The Emperor’s New Clothes 2020

I am not a scientist, so what I write here has to be viewed as the product of an interested, but inexpert, mind.

I have been repeatedly struck by the similarity between the Hans Christian Anderson fairy tale, The Emperor’s New Clothes, and the UK Government’s response to the Covid-19 pandemic.

For any reader not familiar with the story, a pair of con-men tailors persuade an Emperor that they could make him a magic suit of clothes. The suit would be so special that only superior citizens could see and appreciate it. Nobody would admit to being inferior, including the Emperor himself, so nobody would say that the suit was imaginary: it didn’t exist. Eventually it takes a small child to puncture the community conspiracy and call out that the Emperor is naked. I am calling out. I am saying our political leaders, and the scientists they defer to, are naked: they don’t know what to do (or are unable to do what they need to do) even though they profess to know.

It seems to me that the UK, and UK media in particular, is bewitched by the 2020 Covid-19 ‘smoke and mirrors’ version in which they, and we, are told to believe in something patently untrue because they, and we, are afraid of looking stupid in the face of “the Science”. We, the mere mortal citizens, cannot understand the complexity of this pandemic and are afraid to ask difficult questions in case we seem ill-educated.

This is plainly nonsense. First of all our media are replete with clever, well educated, people. Moreover we, the populace, are not only not generally ill-educated but we are also blessed with something which seems singularly lacking in the narowly focussed Government science community and the Government itself: common sense.

Every day, and I mean every day, a UK Government minister hosts a so-called press conference from Downing Street in which ‘slides’ of graphs, updated from the day before, are presented by a ‘scientist’ to illustrate progress in the fight against the virus. This presentation is followed by questions from the media. Recently, presumably in an effort to engage the public in an illusion of transparent democracy, two questions are first taken from members of the public. The Government claims these questions are ‘unseen’ but it is evidently untrue because you can see the ministers, in particular, consulting notes when speaking in response to the questions. I will try to ‘pick over’ some of the anomalies that arise from these questions and answers.

Being Led by the Science

One of the advantages of saying you are following the science is that you can blame the scientists if it all goes wrong. It’s the job of Government, both as leaders of the country and as employers of the scientists, to test the scientists, or at least ask them hard questions, however ‘daft’ they may seem. It has been marked, really marked, how often the scientists speaking at the daily press conference say something like “it’s too early to say, it’s difficult to draw conclusions from the data, we’ll know what happened when it’s all over”. In short, they often say “we don’t know”, so how can anyone follow that lead?

The charts shown to the public display, and invite, international comparisons and yet the scientists say “it’s very difficult to make comparisons because the data across countries is not recorded consistently.” If it’s difficult (or even meaningless) to draw comparisons why do they show these charts?

Testing

The Government’s approach has, like the science, been ‘behind the curve’. At the outset of the epidemic, before it became an official pandemic, the World Health Organisation advised “Test, Test, Test”. The UK did not. Those countries that did, seem to have had a different level of transmission. Some countries imposed travel restrictions, quarantine and scanning for elevated temperature in arrivees. The UK did not. Some countries were very quick to impose lockdown, the UK was not. Worldwide, but especially in S.E. Asia where they had both a culture of routinely wearing facemasks when ill, but also experience of epidemics of respiratory diseases like SARS and MERS, the community response was immediate and effective. The UK’s was not. In the UK our limited capacity for testing outside of hospital was initially focussed on getting medics and carers back to work because the medical workforce was under pressure. Once the decision was taken to increase testing (and I think this decision was forced by public pressure) the figures of tests undertaken became a politically, not medically, important key performance indicator and therefore had to be presented in a ‘managed’ way. The results from those tests, especially in hospitals, became a key indicator in the progress of the disease through the population and of the prevalence of the disease in the country as a whole. It emerged very early on that there was a range of severity: the majority of infected people would experience only mild symptoms and some would have no symptoms at all. A smaller number would need hospitalisation, about half of those would need intesive care, and of those requiring the highest level of hospital intervention (sedation and ventilation) a significant number of those would die. These numbers became key indicatiors of the progress of the disease, and of healthcare performance through mortality rates.

What nobody seems to have grasped (or been prepared to call out) is that testing, any kind of testing in the sick population, that is to say those persons presenting in care settings and exhibiting symptoms, is only confirming what is already suspected. Two cohorts of the population were missed by this approach to testing, and therefore any measurement of population prevalence is distorted. First, those people with ‘mild to moderate’ symptoms were (and still are) required to self-isolate at home. Until the proposal to use an ‘App’, see below, they were not counted as cases. They were not tested (unless as part of the belated testing of key workers), they were not confirmed cases of Covid-19 and their contacts were not traced. Secondly, those people with no symptoms at all, or misidentified as ‘just having a cold or hayfever’ were, and still are, free to circulate in the population to potentially shed and spreading the virus: the Typhoid Mary effect.

Laterly, in May 2020, the Government has started a limited trial of an ‘App’, a technological solution to tracking and tracing outbreaks of disease. If deemed successful it will be rolled out across the UK. People who use this ‘App’ will be asked to monitor their state of health and, if exhibiting symptoms, report illness. The ‘App’ will then inform their ‘contacts’ who will be advised (advised!) to self-isolate and so break the chain of transmission. It seems to me there is an obvious, and fatal, flaw in the logic of this approach, and that is the Typhoid Mary effect. Track and Trace only works on those people who have symptoms: officially at least 30% of the infected population are asymptomatic.

Chasing the ‘R’ Number

The distortion of the real, natural, level of community transmission of Covid-19, and therefore pursuit of the magic ‘R’ number, has been profound.

The ‘R’ number is the reproduction rate, the rate by which one infected person passes an infection on to others: its ‘natural’ infectivity in a population with no immunity. An ‘R’ of 1 means one person will infect one other and the infection rate is stable, while anything above 1 means an exponential growth of infection. The ‘R’ of normal ‘flu is about 15 – it’s highly infectious. The natural ‘R’ of Covid-19 is said to be 3. There is no way to change the natural infectivity, the ‘R’, of Covid-19. Until we can develop a vaccine, all we can do is reduce it’s opportunity to make people sick by hygiene measures and, crucially, keeping people away from each other. What we have managed to achieve, with extreme restrictions and the wrecking of our economy, is an un-natural ‘R’ number hovering between 0.5 and 0.9. Clearly, though, something is going on which is sustaining new infections. The UK government is saying the locus is now Care Homes. I really struggle with the logic of this; Care Homes are, more-or-less, ‘closed’ communties. Once the problem was identified, even with mass mortality as we have had, how does that drive infection in the wider population? I suggest that it is the reservoir of undiagnosed, untested, and asymptomatic infection. That being the case, the relaxation of the measures to keep people apart will inevitably result in a resurgence of the disease.

What the UK government seems to have decided is that the economy must be restarted, and has embarked on an experiment in which we are the guinea pigs, to see what happens if we let the reins slacken. The government says that ‘lockdown’ can be reinstated if this happens, but I suggest this is unrealistic: once the freedom genie is out of the bottle there is no way the public can be persuaded to put it back and comply with the measures in the way they have, broadly, until now. I don’t doubt that behavioural science is informing some of the epidemiology, but we have already seen the extent of wilful disregard for lockdown measures, as well as plain misunderstanding. The UK Prime Minister has pleaded for “good British common sense” to apply: in effect this sounds like “it’s too complicated to explain or advise about, even for me, so just do whatever you think is right”.

Epidemiology

We know that the first widescale outbreak of what became labelled Covid -19 was identified in a Chinese city of 11 million people called Wuhan, in the province of Hubei. As far as we know it was noticed in December but officially denied. Travel in and around China continued, and critically beyond China’s borders. Blaming China has become a politically convenient distraction. What has only recently become general knowledge is that cases appeared in Europe in December, before it was reported in Wuhan. That means it was circulating more widely there (and elsewhere) for longer than was suspected, and therefore maybe even calls into question the location of the original outbreak. Moreover, DNA-based research has shown that the origin of disease in other parts of Europe was significantly driven from the UK. We know the virus is highly infectious, and we now know it has been mutating: the strain that subsequently arrived in the West coast of the USA, from Asia, was different from that which over-ran New York that came via Europe (and therefore the UK).

Virology

When we bagan to hear about a virus outbreak, we were told “Catch it, Kill it, Bin It” – and wash your hands thoroughly and often. We were told this was because the virus was spread by “droplets” getting from an infected person to someone else, directly by coughing or sneezing, or indirectly by the droplets landing on a surface and then being picked up by them and transferred to the mucus membranes of a face / mouth / eyes. Initially we were told that you had to be in close contact, face-to-face, for 10 to 15 minutes, and to stay more than 1.5 metres away. The obvious question then was how long the deposited virus ‘droplet’ remained viable on a surface, and it wasn’t (and still isn’t) clearly answered. Then we got the 2m ‘social distancing’ rule, but evidence emerged that droplets were spread over varied distances in an aerosol according to the environment, inside or out, by someone with virus on their hands touching something, and what people were doing like exerting exercise, which called into question the adequacy of 2m as a safe distance. Now we are advised to stand side by side, not facing each other, and as near as 1m if using “mitigation” measures. We have also now found that the virus can remain viable on clothing for several hours and that we should wash our clothes frequently, which makes a bit of a nonsense of the original advice to sneeze or cough into our elbow and shaking hands by ‘touching’ elbows.

The fact (and I use that word with caution) is that the virology, based in laboratories, cannot keep pace with the developing ‘field’ epidemiology with sufficient speed. That is to say that what’s happening in the epidemiological ‘reality’ is outstripping laboratory science’s ability to answer the new questions raised by changes in the experience on the ground. And so those of us without specialist expertise are watching the news from other parts of the world to see what they are doing, and how effective it has seemed to be, and applying our own common-sense response. Some people (me included) ordered facemasks, gloves and hand sanitizer, and began to adapt our behviours in and outside the home, even before a pandemic was declared. I mentioned the question of facemasks earlier in this piece, and of all the visible measures that various countries could have taken, the wearing (or not) of facemasks has been an obvious point of difference. Facemasks are routinely worn in a medical setting for two reasons, the principal one of which is not contaminating the patient by breathing on them. The secondary reason, except in specific cases, is protecting the clinician from any bacteria the patient may pass on to them. The specific exception is where the risk from the patient is bacteria (or viruses) transmitted by them in an aerosol spray – in which case a high performance, moisture resistant, mask is required (to standard N95 or higher).

The UK government, and its scientific advisors, consistently said that masks had no benefit in protecting the wearer, in fact suggesting they risked the health of the wearer because they would contaminate themselves putting them on or taking them off. This inexplicably ignored that the principal benefit they admitted was in reducing the risk of an infected person passing the virus on, and reducing transmission was the key objective of the lockdown! For weeks the government steadfastly refused to recommend general wearing of masks, even in the face of a growing public clamour, and this week (11 May) has only grudgingly “advised” (not mandated) the use of masks, as long as they are home made, saying that medical grade, or style, masks were inappropriate and should be kept for clinical settings because clinicians, nurses, carers, paramedics etc., need them for their protection. One has to ask if a mask protects a paramedic, why doesn’t it protect a member of the public? Of course, all of this has to be seen in the context of a massive failure to hold stocks of, or procure, adequate Personal Protective Equipment (PPE), of which masks are but one example. Almost uniquely in the “western” world, the UK has a universal and centralised healthcare service: the NHS. However, successive politically Conservative governments have sought to privatise the service and so the delivery of healthcare has been incrementally fragmented under the cloak of “efficiency improvements”, and responsibility devolved to area Care ‘Trusts’. The UK government was warned a year before the outbreak that we were unprepared for a pandemic and that central stocks of essential equipment were low. The government initially sought to blame the Trusts for mismanaging their ordering and stockpiling of PPE, ignoring the fact that the NHS had been systematically ‘bled’ of funding in the wake of the 2008 world financial crash. Then they sought to blame the public, who had bought their own PPE, for using up finite resources. Once they realised this blame game was not going to work with the public, their failure to deliver PPE to the front line medics, and care homes, resulted in the government giving daily scores of “items of PPE delivered” as fatuous as counting an individual glove as an item. The government clearly could not recommend the public to wear masks when there weren’t enough for doctors, nurses and carers. Now we know there is mounting evidence that facemasks do, indeed, protect the wearer (and in early June both the WHO and our UK government recommended widespread us of “face coverings” and specifically medical grade masks for the over 60s). By early July the WHO raised the possibility of airborne transmission, which suggests more widespread use of facemasks will be required.

What Next

We have no vaccine. We may never get a vaccine. If we do it may need to be redeveloped every year like the ‘normal’ seasonal ‘flu vaccine because the Coronavirus naturally mutates. There is some evidence that some infected persons have developed antibodies and therefore some immunity. Our NHS is experimenting with infusing sick people with plasma drawn from previously infected people. We do not know if this immune response is consistent across all sections of all populations, and even if it is we do not know how durable the immunity is. Without an effective vaccine we are going to have to live with, i.e. adapt our ways of life, the presence of Covid-19 (or Covid-20/21/22 etc.) for the long term and depend on improving therapeutic treatments to help us survive infection – if not knowing very much at all doesn’t kill us first.

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