Coronavirus: awaiting the cavalry

Wednesday 1 April 2020  



The government needed two goes at publishing the Covid-19 figures yesterday. When they first came out, there had been 25,150 cases (up 3,009 from 22,141) and 1,651 deaths (up 367 from 1,284).

No sooner had they been absorbed, though, than the figure for deaths rose to 1,789 suggesting a truly massive hike in the day-on-day figure of over 500. But, almost in the manner of Winston Smith re-writing The Times in 1984, the day before's figures for deaths jumped to 1,408, producing a more modest but nonetheless considerable increase of 381.

To give some indication of the scale of this jump, three weeks ago, Mrs EUReferendum and I were looking forward to a visit from our granddaughter, coming down from Scotland to stay with us for a few days. Watching the daily Covid-19 figures mount, I suggested that, if the cases topped 1,000 by the weekend, we would call the visit off.

As it turned out, the figure reached 1,061 by the Saturday, at which time 21 deaths had been recorded. From that point, we went into our own personal lockdown, which was just as well.

By now we have seen cases multiply 25-fold, and while the official death toll is short of two thousand, there are those who argue that about 25 percent more people have died, putting the number at well over the two-thousand mark.

Nevertheless, according to Public Health England, the average number of deaths in England for the last five flu seasons, 2014/15 to 2018/19, was 17,000 deaths annually. This ranged from 1,692 deaths last season, 2018/19, to 28,330 deaths in 2014/15.

On the face of it, we have a long way to go before we match the 2014/15 figure, but that was particularly bad as the main strain of influenza mutated after the annual vaccine had been prepared, rendering the protection of very limited value.

However, given the current rate of increase of Covid-19 deaths, doubling every four days, the death toll for this epidemic could exceed the 2014/15 flu figure in just over two weeks, compressing the mortality into a brief six-week period, compared with the flu season which lasts four to five months, with deaths peaking over the winter months of December to February.

In terms of control, the principal difference between Covid-19 and winter flu is that the latter is constrained by an annual vaccination programme and, given an effective vaccine, the death rate can be held to relatively low levels.

Without such an aid, Covid-19 might be expected to increase exponentially, infecting up to 80 percent of the population, with a case fatality rate in the order of one percent. It was this projection, with a potential case load of 50 million that gave rise to an estimated death toll of 500,000.

What is not fully appreciated though, is that if coronavirus was left to spread freely in the population, from the current level of two thousand deaths, the half-million deaths would be reached after just nine doubling cycles – in just over five weeks' time.

That is the nature of an exponential growth rate where, in a population with no natural immunity, we would see half a million dead within the space of just over two months. There is not a health system in the world that could cope with that burden. Long before the final death toll was reached, the NHS would have collapsed.

In real life, however, epidemics don't work that way. As the numbers falling ill increase, the incidence of infection slows, with the graph taking on the profile of the classic bell-shaped curve. Nonetheless, in theory, this might extend the epidemic by a few weeks, so we could still see a grotesque number of deaths compressed into a period that would swamp the health service.

And yet, even that isn't going to happen. A very good point made by the BMJ yesterday is that, while there is one epidemic in the UK, there are multiple outbreaks, each with their own unique profiles. At the moment, the largest of these is in London, and there is another hotspot in the West Midlands.

Given unconstrained growth, we can expect the outbreaks to radiate out from London, to the west and north – rather like the Italian experience where the epicentre is moving south. Over a period therefore, we can expect a series of spikes in incidence and mortality, as the disease spreads.

This gives a longer period with which to cope with the epidemic but, without specific controls geared to this specific disease, there would be no overall impact on the number of dead. Rather, the deaths would be spread over a longer period.

You can play about with the statistics, and come up with different projections – with or without the spurious authenticity of calling them computer models – but these will have no effect on the overall dynamics of this outbreak.

Thus when confronted with a novel virus, giving rise to acute respiratory disease, in the absence of a vaccine, there are only very limited control options. The first – as favoured by the WHO – is to carry out an aggressive testing programme to detect cases, combined with equally aggressive contact tracing and testing, to remove the infection from the community.

The other main option, applicable where the community spread is uncontained, is to impose a widespread lockdown, distancing the population from the sources of infection in the hope that the epidemic will slow down sufficiently to allow the health services to deal with the onslaught of cases.

But, in fact, it now transpires that the UK government has gone for neither of those options. The clue to this came with last weekend's article which recorded the failure of a pandemic test run carried out three years ago, under the title "Exercise Cygnus".

What emerged from the article is that, even though the system failed, no amendments were made to the strategic roadmap for a future pandemic, with the last update having been carried out in 2014. The actual working model for the current Covid-19 epidemic, therefore, is the Pandemic Influenza Response Plan, augmented by the Pandemic Influenza Strategic Framework, both published by Public Health England in August 2014.

And in those pages is the previously "opaque" reason why Public Health England so precipitously abandoned the "test and trace" programme, an action which has attracted so much criticism.

The point emerges from the plan that the savagely diminished field epidemiology service was never intended to carry out this programme. Its function was merely to monitor the emerging epidemic, looking for "evidence" of sustained community transmission.

This would be undertaken during the first two phases of the plan, labelled "detection" and "assessment", following which the field service was effectively stood down, while the plan moved to the "treatment" phase, in preparation for "targeted vaccinations" – all based on the assumption that a vaccine would be available 5-6 months after the decision to order it had been given.

With that, the plan moves into the "escalation" phase, amounting to "surge management" of cases by the NHS, which includes "prioritisation and triage of service delivery with aim to maintain essential services". Also introduced are "resilience measures, encompassing robust contingency plans" and then, in the ultimate statement of complacency, Public Health England considers "de-escalation" of its response "if the situation is judged to have improved sufficiently".

This then leads to a "recovery" phase, the end point where we are supposed happily to settle down to the "normalisation of services" and "perhaps to a new definition of what constitutes normal service". And with that, we get "restoration of business as usual services", including "an element of catching-up with activity that may have been scaled-down as part of the pandemic response".

Such a happy outcome is, however, entirely dependent on the development and administration of an effective vaccine, without which there is neither hope nor intention of controlling the epidemic. Stuck as we are in the "escalation" phase, the plan is to hold the fort long enough for the cavalry to come galloping over the hill.

And, seriously, that is what the government is doing.



Richard North 01/04/2020 link

Coronavirus: addressing the issues

Tuesday 31 March 2020  



I wonder if Peter Hitchens and his supporters would dismiss this as a fantasy got up by the Daily Mail, or claim that it represents just a typical week in the life of an NHS doctor.

But then, we could simply accept that the 22,141 reported cases of Covid-19 are nothing different than one might expect from a normal winter flu outbreak, in which case the "lockdown" policy is indeed "grotesque, absurd and very dangerous".

As for the 1,408 dead, they are apparently just a reporting artefact arising from the failure of doctors to understand reporting guidelines, thus mistakenly pronouncing Covid-19 as the underlying cause of death when it should merely have been noted as a contributory cause.

We must also believe that physicians throughout the world – even in relatively sophisticated regimes such as that prevailing in Northern Italy – are repeatedly failing to conform with the WHO recommendations in the International Statistical Classification of Diseases and Related Health Problems (ICD), and the standard coding for Covid-19.

It must also be accepted that the medical profession is routinely ignoring the long-established WHO Instructions on recording causes of death, even though they have been in place since 1979.

Thus, having discounted so many erroneous reports, and completely ignored multiple suggestions that the true death rate is being substantially under-reported, we can rest easily in our beds in the knowledge that Peter Hitchens is the one true voice of sanity.

Clearly, we must regard this epidemic as nothing more than a minor perturbation. The disruption and costs of taking action quite obviously outweigh the minor inconvenience of geriatrics dying earlier than they might otherwise have done, especially those who have died with coronavirus and not of it, after all those doctors have bungled the certification.

On the other hand, it might just be possible that what we are seeing is a real epidemic of a dangerous disease which has caught out most of the nations in the world, including the United Kingdom which is showing itself to be demonstrably unprepared for dealing with a crisis of this nature.

If this seems to be a more plausible interpretation of current events, then we can forego the wisdom of Mr Hitchens and devote ourselves to an analysis of what went wrong, and what must be done to fix it.

That other countries might have been similarly unprepared is of no real comfort to us here in the UK. Each country has its own system and its crosses to bear, and what applies to other countries might not necessarily have any relevance to our situation.

However, it is germane to note that it isn't only the Lancet that is raising a hue and cry over the government's failures. The British Medical Journal has joined in, with a long editorial declaring that: "Testing and tracing must resume urgently".

On 24 February, it says, there were nine confirmed cases of Covid-19 in the UK. On the same day, the World Health Organization recommended countries outside China with imported cases or outbreaks "prioritize active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantine of close contacts".

On 22 March - when there were 5,683 confirmed UK cases - Michael Ryan, executive director of the WHO health emergencies programme, repeated the message on the BBC: "What we really need to focus on is finding those who are sick, those who have the virus, and isolate them, find their contacts and isolate them".

Says the BMJ, echoing exactly the message I have repeatedly published on this blog: "This is entirely unexceptional. Case finding, contact tracing and testing, and strict quarantine are the classic tools in public health to control infectious diseases".

This really cannot be emphasised enough or repeated too many times. We are not talking about some arcane or disputed procedure, but the very basic nuts and bolts of outbreak management.

The WHO, we are told by the BMJ, says the recommendations "have been painstakingly adopted in China, with a high percentage of identified close contacts completing medical observation". In Singapore, Vietnam, and South Korea meticulous contact tracing combined with clinical observation plus testing were vital in containing the disease.

This combined with strong measures to enforce isolation for travellers returning from high incidence areas obviated the need for a national lockdown and closure of all schools in Taiwan and Singapore.

Furthermore, the mathematical model used by the UK government clearly shows that rigorous contact tracing and case finding is effective: the prediction of 250,000 deaths was predicated on what would happen without contact tracing.

Despite this, contact tracing started in the UK but stopped early in the epidemic. How effective it was is questionable, especially in England and Wales, which made Covid-19 a notifiable disease only on 5 March, two weeks after Scotland and a week after Northern Ireland. This, coupled with the lack of surveillance and testing of those contacting primary care, says the BMJ, suggests the number of confirmed cases is an underestimate.

It then declares that the reasons why tracing was stopped, against WHO recommendations, have not been published. They seem, it says, "to be connected to a shift from 'contain' to 'delay' in the government’s action plan, when contact tracing was replaced rather than supplemented with other control measures".

One reason, it advances, seems to be a lack of tests and testing facilities. However, it says, testing is a support not a substitute for tracing or medical observation, which is crucial.

Current tests for the virus require careful validation and have low sensitivity, resulting in many false negative results, especially in the pre-symptomatic phase when viral load is low. As many as 40-50 percent of patients tested negative initially in China, and so the definition of confirmed cases was changed to include those with clinical symptoms.

But it then goes on to say that another factor is the decision to treat the situation as a single national epidemic rather than scores of local outbreaks each at different stages, needing to be tackled locally.

National figures conceal huge variation in confirmed cases, ranging from over 400 in Birmingham and Hampshire to fewer than 20 in Blackpool, Hartlepool, Darlington, and Rutland. In Scotland the first case was identified on 1 March, and Orkney and the Western Isles still have no cases.

In the much less severe H1N1 flu pandemic in 2009, this same approach "seriously impaired the ability of local agencies to respond in a flexible, timely and pragmatic way to the rapidly emerging situation".

Matters have worsened since 2009. Central control in England was entrenched by the 2012 Health and Social Care Act, which created Public Health England (PHE) to protect the health of the public in England and gave local authorities the duty to improve the health of their local populations.

PHE is legally in charge of communicable disease control and sits outside the NHS and local government in its regional hubs and field epidemiological services. Directors of public health in local authorities have little scope for proactively taking local control.

These changes are exacerbated by the decimation of public health and laboratory facilities for testing. The decrease in numbers of consultants in communicable disease control and community control teams, together with swingeing local authority cuts since 2010, have reduced the chances of a strong local response.

Local pathology and virology services have been centralised and partly privatised, leading to a fragmented mix of for-profit and public laboratories and serious staff shortages.

The scientific evidence has been dominated by behavioural science and mathematical modelling, with communicable disease control and public health sidelined. This leads to a lack of scientific challenge, as in the 2009 flu epidemic.

This very much tallies with the comments of Gabriel Scally, a former regional director of public health. He reinforces the theme of this blog that the public health service in England and Wales has been seriously depleted.

The result, he says, is the absence of any integrational, coordinating or management function at a regional level in England that could operate between Whitehall departments and the various bodies, often very local, that are charged with implementing government policy.

But it goes further than that, a situation to which Pete alludes, where the fundamental structures of government have been forgotten. This is the "invisible government" which I discussed back in 2008, the vital systems that keep society functioning, mostly without people realising they exist.

Predictably, the BMJ is urging that WHO's mantra of "trace, test, and treat" must be followed. It is not too late, it says, to adopt WHO Guidance. A second and third wave of the epidemic is likely. Contact tracing must recommence.

This, it says, means immediately instituting a massive, centrally coordinated, locally based programme of case finding, tracing, clinical observation, and testing. It requires large teams of people, including volunteers, using tried and tested methods updated with social media and mobile phones and adapting the manuals and guidance published by China.

Sadly, it ain't that simple. Having done the job in the field, I can attest that contact tracing is not an easy job. It requires training, skill and experience – and local knowledge, which can shave hours off the process of actually finding people.

This is a job that could and should be done by local authority environmental health departments which, if pushed, could put 10,000 trained professionals into the field. It is a measure of how far the system has deteriorated that these departments were not engaged from the very first.

Sadly, the BMJ concludes that the structure and capacity of our depleted healthcare system is now largely driving the response to this epidemic. It will, it says, continue to do so until services that support local communicable disease control are rebuilt and reintegrated.

And that is the truth. The blue light brigade may have the glamour and the happy-clappy support of the nation, but attention to the routine nuts and bolts of public health could have made all the difference.



Richard North 31/03/2020 link

Coronavirus: apportioning blame

Monday 30 March 2020  



Chris Hopson, chief executive of NHS providers, is not happy with the criticism meted out by the Lancet over the handling of the Covid-19 epidemic. In his view, "We need to ignore the siren voices seeking to divert attention from the task at hand. The time for debate about what could have been done better and why is for later, not now".

In this, Hopson has the support of David Nabarro, described as "a special envoy of the WHO director general". He says that this is not the time for blame, arguing that we need to get ahead of the pandemic. In this rapidly evolving situation, he adds, we must think ahead and react fast. It is far too early to judge what has worked and what has not.

That plea, however, is less impressive when one learns that Nabarro has his feet under the table at Imperial College, London, home of the Covid modellers whose dark arts have done so much to shape the government's response to this epidemic.

Yet, as the epidemic reaches 19,522 cases and 1,228 dead, there is by no means a consensus about shelving any criticism for the time being. Former Defra chief scientific advisor, Ian Boyd, observes that, "The middle of a crisis may not be the best time to suggest why we should learn lessons". But, he says, "many people are more likely to listen now. Certainly, nothing should distract us from getting ahead of Covid-19. My concern is that we should come out of this much wiser".

He is not wrong there. Although Michael Gove asserts that, "once this dreadful epidemic is over there will be an opportunity for all of us to look back and to learn appropriate lessons in order to make sure that our public health system is as resilient as possible", there are endless examples of government inquiries, ranging from BSE to Foot & Mouth, turning out to be useless whitewashes.

Certainly, in addition to this blog, there are others who are not holding back their criticism, not least Peter Hitchens. However, rather than tackling the inadequacy of the government's actions, Hitchens is one of those who is calling into question the whole basis of the crisis, joining what might be called the "Hannan tendency" (pictured).

Referring to the response to the epidemic as the "Great Panic", Hitchens seems to rely on the views of Sucharit Bhakdi, a Germany-based medical microbiologist, who dismisses what he calls the "extreme preventive measures" as "grotesque, absurd and very dangerous".

Strangely, this man – while recognising the epidemic in Italy - attributes the high death rate to "exceptional external factors" such as air pollution, compounded by the multi-generational nature of many Italian families. He thus posits that "scenarios like those in Italy or Spain" are not "realistic" in Germany – an exception which Hitchens takes to apply to the UK.

Hitchens is anxious to talk up the credentials, referring to the professor "as one of the most highly cited medical research scientists in Germany", who was "head of the Institute for Medical Microbiology at the Johannes Gutenberg University of Mainz, one of Germany's most distinguished seats of learning".

This is a classic resort to prestige, amounting to an appeal to authority, but one should note that Bhakdi has no record of any work in the field of epidemiology, and it is very much the case that "medical microbiology" is not a qualification in that very different field.

A balanced view might take account of the doubts about Bhakdi's assertions but, armed with his "expert" Hitchens evidently feels equipped to challenge the entire global medical and scientific establishment.

I have a lot of time for Hitchens and recognise his position, having been there with Salmonella and eggs, the non-existent listeria epidemic, and the furore over BSE. When it comes to the projected figures for UK deaths in this epidemic, it is easy to make the case that some of the estimates are overblown.

Even the famous Foot & Mouth modeller, Neil Ferguson, who recently warned that around 510,000 people in Britain would die if no action was taken to control Covid-19, also predicted that up to 150,000 people could die from CJD transmitted from cattle. To date there have been fewer than 200 deaths and vCJD has all but disappeared.

Nevertheless, I am strongly inclined to the view that the Covid-19 epidemic is real, and serious – even if the peak illness and the mortality rates for the UK are as yet unknown.

On the basis of the facts known about this newly emergent disease and its increasing incidence in the UK, no responsible government could have refused to take action, bearing in mind that epidemics are public events and the response is as much political as it is medical.

If there are valid criticisms to be made – and I believe there are – I would put three specific issues at the top of the agenda.

The first is the deterioration of the epidemiological field service in the UK, which has clearly meant that the early stage "test and trace" response was abandoned – almost certainly prematurely. Richard Horton may be voluble about the failure to act over that last few months, but here we are looking at structural issues which go back decades.

Secondly, one must question the lack of preparedness, even though it was known, after an exercise in October 2016, that the capacity to deal with a major epidemic was wholly inadequate.

Thirdly, I would question the reliance of the NHS on its established "surge" programme, expanding capacity in existing hospitals to deal with the illness generated by the epidemic.

In a situation where the service is dealing with a highly infectious viral disease, for which there is no cure and for which there is no vaccine, it seems to me a higher form of madness to bring affected patients into buildings already populated by the sick and vulnerable.

One could argue that the planners have succumbed to a form of arrogance, amounting to hubris, in assuming that they could manage a rampant infection within existing facilities, when our forefathers – without the benefit of modern medicines and techniques – kept infection away from the general hospitals, in fever hospitals, sanitoriums and the like.

Here, one must also express concern that the conversion of the NHS into a National Covid-19 Service, abandoning patients with other conditions, is not the wisest use of resources.

It is a pity, therefore, that Hitchens (and many of like mind) have launched off in what appears to be the wrong direction, when there are serious issues to confront and where, in the fullness of time, blame must be apportioned. The failures should not be treated solely as "learning opportunities" from which those responsible can walk away with promotions and higher salaries.

Richard Horton argues that something has gone badly wrong in the way the UK has handled Covid-19. Somehow, he says, there was a collective failure among politicians and perhaps even government experts to recognise the signals that Chinese and Italian scientists were sending.

We had, he says, the opportunity and the time to learn from the experience of other countries. For reasons that are not entirely clear, the UK missed those signals. We missed those opportunities and, in due time, there must be a reckoning.

But here, I am with Ian Boyd. Unless the issues are identified in the here and now, and kept alive in the public consciousness, when it comes to the ex post facto evaluations, inconvenient facts will be quietly buried and forgotten.

And even if it turns out that the response to Covid-19 has been overblown and we weather this epidemic, like the proverbial No.9 bus, there is always another one behind. We are paying for this epidemic in blood and treasure. As well as sanctioning the guilty, it would be a tragedy if we did not learn the lessons it gives us.



Richard North 30/03/2020 link

Coronavirus: uncertainty and confusion

Sunday 29 March 2020  



You don't have to be a genius - or even the "brilliant" Neil Ferguson, whose computer modelling is taking a bit of stick - to work out where we could be going with Covid-19 epidemic.

Yesterday's burden of reported cases stands at 17,089 and if we make the conservative assumption that the numbers will double every five days, then by the end of the next fortnight we will be looking at 85,000 cases – not far short of the 92,472 being reported in Italy.

As for deaths, with 1019 reported yesterday (those who died in hospital) we could be looking at between 8-10,000 by the end of the fortnight, not far short of the 10,023 currently being reported in Italy, even if there is no guarantees that that figure is accurate, when local mayors suggest that the true death rate could be four times that posted.

In fact, we're not going to get accurate figures for a while yet – if at all – and we may have to rely on year-on-year comparisons, looking for a spike this year when compared with last year's figures – with adjustments which will keep the academics arguing for decades to come.

But, if we take the current Italian figures as a rough marker - against which to measure the UK performance in containing the epidemic – then if in a fortnight's time we weigh in with smaller numbers then we might take this as small sign that that the "lockdown", imposed last Monday, is beginning to have an effect.

Even then, the figures – as always – will need to be interpreted with care. We tend to use the words "epidemic" and "outbreak" interchangeably, but they are not actually the same. Technically, an epidemic is an incidence of communicable disease in excess of expectations so, in theory, since Covid-19 is a new illness and the expectation was zero, even one case could be regarded as an epidemic.

An outbreak, on the other hand, is two or more cases linked to a common source. This means that, as the epidemic has progressed, multiple sources have given rise to many different foci of infection, each becoming outbreaks in their own right.

Thus while we have one epidemic, we now have multiple outbreaks, each at a separate stage of development. The London outbreaks (probably in the plural) seem to be most advanced, which means that they will peak earliest and begin to decline.

By that time, however, we could be experiencing a ripple effect: as cases in some areas are on the decline, others might be increasing. And, as those in turn peak and start to decline, other areas may be experiencing rapid increases.

Thus, crude national figures may not give an accurate (or any indication) as to the effect of controls in specific areas (successes or failures), and it is only when we see a sustained downturn that we'll be able to say that the disease is in check – for the moment.

That, however, does not stop us experiencing a resurgence of the disease later on, and we could perhaps see a cyclical incidence, especially if acquired immunity is short-lived and/or the virus mutates, whence we could see a repeat performance of the last few months. And that state could continue until a vaccination is available in sufficient quantities to launch a national vaccination programme.

In the meantime, all we have to look forward to is uncertainty – and much confusion. For instance, on the one hand, we have Tom Pike of the Imperial College, London, playing with his models to tell us that the UK might get away with the surprisingly precise figure of just 5,700 deaths, on the assumption that social distancing will keep the daily toll of deaths below 250.

Given that yesterday's total was 260 deaths, and today's figure will almost certainly be higher – as we are recording the demise of people who may have acquired their infections more than two weeks ago – the chances are that we will be seeing steady daily increase for at least the next week, and high levels beyond that.

Clearly, Stephen Powis, the medical director of NHS England (pictured), hasn't got the memo. Answering questions via a video link during a coronavirus media briefing at Downing Street yesterday, he ventured the opinion (initially advanced by Imperial College) that, "If we can keep deaths below 20,000 we will have done very well in this epidemic".

Powis is confident that, if the overall figure is held below that level, we can stay within the NHS capacity, which is probably a reasonable assumption given that, in addition to the three emergency treatment centres being planned (in London, Birmingham and Manchester), one is being considered for Cardiff and, in all, some 13 venues around the UK may be used to give emergency treatment.

It is debatable, however, whether these centres will have as much effect as hoped. Reports indicate that, to date, patients in UK intensive care only have a 50 percent survival rate.

In the new centres, there will undoubtedly be a dilution in the standards of care – this much is anticipated – in which case the survival rate might be even lower. This is leading to suggestions that much of the effort being expended will be wasted. "The truth is", one doctor says, "that quite a lot of these individuals [in critical care] are going to die anyway and there is a fear that we are just ventilating them for the sake of it, for the sake of doing something for them".

This rather puts into perspective the comments of deputy chief medical officer who declared that, although WHO recommends testing (and tracing), it is advising all countries including low and middle income countries. But, for Britain, this is "not appropriate". She says:
We have an extremely well-developed public health system in this country … when you come to the UK, we have made it very, very clear that there has been a plan right the way through this which is entirely consistent with the science and epidemiology. We started with a containment phase and every early case of this disease was followed through, every contact was traced exactly as we would do for other diseases … but there comes a point in a pandemic where that is not an appropriate intervention and that is the point really where we moved into delay and, although we still do do some contact tracing and testing … that is not an appropriate mechanism as we go forward. At that point, what we need to do is focus on the clinical management [of new patients].
The point is, of course, that if "clinical management" is only partially effectively, then it is hardly appropriate to rely in this. The emphasis on prevention must surely take precedence.

This, therefore, simply adds to the confusion, especially as The Lancet has condemned the government's handling of Covid-19 as "a national scandal", stating that [the] "basic principles of public health and infectious disease control were ignored, for reasons that remain opaque".

The article goes on to say that the UK "now has a new plan: suppress; shield; treat; palliate. But this plan, agreed far too late in the course of the outbreak, has left the NHS wholly unprepared for the surge of severely and critically ill patients that will soon come".

Nevertheless, the government is sticking to its story, with Yvonne Doyle, Medical Director, Public Health England, giving oral evidence to the Health and Social Care Committee last Thursday (26 March), claiming that, from mid to late January until the middle of March, the strategy was one of test and trace.

At a point before we stopped that intensive contact tracing, she says, "it became clear to us that there were what I call dead ends of contacts where you had a case, you tried to find the contact, and it just was not possible, because that gave us the indication that there was sustained community transmission". There was, she also said, "limited capacity in the field service to contact hundreds of thousands of people".

What she doesn't say, however, is quite how limited that "field service" actually is, with the latest Public Health England report identifying a total staff resource of 2,093 (with a budget of £86.9 million) dedicated to "protection from infectious diseases". That includes operating national centres, regional network and maintaining the capability to identify infectious disease, its surveillance and the management of outbreaks.

The report does not identify the specific number of field staff dedicated to contact tracing but, in the nine regional centres, it is probably substantially less than 1,000 – the entire front-line, national capability available to deal with this Covid-19 epidemic.

An article in Zeit has Doyle complaining that there was "a lack of staff" to deal with the epidemic, but that is not the real problem.

No government is ever going to maintain thousands of professional staff, sitting idle on the off-chance that a major epidemic will come along – any more than it will keep a vast standing army to protect us in the event of war. As with the army, we need a core service capable of expanding very rapidly to deal with emergencies as they arise. This is not a staffing problem, per se, but a structural one, and one which the government seems rather keen to conceal.

Meanwhile, Mr Foot & Mouth says the lockdown will have to last until June if we are to avoid the worst effects of the epidemic unless, of course, Ferguson repeats his brilliant wheeze and has the government slaughter all coronavirus contacts – which is what it seems to be doing anyway, albeit by default. Never mind, the "British spirit" will see us though, says Johnson – those who survive.



Richard North 29/03/2020 link

Coronavirus: a system failure

Saturday 28 March 2020  



Predictably, a media obsessed with personalities, has made its focus of the day the infection of the prime minister with coronavirus, along with the health secretary and the chief medical officer, all of whom have been tested and found positive for the virus.

Whether this trio are included in the 14,579 reported positive in yesterday's figures is not known, although they most certainly are not included in the list of the 759 dead. But their infection has served to drive off the front pages what are most certainly figures of concern, the cases up from 11,658 the previous day representing a 25 percent increase.

The deaths are of even more concern, up from 578, 181 more than the previous reporting period, representing a 31 percent increase, the overall total having doubled in less than four days, despite being limited to a record of those hospitalised in the UK who have died.

Away from the tedious fluff of the personalities game, though, there are serious questions being asked about the management of this epidemic in the wake of the publication of the minutes of the meetings of the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG), which has been advising the government on the Covid-19 epidemic.

Of special interest are the minutes of the Wuhan Novel Coronavirus Fourth Meeting on 30 January 2020, just as the first cases of what was to become known as Covid-19 were being reported in the UK.

It was then that the deputy chief medical officer, Jonathan Van-Tam explained that "the aim of case detection at this stage of the epidemic was to do everything possible strategically and operationally to prevent the establishment of community transmission in the UK – detection and isolation being the critical things".

This was exactly the right thing to say, and hardly controversial, coming straight out of the basic primer on the management of outbreaks of infectious disease. I referred to this as a strategy on this blog on 7 March and again a week later on 14 March, when I spelt out in detail the procedure which must be followed if there is to be any chance of ending this epidemic. Starting with the cases, I wrote:
These must be isolated from the population until they have ceased to shed the infective virus. But, bearing in mind that these people may have infected others before being removed from the infection chain, one must carry out a rapid process of contact tracing, with testing to establish whether they have been infected, and isolation of those who are infective.
Even then, however, we knew that the government had already abandoned the process of what is called in short "test and trace", in favour of an essentially laissez faire strategy of allowing the illness to rip though the community to achieve "herd immunity".

As to why the testing was abandoned, we now have the Financial Times on the case (free to read), purporting to tell us: "How the UK got coronavirus testing wrong", noting that the government had at first seemed to want a concerted contact tracing effort, but had then eased up.

This picks up on the comments of Anthony Costello, a UK paediatrician and former director of the WHO, whom I quoted on 16 March after he had been quoted in the Guardian, declaring that: "You test the population like crazy, find out where the cases are, immediately quarantine them and do contact tracing and get them out of the community". This, he said, was the "key bedrock" of getting the epidemic under control.

The FT has a shorter, more pithy version of this, having Costello say, "Testing is the basis of public health detective work to shut down an epidemic", adding that tests were vital for tracking down people with symptoms, identifying their contacts and quarantining them all until they were no longer infectious.

At first, says the FT, it seemed that the UK was going to follow this approach. But the steps it took next have become a source of concern for an anxious public and National Health Service workers on the front lines of the outbreak.

Although the UK became one of the first countries to develop an accurate test for the presence of the virus in patients, initially it used just one laboratory - Public Health England's Colindale facility in north London, which was processing about 500 tests a day this week.

As coronavirus began to spread around the world, the UK gradually enlisted more labs across the country, announcing on 11 March that it had carried out 25,000 tests in total and was aiming for 10,000 a day — a target it has yet to reach. Only gradually were more labs eventually involved.

Some experts, we are told, believe bureaucratic fiefdoms might explain why the Colindale lab was only gradually joined by others. The paper cites a senior academic, who says, "If I'm running a lab where every sample of a really interesting new disease has to come to me for testing, then I am in control of the data". He adds, "In that situation, it's a bit difficult to think 'We need a network of places and it doesn’t matter where the tests are done as long as all the data come together'".

That this could partly be the case would not surprise me. Before it became part of Public Health England, the Colindale facility was the headquarters of the Public Health Laboratory Service (PHLS), and home to the secretive Communicable Disease Surveillance Centre (CDSC), the organisations who put Edwina Currie up to launching the Salmonella and eggs scare in 1988.

When researching the structure of the public health system in England for my PhD, after discovering that a CDSC scientist had falsified data in a paper to the Lancet, wrongly attributing a food poisoning outbreak to eggs, the response of the organisations was to instruct their staff not to speak to me or answer any of my inquiries.

Not very much has changed, it seems to me, as the facility is still taking a dog-in-a-manger approach to the collection of data, unlike Germany which has a far more open and decentralised system, and one that is producing very different results.

The German system is also said to be far more effective in dealing with the epidemic, with a higher testing rate enabling the authorities to identify cases of coronavirus quicker and isolate people who have been infected, helping prevent the disease from being spread to vulnerable groups.

But there is something missing from the current narratives. There is a lot more to a "test and trace" programme than laboratories and the availability of tests. You need the "boots on the ground" to administer the tests, to interview cases and then to search out and interview potential contacts.

It is here that the UK system, as I explained in a recent blogpost, is dangerously weak, having centralised the system under the banner of Public Health England, concentrating the resource in a mere nine public health protection teams (HPTs) to cover the whole country.

To this day, therefore, there seems an inability to understand how poorly prepared we were for dealing with a major epidemic, despite claims to the contrary in late February.

As we now progress through an increasingly intrusive (but nonetheless incomplete) "lockdown", and the NHS is planning now on its third emergency treatment centre, this one in Manchester, the gruesome news is reaching us that a temporary mortuary is being built at Birmingham airport, with space for 12,000 bodies (pictured).

It is all very well, therefore, applauding the NHS, but one should realise that the front-line management of an epidemic is done in the field and in the laboratories. Only when that system fails does the hospital service have to get heavily engaged, while the population goes into lockdown.

Thus, when the clapping dies down, we need to be aware that we are actually dealing with what looks distinctly like a system failure – the price being paid in the steady accumulation of corpses, the curtailment of our liberties and the wrecking of the economy.



Richard North 28/03/2020 link

Coronavirus: off the agenda

Friday 27 March 2020  



When the government starts playing about with the daily case reports, the temptation is to conclude that it is purposefully fiddling the figures. That's what governments do whenever they are in trouble.

Thus, after the partial figures which we reported yesterday, we get a new tranche where the recording cut-off has been moved to 5pm on 25 March 2020. In future, there will be a time lag of almost a day in reporting deaths, which will be published at 2pm and reflect mortality figures for the 24-hour period before 5pm the previous day. With this new period applied, we get 11,658 cases, and 578 deaths.

Perhaps significantly, Public Health England reports that the deaths relate to those hospitalised in the UK, which means that this figure as well as the case rate is being under-reported, where testing is now confined to patients only when ill enough to be admitted to hospital (unless, of course, you are the Prince of Wales).

It is fair to say, though, that at the height of an epidemic, the first thing that goes is the administration – people at the sharp end tend to have more urgent priorities than filling in the paperwork. Standards slip and delays occur. That is real life.

All that, though, goes to show up the fatuity of the armchair pundits and the modellers who over-interpret flawed data, to draw conclusions which bear no relation to the real world.

How tragic it is, therefore, to see how different things are in that real world, a mere day after headlines carried the words of Foot & Mouth modeller Neil Ferguson telling us that the crisis could be over by Easter and that the NHS could remain "within capacity" and cope with the surge of cases.

The single day has seen multiple reports, with headlines such as this, declaring: "London hospitals facing 'tsunami' of patients", with hospital bosses saying that health trusts will be "overwhelmed in a few days".

This had Chris Hopson, the chief executive of NHS Providers, telling the BBC Radio 4 Today that the hospitals were "struggling with the explosion of demand in seriously ill patients".

The number arriving and the speed with which they are arriving and how ill they are, coming in "wave after wave after wave" evoked the description of "a continuous tsunami". One administrator told Hopson, "it's much bigger and large numbers with a greater degree of stretch than you can ever have possibly imagined".

Not least of the problems faced by the hospitals is the number of staff off sick with suspected coronavirus or in vulnerable groups, with 30-50 percent off work in some trusts.

In this context, one might recall those neat graphs on "flattening the curve", showing that as the disease incidence fell, the capacity of the medical services miraculously increased, thus ensuring that NHS capacity was never overwhelmed.

Now reality is mocking these graph-makers as the hospitals struggle to cope, while the emergency facilities at the ExCel conference centre are not yet ready, despite the Army taking over the conversion operation (pictured). It is being described as the most ambitious medical project Britain has seen since the end of the Second World War. At 4,000 beds, it will dwarf all other hospitals in the UK.

Although the unit may be able to take some patients next week, a more realistic estimate is that it will take a fortnight to get the operation up and running, with equipment sourced and staff in place. Those weeks of delay, when Johnson frittered away his time preaching about hand-washing, are now going to cost lives.

The point, to contradict Hopson's informant, is that the current situation could easily have been imagined, after the graphic examples from Italy pointed to how serious this epidemic could become.

As of now, we learn that 41 health workers in Italy have died from Covid-19 since the outbreak there began. More than 5,000 doctors, nurses, technicians, ambulance staff and other health employees have been ill, the majority affected at the start of the outbreak when protective equipment was lacking.

"It's as if a storm hit us", said Roberto Stellini, a doctor of infectious diseases at Poliambulanza hospital in Brescia. "The problem is that when this storm hit us we were unprepared, perhaps ignoring what might have been the consequences. Some of the dead were doctors who died at the beginning of the emergency, when we knew nothing about this storm. I knew some of them. Now we are more prepared and we continue to fight".

Now that storm is about to descend on the UK, front-line services are massively under-provided at a time when it really matters, while the authorities play catch-up. All too soon, it looks as if the NEC will have to be roped in as another emergency treatment centre, as the Birmingham and West Midlands illness figures continue to rise.

For all that, there are those who would play down the seriousness of this crisis, and the nature of the government response, with Sherelle Jacobs in the fanboy gazette arguing that Johnson has been "panicked into abandoning a sensible Covid-19 strategy, and has plunged society into crisis".

For sure the degree of economic disruption here (and elsewhere in the world) has been unprecedented, but this gifted infectious disease expert is asserting that the UK should have stuck to the "herd immunity" strategy of "getting the most vulnerable to self-isolate, while allowing lower risk people to get infected on a scale that wouldn't overwhelm the NHS".

But, she says, "doing the right thing at the right time" has proved no match for wails about the need to be seen to be "doing whatever it takes". Thus, Johnson and other leaders "have ignored the unquantifiable damage of their actions (from the sinking of the world economy to the sacrifice of the global middle class) in order to meet spurious quantifiable targets".

Ironically, the same newspaper rails against "covid deniers", the "shadowy social media groups" that are spreading myths and conspiracy about coronavirus. Perhaps the journalists should have a good look at their own office and the myth that relying on herd immunity would bring this epidemic to a halt.

For the media at large though, much of the focus is on the chancellor's aid package for the self-employed, on a "don't call us, we'll call you" basis, where those in need will not get any assistance until June, and will not even know whether they qualify for payments until then.

Some newspapers are concentrating on "checkpoint Britain", where the police yesterday acquired powers to enforce the lockdown and were setting up vehicle checkpoints to turn back drivers who were out and about without reasonable excuse. Treatment of the police action ranges from the Daily Star describing errant drivers as "morons", to Delingpole who labels some police forces as Covid Nazis.

Another big story is government action which has the effect of freezing the property market, with current buyers being urged to delay completion dates in order to avoid breaching social distancing rules. Thus does the Mail headline: "Don't Move Home".

With millions "clapping for the NHS" in a toe-curling display of gushing sentimentality, that occupies the front page of the Mirror (whatever happened to "Jazz Hands"?), leaving only the Guardian to run with the desperate plight of the health services in London, confronting their "tsunami" of Covid patients. It is almost as if the reality of the actual epidemic is too uncomfortable to report.

If coverage of the actual epidemic has all but been abandoned for a brief period, a more lasting effect awaits the Brexit talks which are effectively in deep freeze.

All planned negotiating rounds on the UK's future relationship with the EU have been abandoned as a result of the pandemic, and the UK has been unable to table a legal text which would form the basis of its ideas for the final treaty. That leaves the 441-page draft treaty, published on 13 March to a wave of indifference, as the only document on the table.

But since UK's position in the texts are in a "different galaxy" to those of Brussels, the talks can go nowhere, the more so since Barnier, is in quarantine having been infected with the coronavirus and the UK's David Frost, has been in isolation after suffering symptoms.

Next up is a serious discussion on whether there should be an extension to the transition period but, like the epidemic for the moment, that is not on the media agenda either.



Richard North 27/03/2020 link

Coronavirus: buying time

Thursday 26 March 2020  



The daily figures for Covid-19 cases and deaths have been getting later each day but yesterday Public Health England excelled itself. It was well past nine in the evening before they finally appeared and then with the caveat, "these figures do not cover a full 24 hour period".

Nevertheless, the 1,542 increase in the cases was impressive enough, bringing the total to 9,529. But the 463 dead reported – up only ten percent from 422 the previous day – is significantly less than might have been expected.

Conveniently, the lateness of the hour and the fact that they are incomplete have kept the figures out of the headlines, leaving the media all over the place. Some newspapers have Johnson's "volunteer army" for their front pages while some pick on the promised availability of a virus test. Almost all feature Prince Charles as a mild coronavirus sufferer.

But yesterday was also a day when, it seems, there was an intent to inject a note of optimism into the proceedings, with Foot & Mouth modeller Neil Ferguson from Imperial College London telling us that the crisis could be over by Easter. Furthermore, Ferguson is "confident" that the NHS can remain "within capacity" and cope with the surge of cases.

Ferguson is a member of the government's scientific advisory group for emergencies (Sage), and has produced a report suggesting no more than 20,000 people might die from coronavirus. And in his optimism for an early peak for the epidemic, he has the support of deputy chief medical officer Jenny Harries who also believes the worst might be over by Easter.

Strangely, though, even the fanboy gazette is casting doubt on the magical predictions of the modellers, noting the absence of reliable data and urging caution in its interpretation.

It quotes Rosalind Smyth, director and professor of child health, at the Great Ormond Street Institute of Child Health, warning that Britain simply has no idea how many cases it has because of a lack of testing. "On conservative estimates", she says, "the true figure is likely to be five to ten times higher".

These are the sort of issues I was addressing a week ago in my post on "number crunchers", and now, even the Guardian is getting in on the act with a piece headed: "The UK's coronavirus policy may sound scientific. It isn't".

This is a commentary by Nassim Nicholas Taleb is distinguished professor of risk engineering at New York University's Tandon School of Engineering and author of The Black Swan, together with Yaneer Bar-Yam, president of the New England Complex System Institute, and they have some interesting observations to make.

Firstly, the pair rather put the modelling fantasy into perspective, telling us that their work did not use any complicated model with a vast number of variables. It was no more necessary that "someone watching an avalanche heading in their direction calls for complicated statistical models to see if they need to get out of the way".

The trouble I find, though, is that these modellers, with their graphs and charts and the faux certainties offered by complex computer calculations, based on mysterious formulae and algorithms, have a strange allure for hard-pressed politicians in crisis situations, seemingly giving the comfort of certainties that simply do not exist.

Taleb and Bar-Yam actually point out that the error in the UK, in managing this epidemic is on two levels: modelling and policy-making.

Firstly, at the modelling level, they say that the government relied at all stages on epidemiological models that were designed to show us roughly what happens when a preselected set of actions are made, and not what we should make happen, and how.

As such, the modellers use hypotheses/assumptions, which they then feed into models, and use to draw conclusions and make policy recommendations. But the assumptions are untested and lack robustness. They are fine as academic models but, say Taleb and Bar-Yam, "if we base our pandemic response plans on flawed academic models, people die. And they will".

This was the case, they say, with the disastrous "herd immunity" thesis which, in fact, was nothing more than a dressed-up version of a "just do nothing" approach which never had the slightest chance of working – as indeed I pointed out at the time.

But the second, and more grave error, is the policymaking. No 10, we are told, appears to be enamoured with "scientism" – things that have the cosmetic attributes of science but without its rigour, this making it so attractive to politicians (and their advisors) who have a limited grasp of science.

This, say Taleb and Bar-Yam, manifests itself in the nudge group that engages in experimenting with UK citizens or applying methods from behavioural economics that fail to work outside the university – yet patronise citizens as an insult to their ancestral wisdom and risk-perception apparatus.

Social science, they say, is in a "replication crisis", where less than half the results replicate (under exact same conditions), less than a tenth can be taken seriously, and less than a hundredth translate into the real world.

So what is called "evidence-based" methods have a dire track record and are pretty much evidence-free. This scientism also manifests itself in Cummings's love of complexity and complex systems - which he appears to apply incorrectly. And letting a segment of the population die for the sake of the economy is a false dichotomy – aside from the moral repugnance of the idea.

The view of Taleb and Bar-Yam is that, when dealing with deep uncertainty, both governance and precaution require us to hedge for the worst. While risk-taking is a business that is left to individuals, collective safety and systemic risk are the business of the state. Failing that mandate of prudence by gambling with the lives of citizens is a professional wrongdoing that extends beyond academic mistake; it is a violation of the ethics of governing.

The obvious policy left now, they say, is a lockdown, with overactive testing and contact tracing: follow the evidence from China and South Korea rather than thousands of error-prone computer codes. Thus, "we have wasted weeks, and ones that matter with a multiplicative threat".

Yet, for all that, they have said nothing that hasn't already been said on this blog, and elsewhere. There only place where there is no sense of control is No.10, where Johnson continued to wing it, buoyed by extremely dubious modelling from the same team that brought us death and destruction in the Foot & Mouth epidemic.

As yet, though, the Johnson administration doesn't have a plan B, but you have to admire its skills in creating the superb distraction of the "volunteer army", which has the media taking its eye off the ball. But, with both Italy and now Spain, leading the way in emergency treatment (pictured), indicating our direction of travel, this can surely only be short-lived.

One gets a sense though that, deep down, Johnson still thinks this is a problem that will go away of its own accord, and that all he needs to do is hold his nerve until the crisis abates. And if that is the case, the likes of Neil Ferguson are playing to his weakness, bolstering his fantasies.

For the moment also, this is buying time, as is the promise of home testing kits, which may or may not be available in the near future. But while, as I recently warned, you can't bullshit a virus, fudging the figures will only give you so much respite before reality comes crowding in.

And, as Pete illustrates, there are complications to this epidemic that go way beyond Johnson's limited competence to deal with. Having failed even to grasp the domestic dimensions, his dire tenure as foreign secretary make it unlikely that he will be able to deal with the broader international issues.

However, if it was buying time that Johnson was after, it looks as if he has partially succeeded. An astute politician, though, buys time to seek solutions. Johnson seems just to be deferring the crisis in the hope that it will go away. It won't.



Richard North 26/03/2020 link

Coronavirus: for want of revolution

Wednesday 25 March 2020  



The picture (above) of Army trucks (Austrian-built, by the German firm MAN) crossing a deserted Westminster Bridge in broad daylight, depicts the sort of scene one might associate with a military coup.

But it is not the military who have overtaken this country but a microscopic organism, turning our society on its head in a way that we could not even have begun to predict a few short weeks ago. With the first two cases being reported at the end of January, less than two months later we had reached 8,077 by yesterday, with 422 dead – results produced by a woefully inadequate system which is massively under-reporting the true case load.

As it stands, despite guesses from a variety of sources, we can have no real idea of the extent to which coronavirus has penetrated the UK population, although it is probably fair to say that the distribution is probably patchy and that the main hotspot is London.

It is just as well therefore, that the authorities have finally reacted to set up an emergency treatment centre in the London's ExCel conference centre, although this action should have been taken weeks ago. If the need was obvious to me two weeks ago, sitting in Bradford relying on open source material, then it should have been obvious to the authorities some weeks earlier.

Now that we are seeing warnings that NHS hospitals could run out of beds in a fortnight, this development has come not a moment too soon, with the centre expected to be handling cases within a week.

We have also learned that the National Exhibition Centre in Birmingham has also been offered as an emergency treatment centre – another huge venue which could be converted to take thousands of new cases.

The great pity is that this wasn't thought of earlier, using such centres as the main treatment resource, rather than employing the existing NHS hospital network, and thus shutting down much of the routine health care for the nation. Part of the grisly death toll of this epidemic, therefore, will have to be measured in the untreated illness in people who could no longer get the help that they needed.

When we finally get through this, as we undoubtedly will, there will need to be not one but several searching inquiries into the management of the epidemic response, and such factors should feature high in any deliberations.

And since we cannot (or must not) assume that the Covid-19 epidemic is a one-off, the like of which will never be repeated in our lifetimes, we must use the experience gained to re-configure our public health systems to ensure that we are better equipped to deal with the challenges that the future might bring us.

With that, I must admit that I am getting a little tired of the "shock-horror-probe" denouements by sundry, wise-after-the-event journalists, keen to show how different aspects of the response led to the situation in which we find ourselves.

Much as I detest Johnson – and have little respect for the team of experts around him – given the deterioration of the public health systems over the decades, it is likely that the initial response would not have been much better, regardless of who was in charge.

The same, however, does not go for the more recent responses, and it is of some interest that Johnson received a call from Chinese president Xi Jinping about measures to prevent and control the Covid-19 epidemic.

It seems that, rather than mobilising resources, the prime minister frittered away his time – and his declining credibility – in giving health education lectures on personal hygiene. The current shape of the epidemic curve is mute testimony as to how fruitless those efforts were, with his actions being condemned internationally as "confused, dangerous and flippant".

Now we are in a partial lockdown, the effects of which are patchy, with confusion in many quarters, it is up to the police to take on an enforcement role where there are so many exemptions that it is hard to see how the law can be applied.

That much is evident from the police response, with police "chiefs" demanding urgent clarification from government as to what their precise duties should be.

Martin Hewitt, chairman of the National Police Chiefs' Council, says that police would have to use persuasion until new enforcement powers were made available under emergency legislation. "These are new rules. They are trying to be as clear as they can but it will take a while, I think, for everybody to get that understanding", he says.

In other areas, though, police leaders are saying that the lockdown may be impossible to enforce through lack of resources, not least because about ten percent of police officers are already off sick or self-isolating because of the virus.

Once the enforcement system is in place, though – with initial penalties of £30 being discussed, with provision for unlimited amounts – there will doubtless be plenty of jobsworths willing to come forward to impose fixed penalty tickets on the unwary. With hordes of under-employed parking wardens at large, there is a ready-made recruitment pool and you can bet that the authorities will be quick to exploit such an easy opportunity to top up their depleted coffers.

In the first days, however, it seems there will be little need for firm action. According to a YouGov poll, there is overwhelming support for the new measures, with 93 percent of Britons backing them, including 76 percent who say they "strongly support" them.

How people will feel after three weeks of "lockdown", especially if the measures are intensified, remains to be seen. One might expect a few localised incidents, and there is the ever-present threat of a repeat of the 2011 riots.

This cannot be dismissed as a possibility when there will be a large number of unemployed, extremely short of money as time goes on, unable to pay their bills and willing to loot supermarkets in order to feed themselves. Warnings that the epidemic could bring out the worst in humanity should not be ignored.

It is perhaps significant that Italy's unions are threatening a general strike over its government's definition of "essential" activities that would be allowed to continue working through the crisis. This is an issue which the Johnson administration has yet fully to tackle.

Furthermore, while there are some limited signs in Italy that the increase in cases might be slackening, there are as yet no firm signs that the epidemic is under control.

Much will thus depend on the ability of the UK government to contain the epidemic in Britain, allowing the restrictions progressively to be reduced, but the auguries are not encouraging. Not least is the growing scandal of the shortage of protective equipment for medical staff, hampering them from carrying out their tasks and putting them at risk.

As the crisis reaches what is expected to be its most dangerous period, we are told that doctors' and nurses' groups are complaining that their members are being expected to take unacceptable risks.

Dr Rinesh Parmar, chair of the Doctors' Association UK, warns that, where PPE continues to be in short supply, some doctors may feel they have no choice but to withdraw their services. The inability of the NHS properly to supply its staff with the necessary equipment, says a great deal for the overall failure to plan for a large-scale epidemic.

More to the point, when doctors at the height of an epidemic are even thinking of withdrawing their services, this is almost revolutionary talk. Perhaps the next time we see Army lorries crossing Westminster Bridge, it will be for real.



Richard North 25/03/2020 link

Coronavirus: of levers and power

Tuesday 24 March 2020  



The last time we saw the police in our road was early in 2019, when two uniformed officers came to question me about squirting a garden hose at a neighbour's noisy dog.

I got two more visits, each time the plod coming in pairs to investigate this heinous crime - the last lot threatening to arrest me – followed by a summons to the central police-station for an hour-long formal, taped interview, accompanied by a solicitor (who advised me to say "no comment" to every question).

Since West Yorkshire Police seem so generously provided with resources that they can afford to pursue such adventures, they should have no problem swooping on me and the rest of the citizens in my street as we take out our wheely bins for the collection next Friday.

Theoretically, it would seem, such a harmless activity has been made illegal by prime minister Johnson who, in yesterday's address to the nation imposed a form of house arrest, all so that we could "beat the coronavirus".

But, while we can't put the rubbish out, we are allowed to go shopping for basic necessities, "as infrequently as possible" – a period which has yet to be defined – and we can also leave the house to take "one form of exercise a day - for example a run, walk, or cycle - alone or with members of your household".

We can also leave to satisfy any medical need, to provide care or to help a vulnerable person, and those who have jobs can travel to and from work – "but only where this is absolutely necessary and cannot be done from home".

One can imagine, though, that any group of scrotes from the council estates in London – or any other urban area – could easily find in these exemptions sufficient excuses to stay out in the streets all day. After all, no one has yet specified how long an exercise walk should take.

In short, therefore – until we hear otherwise – Johnson's "lockdown" will bind those who want to be bound by it, but those who wish to ignore it will be able to exploit so many loopholes that it will become unenforceable.

And that is without those lawfully taking advantage of exemptions, those who can travel to work as normal, without any restrictions apart from the retail, hospitality, entertainment and sports industries. Rubber duck makers – if there are any in the UK – can thus continue their activities, dragging in staff for that purpose.

Thus, while we are told that the police will be able to enforce Johnson's new rules, and impose (unspecified) fines on people who do not abide by them, one wonders whether Johnson is actually serious about controlling the coronavirus.

It seems more likely that he is simply going through the motions, laying down the foundations of an alibi for when the cases hit six figures, whence he can blame us all for failing to observe the rules.

But then, as I pointed out in yesterday's piece, for the next two weeks or so, the die is already cast, with a high probability that we will be seeing around 60,000 cases by the end of the fortnight, with getting on for 5,000 deaths.

With the faux lockdown initially in place for three weeks, that will give Johnson and "team Covid-19" a nervous week waiting to see if the epidemic curve starts slackening off. If it doesn't by the end of the third week, the prime minister will doubtless come under strong pressure to tighten the restrictions still further, reinforcing his reputation for staying firmly behind the curve.

At that point, NHS critical care capacity will be saturated, and the service may be close to collapse. Hence we are seeing reports of plans to turn London's ExCeL centre (pictured) into a makeshift 4,000-bed "field hospital", following in the wake of Madrid.

According to the Guardian, it will be staffed by a combination of NHS staff and military medical personnel. NHS planners are said to think they will need to press it into service in around a month's time. That seems to be their estimate of when all the critical care beds in London hospitals are likely to be full – although it seems hardly likely that they will last that long.

Interestingly, the initial work seems to be being handled by a team of military planners. They have been reported to have visited the ExCeL centre to determine how the centre might benefit the NHS response to the outbreak.

And while this is a welcome move, the intention seems to be to use this as an overspill facility, rather than it being used as a treatment centre in its own right, keeping infected people out of the hospitals – where the concentration of infection puts existing patients at risk, while their treatment interferes with the provision of other medical services to the community.

Madrid, of course, is seeking the same overall solution, using a conference centre to provide an extra 5,000 beds, but one wonders whether it is possible, effectively to manage a unit of this size, to say nothing of the provision of basic services, such as provision of electrical power, drainage and even toilets for such a large number of people on a continuous basis.  

It would surely be easier to organise a network of smaller units, such as converted leisure centres and community halls, each providing care to about 100 patients, dispersed throughout London and the regions.

Disturbingly, while central government seems keen to use the military, there seems to be no role for local authorities, which collectively manage a huge estate and are used to dealing with emergencies, such as the recent spate of floods. Their properties might be more suitable for conversion, and impose less stress on the system as their provision would be on a more human scale.

But this is not the only area where local authorities appear to be left out of the action. As even some Dutch authorities realise the folly of not carrying out testing of all sufferers, with aggressive contact tracing, there are some 10,000 trained and experience staff in local authority environmental health departments who could undertake these tasks and are not being used.

In England and Wales, the very history of modern local government is the history of infectious disease control, with local health boards and their medical officers of health and sanitary inspectors providing the first-line response in the management of epidemics, providing the template for local authorities as we now know them.

Prior to the 1974 local government reorganisation, there were over 400 local authorities, each with their local public health teams but, through progressive reorganisations, their functions have been absorbed into the NHS, executed by "local" public health protection teams (HPTs).

But with the reorganisations came a savage contraction of the system, with better than 400 semi-autonomous local authority units being replaced by a mere nine HPTs, with only one covering the whole of London. When it came to testing and tracing, therefore, there simply wasn't the resource, while the service has lost touch with its local authority roots and is unable to handle a massive increase in workload.

Many years ago, I met Roger Freeman in his office in London, when he was Major's Chancellor of the Duchy of Lancaster. Rather wistfully, he compared his role with that of a signalman in an old-fashioned signal box, lined with gleaming levers. These, he said, were his levers of power. "But, do you know what, Richard", he said, "they're not connected to anything".

I was reminded of this when thinking of ministers trying, in the early stages of this epidemic, to organise a "test and trace" routine. But in this case, not only are the levers not connected to anything, the signal gantries have been pulled down and the points grubbed up.

It is all very well writing grand conspiratorial pieces about why Johnson failed to act, but the more prosaic reason is that the public health system in this country is so far degraded that it no longer had the resources or the capability to deal with an epidemic on the scale we are now experiencing.

Thus, with the most effective means of control having been abandoned, we had yesterday a prime minister imposing draconian limits on our liberties in an attempt to control an epidemic that should never have got to this stage.

The tragedy is that, even in the unlikely event that the new measures actually work, the damage done and the suffering caused will far outweigh the rather marginal saving achieved by contracting public health services to a level where they could no longer function effectively.

That much, to be fair to Johnson, is not all his fault: when finally he started to pull levers, nothing happened. And now, with a total of 6,650 people found positive for coronavirus, and 335 patients having died, even the full resources and power of the state hardly seem enough.



Richard North 24/03/2020 link

Coronavirus: the killer with a benign face

Monday 23 March 2020  



I am not sure I want to be part of a country where the prime minister (any prime minister) is delivering daily broadcasts to the nation, which then become a central part of our lives upon which so much hangs. But it is a singularly cruel deity (or one with a magnificently warped sense of humour) which foists upon me in particular a man who I detest so much that it is quite unpleasant merely to watch him.

Yesterday's press conference, therefore, offered the usual dose of torture (mercifully absent on Saturday), when the Great Leader told us why the government was taking its "unprecedented steps".

The reason "of course", he said, was that "we have to slow the spread of the disease and to save thousands of lives", at which point we entered something of a fairy-tale land - the one in which we actually have a government which knows what it is doing.

Thus today, said the Great Leader, "we've come to the stage of our plan that I advertised at the outset, when we first set out plan of the UK government, when we now have to take special steps to protect the particularly vulnerable".

Up to a point, Lord Copper, one might say, but reference to this fabled plan does not exactly support Johnson's claim.

Far from seeking to take the vulnerable out of the infection loop, it actually noted that "there could well be an increase in deaths arising from the outbreak, particularly amongst vulnerable and elderly groups". One was supposed to take comfort from the alertness of the beneficent UK Government and Devolved Administrations. These would "provide advice for local authorities on dealing with this challenge".

Nevertheless, Johnson told the assembled hacks that "You'll remember when I said the moment would come when we needed to shield those with serious conditions. There are probably about one-and-a-half million in all", but this is notably absent from The Plan. It was raised on 15 March, after the government had "faced pressure to do more to tackle the epidemic".

In response, Downing Street had said it would continue to be guided by its medical experts. Its Scientific Advisory Group for Emergencies (Sage) had thus listed "shielding the vulnerable" and "household isolation" as the next steps to tackle the spread of the virus.

However, all is well says Johnson. "This shielding will do more than any other single measure that we are setting out to save life. That is what we want to do. Also to reduce infection and to slow the spread of the disease".

One can hardly avoid wondering, though, why – if this shielding is such a potent weapon - it wasn't specifically identified earlier. But then, if we are to believe the Sunday Times, young Master Cummings had originally convinced the Great Leader that slaughtering the sick and elderly was the way to go.

In a hotly disputed passage, dismissed as a "defamatory fabrication", the ST has it that Cummings "became convinced that Britain would be better able to resist a lethal second wave of the disease next winter "if the CMO's prediction that 60 to 80 percent of the population became infected was right and the UK developed "herd immunity".

Thus, at a private engagement at the end of February, the "career psychopath" outlined the government's strategy. Those present say it was "herd immunity, protect the economy and if that means some pensioners die, too bad".

Something of this "bring out your dead" policy, was evident even without the inside track, although we had pointed the way to a shielding strategy on 4 March when we suggested that:
Where most of the young(er) victims are only mildly affected, perhaps the best thing to do would be to isolate the "at risk" groups and then let the virus rip through the community until herd immunity reaches about 80 percent and the epidemic peters out naturally.
Deliberately or otherwise, this seems precisely the strategy on which the government is now embarking – a strategy of last resort as its half-hearted measures are unlikely to have a decisive effect.

This clears the way for a timely intervention from Peter Hitchens, who asks: "Is shutting down Britain – with unprecedented curbs on ancient liberties – REALLY the best answer?"

He is not wrong to ask that question – it should be asked. And in getting to that point, after recounting an unfortunate experience with a medical doctor, he asserts that, "A mere title, a white coat, a smooth manner, a winning way with long words and technical jargon, will never again be enough for me". One could not disagree with that.

As to the number crunchers of the Imperial College in London, about whom we have been less than complimentary, Hitchens has this to say:
In a pungent letter to The Times last week, a leading vet, Dick Sibley, cast doubt on the brilliance of the Imperial College scientists, saying that his heart sank when he learned they were advising the Government. Calling them a "team of doom-mongers", he said their advice on the 2001 foot-and-mouth outbreak "led to what I believe to be the unnecessary slaughter of millions of healthy cattle and sheep" until they were overruled by the then Chief Scientific Adviser, Sir David King.
In principle, I could hardly disagree with that and I can only agree with Hitchens when he adds that: "I despair that so many in the commentariat and politics obediently accept what they are being told. I have lived long enough, and travelled far enough, to know that authority is often wrong and cannot always be trusted".

As to whether all these restrictions are necessary, I have already articulated my view that, if the government had got to grips with "test and trace", they would not have been necessary. Probably now, because of earlier government failures, they are necessary, but I don't believe they are sufficient - we still need an aggressive programme of "test and trace".

Overall though, I think Hichens fails to understand the distinction between absolute mortality and mortality rate. Coronavirus produces a relatively low death rate but, because of its infectivity and the disease profile, it is capable of killing far more people (absolute mortality) than a less virulent organism.

The reason why this virus is so dangerous is exactly because of its relatively low virulence, causing only mild illness in the majority of the population that it infects. Ebola, by contrast, killed as many as 90 percent of the people it touched, so it never spread. It killed off its victims too fast.

The same goes for the clinically indistinguishable Green Monkey (Marburg) Disease which is so deadly that investigators in the early days were stumbling on whole troops of dead monkeys in the forests of Equatorial Africa, with no spread to their neighbours.

By contrast, coronavirus is our worst nightmare. The high proportion of asymptomatic infections and mild illness means that it can spread undetected throughout the population to become a huge reservoir of infection, and then pass to the vulnerable whom it kills.

Furthermore, because the mortality rate is so low, many people under-estimate the danger, mainly because – like Hitchens - they don't understand the difference between mortality rate and absolute mortality.

This virus may kill a smaller proportion of the population it infects than Ebola, and the less deadly influenza virus, but because it is so supremely efficient at spreading, it will infect vastly more people – potentially running to millions unless checked. In terms of absolute numbers, it could kill far more people than ostensibly more dangerous viruses.

But we cannot rely on this virus only infecting the sick and elderly. There are clear indications of a dose-response, which probably works both ways.

Low doses spread via air conditioning systems, or airborne transmission from pre-symptomatic carriers, may result in lower infection rates and more benign outcomes for most sufferers than heavy or multiple doses passed directly from symptomatic patients - putting medical personnel particularly at risk

There is no good argument, therefore, to support the idea that we should take a relaxed approach to controlling this disease. Should we be forced to take such stringent measures as a complete lockdown, this could be taken in part as a reflection of the incompetence of the authorities in dealing with the threat, but that doesn't mean they are unnecessary.

This is a killer with a benign face, and all the more dangerous for that.



Richard North 23/03/2020 link
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