Covid-19 – A final rethink.

On 26 November 2020 I published this piece on Covid-19 but, as so much has happened since then, an update seems very necessary.

In late November 2020 it felt like we were surfing down the face of a “second wave” of the Covid-19 pandemic. There were one or two “good vibrations” in terms of progress with vaccine development but it was scary because, sadly, a lot of us were and are still going to experience “wipe out”. I deliberately used the surfing analogy because there had been more than a small element of wilful risk taking that had brought us to this ‘place’. As of 2nd December the latest lockdowns were replaced by a set of restrictions, dividing the home countries into ‘tiers’, in order to let the populatiuon “have a Christmas”. These tiered restrictions seemed likely to last until March 2021.

Since my piece in mid-June, much of what I then feared (even predicted) came about. The UK’s so-called “world class” track and trace system failed miserably, and for the reasons that have been obvious from day one:

It lacked the capacity to test widely

It lacked the ability to reach enough ‘contacts’

It depends on people to report symptoms and then, diligently, self-isolate

From the very earliest days of the UK’s pandemic, certainly before the initial ‘lockdown’ in mid-March 2020, it has been clear that the extent of asymptomatic disease, and transmission, was underestimated and driving community incidence. Its effects were compounded by our UK government’s flip-flopping on social distancing, on the use of face masks and, critically. It was also compromised by the overwhelming desire to “get back to normal” and to re-open the economy (see “Shop til you drop” and “Tombstoning..” elsewhere in this thread). In the summer of 2020, when Covid-19 was relatively under control, it now appears our population was used, guinea pig-like, to experiment with what happens if you let the brakes off in various ways. We were told to we could go on holiday. In the UK people streamed from areas with higher incidence rates to areas with lower incidence. People relaxed whatever adherence to anti-Covid measures they were observing, naturally enough, and largely forgot about social distancing. Young people, especially, threw themselves into party mode. At the same time we were told to “eat out to help out” and many holiday hot-spots became “super-spreader” locations. We now know that those who did venture abroad, especially to Spain, brought us back a new strain of Covid-19. Schools re-opened and, significantly for some local ‘spikes’, so did Universities. It seems nobody thought that mass movement of young people to University halls of residence across the UK might be a problem – or did they?

In the face of regional disquiet over the UK government response, and rising infections in university cities, the devolved administrations began to apply their own (some might say improved) responses. We already had confusion about what Covid-related restrictions applied, and the inevitable anomalies were (and still are) wilfully exploited by some. It just got even more confusing. Only the Welsh authorities imposed widespread travel restrictions, while in Scotland there were regional closures.

As I saw it, a significant proportion of the UK population was (and is) not disposed to following guidance, never mind instruction. Whether this is because they are incapable of understanding, or are wilfully disregarding, the importance of their part in suppressing transmission, I don’t know. With the population suffering, what was called, Lockdown Fatigue, pent up frustration, and being somewhat encouraged to anticipate a “festive season”, one had to hope that enough common sense prevailed. I thought it was highly likely we would see a third wave of infections in the new year. but actually the third wave was already under way.

Then, in short order, we got the first deliveries of two approved vaccines and the government approved plan for a 5-day family Christmas was belatedly abandoned and cut to one day. Into January and the first of the so-called “variants” was acknowledged, but we now know that one that had emerged in Kent in September began driving the third wave well before Christmas. It was this that caused the abrupt cancellation of Christmas festivities, and the imposition of another total lockdown.

Fast forward to now, late february 2021. In the UK we have a rolling programme of vaccination, with 2 vaccines available and more waiting to come ‘on stream’. 17 million + people, in the clinically most at risk groups, have had their first does of a planned 2-dose. The essential second dose is not now to be administered until 12 weeks after the first, which is not how the designers tested it. The programme is going so well that the government has now decided they have the ability to vaccinate all of the adult population by the end of July 2021 with the first dose.

The third wave has seen us pass the ghastly milestone of 100,000 dead (and as I write this update, passing 120,000). Although the third wave seems to have peaked I can see no reason why the death toll will not eventually pass 150,000. Nevertheless, hand in hand with this perceived ‘peaking’, and the available vaccine programme apparently going well, the government has decided we can plan for coming out of lockdown. It would appear that the ‘data’ supports a cautious relaxation of restrictions, with several weeks between each relaxation to monitor the effects on infections. The official view is that this is the last of the lockdowns, that this direction of travel is “irreversible”, but this is where I have fears for a fourth wave.

We know that human (at least in the UK) will not do as they are told. We know that sometimes this is because the don’t understand, sometimes because they don’t care, and sometimes because they are confused by variable and nuanced government messages. We know the economic and political imperative to reopen commercial life is powerful. We know the virus will continue to mutate. I think it reasonable to assume the government has learned epidemiological lessons which, I believe, it experimented with throughout 2020. I believe the government anticipates a fourth wave but feels it has enough data to pin its hopes on vaccines that can limit the size of that wave, and that can be ‘tweaked’ to deal with serious mutations, and in the context of coming summer weather which naturally suppresses the virus.

In the end I believe the success or failure of managing Covid-19, going forward to the winter of 2021 and beyond, will depend on whether people can remember, and apply, what they have learned over the last year to mitigate their own risks (hands / face / space), for the long term. Whether Covid-19 becomes like seasonal influenza, something we live with and manage with an annual vaccine, it certainly won’t be the last we see of it and neither will it be the last pandemic we see.

Shop ’til you drop?

On 15th June 2020, the UK government re-opened “non-essential” retail business (then, in England only) to trading.

TV reports showed queues forming outside retail parks, and interviews with representatives of other parts of the economy still closed, like ‘hospitality’. There were opinions from medical science about the safety of reducing ‘social distance’ from the present 2 metres, but not any behavioural science underpinning the relaxation.

I struggle to understand why any, never mind many, people are in such desperate need for “non-essential” items to the point they would queue overnight – as happened in some places. Crowds, bordering on disorderly, were seen outside so-called flagship ‘brand’ shops. What the social distancing was like inside the stores we do not yet know.

The point of this post is not to focus on the unquestionable health risk associated with this behaviour, but on what I perceive to be the fragile, and fundamentally unsound, basis of our economy which caused the government to allow shopping to resume in spite of the risks.

The UK is a service-led economy. We don’t manufacture much to sell to anyone but ourselves, and most of what we do sell to others is services, not goods – apart from very specialist and high priced items like luxury cars and aeroplanes. We sell ideas, designs, science, ‘systems’, lifestyles. We buy goods from (mainly) developing nations because they can make ‘stuff’ and ship it to us cheaper than we can make it ourselves. In consequence our economy, the flow of money round the nation, and critically into the coffers of the tax man, depends on us spending – especially discretionary spending. Much of our retail, and of course our leisure travel, sector is dependent on this sort of activity but the Covid-19 pandemic has also starkly exposed how dependent we are on routine international air travel for underpinning supply chains with freight carried on passenger airliners.

The latter part of the 20th century saw the confluence of two developments in the economic activity of so-called first world countries: on-line commerce and “just-in-time” manufacturing. Very few major sectors of our UK economy, whether it be retail (including food retailing), car making, construction, or even heavy industry like ship building or wind turbine manufacture, hold ‘stock’. This means, as an island nation, we are extremely vulnerable to disruption of supply chains. In the past we, as individuals, went to ‘agents’ for purchases and they co-ordinated all our purchases and placed orders with suppliers. Now we are all our own agents, making individual direct purchases and “cuttting out the middle man”. This sort of activity is almost impossible to plan for, whether in materials, manufacture or logistics, and so there have been shortages. Shortages create unease, unease creates panic, panic influences our buying behaviour to such an extent that we will buy things we wouldn’t normally buy – in order to get ‘something’: a sort of displacement purchasing.

And so, back to the point of this post. Judging by the queues, and excitement, as shopping became just a little bit easier it seems that we have become so dependent on buying, and spending (even getting into debt to do so), for our emotional and psychological health that we are individually prepared to take Covid-19 risks with our physical health. It also seems our economy is so dependent on our spending, even on “non-essential items, that our government is prepared to encourage us to take risks too.

Sadly, for some, “Shop ’til you drop” may become the reality.

Are we all ‘ists’ practicing ‘isms’?

There has been worldwide reaction to the illegal killing of an African/American (George Floyd) by police in Minneapolis. In ordering my own thoughts about this issue, and the current unrest in and on behalf of the BAME communities about it, I have come to the troubling conclusion that I am an ‘ist’, or at least guilty of ‘ist’ behaviours – or ‘isms’. This realisation has helped me to understand, I hope to some extent, the institutional and inherent racism in my own country.

The manner of George Floyd’s killing, by a police officer kneeling on his neck for almost 9 minutes, could not have been more calculated to evoke the history of black slavery in the Americas. However, not all of the understandable reaction has been well intentioned. While it has given people from ethnic minorities a focus around which to express their anger over past and present injustices, it has also provided opportunities for “racists” to promote their views during demonstrations against them. It has also provided opportunities for those who benefit from creating and maintaining division, in society more generally, to exploit the situation by provocation.

The event sparked the creation of a movement (fuelled and fanned by social media) that self-identified as “#BlackLivesMatter”. Curiously in the UK (so far) #BlackLivesMatter has not appeared to focus much on similar events in the UK. In other words it does not appear to be using the George Floyd incident to draw attention to occurrences of UK people, often young male people of ‘colour’, dying while in British police custody.

In the immediate upwelling of protest, some individuals defaced or destroyed statues, and other memorials, of historical people with links to slavery, the British Empire’s colonial past, or believed to be associated with support for historically contentious figures like Mussolini and Hitler. In passing it made me wonder whether, across the former British Empire, in fact all of the former Empires of European nations, similar things are happening? Are statues being torn down in the former African colonies of Belgium or Germany, the French colonies of north Africa and South-east Asia, the Far East colonies of the Netherlands, the Portuguese and Spanish colonies of South and Central America?

In the fairly recent past of other nations, effigies of world-influencing people have disappeared from view. In the former Soviet Union, once replete with images and statues of Stalin Marx, Lenin, Engels etc., such are hard to find except in museums, while those of pre-Soviet personalities are reappearing and revered. Iraq and Libya have seen statues of former dictators torn down after regime change; the same happened in Cambodia, Romania and many more.

For what my opinion is worth I think we’ll have to reconsider how, and where, we ‘memorialise’ people in future, but I’m happy to think of existing statues being moved to a “walk through history” sculpture park – not a theme park, but somewhere that allowed space for interpretation, information, and context. Where exisitng statues of contentious individuals cannot be moved, why not add some interpretative panels nearby or even erect another statue adjacent which depicts another part of their story? I believe we have to face up to our past, and through education learn from it, not try to expunge or edit it. To do so is to deny their context: a context that seeks to explain, not excuse. Otherwise we are no different than those who seek to deny the reality of the WW2 Holocaust, and murder of 6 million Jews by the Fascist Nazis.

Naturally as a person with some Jewish heritage and DNA, I have a reaction to this last point in particular, and it’s visceral. A novella by John Buchan, “The Thirty Nine Steps”, is a favourite story of mine but there are profoundly, and explicitly, antisemitic passages in it which I really struggle with. I have to skip past them in order to read the rest of the book, but I couldn’t burn it. Antisemitism is not part of my direct experience: I’ve never been abused, called a ‘Yid’ or a ‘Jew boy’ (not to my face) so my response is taught, learned and passed on, inherited. I am a white, middleclass, well educated and, I like to think, ‘liberal’ person and yet I have a direct instinctive response to an indirect stimulus: I am preconditioned by my environment (upbringing) to not have a rascist bone in my body and yet, and yet, I find myself admitting to prejudice about people I have never met.

In considering the undoubted rascism experienced by our BAME citizens, and trying to imagine how people of those communities must feel, really feel, I tried to put myself in their shoes. Of course that’s impossible, but in my head I tried to go through some benign scenarios, such as how would I react to people of different appearance, dress, skin colour, race, ‘presentation’, turning up unannounced at my door, say to conduct a survey. I had to admit I might be, probably would be, instinctively more wary of a young black man in a ‘hoodie’, and talking in ‘urban patois’, than I would a white middle-aged man in a suit. That is prejudice. That is racism. And there is nothing in my direct experience that leads me to this, quite the opposite, so it must be environmental. I must have been insidiously exposed to imagery and attitudes in various ways, some so subtle that they have been un-noticed, that I have formed some underlying attitudes to stereotypes. I suspect most of us have, and so it is entirely understandable that for some people, without the priviledges of a good education, sound upbringing, decent housing and work opportuities, these prejudices are nearer the surface than in others.

I recently undertook a DNA-based exploration of my family history. There were few surprises: I expected my genetic makeup to be mostly Celtic and European (Ashkenazy) Jewish, and it is. However, I also had a few ‘outlier’ strands, some from north and west Africa. I wonder if some of the Nazi-saluting fascist thugs who counter-demonstrate #BlackLivesMatter gatherings might be similarly surprised to find how cross-cultural their DNA is? Those who parade proudly under the cross of St. George or Union Flag, and proclaim themselves thoroughly English or British, might be surprised just how polyglot they are.

When I lived in Scotland, from where my Celtic DNA derives, my wife experienced occasional low level anti-English bigotry. She is not identifiable as being from a particular racial group, or origin, until she speaks. At that point, some deep seated stereotyped response was triggered in some people she met. Not based on who she was, or on appearance, skin colour, attitude or behaviour, she was made to feel unwelcome. That was 30 years ago, and yet it has coloured her feelings about the Scots ever since. She knows that this is irrational, but her slight experience has created an emotional ‘trigger’ in her. How do we expect people of BAME origin in the UK feel, when they are individually and collectively subjected to much more overt, systemic, and frankly nastier, abuse?

The unpalatable truth, as I see it, is that humankind is tribal. It is complex and multi-layered, but we have an animal need to belong. Whether that be defined by race, religion, politics, profession, class, sporting affiliation, age, gender, neighbourhood (and sometimes several of these) we seem to need the safety of our ‘clan’. In times of societal stress, whether that be caused by a pandemic, a financial crash, or even a war, we fall back on the instinct of what makes us fit in with our group to feel safe. We are frightened, especially just now, and frightened people are often irrational.

And so I would ask that we self-examine our motivations, and feelings about #BlackLivesMatter, both for and against, and whether over this or other things, we are also ‘ists’ and practice ‘ism’s. I know I do, and it’s not a very comfortable place to be.

UK Covid Travel Quarantine

On 8 June 2020 the UK government initiated quarantine restrictions on incoming travellers. With a few minor, and clearly (?) defined, exceptions everyone arriving in the UK by air, sea or rail, has to self-isolate for 14 days.

In the weeks since ‘lockdown’, during a period of unusually fine weather, 1000 illegal migrants arrived on the shores of the UK by various means – mostly small boats crossing the English Channel. In one day alone, in the week before the new restrictions, 160 arrived. How many arrived undetected is obviously not known.

In the context of quarantine restrictions intended to prevent ‘importation’ of new Covid-19 infections, one has to wonder where, and how, the illegal migrants are being quarantined – for their safety and ours – and how many of them have been tested and proved ‘positive’ for Covid-19?

Violent Protest in UK – George Floyd

Violent behaviour in demonstrations is unacceptable, but mass public protest has always been ‘hi-jacked’ by violent elements. I’m old enough to remember what happened during the height of the Vietnam War protests, and the CND movement, and the Miner’s Strike where sometimes extreme violence was perpetrated by, and against, protesters.

However, our society at large is tolerant, even encouraging, of violence legitimised by context. You just have to look at mainstream Film, TV, video ‘gaming’ to see how we glorify violence.

It is also the case that political protest has always been exploited by ‘agents provocateur’ – for example police dressed as miners during the miner’s strike – and unscrupulous media looking for a ‘good’ story. I’m not saying these incidents in London and Bristol are like that, but you have to be mindful that those small number of violent protesters may have an ‘agenda’.

Finally, I would ask those who are uncomprehending of protests triggered by an event thousands of miles away, to consider these 2 points:

1) The sort of casual and institutional violence exhibited by those police officers in Minneapolis sometimes happens here in the UK. Simeon Francis, a 35 year old black man, died in police custody in Torquay Devon on 20th May this year. Whatever the cause proves to be, you can be sure that racism is in the UK too.

2) Put the boot on the other foot. How would you feel if your society was largely of a different ethnicity from yours, where justice and law enfocement was delivered by a judiciary and police force largely of that different ethnic group, and where members of your ethnic group were routinely abused, even killed, by them without sanction? When you come to the point where, even in a pandemic, you think “Enough is enough”, would you be calm and measured? Would you maybe lose the plot, or be susceptible to the encouragement of others to do so?

Generation after generation, the words of Martin Niemoller are there to remind us that if we turn our eyes away, and stay silent in the face of such events, we are complicit. However ‘liberal’ and fair-minded we believe ourselves to be, if we do not protest we are no different from those who allowed the stain of fascism and Nazism to spread across Europe in the 20th Century.

‘Tombstoning’: Metaphor for Relaxing Lockdown?

In recent years there has been a growth in numbers of people (mostly young people) undertaking physical challenges that involve high risk. One of these is ‘Tombstoning’ – the practice of jumping from height, sometimes considerable height, into a body of water.

Over the sunny weekend of 30/31 May, in Dorset (UK), there was an incident involving ‘tombstoning’ which provides a clear metaphor for the UK government’s decision to relax the strictures of ‘lockdown’.

People were frustrated by being confined, at that time for 10 weeks, and the government had signalled that we could have a degree of freedom to go outside. It began by saying, three weeks previously, that we could travel any distance to enjoy exercise, as long as we maintained the prescribed social distancing of 2m. Predictably, people took that as a green light to go to the ‘seaside’ – in their thousands. Cars streamed to the coast, clogging roads and carparks, disgorging their occupants in confined locations where it was inevitable that ‘social distancing’ would be challenging if not impossible.

Durdle Door, in Dorset, is an iconic and beautiful location where an enclosed shallow bay features a natural arch over the water. It is, or should be, self-evident that an enclosed bay surround by cliffs will have limited access, and the limited space on the beach will be influenced by the fall and rise of the tide. Apparently not. Many hundreds of people arrived and spread themselves on the beach. Amongst them were three who decided it was a good idea to test their bravery by climbing up the cliff, over the arch of the ‘door’, and ‘tombstone’ 70 feet into the shallow water, encouraged by the onlooking crowd shouting “Jump, Jump”. They were all seriously injured and had to be airlifted to hospital, although it is questionable whether land ambulances would have been able to get anywhere near on the clogged roads. To make room for 2 helicopters to land safely, hundreds of people were compressed into a small space, destroying what remained of any potential social distancing, and were eventually evacuated from the beach up the single access path in a massive ‘crocodile’ file. In this case, amongst the unknowable infected people, any one or all three of the jumpers might have Covid-19, presenting risk to their rescuers and medics, not to mention that flying helicopters into that location is not entirely risk-free either.

This event is where my case for ‘metaphor’ comes in. Over a fairly short time frame UK governments (there are 4 devolved administrations) have decided to shout “Jump, Jump” while we contemplate tombstoning off a lockdown cliff. In the face of conflicting (and in some cases absent) evidence and scientific advice, we are being told we can come out of lockdown but, explicitly, to do our own assessment of risk. The problem with this is that the assessment of risk, in relation to Covid-19, remains, as it has been all along, selfishly focussed on not catching the disease rather than not spreading it. One thing the scientists are agreed on is that we need a robust, fully functional, ‘track and trace’ system to pick up, and isolate, outbreaks of disease. We have seen the value of this in other countries where they had systems for, and experience of, population scale testing and tracking in pandemics. To be robust and fully functional it needs to have adequate capacity, both for carrying out tests and analysing the results, and critically that means speed because outbreaks must be stopped quickly or they rapidly get out of control. At present the UK does not have this and, by all accounts, the statistics on tests carried out are suspect. The evidence, or should I say experience, from other countries where they have had a better grip of Covid-19 is that it keeps coming back. Other countries experimenting with coming out of lockdown have low rates of new infection, in the low hundreds at most. Our daily rate of new infections is stubbornly high, apparently around 8000, of which perhaps 25% are actually confirmed by a test. After 10 weeks of lockdown, which has limited movement and contact, one has to ask why? What is driving community transmission? I have my own theory, which is asymptomatic spread. Asymptomatic infectees will not be picked up by track and trace, or other existing testing, because they fundamentally require self-reporting of symptoms. Those contacted by ‘track and trace’, as having been in contact with someone who is confirmed (by another test) as infected, will be asked to isolate. However, though they may also be infected they may not have, or go on to develop, symptoms. In fact they may be the person who unknowingly gave the infection to the reporting person in the first place!

The science around modality of spread, of viability of deposited virus, of viable infectivity in a person after infection, of any acquired immunity and persistence of immunity, is weak. This brings me back to my metaphor. In a country where some seem only too ready to accept the government’s encouragement to “jump”, while applying their own assessment of risk to them, I fear we are all tombstoning to potential disaster with them.

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.

Thank you Lord (gospel)

Verse 1

Thank you Lord for a helping hand

Even tho’ I didn’t understand

 It was you who bound my wounds

 I felt peace in the calm I found

(Chorus)

I Thank you Lord; Thank, thank you Lord

WE Thank you Lord; Thank, thank you Lord

Verse 2

You lifted me when I was down

 Bore me up when I thought I would drown

Tho’ I would kneel you helped me stand

 Thank you Lord for your helping hand

Verse 3

 Turned inside my deepest sorrow

 Couldn’t see a sunny tomorrow

 But for you I would be lost

 my wounded pride the pointless cost

(Chorus)

Thank you Lord; Thank, thank you Lord

I thank you Lord; Thank, thank you Lord

 Verse 4               

Now I know the sweet surrender

 When I gave my stubborn will away

 Your care so safe and tender

 Helps me thro’ another hard day

Verse 5

Here I am in the promised land

By my side, I know you stand

 It is you who heals my wounds

 Your Grace is the calm I have found

(Everybody)

Praise you Lord;

Thank, Thank you Lord

Love you Lord,

Thank, Thank you Lord

Praise the Lord.

Thank you Lord

(Repeats as required)

© Andrew Gold October 2005

Somewhere on the Road

You remind me of a boy I knew

and a summer long when my heart just flew

I thought he was strong he thought I was quirky

when we were living in Albuquerque

but not quite ready to move on.

The road is long from there to here

memory’s hazy from the grass and beer

but it seems to me that we’ve met before

somewhere on the road back then.

Yeh, back then I had the world in my hand

living on the banks of the Rio Grande

my life was slow and my hair was long

we had nothing to do but sing our song

until we felt ready to move on.

The road is long from there to here

memory’s hazy from the grass and beer

are you sure that our tracks have never crossed over

somewhere on the road from back then.

But he went first up to Santa Fe

so I headed west for the lights of L.A.

we kept in touch for a while by letter

then the next guy or place began to look better

and I told myself to move on.

The road is long from there to here

my memory’s hazy from the grass and beer

but I’m sure I’ve seen that pretty smile of yours

somewhere on the roadside back there.

There’ve been many more places and many more fellas

I met some in the street and some in bordellos

But none came close to the flame we fanned

or the songs we sang by the Rio Grande

before he decided to move on.

You remind me of a boy I knew

and that summer long when our hearts just flew

he was strong and I was quirky

I thought we were happy in Albuquerque

but he was ready to move on.

And I remind me of a girl I knew

through this dirty mirror and the light so blue

in back of a car on Franklin and Vine

now I’ve got a bellyfull of cheap red wine

but I’m still not ready to move on,

No sir, still not ready to move on.

The road’s so long from there to here

my eyes are streaked and I smell of fear

but I’m sure I’ve seen your handsome face

somewhere on the road back there

somewhere on the road back there.

I’m lost somewhere on the road back there.

© Andrew Gold 16 August 2003