are being COVID-19 swabbed.

I have highlighted in bold essentially the only group for whom the swab result makes a significant change in behaviour or treatment outside of a hospital environment – that is, if you happened to swab a completely well person and they happened to have a positive test.

However, remember, the swab will only return a positive test for a few days during the course of your illness, and even then, only in about 70% of cases. What are the chances of just happening to swab a random well person at that point in their asymptomatic infection? Very low indeed. For this to be a significant effect you would need to be swabbing not one person once, but every person every few days. You’d be talking millions upon millions of tests to pick up asymptomatic positives with any regularity.

This is partly why Prof Chris Whitty and Patrick Vallance have shown far more interest in the IgG test – a test to find out whether someone has had COVID-19 – because that will be a far more stable result over time. However, they are still not happy that a test exists which is sufficiently reliable for this.

It should be pointed out the IgG tests that are available probably are around 70% reliable – which makes you wonder why the PCR test for active infection is considered good enough with 70% reliability, but the IgG test isn’t considered good enough at the same figure. Could it be that we simply need to be seen to have some test so it looks like we are doing something?

Dr. Allin-Kahn says the government’s testing strategy has been non-existent. Well, in a sense, that is right. In all of the pandemic planning before COVID-19, widespread testing of the population was never considered a useful or meaningful intervention for an airborne virus. No one war-gaming an influenza-type pandemic prior to COVID-19 ever advocated vast amounts of indiscriminate testing of the general population. It simply does not change anything, and for the reasons outlined above it is possibly harmful.

Now, here is the problem with Dr. Allin-Khan speaking as both a politician and a doctor at the same time.

As a doctor, surely she knows how unreliable the COVID-19 PCR test is?

Surely, as a doctor, she knows there is no great magical significance to doing 100,000 tests a day? It all depends who you test, when, and why, and what you want to do with that information.

If that’s the case, she knows that her comment that “lack of testing…is responsible for many families being unnecessarily torn apart in grief” is hyperbole at best, and downright misleading at worst?

Surely, as a doctor, it’s bad for her to be stirring up unnecessary alarm in patients who will trust what she says as a doctor, and worry that lack of testing means that they, or someone they love might die? Surely it’s bad that those people may then be on the phone to their GP tomorrow to demand a test because “the Doctor” on TV said they might die without one?

So should I be criticizing that as doctor she is misleading her patients?

Alternatively, if she was simply speaking as an MP, she was, like 95% of MPs, being disingenuous, twisting facts to fit her political narrative and launch an attack on an opposition MP?

Well, that’s just the normal practice of MPs. It’s depressingly unremarkable and should simply be ignored.

I honestly don’t know – which would she prefer? What would be her preferred “tone” there?

 

Government, Experts, and the COVID-19 Body Count. Who’s to Blame?

Government, Experts, and the COVID-19 Body Count. Who’s to Blame?

At time the time of writing, BBC are reporting that the UK has a higher COVID-19 death toll than Italy. The knives are out for government. Apparently, we have “failed” in the UK on COVID-19, and it’s all Government’s fault.

The rhetoric on this is reaching simply hysterical proportions. Such as many people sharing online grotesque images of Tory politicians with hands covered in blood.

This is utterly disgusting political posturing. While the majority of people who swallow this vitriolic narrative will do so in good faith, there must  be people actively propagating this gutter-press coverage who know it is misleading.

The only question of pre-preparedness for COVID-19 is really around the PPE stockpile. There, it is quite clear that we could, and perhaps should have been much better prepared. However, even there, it is not at all clear that is the fault of Government. I have written extensively on the PPE issues previously.

To be clear what is the fault of Government in a situation like this, we need to be clear on what is the role of Government in a crisis like this. We live in a democracy. This means, yes, we get to vote for who our leaders are, but perhaps more importantly, it means our leaders are elected from amongst us.

We have perhaps lost sight of this, in a time when politicians seem very big, important, powerful figures, but the reason it is called “The House of Commons” is because the people who sit in it are “commoners”. The rather quaint underlying principle is that the people of a given area, select a person, an ordinary individual from amongst themselves, to go and represent them, and their local area, in Westminster. That is what your MP is supposed to be: An ordinary person selected from amongst you, to represent you in government.

The health secretary, who is just an ordinary elected MP, is not made health secretary because he knows anything at all about health. That’s not the point. That’s not how it works. The whole point is he is supposed to be a representative of “The average person” – the “lay-man” and give that lay-oversight into how healthcare is run.

This is, contrary to popular opinion, largely how it all does work. Anyone who has been involved in local politics or sat on a committee which has “lay members” will understand this concept.

It’s thus particularly galling when politicians who know full well how the system works, pretend not to when it gives them a chance to slate the Government.

To his credit, this is not coming from the Leader of the Opposition Keir Starmer, who thus far has been statesmanlike in his role as Leader of the Opposition in this crisis.

Last week’s Prime Minister’s Questions between himself and Dominic Raab, standing in for the PM was remarkable to watch. In recent years PMQs has descended into a bear pit of bad jokes tedious soundbites and personal insults. In contrast, what we saw last week, to the credit of both men, was sensible, relevant and enlightening questioning from Starmer, responded to appropriately and reasonably by Raab, and actually delivered meaningful dialogue to the viewer. The two men talked to each other like reasonable adults. It was really quite astonishing. Predictably, Starmer has been hauled over the coals by his own side for not being “tough enough” on the government. I think they have severely misread the mood of the country on that. Starmer’s approach, is exactly the right one in terms of rebuilding Labour credibility from an all-time low.

To understand how Government and experts interact, it is very instructive to actually watch it happen. I’d recommend watching this commons select committee hearing chaired by Jeremy Hunt, in which politicians are questioning the government’s chief science advisor Sir Patrick Vallance. It is important to note, for context, this meeting was held in mid-March, before lock down and strict social distancing measures were imposed.

What is extremely clear from this kind of dialogue (Which is representative of many others I have seen) is that politicians in this crisis have not had delusions of grandeur that they know better than the experts. What is striking in this video is how earnestly and readily they defer to Vallance’s expertise. Arguably almost too much.

There are several points at which the politicians clearly express concern about the UK’s strategy, they question Vallance on it, and he reassures them. It is particularly worth watching the exchange between Hunt and Vallance at 37min to 39min into the video.

Here, Hunt asks a very sensible question, with obvious concern, about why the UK strategy differs from the Korean strategy. This is in response to the approach whereby the UK has not tried to isolate and eradicate every single case of COVID-19, because in the view of Vallance and Whitty this is not possible. Their view is there is simply no point doing this, because as soon as you lift the control measures, the virus will simply re-emerge, and that will keep happening until you get herd immunity.

Hunt raises concern about this. Vallance shuts him down, in the gentlest possible way, by reassuring him that the science behind the mitigation strategy is sound.

Hunt here shows obvious tentativeness in the way he asks the question as a “non-scientist” and backs down from questioning Vallance too much further on this.

What is notable here is not that the government is ignoring the science and bullying them and telling them they know better, but rather, over and over again, that the politicians are in extreme deference to the scientists.

It’s important for people to see the kind of interaction in this video, because this is how Government actually works.

If the Government have failed on anything, it is that they have not held the scientists strongly enough to account for their strategy. However, that is not what they are mostly being criticized for, quite the opposite, in fact.

If you believe the rhetoric, the nasty Tory government have been bullying experts into submission and making them tell them what they want to hear so they can kill off as many doctors and nurses with COVID-19 as possible because they hate them. (Or something very much like that.). There is simply no evidence this is the case.

In fact, there is far more evidence that Government have been very meekly accepting of their scientific advice, and perhaps not questioned it strongly enough.

However, we now have a pro-brexit government. It’s primarily remainers who criticise them, and remainers love to be on the side of “The Experts”. They rolled their eyes at Gove’s “people have had a enough of experts” remark from the referendum, so they desperately want “the experts” to be on the right side of the COVID-19 debate, so they can have a “Told-you-so” moment. The facts do not fit that narrative, but they simply choose to believe the facts fit that narrative, because it fits their preconceptions.

The remainer opponents of the Brexit government could hardly now make the case that the Government should be ignoring the experts could they? They have rather painted themselves into a corner it seems.

The awkward fact is that the “mitigation” approach, not locking down early, was not the government’s idea. It came from the experts.

The Expert View on Mitigation of COVID-19

So why was this “mitigation approach” the expert’s strategy in the first place?

Prof Chris Whitty, an epidemiologist, and the chief medical officer, has lectured extensively on epidemics prior to COVID-19, so we can establish with a high degree of certainty, what sort of approach he would have been advocating for right from the start.

First let’s consider a lecture he gave in 2018, at Gresham college, entitled “How to control a Pandemic”. I think it’s fair to say that this should give us some insight into what his thinking would be.

First, Prof Whitty is absolutely emphatic that mass transport and travel is irrelevant to epidemics. he states at 5min40 in the video “it is possible, but wrong…many newspapers make this point, but wrongly…that we are increasingly vulnerable to epidemics because of the massive transport networks we have by land sea and air. The reason this is not as worrying as it looks is that being rich massively hardens society against epidemics of any sort. “

Now, I think we might venture to say that, on COVID-19, Whitty might have got this very very wrong. The risk profile for COVID-19 is being an overweight, diabetic elderly man. Obesity, diabetes and elderly populations are exactly the things which target the rich west. I rather suspect that COVID-19 may pass by the developing world much more unnoticed  than it does the West.  It is intriguing that a virus has emerged which exploits the evolutionary weaknesses of wealth rather than poverty. It appears Whitty may have got this wrong.

The other point we need to look at is his discussion of influenza epidemics at 45min
It is important to note here that he makes an assumption that an airborne infection would be influenza. The possibility of a pandemic Coronavirus may have  slightly blind-sided Whitty. It is very likely he approached it as being largely similar to an influenza epidemic.

A key quote from 48min45 speaking about past responses to influenza pandemics, he says:

“A whole bunch of interventions were called for, like screening at airports and banning of travel which are utterly useless, or as close to utterly useless as makes no difference.”

He goes on to say

“We can certainly put the building blocks in place to try and address an influenza epidemic, but we have to be aware that this would be chaotic and big.”

He then lists some preparations which might be made, none of which are PPE stockpiling or testing cases.

So let’s recap:

The CMO’s position on an influenza epidemic in 2018 was:

  • Shutting airports, limiting travel etc (basically the New Zealand “don’t let it in” approach to COVID-19) would be “utterly useless”.
  • That being a wealthy western nation would intrinsically protect us
  • Preparation doesn’t mention stockpiling PPE – only “Antiviral drugs”
  • He makes no mention at all of the role of testing in an influenza pandemic
  • It WOULD be “chaotic” and “big”. – He admits this right off the bat.

It is not unreasonable to think that Prof Whitty’s thinking, and therefore his advice to government on COVID-19, would broadly speaking have followed this pattern as it’s pretty clear his thinking at the outset was  to model our approach to COVID-19 along that of an influenza pandemic.

Now, as far as I can see, one assumption he made for an influenza pandemic turns out to be demonstrably false for COVID-19: Namely that rich western countries will be less affected. This turned out to be wrong, because although it spreads as a respiratory disease, the really nasty effects of COVID-19 turn out to be cardiovascular and autoimmune. The risk factors for this broadly follow the epidemics of the west: diabetes, obesity, and frailty of old age.

However, Whitty’s ultimate conclusion is almost to shrug his shoulders and say a flu pandemic would be “Chaotic and big” and suggest there is not that much one can do about it.

The big criticisms of government have been over not “shutting down sooner” and not testing more sooner. It’s surely obvious from the mentality expressed here by Whitty why these things did not happen? Neither have been features of Whitty’s thinking on Airborne pandemic infections prior to COVID-19. It’s important to point out that these are not esoteric views of Whitty. They are entirely mainstream epidemiological doctrines held to be true by most experts in Whitty’s field for years.

The miscalculation on who the pandemic would affect most may change the numbers somewhat, but doesn’t actually change that principle. So was Whitty right? Is there nothing we can do about Pandemics?

For that we have to address an underlying assumption that Prof Whitty is making. He is assuming that there are ultimately only two end-games for an pandemic disease: Either it moves through a whole population, almost everyone gets it, gets immunity, and then it dies out, or dies down to brief outbreaks amongst pockets of people who are not immune, or you completely eradicate the disease.

He doesn’t seriously entertain the possibility of holding the epidemic to “small outbreaks” in the context of a population which is largely not immune.

His views on disease eradication, are clearly explained at 7min22 seconds into another lecture. given at Gresham college in May 2017.

The full relevant quote is here:
“If you want to eradicate a disease for all time, you are going to have to have a series of things which everyone agrees, you absolutely need. If you do not have ANY one of these, you are guaranteed to fail and YOU SHOULD NOT START.

The first is you should have an effective intervention which can interrupt transmission, that is, get R0 below 1, for a prolonged period of time. If you do not have that, you should not start.

Secondly, you need a disease which is relatively easy to diagnose, because otherwise you do not know when outbreaks of the disease are occurring around you. So if you have something, which all you have is someone who’s got a bit of fever, and that’s about all, you’re going to find it pretty difficult. Smallpox, for example, was very easy. You could see someone with smallpox with good lighting at probably about fifty paces.

The third is there cannot be a significant animal reservoir.”

Whitty points out that the only disease to be eradicated successfully is Smallpox. Smallpox met all three of the tests Whitty laid out. There was a simple vaccination, cases were easy to spot, and it was not found in animals.

COVID-19 fails all three tests. The only intervention that gets R0 below 1 is total national lock-down. This is highly impractical as an intervention. The disease is not at all easy to spot. Every case is different. Symptoms are vague. Many patients have no symptoms at all. The testing is not even terribly reliable, throwing up both false positives and negatives regularly.

And on top of all that, we know this came from animals, and if it did it once, it can do it again.

So do we start to see how the government came to get the advice they did? The pattern of approach that the government has taken, exactly follows Whitty’s laid out thinking in lectures long before COVID-19.

And if you think back, you will see that the thinking Whitty is outlining in these lectures is exactly in line with the thinking of Vallance in response to Hunt’s question in the first video clip I linked.

Do SARS and MERS mean Whitty was wrong? 

One thing that is singularly lacking from Whitty’s lectures is much on SARS and MERS and how they were eradicated. Indeed, Whitty repeatedly references that smallpox is the only disease that has been eradicated from humans.

Why does he not put SARS in this group too?

There are two schools of thought on this. One is that the human interventions wiped out SARS and controlled MERS to very low levels. The other school of thought is that these viruses are just very unstable in humans and don’t really sustain large epidemics. They aren’t eradicated, because they were never truly stable diseases in a human population in the first place.

This is partly because they are so deadly. A disease which viciously kills a very high percentage of its hosts very quickly doesn’t give itself the opportunity to spread. It’s also easy to spot.

Intriguingly, some research on old camel tissue lab samples has shown that MERS has existed in Camels since at least the early 1980s. This makes it quite likely it has been crossing unnoticed from camels to humans for many years, probably causing a handful of nasty deaths, and then dying out of its own accord.

COVID-19 is clearly not like that. It is clearly showing a pattern of sustained human to human transmission.

For that reason, Whitty likely thinks of COVID-19 as fitting the Influenza framework of thinking far better than the SARS/MERS way of thinking.

The thing about this is, we simply do not know if Whitty has got this right until well after all nations start lifting their lock-down and normalising. If at that point the nations with the lowest numbers of cases in the first wave start getting hit hard with a second wave, they will have two options. Either they lock down again or, they take a more mitigated approach like the UK did first time around. In which case we will find ourselves rather further down the road to recovery than they are.

At this point, we simply do not know if Whitty  and the other expert advisers to the government have made the right call. What we do know is that anyone who tells you the government has ignored the experts, simply has not been listening to what the experts have actually been saying for several years.

And if anyone starts talking in hysterical terms about the UK death rates in comparison to the rest of the world, particularly if they do so to criticise the government’s response, they are misleading you, and probably doing so for political point scoring, which given human lives are involved is really a very low thing to do indeed.

 

COVID-19: You “Aim” for Herd Immunity the Way You “Aim” for the Floor When You Trip Over

COVID-19: You “Aim” for Herd Immunity the Way You “Aim” for the Floor When You Trip Over

“Herd Immunity” – The phrase was mentioned briefly  in press briefings near the start of the COVID-19 crisis and then rapidly disappeared. It disappeared because of a sudden howl of anguish from left wing political opposition and the media which broadly interpreted “Herd immunity” to mean “The nasty Tories are going to sacrifice your dear grandmother to COVID-19 for the sake of the economy.”.

There are so many false assumptions in this. For one thing herd immunity is the elderly and vulnerable’s best hope of surviving COVID-19, but we will come back to that.

The more fundamental point is this: We “aim” at herd immunity the same way you “aim” for the floor when you trip over. i.e. You don’t. It’s just where you end up.

You might try, with varying degrees of success, to reduce how hard you hit the floor, and likewise, we can try with varying degrees of success to control how hard we “hit” the herd immunity “floor” for COVID-19, but there is an inevitability about the fact that, at some point we have to get there.

Covid-19 will not end until whenever the virus finds itself inside a newly infected person it then finds it has nowhere else to go because everyone around that person is either already dead, or already immune. 

I strongly suggest taking some time to contemplate that sentence.

The second of the alternatives is the “herd immunity” end game, if you don’t like it, do you prefer the first option? That everyone is already dead, rather than already immune? Thought not. Fortunately, for COVID-19, the first outcome is very rare, and the second is very common.

Now, of course, that herd immunity mentioned, could come from a vaccine if we had one, but we don’t, and although there are lots of positive noises coming out of vaccine trials, we must be aware that every vaccine trial makes positive noises in its early phases, and rarely do they come to fruition. We hope for a vaccine, but it would be nothing short of miraculous if we had a viable vaccine able for delivery for COVID-19 in anything less than 18 months, in my view, and it could be a lot longer – if ever at all.

Which means we have to assume that immunity is coming primarily from people contracting COVID-19.

Those who stopped to contemplate that sentence above earlier as I suggested, may think they have a third “out”. They might want to rephrase the sentence as follows…

Covid-19 will not end until whenever the virus finds itself inside a newly infected person it then finds it has nowhere else to go because everyone around that person is already either dead, or already immune…or that person doesn’t get to spread it to anyone else because they are isolated.

This, is the lock-down principle which attempts to turn a dilemma into a tri-lemma and give us an escape.

Except, it doesn’t work. And here’s why:

If someone has COVID-19, they got it from someone. So, by definition, if you caught it – you were in an interacting network with other human beings, such that you were able to contract it. It’s thus highly unlikely that you won’t be in contact with at least one other person to pass it on.

And remember the “R0” force-of-transmission principle? For a quick Re-cap: “R0” is the number of people that the virus, on average, infects. R0=1 means that each person infects one other person, R0=2 means that each person infects 2 other people etc.

If R0 is less than one, the epidemic will burn out

If R0 is greater than 1, even by a small amount, the epidemic will continue to grow.

Saying “R0 is less than 1” is slightly too mathematical to really take on board what that means in practical terms: It means that, after contracting covid-19, you come into so little contact with other people that you don’t spread covid-19 to anybody. Not a single soul. On average, everybody needs to infect less than one other person, or else the virus will not die out. And because you can’t have have “half a person”, that means plenty of people not passing it on to anyone at all after they contract it.

Let’s remember, this is a virus which very often makes people hardly unwell at all, and it incubates for up to two weeks, and for some of that time you may be infectious before you know you have it. And all you may need to do to infect someone else is get within 2 metres of them, or for that person to touch a surface you touched – possibly many hours later.

And if that happens once you’ve failed to help reduce the spread, and if it happens just twice you’re actively part of the problem of the exponential growth of the virus. Don’t feel bad – you won’t be the only one by a long way.

It is actually astonishing to me that the lock-down measures we have are being as effective as they appear to on this count, and yet, it appears with our current measures we are getting the R0 just below 1. For now. Bear in mind, if R0 is only just below 1 it will take a long time for the virus to burn out, and it will only remain below 1 while lock-down remains in place.

Virus eradication? Is it possible?

Those who are rejecting the concept of herd immunity seem to be toying with the idea of eradication. They seem to think that maybe we can “stamp out” COVID-19. We can simply lock it down until it’s gone.

I’m afraid we are going to need a history lesson here. But not very far back in history.We need to go back to a lecture on disease eradication from Prof Chris Whitty in 2017. It’s important that this lecture was given just before the COVID-19 crisis, which is why I refer to it as history, because I strongly suspect he says things here, which politically, could not be said in the midst of the current crisis. However, in 2017, he could speak more freely.

At 7 minutes 24 seconds into the video, Professor Whitty makes the following statement:

“Now if you want to eradicate a disease for all time, you’re going to have to have a series of things which everyone agrees you absolutely need; if you do not have any one of these, you are guaranteed to fail, and you should not start.” 

Wow. That’s a pretty powerful statement. Do we want to eradicate COVID-19 for all time? Yes, I rather think we do…and if we aren’t going to arrive at herd immunity and want to eradicate the disease instead, we are going to need to listen to this aren’t we? Prof Whitty lists three key criteria thus:

  1. An effective intervention to interrupt transmission
  2. Easy to diagnose and detect cases
  3. No major animal reservoir

There is only one human disease in history which has been completely eradicated: That was smallpox. Let’s think about how the criteria apply to smallpox.

  1. The intervention was the smallpox vaccine. This was very easy to give, and highly effective. Not only that, the vaccine acts quickly
  2. Smallpox is incredibly easy to spot. It covers a person in massive ugly lesions. You are not going to “miss” a case.
  3. Smallpox occurs only in humans in nature.

Even so, Smallpox had a 20 year eradication programme  between 1959 to 1979. It almost didn’t happen and the programme nearly collapsed on several occasions.

The total worldwide eradication programme cost $300million at the time, which is something in the order of $1 Billion in today’s money. Actually, not that much when you think about it. Less than 1% of the annual NHS budget for example

Now, let’s think about  how those 3 tests of Prof Whitty are going to apply to COVID-19 today.

  1. The only intervention which gets the R0 below 1 and interrupts transmission is near total society lock-down. Nothing else does it. As soon as you remove lock-down, R0 will go above 1 almost immediately if the virus was not completely wiped out first. i.e. every last case traced and excluded
  2. Which is where the point about disease identification comes in. How will you know that you have got the last COVID-19 case? The “last case” may be someone who is completely asymptomatic. If you don’t know, and they don’t know, they are the last case of COVID-19, they may easily go and spread it to two other people. You could get that tantalizingly close to eradication and be foiled. This is why Whitty insists that being able to easily detect and diagnose cases is a pre-requisite for even starting an attempt to eradicate a disease, because when you get down the last few cases, that’s where it will become critical to identify every last case. You simply cannot do that in a disease which is often asymptomatic.
  3. COVID-19 came from animals. We know there is at least some evidence of animals which live close to humans contracting it. It is therefore sadly possible we could eradicate it completely from humans and still have it bounce back into the human population from animals

Now, why is Prof Whitty so pessimistic about attempting disease eradication programmes? Is it because he’s lazy about trying to wipe out disease? Why does he insist that you “should not even start” if these three tests are not met?

There is a simple reason: You are simply wasting resources which would be better spent elsewhere. And in the case of COVID-19 the intervention in point 1 is total lock down. This intervention is hemorrhaging billions from our economy by the week.

Economically, what lock-down is doing is blood letting. We are letting the economy bleed out. Rapidly. This matters because a healthy economy pays for health care, it pays for social care, it pays for medicines. 

What happens if the following scenario plays out?: After all that cost, after pouring all our blood and treasure into the lock-down cause, we think we have eradicated COVID-19. There are no reported cases for several weeks…the country is COVID-19 free!

So we lift lock-down. It’s cost us hundreds of billions of pounds up to this point. It has crippled us with new debt for our grandchildren’s generation onward, but at least we have eradicated COVID-19!

Then, 6 weeks later, someone shows up breathless at a hospital in Brighton, three days later a nasty cough arrives in a hospital in Newcastle. Then two cases the same day in A&E in London. The swab results start coming back positive for COVID-19

What then? Straight back into lock down? How long for this time? And if not lock-down again, then what do we do? And if we do something else second time around, what was the point of wiping out the economy with lock-down the first time around?

You could go for a track-and-trace individual cases approach, but COVID-19 slipped through our track and trace net last time, and within 6 weeks we went from one businessman in Brighton returning from Singapore to having to lock-down the nation.

Locking down until the point of being assured of disease eradication is phenomenally high risk. It will cost a fortune so utterly eye-watering it is scarcely imaginable, and if just one case slips through the net (and it very likely will) we will be back to lock down mode again within weeks of lifting it when the trickle of cases starts turning back into a flood.

On that cost question. Remember the worldwide cost of eradication of smallpox was $1 billion in today’s money We have already funded the NHS to the tune of an additional £16 billion, and it is estimated that lock-down is costing around £2.4 billion a day to the UK economy alone.

Think about that. We are spending two and a half times as much per day to to attempt to eradicate COVID-19 in the UK alone, as was spent over a 20 year programme worldwide to eradicate smallpox.

There is a point, where we have to consider the money. There have been 27,510 deaths of COVID-19, each one will be a personal family tragedy. However, there are those who think that the government do not “care” about that death toll.

Well, let’s think about it this way. Taking into account the cost of the lock down and working it out on a “per death” basis, each of those deaths has so far cost £3.6 million pounds to the uk economy.  It is utterly unheard of for a UK government to sink this kind of money into attempting to save the lives of the population. Please do not tell me they do not care.

It matters to consider the costs, because anytime a government is spending money one way, we always have to wonder if it would be better off spending it another.

Aside from Smallpox, we have come close to eradicating just a few other major diseases, and then the attempts broke down.  We remain desperately near–but-far from eradicating Polio. One disease we came close to at one point eradicating was Malaria. Malaria kills a million people a year. A million of the poorest people in the world. Probably with enough political will and spending power, it could be completely eradicated. It is estimated that an attempt to completely eradicate Malaria would cost $90 Billion over 20 years.

In other words, the amount of money the UK alone has spent on COVID-19 in just over a month, could have paid for a 20 year programme to eradicate Malaria, worldwide, forever.

COVID-19 will not affect the third world particularly severely in my view. Although, in the UK, there does seem to be a slightly disproportionate effect of COVID-19 on Black and Ethnic minority groups, this effect is tiny compared to the age-related risk factor.

Essentially, in the scheme of things, COVID-19 kills two groups: Old people and young people with complex immunosuppressing health conditions.

Sadly, both of these groups are only found in small numbers in Third world and developing world nations anyway, where life expectancy is low, and the young people with those complex conditions don’t survive as long anyway, due to less advanced health care.

Thus, COVID-19 is likely going to be a disease of the Western world. (Unless it throws up another surprise, which this disease has proven very good at doing.)

So when a left-wing leaning political person criticises right wing governments for “not doing enough on COVID-19”, please remind them that we are, surely, by the same token, not doing nearly enough on Malaria. They want us to open the floodgates on spending on COVID-19 so that 85 year olds might live to be 90 (and believe me, every western government is opening those spending floodgates), when we should remind ourselves that 67% of all Malaria deaths worldwide occur in children under 5. A child dies of Malaria every 2 minutes.

So am I saying we shouldn’t spend this money on COVID-19? No, although I think if left-wingers are going to be really consistent with their own values they ought to be considering that position.

What I would want to know however, is that the money we are spending is at least going to achieve what we want it to achieve. If we are going to take this approach to COVID-19 we’d better not be pouring all that investment down the drain.

The Graphs which outline the COVID-19 strategy

So, it appears that lock-down on COVID-19 is an attempt to pursue an eradication strategy for COVID 19, despite the fact that COVID-19 fails every test for being a disease which is amenable to enforced eradication.

Perhaps you thinking “Why does it have to be so extreme? Why are we talking in terms of total eradication? Why can’t we just use lock down to push COVID-19 down to manageable levels?”

The answer is because COVID 19 just doesn’t work any other way. And we can see why from some graphs below.

First is a graph that Prof Chris Whitty used from Imperial College in a recent speech he gave at Gresham College. (Interestingly in this speech, Whitty stated he would not “aim” for herd immunity – I suspect, although he didn’t vocalise this, he meant this in much the same way I phrased the title of this article.)

graph1

What this graph shows is how different combinations of suppression methods of COVID-19 can “flatten the curve” according to Imperial College’s modelling.

Here’s the bad news: That flat red line across the bottom represents UK ITU beds and the graphs of the other lines represent the number of patients who will require them.

There are a few points to make about this graph.

  1. The various different lines on the graph are all pretty closely bunched through mid to late April. It would be phenomenally hard to tell which line you were on, accounting for the margins of error, until the start of May at the earliest. It demonstrates how most talk of how “well” or “badly” we are doing  in the press is basically premature.
  2. The more suppression you have the later the peak moves in time.From mid may with no suppression to mid june with greater suppression efforts. More effective suppression means the peak comes later, and the thing goes on longer.
  3. All suppression methods appear, on the basis of this modelling to massively overwhelm our ITU resources by mid May to varying degrees. And by “massively” I don’t mean “a bit busy”. I mean nearly 100 ITU requiring patients to every available ITU bed even on the best case scenario
  4. None of those graph lines represent what we have actually done, which is total national lock-down. Largely because point 3 means there was little other option.

So what is the projection of the actual course of action we took? “Lock-down”?

For that we need another graph which is here:

graph3

In this graph the green line represents broadly the strategy we have taken of lock-down, with orange being a sort of “soft lock down” option.

It’s difficult to see, so let’s zoom in…

graph4

 

Now we can see how that green line (our current lock down strategy, stays underneath the all important “NHS capacity” line. See the downturn from mid April into May? That’s the “peak” which Boris Johnson announced we are “past the peak” on May 1st. Possibly a few days later than than the graph suggests we might reach that point, but not far off.

This looks like great news doesn’t it?

Except, wait…look back at that first graph and notice what happens right at the far right hand edge…

See that slight up-tick starting again in November? I’m afraid I didn’t show you the whole graph:

graph5

 Oops. look at what happens in November on the “hard lock down”. The blue shaded area of the graph represents “hard lock down” until September and yet we still see an enormous second peak in November after the lock-down lifts. In fact, it’s slightly higher than the “do nothing” peak. This is presumably because we would anticipate the whole situation of COVID-19 occurring in the winter months would be much worse than happening during the summer. What is interesting to note is that a “softer” lock down gives a softer (though still worryingly large) peak in November.

Why does this happen? Because unless you are developing herd immunity amongst the younger, fitter, healthier population, you are not actually moving forward in the battle against COVID-19 you are are just delaying starting the fight. Lock down is simply pressing the “pause” button, and as soon as you unpause, the story picks up where it left off.

The only way this wouldn’t happen is if the lock down really managed to achieve total eradication, but we have already seen that COVID-19 is a terrible candidate for trying to achieve that. If you leave even a handful of cases behind, that second green November peak is still the outcome after lock-down ends

What is the solution?

So in the final analysis, while we want to do as much as we can to soften the blow as we can, and, up to a point, lock down helps achieve that, we have to bite the bullet with COVID-19 at some point. And it would seem to me, the way to do that is to try to let it circulate amongst the youngest, fittest, healthiest people first if we can, as much as possible, (While protecting the vulnerable as much as we can) to build up heard immunity.

Around 37% of the population of the UK is under 30. Mortality in this age group is no higher than 0.06% for COVID-19 and even that mortality is likely to be amongst those with predictably high risk (those  with immuno-suppressive illness etc who could be protected and shielded.)

If you told most under 30 year olds there was a vaccine which would enable them to continue their lives as normal and was 99.94% safe, would they take it? I rather think they might.

You need to be as careful as you possibly can that this group do not mix with vulnerable and more elderly groups.

The way to do this is to “release” the under 30s into normal life as much as possible and quite soon before lock-down fatigue sets in too much and the older and more vulnerable population start coming out of isolation.

Then once we have  well circulated COVID-19 in that population group, we would start to cautiously “release” the 30 to 50 age group, then the 50 to 60s, then the 60s to 70s (narrowing the age bands because the risk is going up in these groups.) Once we get to the 50s/60s group we are getting over 60% of the population exposed and immune.

The rate of release would be determined by the case numbers in response. Geographical limitations could also be used to limited the release rate and control the rate if necessary.

Each group is being released into a successively “safer” environment because of the established immunity level rising.

What is crucial is to start to do this relatively briskly. Once the initial tide has been turned on the pre lock-down rising wave of cases, there is very little point in waiting. There are several reasons for this:

  1. We actually want to “get through” this before the autumn/winter. For numerous reasons this is all going to be much easier to cope with when the health service is less pressured in the summer. We must not delay too long or we risk a second winter peak.
  2. The success of lock down will tail off. Patience will start to wear thin with people, and the absolute disaster scenario is for the vulnerable and the non-vulnerable populations to emerge from isolation at the same time.
  3. Every day of lock down beyond necessity is damaging the economy and we need the economy to pay for all this.

This is not a perfect solution. There will be deaths. They will be tragic, but there are avoidable deaths and unavoidable deaths. What we want to do is ensure as few avoidable deaths as possible occur. Go back to the title of this piece. We’re not “aiming” for herd immunity here, we are simply trying to mitigate the damage of arriving at that inevitable end point.

Unless immunity levels rise in the community, the community is going to remain a fundamentally unsafe place for the elderly and vulnerable to go.

Do we expect those people to stay shielded in isolation for, 6 months? a year? 18 months?

If you are 75 years old, you might live another 10 years. Do you want to spend a tenth of that cooped up in your house just so you can stay alive? Probably not. If you could be “released” back into an environment that had built towards something like 60% herd immunity would that seem a risk worth taking? I think it probably would. It is the safest, and fastest way that I can see to get people their lives back.

At this level of immunity building, there would still be hot spots of COVID-19 crop up, but, the higher levels of established immunity around those early cases would drop the natural R0 of COVID-19 in those areas, down to a level where healthcare services have a chance to react to it, and lock it down locally, before it moves quite so far through the population. Some degree of herd immunity slowing transmission will give a “track and trace” strategy more of a chance to work.

None of this means an initial hard lock down was wrong. The initial hard lock down, simply to buy  time was extremely sensible. Time to reconfigure the NHS, time to just think about how to sort this out, time to develop decent testing. (widespread IgG immunity testing will be extremely useful in this strategy to figuring out how and when to “release” different age groups.)

This seems to me a way out of the current dilemma. I’d be interested to see what the modelling looks like for it. The problem is, it depends on us taking a mature approach to herd immunity and distinguishing between avoidable and unavoidable deaths in a compassionate, but clear-headed way.

Footnote: What about SARS AND MERS ?

I have maintained throughout this article that the only disease successfully eradicated in humans is Smallpox.

This is the conventional thinking. Some may be confused. Have we not eradicated SARS and MERS in the past using hygiene and population quarantine measures?

Probably not. The truth is SARS and MERS may have virtually eradicated themselves. It’s not really clear that they did truly develop sustained long term compatibility with their human hosts. Viruses are parasites, and like all parasites, for any degree of long term propagation and success they need to have some consideration for the welfare of their hosts, long enough to allow for reproduction.

There were 8098 cases of SARS, causing 774 deaths. There have been 2519 cases of MERS causing 866 deaths.

These numbers are so tiny in proportion to world’s population,  that it’s very probable stochastic effects were at work, as discussed in this paper. – That is to say, the diseases never really got off the ground enough for the “laws of large numbers” to apply to the cases and exponential growth to be established.

Early on in the current crisis, an article in the Lancet considered the question of whether COVID-19 could be contained the way that SARS and MERS were, and the article comments “Because of the extent of community spread, traditional public health measures might not be able to halt all human-to-human transmission, and we need to consider moving from containment to mitigation.”.

SARS and MERS, you can see coming. They make most of the people who contract them pretty catastrophically unwell. They kill  and incapacitate such a large proportion of the people who catch them, that they essentially enforce their own quarantine and force themselves out of existence. They make their presence known to healthcare services quickly and loudly in the first few cases.

Moreover, we don’t think they have really completely gone away, because of their animal reserves. MERS comes from Camels. The first cases were reported in humans in 2012, but, scientists have managed to turn up some lab samples of camel tissue from 1983 and found MERS antibodies in it indicating that camels were just waiting to pass this disease onto humans for at least 30 years, and thus easily could do so again.

For this reason, SARS and MERS containment do not seem terribly relevant. The only country that really seems to give hope of those kind of measures working for COVID-19 is South Korea, but it is early days yet, and it’s extremely difficult to understand exactly why they have been so successful at this point. They have recorded barely 10,000 cases of COVID-19 at this point, which I think simply means the numbers in South Korea may yet be too low to draw final conclusions on. We need to see what happens when more international travel resumes  and inevitably some COVID-19 starts slipping through their security nets.

 

 

The PPE Scandal. What BBC Panorama got Right and What it Got Wrong

The PPE Scandal. What BBC Panorama got Right and What it Got Wrong

Everyone is now an expert on what the Government should have done about COVID-19 in January or February. Most of this is highly speculative, but there is one area where there has been a clear failure: Personal Protective Equipment (PPE). The BBC’s Panorama addressed this with a programme entitled “Has the Government failed the NHS?”

What should have been an excellent opportunity for some root cause analysis of what has been a catastrophic failure on the PPE front, was instead, turned into a political hit piece against the Tory government. You can have one guess what the programme appeared to conclude the answer to the title question was. The problem is that the question itself is wrong: A better question would be “Has the NHS failed itself and its staff?”. 

Before we get into that, let’s first agree about what Panorama got right:

There has been a clear failure to acquire sufficient stocks of the right kind of PPE. The clearest example of this is full body-covering gowns.

What should be pointed out here is that there is no shortage of pathetic flimsy plastic pinny aprons which do not cover the whole body. I have not heard a single member of NHS staff complain that they have been unable to get hold of one of those.

In the view of anyone with any degree of expertise in microbiology and viral transmission these aprons are a complete joke for preventing a virus which spreads by airborne droplets.

There is something almost willfully illogical about the plastic gowns which makes me especially angry: If you think the virus can spread from coughing/sneezing/talking and hit your body, then clearly you need to cover your body. If you don’t think it can, and can only spread by fluid or bodily contact – then you don’t need to cover your body for most minimal contact clinical interactions.

It takes a special kind of stupidity to offer an item of clothing which covers half your body. What ridiculous kind of message is that trying to send? Of course, these aprons are in no way intended for use for an airborne droplet-spread disease. They are intended to reduce spread of diseases like MRSA which are only spread through direct contact and provide basic cleanliness and hygiene from splashes of bodily fluids.

It would somehow be easier to respect the position of Public Health England if they simply stated “Bodily covering is not required for COVID-19”. They’d be wrong, but at least they’d be consistently wrong.

The assertion that you must wear a pathetic plastic apron that barely covers half the chest of a large adult man, but that you definitely don’t need a proper gown covering is so patently absurd, that you know it was a decision that could only have been made by a committee. No individual can possibly have proposed it.

The aprons are not free after all. Yes, of course they are cheaper than the full covering gowns per item, but spending less money on an item which is useless is clearly worse than either spending more money on an item that works or just spending no money at all. It is the worst of all worlds.

And yet, millions of these wretched aprons are in every NHS clinical environment.

So right off the bat we should re-frame the  question: It is not “Why do we not have enough PPE?”, the correct question is “Why do we have the wrong PPE”? Why do we have mountains of pointless aprons?

Is that the Government’s fault? Is that Matt Hancock’s fault?

Here now I will make an uncontroversial statement: The health secretary, Matt Hancock knows very little, if anything at all, about healthcare in general, and even less about infection control and appropriate PPE.

And that’s ok. He’s a politician. The point of politicians, as elected representatives is to be the representative of the lay-man. Matt Hancock’s only required (and arguably, actual) qualification for his job, ultimately, is that the people of West Suffolk voted for him, from amongst themselves to go and be “their man” in London. The point of your MP at parliament is not that they are special. It is that they are ordinary. Anybody can become an MP. And Matt Hancock is as close to “anybody” as you can get. That’s the point. That is why it is called the House of Commons. They are “commoners”.

It’s strange that we live in a democracy, and yet constantly talk about the “competence” of our politicians as if we expected them to be technocrats. They aren’t, because this is  democracy, not a technocracy.  We end up blaming them for things which aren’t supposed to be the role of democratically elected MPs in the first place.

We don’t make this mistake when we think about our law courts: There, we have the professionals – the Judge, and the lawyers, and we have the amateurs: The Jury.

We all understand two things about the Jury Law Court: A) That the jury, in a sense, are ultimately in charge. Not the judge. It’s the Jury who have the final say and B) The Jury have this power precisely because they are ordinary not special. We do not see these two things as being in contradiction. When there is a miscarriage of justice, seldom do we blame the Jury and say they were incompetent.  We tend to blame the judge, the CPS or the lawyers for misleading or mis-directing the Jury.

We understand that it is the job of the professionals, the judge and the lawyers to present sensibly to the lay-men and lay-women of the jury a complex legal matter in such a way that the lay-person can make sense of it, and come to a fair-minded decision.

Yet, when it comes to government, where, often, a similar principle should apply, very rarely do people ask the question “Were the government misled by the advice provided to them by their civil servants?”.  It’s at least worth considering the possibility. Especially in this current scenario.

So it’s not the health secretaries job to decide what kind of PPE is supplied. I do not expect the health secretary to decide this. What I expect is for him to be suitably advised by appropriate experts to give him the assurance that the appropriate PPE has been procured.

Of course, I would hope and expect he would ask sensible and probing questions of people like Public Health England who report to him, but they also have a duty to be candid with him and advise him correctly. If they advise him, and he  goes against that expert advice, they also have a duty to be transparent about that at the time, overtly voice their concern, or even resign, and if they do not do so, then they take collective responsibility for the decision made.

The problem is, on this question of PPE, it seems those things did not happen. Either ministers were just briefed incorrectly, or they were briefed correctly, rejected that correct advice, and did their own thing, but those briefing them did not publicly and clearly voice their concern, and thus take collective responsibility.

We are going to look at this in some depth, this may get a little technical but not too much, so bear with me:

Public Health England’s guidance on what PPE is required is here (don’t go reading it all).

A key concept to understand in the PHE guidance however is “Aerosol Generating Procedures”.

Think about the fine mist that comes out of a spray can – an aerosol. Think how it “hangs” in the air. Clearly if the virus can hang in the air like this, it would be easily spread. The very fine particles can be inhaled, settle on clothing and pass through or around anything other than a proper respirator mask.

The official position on COVID-19 is that it does not form a fine mist from normal coughing and sneezing, but only forms a fine mist like this under certain circumstances of performing certain medical procedures (Such as inserting an airway tube.) These are called “Aerosol Generating Procedures (AGPs.)

This is important, because all of Public Health England’s Guidance on what PPE is required is based around whether or not a particular circumstance is an “AGP”.

Their position, rightly or wrongly (and it’s wrongly in my view) is that “Full” PPE, that is, a full body covering gown and proper respirator mask, are only required for AGPs, but not for other normal patient contact work.

The problem is this distinction is highly controversial, both on what is or isn’t an AGP, and on the wider question of whether a lower level of PPE is appropriate for non AGPs anyway.

Public Health England, however, simply whitewash this controversy, and i suspect whitewash it when they present it to Government too. Here is one specific example of what I mean:

The CPR Controversy  

In the document mention above, in section 8.1 we find the following statement regarding what PPE is required for performing CPR and resuscitation:

“Chest compressions and defibrillation (as part of resuscitation) are not considered AGPs; first responders (any setting) can commence chest compressions and defibrillation without the need for AGP PPE”

Now, here’s the thing: Resuscitation protocols are regulated in the UK by an organisation called the UK Resuscitation Council. Not Public Health England. Did you do a St Johns Ambulance or Red cross first aid course many years ago and get taught you should do 15 chest compressions  to one breath? Some years later if you did a more recent course did you get taught you should do 30 chest compressions to two breaths? (By the way, if the answer is “no” and you have never done a basic first aid course then you really should do. 3 Hours of your life could save someone elses. St John’s Ambulance provide courses for £30 )

Those 15:1 and 30:2  compression:breaths numbers are decided by the UK Resuscitation council, which is why they are the same on every course. They review the guidelines every few years and make changes in accordance with latest evidence. When it changed from 15:1 breaths to 30:2, that was because they said so. They determine every aspect of the national protocols for resuscitation in the UK and set the standard of best practice for clinicians in this area.

So, obviously the statement that I quoted above from PHE would have been cleared with the Resuscitation council first, right? The PHE wouldn’t have issued an effective change to CPR protocols that hadn’t been approved by the UK resuscitation council, right?

Umm…well, not exactly. The Resuscitation council released an extraordinary statement about this stating “We are deeply concerned by Public Health England (PHE)’s continued insistence on designating chest compressions as non Aerosol Generating Procedures (AGPs)

The resuscitation council have stated that they “were not consulted” by PHE. This is truly extraordinary. One would assume that, at some point, people from PHE were sat in a room and someone said “We need to consider COVID-19 protocols for resuscitation..can anyone think of who we should speak to about that?” and no-one in the room suggested speaking to the expert authority on resuscitation protocols? This is simply shocking.

Here’s the problem though: You now know about The UK Resuscitation Council because I just told you, but does Matt Hancock? Quite possibly not, because when he sits in a board room the people there with him are Public Health England. Not the UK Resuscitation Council. This is because, at the end of the day, while the Resuscitation Council is the highest respected professional body on all questions of resuscitation in the UK, it is ultimately not a government organsiation, but a charity, (and an extremely worthwhile one, which if you wished to donate to, you can do so by going here)

So in the unlikely event that  Matt Hancock were to ask an intelligent question like “Do we have enough of the right PPE for doing resuscitation then?”, Public Health England will tell him “Yes”, because they insist that full gowns etc are not required. It’s perfectly possible that Matt Hancock would be completely unaware that the leading experts in the field of resuscitation would disagree. Hancock’s “experts” are Public Health England. They are the only people in the room with him for him to get an opinion from.

On what “expert” information should politicians based their decisions?

At this point I expect someone will be saying “Well, why does Matt Hancock only listen to Public Health England? Why doesn’t he read letters people send him? Or the replies to his tweets? Or watch the news?”.

The problem with this, is that it’s just not the done thing. It is expected that a minister will only take into consideration that information which comes to him through the official channels up to his office, and is officially presented to him in official reports.

Why? Precisely because he is a layman, and if, as a layman he started trying to weigh up the evidence being given to him from his “official” channels against what someone told him on Twitter, where would that end up?

Well, actually, we know the answer to that question. Lets talk about an example of where that ends up: For an number of years, there have been advocates of a particular “alternative health” ilk, who have promoted something called “Miracle Mineral Supplement”. They believe a few drops of “minerals” (sodium chlorite), mixed with juice containing citric acid from citrus fruits creates a powerful health-boosting mineral drink.  Many news outlets have covered this idea for several years, such as this report from four years ago, and it can be sometimes sound quite plausible..

The thing is, what you get when you put sodium chlorite in acid is Chlorine dioxide, which is bleach. This “health food” craze is literally advocating drinking bleach. This is a staggeringly bad idea. (i.e. Potentially fatal.)

This would have remained an obscure thing, if it were not for the fact that the President of the United States was perhaps browsing late night cable TV at some point, maybe came across something about “Miracle Mineral Supplement” and next thing you know the internet lights up with “President tells people to drink bleach” type headlines.

This is exactly what happens when politicians go outside of their usual channels for information. You cannot expect a layperson politician to know the difference between a reputable organisation like the UK resuscitation council and nutcases like Miracle Mineral Supplement advocates, once they start going off-piste with where they take their advice from.

So when Matt Hancock and Boris Johnson tell us they are being “led by the science” I tend to believe them. I believe they probably are responding to exactly what they are being spoon-fed by their official experts

The Panorama Assumed Narrative

So, what exactly did happen? How did we end up with the wrong PPE?

Well, according to the BBC Panorama narrative, the government “failed” The NHS. If you watched the Panorama programme, you might well think that a dialogue something like this occurred sometime last year:

Hancock: “Hey, Chris Whitty, I’ve been going through the list of items for PPE. Line by line. I noticed at line 4032, you wanted to order “4 million gowns, colour blue, long sleeve”. Is that really necessary?”

Chris Whitty: “Why, yes, without them if there is a pandemic our brave doctors and nurses will surely die..”

Hancock: “Will they? Really though? Look…I read it last night, I went on E-bay and I found I could get this roll of plastic aprons 1000 per roll, for just 2p per Apron..seemed legit to me. And i got a £20 cashback offer for bulk ordering too. I’ve stuck the order in and crossed out the gowns? Only thing is – they are green, not blue – is that gonna be ok?”

Whitty: “You can’t do that! Our doctors and nurses will perish”

Hancock: “Nah, they’ll take their chances. Tel ’em to wash their hands and sing Happy Birthday or something.  It’ll be fine. Probably never need them anyway. I will see if I can re-order in blue if it makes you happier, and besides, I’ve already spent the money I saved on 100 cases of Bollinger. See ya later looser!”

The Panorama documentary came across that way. It set up a simple narrative of “Government ignoring advice” with no explanation of what that actually means, or would have looked like in practice.  There was absolutely no attempt to understand why the government might not have responded to concerns.

Would it not make more sense to at least consider the possibility that government ministers were misled and falsely assured by those under them? Or there was a miscommunication which meant they never really “heard” the warnings? Doesn’t that narrative at least merit exploration?

The Panorama Hit-piece source biases

It would merit explanation if the Panorama programme was remotely interested in the truth, but the entire way it was configured smacked of being a hit piece on the government.

During the programme, Panorama interviewed a couple “ordinary” junior doctors.

Except, a brief google suggests that these are not average junior doctors:

Dr Irial Eno –  A quick google finds Dr Eno has been politically active on migrant rights for a some time, and was “founder of the Birmingham branch of docs not cops”  (An organisation opposed to limitation of migrants access to NHS services)

Dr Sonia Adesara has her own highly political website . She is communications officer for Pro-abortion rights group “Doctors for Choice” and a former director of “5050 parliament” – a lobbying group pressing for gender equality in parliament.

Do we think these people were Tory voters at the last election?

Of course there’s no reason why the BBC shouldn’t speak to these two doctors, but it’s surely not reasonable to suggest that it’s sheer random chance that what were presented as two typical NHS junior doctors both turned out to be notable politically active individuals?

It seriously calls into question the extent to which the BBC can be said to be playing with a straight bat when they present someone in a programme as being an ordinary rank and file doctor who actually has her own wikipedia entry.

To be clear: I don’t in any way blame the doctors in question, who are perfectly entitled to both their careers and airing their political views, and for what it’s worth, the points they made in this programme were by and large reasonable, but it reflects poorly on the BBC to pass this off as rank and file doctors. It’s also tempting to wonder what conclusion can be drawn from the fact that they apparently couldn’t find any non-left wing doctors to talk to them?

Panorama also made a big deal out of talking to Prof John Ashton.  He was very happy to spout off his opinions (with little factual basis) that the Government had acted terribly. However, that’s hardly surprising, because according to this independent article he states he has been a member of the Labour party since the age of 17. He was also awarded a CBE in 2000 (i.e. under the Blair Labour Government).

Of course, he was awarded his CBE purely for his services to the NHS, and it would be unfair to suggest that the fact this happened under a Labour government when  he has been a member of the Labour party for many  years and, according to his wikipedia page,  supported every left wing progressive political cause going was anything other than a coincidence.

Is it really such a stretch to suggest that presenting him simply as an “expert” without any reference to his political affiliations is not exactly the BBC telling the viewer everything they might want to know when weighing his expert opinion?

Next up in the BBC’s expert parade was Agoristsa Baka of the European Centre for disease prevention and control

The clue is fairly obvious in the name here. the ECDC is an EU agency. Back before COVID-19 dominated the world, you may remember something about an event called “Brexit”. Again, is it any great surprise that an EU agency and its representatives would take the opportunity to stick the knife in Boris Johnson and his government?

Now, it’s not wrong that the BBC interviewed any of these individuals, but taken together, the fact that every one of them has potential political biases against the government of the day, and those biases were not made transparent to the viewer is surely concerning?

It was that surface level of disingenuous presentation of sources which made me want to dig into some of the specific claims a little more. And here’s what I found:

Misleading Panorama claims

Misleading claim 1. “The Government ignored warnings to buy gowns”

The key claim in the BBC Panorama programme comes at 11:05 “Panorama has discovered that just last year, the government’s own advisors warned that gowns were needed in the stockpile, but still none were bought”

The programme helpfully gave the source for this claim and the document is from the NERVTAG Minutes June 2019 (New and Emerging Respiratory Virus Threats Advisory Group). The relevant section is 6.0 PPE Stockpile. Gowns are mentioned 4 times in those minutes, as follows:

“Gowns are preferential to aprons (better coverage of uniform/clothes) where there is a risk of extensive splashing of blood or bodily fluid, and for aerosol generating procedures. Again,this is in line with HSE recommendations”

“The committee agreed that the addition of gowns to the pandemic stockpile for use during splash-prone or AGPs would be of benefit, as this would bring the stockpile in-line with standard infection control procedures for seasonal influenza”

“NERVTAG recommends the procurement of gowns which is consistent with the infection control guidance. Additional feedback from the subcommittee was that the gowns selected for procurement should be blood/body fluid repellent as a minimum standard.”

 

Following that, we have an “Action 9.11 BK to review and revise the current PPE stockpile paper including recommendations from NERVTAG. Secretariat to forward to MU with minutes of the meeting as evidence that NERVTAG has ratified the recommendation.”

BK is Ben Killingley – a Consultant in Infectious diseases.

MU is Martyn Underdown – An Observer from Public Health England.

Two things need to be made clear from this:

  1. The recommendation from NERVTAG was only to provide gowns “For use during splash prone or Aerosol Generating Procedures”

This is sounds like a technical point, but it’s a crucial one. AGPs are rare procedures even in hospital. Intubating a patient, performing certain surgeries, or resuscitation. If you were supplying gowns only for this kind of procedure, you would only be supplying gowns in tiny numbers, probably less than 1% of the the number of gowns you would need to be supplying were your policy to use gowns for all face to face procedures.

Whether the gowns were or weren’t bought for the stockpile is therefore a moot point. The numbers involved would have been a token amount in any case, if the suggestion is that they would have been made available for general medical work, as it was only ever recommended they be procured for AGP work.

2. NERVTAG did not report direct to Matt Hancock or anyone in Government

Look at the action point – one member of NERVTAG went back to update the recommended inventory list for the PPE stock pile, and a copy was passed on to Public Health England via another member of the meeting.

Also, a more general overview here tells us that NERVTAG does not report directly to politicians but to the Chief Medical Officer – (Prof Chris Whitty) and only through him does NERVTAG reach the ears of ministers.

There is absolutely no evidence presented here that a minister was ever directly aware of this recommendation of gowns being added to the PPE stockpile.

Now, clearly something did go wrong if that PPE was not purchased and put in the stockpile. However, even if it had been purchased,  it would only be a quantity of PPE commensurate to use for AGPs, therefore it would have been absolutely irrelevant to the current debate about adequate PPE for all clinical procedures.

It’s also worth noting at this point that the PPE stockpile list was originally conceived in 2009 – under a Labour government. And no gowns were included at that time.

This information was really the big journalistic “Reveal” of the whole Panorama programme, and it turns out to be a very damp squib indeed.

Misleading claim 2: COVID-19 was downgraded as a High consequence infectious disease (HCID) in the UK

This is another claim that the Panorama programme makes, which is, in essence true, but the programme appears to blame  it on “The Government”.

The programme makes no real attempt to explain HCIDs or the decision to downgrade COVID-19, so some context here will help:
Here are some examples of diseases which are considered HCIDs in the UK:

Ebola., Lassa Fever, Bolivian Haemorrhagic Fever, Monkeypox, Pneumonic Plague

You will notice all of these examples are phenomenally rare diseases, especially in the UK. The whole of the HCID protcols are built on the assumption we are only dealing with a handful of cases.

For example, the  government’s own guidance on HCIDs here states “Once an HCID has been confirmed by appropriate laboratory testing, cases in England should be transferred rapidly to a designated HCID Treatment Centre.”

What is an HCID treatment centre? Well, there are just four certified HCID treatment centres in England:

  • Guys and St Thomas’
  • Royal Free London
  • Royal Liverpool and Broadgreen University Hospitals trust / Alder Hey Childrens Hospital
  • Newcastle upon Tyne Hospital

It should be pretty obvious now why COVID-19 had to be de-classified at a certain point in case numbers. The point of HCID status is to isolate rare and highly deadly diseases into highly specialist treatment units before they become widespread.  Once COVID-19 slipped through that net, it was inevitable it would be downgraded.

There clearly came a point in this crisis where it was no longer practical to suggest that every case of COVID-19 be managed in one of 4 specialist infectious disease hospitals, and at that point it became impossible for COVID-19 to continue to be an HCID.

HCID diseases are treated with massively high levels of protective equipment, not to protect the wearer but to attempt to limit any onward spread of the disease to zero.

For example, Ebola is far less infectious than COVID-19 – (it is only spread by direct contact), and yet, because of its HCID status, extremely high levels of PPE would be worn for it.

HCID status is about preventing an epidemic and restricting it to a small outbreak. Once that point has passed, it becomes irrelevant.

Misleading claim 3: “We wasted February”

This claim arose during the interview with EU representative Agoristsa Baka. She stated that “February is when we started seeing the big outbreaks in Europe”

The presenter went on to talk about “four weeks of planning”

Do you spot the verbal sleight of hand there? The first statement is sort of true. By the end of February we were seeing the big outbreaks in Europe, but that is then shifted to talk about “four weeks of planning” as if referring to the whole of February.

Is that really fair?

Let’s remind ourselves: On 1st February, there had been just 304 confirmed deaths from COVID-19 on the entire planet. and a total of 14,553 cases, of which 14380 were in China. The fact of the matter is that the picture of exactly what had happened in China was shadowy at best at the start of February, and the situation was, almost entirely contained to China at that time. Other outbreaks at a similar stage, SARS, and MERS for example, did not become global pandemics.

It’s well understood that Italy was really the big wake up call to the rest of the world, as suddenly we had news and data coming from an “Open” society and confirmation that this was a really significant disease outside of China.

So let’s remind ourselves that  Italy did not report its first death until 21st February; the last week of the month.

It was not until 23rd of February that there were 100 total cases reported in Italy

And on the last day of February, the total number of dead in Italy was just 29 people.

12 days later it would be over a thousand.

So yes, in the last two weeks of February epidemiologists were starting to get concerned. but really only at the end of that period was the true gravity of the situation becoming clear.

With the benefit of hindsight there were warning signs, but we can all be wise after the event. It simply isn’t true that  the government would have clearly perceived a need in early February to do anything other than make sure its pre-prepared pandemic plans were ready to roll. Which they were.

The question that’s really worth asking is why was the picture so shadowy and vague going into the start of February?

The answer to that is because this virus started in China – one of the most secretive and closed societies on earth. The fact is the whole world basically had to wait until the first western nation (Italy) got really badly hit to get a properly clear idea of what on earth was going on. Will we be getting a Panorama expose on China’s behaviour in December and January do we think? Because that really would be worth exposing.

The true lesson? The celebrated ethos of the NHS is exactly why it failed on PPE.

The programme struck me as unbelievably childish. The government are big meanies. The doctors and the nurses are sainted heros. The government were told to get PPE but didn’t because…well…Panorama doesn’t even try to tell us. It doesn’t need to. Probably they did it out of pure spite because they are evil Tories. It doesn’t even occur to the programme makers to look for a reason.

The reality, based on Panorama’s own facts is a whole lot more nuanced and more interesting. The reality is that panels of experts, each of them undoubtedly well meaning in their own right, and brilliant experts, conspired to miss the wood for the trees in their planning.

I strongly suspect that, at all points, the government ministers were under the impression that PPE stocks were adequate and appropriate when in fact they were not.

What actually happened was this: Big system failure. Big  cumbersome state run systems, like the NHS are just innately terrible at getting things like this right.

The proof of this, ironically, was included within the programme. Towards the end we met some doctors who appeared to have some excellent PPE. They were the GPs of Dr. Abhi Mantgani’s surgery.

Why do they have good PPE? Because they bought their own. They did not depend on the NHS supply chain.

Dr. Mantgani, sums this up excellently in a single sentence “I wouldn’t be prepared to work without the appropriate mask, face shield and gown to treat people who are suspected of COVID or have been diagnosed with COVID and I wouldn’t ask my staff to do that”

Now here’s the thing. Dr Mantgani is the senior partner of Miriam Primary Care Group surgeries. That means that, not only is he a doctor on the front line, but he owns the business. This gives him both the responsibility, and the power to make judgement calls about what is right for him, and his staff.

And “his staff” isn’t faceless thousands of people. GP surgeries are small to medium business. He will know the names and faces of them all, and many of them will be his friends as well as his colleagues.

So there are both practical, and emotional reasons why GP partnerships are able and willing to be far more responsive to the COVID-19 crisis than the rest of the NHS.

GP partnerships are private businesses, run for profit by the GPs that own them, who have a contract with the NHS. Yes. That’s right. Prviate, profit making businesses.

Dr. Mantgani doesn’t have to go through three advisory committees and a procurement process to get face masks and gowns. He and his partnership can meet at 8am in the morning, make a decision and  have their practice manager place an order for PPE by lunchtime from where-ever they can find it to be available. The small business model, and being his own boss allowed him to do this.

Other clinicians in the wider NHS simply do not have the free-agency to do this.

Suppose, for a moment, all our hospitals were private, with NHS contracts, much like GP surgeries are. Suppose the senior consultants were actually owner-managers of the hospitals alongside full time management staff. How long do you think they would wait for the NHS supply chains to get in gear before they simply took matters into their own hands and ordered PPE independently? Not long, I would imagine.

Or suppose there were two hospitals in a town, and one of them took their staff’s PPE seriously, and the other did not. How fast would the resignations come from one, and how long would it be before it found itself unable to employ the staff it needed and go out of business?

There is a great irony in constantly celebrating how wonderful the NHS is, while failing to realise that its central state run structure is a fundamental part of the problem of why it has fallen over so badly on PPE.

However, it’s a sort of social taboo to suggest that the NHS is an often badly run, badly organised wasteful and out-dated way of delivering healthcare. So instead we must simply assume it’s all Matt Hancock’s fault, and that’s a shame, because it’s a real missed opportunity for positive change.