COVID-19

by

Following the Science

On 3 March 2020 one of the Scientific Advisory Group on Emergencies’ (SAGE) sub-groups said the government should be advising the public to avoid shaking hands. On the very same day Boris Johnson told a press conference that he was still shaking everyones hand.

One might say, in the face of an epidemic, the like of which the world has not seen for 100 years, this was an initial failure to get to grips with the seriousness of the issue and the epidemiological science around how to respond.

To be fair the early advice from SAGE and others was not as definitive as sometimes supposed. A Special Report by Reuters in April 2020 provides a more nuanced picture of the evolving scientific consensus. It indicates even the scientists struggled to keep pace with the disease.

It was not until Italy had locked down, our TV screens were full of Italian hospitals being overwhelmed and an Imperial College report projected 500k deaths that the Prime Minister said we “must” stay at home and certain businesses “must” close, instituting the first lock down.

We then had nightly press conferences at which the government would always state they were “following the science” and therefore “doing the right thing at the right time”. It was so obviously a mantra with a covert message-management role attempting to push responsibility for actions limiting the freedom and economic activity of the nation, unprecedented outside of war time, onto scientists. Providing cover against the natural concerns of the public and also the concerns of their own back benchers.

It was disingenuous and over time the emptiness of the mantra became plain. The issue of face masks was one where the science seemed to follow availability logistics. Instead of saying there were not enough masks for everyone the message was that the masks were useless, in fact more likely to cause infection, and anyway we needed them all for the frontline staff. Ignoring the inherent contradictions in the messaging its duplicty became apparent as availability increased and masks became increasingly compulsory.

We will not have a real understanding of the culpabilities and mistakes made by government and others until long after the epidemic has run its course. However, there is one simple critique of the “following the science mantra” which can be made in principle. Government’s job is to lead not follow.

Government needs to take account of the science in relation to health, but it needs to combine and balance that with an assessment of the economic consequences of actions to limit the virus and also on the likely impact and response of the general population to calls for severe limits to their freedoms.

As the economic consequences of the lock down began to become clearer the mantra about following the science started to be challenged by back benchers and qualified by ministers. Growing concerns about the impact on the national economy led to arguments being made that the cure was worse than the disease.

The need to open up was argued in order to: save jobs; prevent young people from having their education permanently damaged; improve mental health; and enable hospitals to deal with those with life threatening diseases that had been pushed back in order to deal with Covid-19 patients. Clearly there is real strength in all of these points.

So we opened up, schools, universities, shops and hospitality. As predicted this led to an increase in infection rates. A more sophisticated response was designed to deal with the problem. A “world class” track and trace system combined with a geographic, locally tailored but nationally determined, tiered response was to enable us to simultaneously keep the economy going and control the virus.

It appears the scientific community have a much clearer appreciation of the nature of the threat the virus now poses. They have far fewer reservations about models which predict much worse outcomes. What is more they have experience that the modelling so far has tended to underestimate the virulence and impact of the virus.

From a lay persons perspective the constant increase in infection rates and hospitalisations always looked as if there could only be one outcome. A second lock down. It looks as though that is what is going to be announced imminently. It also looks as if the government are following the science once more but again they are behind the pace, and days matter.

There are strong voices now arguing government needs to give due weight to all the other considerations around the economy, education etc. However, what they do not seem to be taking account of is the synchronisation of the pandemic.

The first wave seemed to roll across Europe sequentially, this time the wave seems to be occurring in parallel across the continent. what is more the second wave is starting from a higher level of infection. If twenty people are infected and the numbers of infection double every 7 days it is one thing. If one hundred thousand people are infected doubling every 7 days it is another matter altogether.

If the disease gets away from us, and it looks like it might if we continue as we are, the hospitals will be overwhelmed. It will not matter whether you have Covid-19 or cancer you will not be able to get treatment.

According to the CIPD more than 30% of the UK workforce are over 50, many others will have underlying health issues. If hospitals are inundated will they be willing to go to work? Will they go out shopping for anything other than essentials.

The idea that we can beat the virus without severe economic pain is unrealistic. We either proactively accept the pain in another lockdown which will help save lives and control the spread, or we try sophisticated tiers of action which will lead to more deaths and ultimately the same economic pain.

by

Why Joe Biden Will not win the US Election

Political prediction is almost always a hope of the heart propelled by a wishful intellect. However…

I hardly dare say it but it does look as if the wheels are finally coming off the clown car which is the Trump administration. Naturally at this point in any predictive article it is important to put the Wilsonian disclaimer in that “a week is a long time in politics” and we are a good four months from 3 November when Americans go to the polls.

When they do go they will not just be judging the performance of their President they will also be voting for 35 seats in the Senate, where the Republicans currently have a six seat majority, and all 435 members of the House of Representatives where the Democrats have a 15 seat majority.

At the moment Mr Biden has a double digit poll lead. Even his closest supporters would be hard pressed to put this down to energetic, charismatic, high profile campaigning. 

What Mr Biden does have on his side is President Trump and an administration which increasingly lacks competence and credibility. An administration long on loyalty but short on ability. Better yet even the long position seems to be starting to crack.

A large number of Americans have been giving President Trump the benefit of the doubt. I have no doubt that, for a very tiny fraction of Americans, the spiteful and juvenile stream of tweets; the coarse behaviour and articulation of clearly racist and misogynist views were welcomed. For a much larger number however, I suspect there was a feeling this was a price worth paying to shake up the elite and drain the swamp. They had been ignored for so long that something radically different was needed. Well they certainly got that.

Having said this it became ever more difficult to understand why the President’s increasingly unconstitutional and bizarre behaviour seemed to come at no cost to his support. People appeared to be willing to accommodate ever more outrageous attacks on the very foundations of the US constitution. 

The separation of powers, the independence of the judiciary, the chain of command, respect for the law, threats to a free press, abuse of office for personal gain, nepotism. As they occurred individually and even as they accumulated they did not lead to the level of public outrage that many thought appropriate and inevitable. However, over the years they have built up a picture which people simply did not focus on when the economy was booming and unemployment was falling to record low levels.

But now, Covid-19 (C-19) has burst the bubble of the Trump narrative. His bluster and incompetence have been revealed for what they are.  

The shotgun the President took early on in his Administration to health care was always pointed at his foot. Having shot off one foot in the mid-terms he carefully took aim at this issue again on the other foot! 

His denial of C-19, his failure to act early, his stupid musings on how to cure it with disinfectant, his refusal to model appropriate social distancing practices, his rush to reopen the economy, prioritising re-election over American lives, all reveal the essence of the man. An incompetent narcissist, with the attention span of a goldfish and IQ to match.  Whilst this has been visible to some for a long time it is now being brought home to all Americans in the most cruel manner.

This awakening is set to lead to a re-evaluation of much of the past five years. The doubt is over. He really is what he appears to be. What is more that re-evaluation may not simply focus on the President. The Republican party and its members of the Senate and House; the cast of venal  incompetents, extreme loyalists and yes men that make up his cabinet, and the upper echelons of the Federal bureaucracy appointed by Trump may all feel the growing wrath of the American people. 

It is clear some of his “team” are beginning to see this. Members of his own party, startled by polling numbers, are starting to put their head above the parapet. Senator John Thune has urged the President to focus on an electoral strategy which, “deals with substance and policy…”  and is presented in a different “tone”. Good luck with that one Senator.

What 4 years have shown is the complete lack of ability of this President. The esteem of the nation in the eyes of its allies is lower than it has ever been. Its  foreign policy a combination of rhetorical triumphs with practical failure, see North Korea and the Middle East. A craven response to dictators, see Russia and its interest in Ukraine, and Turkey and its interests in Syria. A trade “policy” the theoretical idiocy of which is only exceeded by its incompetent implementation. A legislative record, the golden star of which was a tax cut focussed clearly on the 1%.

If the election was tomorrow it is very likely there would be a Democratic landslide. The Republicans must be praying for a miracle because there is nothing on the horizon set to help. The monumental mishandling of the virus means America is now sitting on an epidemic time bomb set to overwhelm the medical services of the richest country in the world. The graph below shows the surging infection numbers. This will eventually force an effective lockdown and an avoidable protraction of the damage to the economy. 

Covid-19 Confirmed Cases. Source: The New York Times


Even if the disease were to disappear tomorrow the impact has been devastating. The virus has already taken more American lives than the wars in  Korea and Vietnam combined (94k), and more than the First World War (116k).  If the current level of incompetence is not addressed quickly and radically it is not inconceivable the final death toll could compete with America’s previous worst, the 650k killed in the Civil War. Of course the Civil War lasted four years, C-19 has killed more than 125k in four months.

Whilst all of this grim reality provides hope President Trump will be gone in 7 months time it also generates fear. It is certain he will not go quietly. A totally compliant Attorney General who confuses his role with that of defence counsel to the President, provides a powerful tool for skewing the election process. Voter suppression is an industry in some Republican States and is set to go into overdrive. Legal attacks on Nixonian type “enemies” is more than a risk, and Joe Biden has already been in the crosshairs. 

Worse, some other form of domestic of foreign crisis may be manufactured. The difficulty with this, for Trump, is that the American people are increasingly  unlikely to be reassured any such crisis will best be handled with him as President.

Trump’s aggressive, vindictive nature is not going to be a pretty sight as it becomes more apparent he is going to lose. We are in for a very rough few months with the US constitution and nation strained to the absolute limit.

Mr Biden’s best efforts may not win the election but there is every chance Donald Trump will lose it and lose it spectacularly. Fingers crossed, for if he does not lose and lose clearly, the prospect for the States is definitely not United.


by

Following the Science

Just looking at some of the bare stats on C-19 you wonder if the Government made a mistake following “The Science”. If we look at the numbers of deaths caused by the virus by country we find only America has more deaths at 110,964, than the UK at 40,597.

Just looking at gross deaths however can be misleading. It is important to take account of the size of the population of countries to get a real handle on how they are doing. If we therefore look at deaths per 100,000 of population we find the UK is no longer 2nd worst they have dropped down the table to 4th worst. Ahead of them are Belgium pop 11,589,623, San Marino, pop 33,931, and Andorra, population 77,257.

The response of Ministers to such numbers is a challenge to the statistics. People record the numbers in all kinds of different ways and when the true numbers are known the picture will be very different. Well certainly accuracy of recording is something of an issue but it would be a brave person to suggest the bias will demonstrate what a great job the UK has done.

As I write there is a press briefing going on. It gets harder to motivate oneself to watch these now. You could write in advance 80% of the content. First, there will be an eye catching new initiative to control the virus or open the economy. Then their will be a change / reversal of the last eye catching initiative.

This change/reversal will be following “The Science” although we will not be able to see “The Science” for fear, no doubt, of misunderstanding it. This will ensure that we are now doing the right thing at the right time just as previously we were doing the right thing, only the opposite, at the previous right time

It is remarkable how the science seems to pirouette and leap around like a frenzied ballerina. If one were cynical one may begin to think the reassurances about how well the Government are doing are perhaps, optimistic.

There is, what I take to be an apocryphal story, of a boxing trainer who was encouraging his latest talent in a fight. The new talent was getting seven bells knocked out of him and returned to his corner at the bell with a black eye, split lip and multiple abrasions to his torso. His trainer, in order to reassure him said his opponent hadn’t laid a glove on him. The boxer replied, “Well keep an eye on that referee, cos some bastxxx’s knocking the stuffing out of me.”

by

Seeing your “R’s”

It seems to becoming clear that in order to transition out of lock down a strategy of testing, tracing, isolating and quarantining (TTIQ), at scale, needs to be adopted. What is interesting is how “the science”  around all this in the UK seems to evolve, almost in lock step, with the availability of the resources to implement the science. This helpfully means the Government can pretty much always do the right thing at the right time.

But how much testing needs to be done? To address this I guess one question is, what is testing for? From a lay persons point of view it seems to me there are broadly three purposes to testing.

First, a clinical one. This is about testing to identify which people, exhibiting serious symptoms are actually infected with Covid-19. The outcome of this being critical in determining the way the patient is managed.

Another clinical reason for testing is to check those managing the disease, working closely with patients and caring for the most vulnerable are not infected and thus in danger of spreading the disease. Ideally, I guess you would want to test front line staff perhaps once a week to ensure they are not working whilst infected but asymptomatic.

With these types of testing you would expect the ratio of positive to negative results as likely to be high. Essentially you are using self selected samples of most at risk people and therefore most likely to prove to have the disease. As of 9.00am on 30 April roughly 690k people had been tested and of those 170k tested positive which is almost 25% of those tested.

The second purpose for testing we might call epidemiological. It is about trying to understand the progress of the disease, its prevalence and spread, where the hot spots are etc. How effective this testing is will probably be critical to the design and success of any transition out of lock down.

This is what I take Pillar 4 of the testing regime to be partly about.  Currently the numbers devoted to this are very low, just short of 10k out of the 690k tested to date. It may be that fancy sampling techniques means this is sufficient. However none of these random tests have so far proved positive so to a lay person this suggests a larger sample may be needed.

Given the 25% ratio between sampling and disease in the self selected groups mentioned above and the zero infection rate in the Pillar 4 sample you suspect there must be a Goldilocks sample size and structure that gives more useful information. One suspects  the size of Pillar 4 sample is currently being determined by availability of tests rather than statistical design.

The third role for testing  is “R” management. This is about running a “wack a mole” programme of early identification of potential carriers and trying to break the chain of infection, of which they are a link, as soon as possible.

We know when we come out of lock down the disease will still be with us, lurking in the community. Success will be about managing not eliminating infection. Keeping the “R” as low as possible, so those who contract the disease and require critical care do not overwhelm the NHS. Or indeed take up all available resource thus increasing the collateral, non Covid-19, mortality rate.

In lock down “R” was controlled by the radical separation of people. Confining them within their homes. The less opportunity people have to interact at all the less opportunity for the disease to spread. This does appear to have been effective  but it is incredibly disruptive economically, socially and also, as time goes by, on people’s mental and physical health.

Having applied the hammer of lock down to get the “R” down to something below 1 we now need to look for more sophisticated ways of managing the spread to keep the “R” in check without lock down. Presumably when the R is above a certain level the only way to control it is through lock down. But when you get it below a certain level (something below 1) the progression of the disease is at least susceptible to less disruptive forms of management.

Social distancing protocols will be important in this but it is impossible they will be as effective as lock down so the virus will inevitably begin to spread again. This is where TTIQ at scale comes in, breaking the chain of infection as soon as the mole emerges into the light.

Ideally of course you would like to track it and intervene before it fully emerges into the light. To do this you would have to test everyone at least once a week to keep absolutely on top of the disease. That is 66m tests per week, 3.4bn tests a year. Mmm, probably not.

In the absence of this fanciful ideal what you need is a very agile and fast regime of TTIQ which responds immediately to individuals with even minimum symptoms, ideally supplemented with some large scale randomised tests to try and get ahead of the disease.

This means having significant numbers tests available and Test and Trace teams. Their job would be to go out as soon as someone identified as symptomatic, even if mild flu like symptoms, and test them. If the test was positive isolating those individuals and then tracing all of their contacts over, say, the past two weeks and ensuring those most at risk are tested and quarantined. For this, speed is obviously of the essence, as every day an infected person is not isolated they are spreading the disease.

TTIQ is foremost a logistical challenge. You need teams of well trained individuals with excellent interpersonal skill. Able to instantly respond to cases in the community, test the person, identify, trace, meet and test all their high risk contacts. Harvard Global Health Institute estimated an average of 10 tests of contacts per infected person.

Given all this how many Test and Trace teams would you need? That has to be a function of how many suspected cases are identified in the community per day. And how many cases a team can manage effectively per day. These are a couple of questions journalists might like to ask.

A related issue is the number of tests available to be used by the Test and Trace Teams. We should be up to 100,000 per day by now. Is that enough? In a recent blog, “Dancing out of lock down” I talked about research coming out of Harvard Global Health Institute suggesting a minimum number of tests as being of the order of 152 per 100k population. Which for the Uk seemed to work out at around 100k tests.

Whether this is right or not remains to be seen. An alternative estimate of the numbers needed comes from Tomas Pueyo who has now written a series of articles on the progress of Corvid-19 and how it is being managed. His latest is precisely about how to do testing. Initially I was cautious about Mr Pueyo’s credentials on this issue, however, over time I have found his common sense approach much more informative and convincing than the carefully honed statements of the UK press briefings.

Mr Pueyo argues sampling needs to be such as to ensure the proportion of positive outcomes is below 3%. This is what those countries which seem to have managed the disease well have done with early mass testing. Whilst I see the logic of his argument I guess this must be sensitive to the stage of the disease and thus general level of infection in the population. However, given all countries are probably at an early stage in this pandemic this is probably not a fatal criticism at the moment.

In the absence of statistically significant random testing identifying the level of “R” must involve working back from hospitalisation and death rates and some, no doubt, very clever epidemiological statistical manipulation.

The problem with this is you are looking backwards at the “R” rate which existed some days previously, and days matter. Fast and effective Test and Trace teams will not stop transmission of the disease but they may ensure, together with social isolation protocols, that its progress is reduced and the “R” kept within what the NHS can manage until we get a vaccine.

Throughout this blog so far I have talked about “the” “R” as if there is a single infection rate. This is not the case. Whilst the “R” in the general community seems to be managed by lock down it does not seem to be anywhere near as well managed in those communities that are locked in care and nursing homes and those locked up in prisons.

Urgent action needs to be taken to support these communities or what is a tragedy for those that live there, their carers and their families will become an ongoing source of infection in the wider community. We need to be able to see and address all the “R’s”

If increased resources are not supplied to these current hot spots, and a combination of social distancing and TTIQ do not slow the disease down enough, over time it will accelerate and we will have to resort, once again, to the blunderbuss which is lock down.

The World Health Organisations advice on managing this disease was “testing, testing, testing”.  As the resources become available “the science” will show this is right and we will begin to do the “right thing at the right time” and see our “R’s”. The sooner the better.