Coronavirus has taken us from the frying pan to the fire. Or, as I said to a friend a couple of weeks ago we've gone from the sitcom/ soap opera of Brexit to living in a scifi end of the world movie. It only took a global pandemic to get Brexit out of the headlines.....
There was a lot of silly talk last year about the climate "emergency". I'm not saying that the global warming situation doesn't require significant and concerted global action but, in the simple two by two box model loved by management consultants, we have seen a vivid example of the difference between something that is important but not, strictly speaking, right this minute now urgent from something that is important and urgent as in a here and right now emergency.
Of course, we're not in a disaster movie - in real life there might not be a sudden positive twist and happy ending. The virus might turn out to be one for which a vaccine provides long term immunity. Or, like flu, it might give protection against the current strain. Or, like the common cold, vaccines might be ineffective. There might be a saviour out there but that person is more likely to be a microbiologist rather than an action hero with film star looks.
It's been fascinating watching the response of governments around the world, in particular how they have nearly all moved to broadly similar policies on lockdown at different paces and with varying degrees of enthusiasm. China started in denial and cover up mode but then recognised the issue in Wuhan and used its authoritarian strength to go for a very firm lockdown. South Korea has had a lot of credit for its tracking and tracing but it has used mobile phone location data in a way I suspect would not currently be legal in the UK, EU or USA. The UK approach had been crtiticised as being very different and much riskier than anywhere apart from the USA, though the position we got to nearly 2 weeks ago looks very like most other countries to me. But wait - Sweden, normally one of the countries that the right-on crew point to as an example of how to do things, has adopted a softer stance on lockdown and social distancing than most, with bars, restaurants and primary schools still open though they finally decided to close ski resorts and advised the elderly to stay at home and families to avoid visiting relatives at Easter.
The UK strategy has been boffin led. It was a deeply thought policy if patently not fully thought through. It was kept under constant review and it evolved with the circumstances and available information. The government was not scared to act differently from other countries and had tried to avoid going for extreme measures until they were really necessary. This seemed to be an attempt to balance public health with other elements of public well-being and recognised that moving to lockdown too quickly risked compliance and fatigue by protracting the lockdown period. The approach of trying to flatten out the peak, to avoid stretching the NHS to breaking point, also seemed to accept that the virus could be not contained and that extreme measures to attempt the impossible would be counterproductive.
If it ever was the UK government's plan that the virus should be allowed to run its course through the general population, delivering enough herd immunity to damp down the outbreak while maintaining economic activity at not far off the normal level and attempting to protect older people to a pragmatic extent, that plan cracked under the strain of Prof Neil Ferguson's modelling which showed the NHS would be swamped and fatalities could be well into six figures. I thought the pictures from Italy of emergency field hospitals set up in tents and military vehicles taking away bodies at night as local facilities were overwhelmed were also material.
At the outset I had a worry about the government strategy which became entirely driven by NHS capacity, in particular intensive care with assisted ventilation. At first few seemed to be asking whether the potentially severe consequential economic impacts were justifiable. My question posed to Mrs H was "can it really be justified to essentially close down the economy, prejudicing the health and well being of the general population to give a few years of life to old people with pre-existing health conditions?" That wasn't to ignore the fact that a very small proportion of younger people die from coronavirus. In particular, it was clear from Italian experience that health workers who get a high exposure to the virus seem vulnerable to the large virus loading they experience. I didn't think, per Trump, that it was "just like flu"; it's clearly a bit more contagious with a somewhat higher fatality rate. I was simply asking the devil's advocate questions I'm fond of and pondering where the balance lay.
Slowly over the last couple of weeks some commentators raised doubts. The first I saw was Richard Littlejohn in the Daily Mail who wondered whether we were seeing "well intentioned over reaction". This was based on a letter to the Daily Telegraph from a retired doctor who argued that, had the epidemic hit when he qualified in 1953, the virus wouldn't have been identified quickly as "new", most cases would be mild and the deaths among elderly people with chronic respiratory disease would have been seen as normal for the time of year. "So there would have been no alarm or countermeasures...trade and travel would have carried on....stock markets would not have collapsed....governments would not have needed to get involved". Hmm. I can imagine that doctors would have spread the word that this "new flu" seemed particularly nasty for the old, of whom there weren't as many then. The world wasn't as connected in travel or information flow terms so what was unfolding might not have been realised until after the event. But that doesn't mean we should just have carried on and ignored it because we wouldn't have known any better in the past.
Soon after I saw several rather better argued articles. Steven Glover* pondered the extent of Rishi Sunak's financial measures:
"As a father of two young men... fretting about their long-term future...We have to ask ourselves a rather shocking question. Is it right that, in order to save the lives of mostly elderly people (I accept that some younger people are at risk, but they constitute a comparatively small minority), the future lives of millions should be devastated? I imagine some among the young think it’s not right — which may be why a few of them are flouting the Government’s rules. I suspect a greater number are silently resentful. Such people have been the chief victims of austerity, and they are being asked to carry the can again."
Glover went on to say that he didn't share this view, but we should examine it (a devil's advocate like me then). He quoted two academics. Firstly, Bryan Turner, an emeritus professor of experimental genetics, who suggested there might come a time when the Government’s medicine caused unacceptable economic harm. ‘As a 72-year-old,’ he wrote, ‘I would rather take my chances with Covid-19 than see further damage inflicted on my children’s future.’ I've read this put more starkly by the Lieutenant-Governor of Texas, Dan Patrick, who said "lots of grandparents" would be willing to risk their lives to protect American prosperity for future generations. "At some point we have to get back to working. Our whole way of life is in jeopardy. If that puts seniors at a little bit more risk I'm willing to take that responsibility..... what is most important to me at this stage in my life is preserving the America that I love for the next generation". Glover's second witness was Philip Thomas, professor of risk management at Bristol University, who published a paper arguing that if the economy shrinks by more than 6.5 per cent, the ill effects in terms of lower life expectancy and other health problems will outweigh the benefits of saving lives from the ravages of the contagion.
Glover suggested governments are in the position of a firefighter confronted with a conflagration which must be put out, however much water is needed. If all the water is used, and there isn’t enough left to irrigate the crops next year, that is a great pity, but the thought can’t be allowed to interfere with the process of trying to extinguish the fire. The practical impulse to save human life is so central to our moral traditions that it cannot be attenuated by fine calculations about whether it would be wiser to hold back greater resources for the future. Glover said if the danger is truly as grave as No 10 believes, the Government is right to throw the kitchen sink at the problem. But, he asked, what if the Government is wrong and has exaggerated the extent of the threat? Hmm. But what if they're not wrong?
Since then I've read several similar pieces including one by Max Hastings in the Daily Telegraph and Lord Sumption, a former Supreme Court judge. Sumption argued in this week's Sunday Times that governments have adopted extreme and indiscriminate measures, albeit with public support. These measures include indefinite house imprisonment for most of the population (a bit of an exaggeration!), abolishing sociability and giving the police authoritarian powers.Thousands have been put out of a job and onto universal credit, a fifth of small businesses are being pushed into bankruptcy and generations saddled with higher levels of public and private debt."These things kill too. If all this is the cost of saving human life we have to ask whether it is worth paying". Sumption argued that we have acquired an irrational horror of death and, while we don't yet know the true case mortality of Covid-19, we also don't know how many of those who have died would have died soon anyway because of their underlying health conditions, appearing as part of the six hundred and odd thousand who are expected to die every year. Indeed one of the government's key advisers, Whitty or Vallance I think, admitted a while ago that he couldn't estimate how many of the coronavirus deaths were "extra" and how many would have happened anyway. Seasonal flu death figures do make that distinction and so coronavirus and flu numbers cannot be compared directly.
Strong stuff from Sumption. But amongst the questions I have are what proportion of elderly patients with health issues survive even with intensive care? If it's very small how can the treatment be justified? This may not be known yet but the experts will have the latest data and it should be known with statistical validity very soon. But even if a proportion do survive I read that, after being on a ventilator, patients can take up to 15 years to fully recover. I don't know if that's true but, if so, what's the point for people over, say, 75? (I am conscious I just quoted an age a few years older than my own....)
I'm not sure it was ever UK government policy to let the virus run its course. After all, even the very early advice on social distancing anticipated stronger restrictions being brought in as the spread of the virus progressed. But there did seem to be a sudden handbrake turn after Ferguson's modelling forecast an overwhelmed NHS. Any other views collided with the stark reality of huge numbers of deaths piling up and the human stories that would go with them of people's mothers, fathers and grandparents. This trumped the longer term detriments which will include fatalities. I was surprised to see that some ante-natal clinics weren't being held, for example and shocked to see that a patient being treated for ovarian cancer found her chemotherapy sessions cancelled. Clearly such decisions will have consequences. But also telling people not to even phone their GP, as per the text I got recently telling me to use their e-consult service via the website, response promised in 24 hours, will store up many cases of delayed diagnoses of serious conditions with inevitable results. However, those fatalities don't have names yet. One might say this is a kind of bird in the hand is worth two in the bush, but counting corpses.
So does the strategy make sense? There's no precedent or roadmap for this in the modern world. But, whether it makes sense or not it's probably the only politically realistic approach. The alternative i.e. the government admitting it can't protect the oldest and frailest in our society and so wasn't going to try, is unthinkable not just for governments in democracies but also in countries like China.
But the best argument I've seen was made by Tomas Pueyo in a paper published nearly 3 weeks ago. It's long and detailed but well worth a read and the clearest picture I've seen about what's happening and what's in store. Pueyo happens to lead a billion dollar education technology business called Course Hero. He worked with academic and business contacts around the world to develop the case that the US needed to take the virus more seriously and save lives by buying time. His paper pulls on information from the progress of the virus around the world and the effectiveness of actions taken by a wide range of countries. He refers to Neil Ferguson's modelling, though he uses a different, published model. He answers some questions, like will the virus mutate? Answer: it already has in several countries. No, I don't know the implications of that for testing and vaccine development either, but it can't help. And if you let the virus rip through millions of people guess what? You give it millions of chances to mutate.
Pueyo's main argument related to what should be done in the USA, though it applies generally. His main point is that, unless you are very well prepared, you don't run towards trouble, you buy time. And if you just try to "flatten the curve" (he shows lots of examples including the Imperial College modelling that caused the UK government to do its handbrake turn) that mitigation still leads to the health service being overwhelmed. And then you don't just get lots of short term coronavirus fatalities, you get lots of other fatalities too. As he puts it:
"What happens if you have a heart attack but the ambulance takes 50 minutes to come instead of 8 (too many coronavirus cases) and once you arrive, there’s no ICU and no doctor available? You die."
I'm not sure I completely agree - traige would mean the ambulance service and ICU prioritised heart attacks over older coronavirus patients, but it would be controversial. Nevertheless Pueyo's main argument holds. He also has a clear idea of what to do and it's essentially the strategy that has been evolving in most countries. He calls it the hammer and the dance**. You have to suppress the virus by hammering down on it with tough social distancing measures. Once you get the R transmission factor right down, well below 1, you can release some restrictions and move into the "dance" phase. This entails releasing restrictions but keeping R below 1 by proper testing, contact tracing, quarantining and isolation. While most restrictions would be removed you have to tighten up when and where needed - the dance. And you figure out exactly which social distancing measures to use by applying cost-benefit analysis with the greater knowledge that has been acquired.
The logic is buying time. If you are facing your worst ever enemy, why run towards them? If you buy time you can understand the virus better and build up intensive care capacity, testing capacity and the capability to trace and isolate cases. And you have time to develop vaccines and devise other approaches to minimising the spread of the virus.
Many have made the facile remark about there being no exit strategy, or have called on the government to publish a "detailed" exit strategy when they know it can't exist yet. I suspect they only want to try to make the government look stupid and score points. But the basis for an exit strategy is clear. If the limiting factor causing lockdown is the capacity of the NHS to cope, then lifting the restrictions depends on the ongoing ability of the NHS to cope. D'Oh!! Restrictions will presumably be relaxed in a gradual and measured way, allowing time to show what the effect has been. As the virus will peak at different times around the country this will probably have to be done on a geographical basis. I'm sure the government has lots of people thinking about this and how it could be made to work. There are all sorts of questions, civil liberties amongst them.
Pueyo made up a chart for what the hierarchy of restrictions might be, which ones you would lift and in which order. We don't yet know what that would look like for sure.But Pueyo suggests that, if aggressive testing and contact tracing get you most of the way down to R=1 then the questions will surround firstly can you re-open schools and then what about pubs and restaurants? And of course larger gatherings, though for me the question is more can you keep people apart rather than how many there are present in total.
But there are still consequences of course, like cancelling elective surgery. What are they going to do with all the surgeons who would normally be chopping out and replacing knees and hips I wonder? Retrain them as intensive care nurses? (Bad idea of course, we know doctors make rubbish nurses).
The UK has had more time to prepare than some countries, mainly because places like Italy and Spain were at a more advanced stage sooner. It has used that time well in the case of providing extra hospital capacity. Remember how we laughed when the Chinese built a hospital in 10 days and said that couldn't happen here? Of course it did, with London's Nightingale Hospital kitted out in an existing building in 9 days. Remarkable. We weren't so well prepared on testing, with poor decisions taken at the outset in January. (Not by the government incidentally, by the NHS and Public Health England who insisted on doing it in house without support from the universities and private sector. The NHS was given full operational control under the Lansley reforms and, like the Bank of England, the government can't instruct it what to do). Protective equipment seems a stranger story - there's supposed to be plenty but it's not getting through everywhere. I've seen this before, people get swamped with the sheer volume of work. It's not an easy thing to test in advance in a table top exercise. "Is there plenty of PPE? Yeh, there's a building full of it. And how would we distribute it? The answer might sound ok but it won't have been tested in practice.
So, in answer to the question I was posing myself around three weeks ago i.e. whether the severe economic and longer term health impacts of a lockdown were justifiable, is that there really was no other choice. That's why just about every other country has gone in broadly the same direction. As Pueyo says the alternative (for the USA) was deaths in the millions rather than the thousands (hundreds of thousands for them it seems to me but that's quibbling). It would have meant an overwhelmed health service (though that still might happen - just look in the faces of ministers and health service professionals you see on TV). The result of that would be very harsh triage measures - no point in bringing people to hospitals if there's no space - and mass burials (which might happen soon in New York).
Nevertheless there will be costs in trading deaths for debt. The financial impact will include public and personal debt on a previously unimagined scale. Readers will know I was already concerned about the amount of debt us oldies are leaving for our grandchildren. The young have seen us baby boomers be able to buy houses, benefit from property booms and generous pension schemes and leave a legacy of climate change and a polluted planet. We have mismanaged the economy causing a financial crash leading to high levels of debt which was managed by quantitative easing to underpin asset prices which again favoured the old over the young (or at least those with assets against those who don't have, but that's much the same thing). This led to low levels of financial resilience before the coronavirus crisis gatecrashed the party. And all for what? Some great rock music they don't even appreciate?
So I feel for the younger generations, while also feeling frustrated at everyone's lives being on hold. If as seems likely once the lockdown is lifted we'll be in for a year or more of restrictions then some things are clear. I don't expect to go to the pub anytime soon and the Premier League and other sports had better get their minds round events staged just for TV. Speaking selfishly, I think it'll be quite a while before I'm pushing through a throng to get to the bar at the pub before a match at Goodison Park. Hopefully it will be a lot sooner when I can get out and social distance on a golf course.
In contrast, Simon Jenkins is still an optimist and was saying only 5 days ago*** that he thinks the crisis will be over in 3 weeks and that we should have stuck with the Swedish approach. He notes that his wife is a pessimist and they can both find scientists on their side. The government's approach is "evidence based" but the interpretation of that evidence still requires scientific judgement and the decisions then made have implications beyond scientific analysis.
As Ian Curtis of Joy Division sang in Day of the Lords "Where will it end?" Go to
https://www.youtube.com/watch?v=DpztcWVVoDc and take a listen. It will really cheer you up (not). Still, a great song for the lockdown.
*Stephen Glover. The old may be at most risk from coronavirus but I fear the young are set to pay a heavy price for the financial cost of fighting it. Daily Mail 25 March.
dailymail.co.uk/debate/article-8153515/STEPHEN-GLOVER-fear-young-set-pay-heavy-price-cost-fighting-coronavirus.html
