In my previous post I said that the initial disorientation caused by the eruption of SARs-CoV-2 was ‘evaporating’, but I got that wrong. I had hoped that what was happening was a recovery from an initial shock so that some rational inquiry would emerge among the general population. This hasn’t happened, at least not as far as I can see.
In part this is due to the mass media, which has a story and are going to run with it; I’m reminded of that great film starring Kirk Douglas – ‘Ace in the Hole‘. It also reflects the disintegration of the socialist and labour movement that there are no scientific organisations, milieu or debate that could focus and inform debate on what approach is in the interests of the mass of working people. Instead we have dependence on the state which breeds deference and subservience instead of critical thought. The illusions that arise are all the greater for their being based on real dependence. I’d hoped that the healthy dislike and skepticism of Boris Johnson among many would lead people to be more critical, although there is still plenty of time for this.
I have stayed away from BBC News and current affairs, with the exception of the web site, for years and especially after seeing some of the coverage of Jeremy Corbyn, but I tuned in this past week to watch the Prime Minister broadcast announcing increased restrictions and the half hour ‘analysis’ afterwards. If this is reflective of the rest of the coverage then I have missed nothing. BBC journalists often complain about the ‘Westminster bubble’ but it is they who are the prime culprits in inflating it; when they are not talking about political personalities they are essentially talking about themselves. I also watched one of the daily press conferences, and this was much more revealing.
None of the questions asked were answered and the two experts demonstrated that they were more skilful in not answering the question than Johnson. What answers were given provided plenty of grounds for skepticism. We were informed that ‘the science is coming from a low base’ and when asked whether it was true that perhaps half the population had the virus, as suggested by a study from Oxford University, the answer was ‘we simply don’t know.’
The Chief Medical Officer stated that it was ‘going to be a close run thing’ whether the health service could cope while another advisor Prof. Neil Ferguson expressed confidence that NHS capacity won’t be breached. Johnson has got by by with promises that testing, protection equipment, and ventilators etc.will all be coming soon while also claiming that everything is going to plan. The machinery of Government has ignored offers of ventilators while giving contracts to Brexit-supporting friends who don’t make them, just like it earlier gave shipping contracts to companies without ships.
It absents itself from cooperating with the EU, giving us all a taste of things to come, while lying about why it did it, the taste of things just past. The only thing more personally aggravating is the silence from the British Labour Party, which is only interrupted by craven agreement with Tory policy and calls for ‘more’; which reminds me of another film – ‘Oliver Twist’.
At the end of February, the Government’s Rasputin – Dominic Cummings – is reported to have outlined the government’s strategy as “herd immunity, protect the economy, and if that means some pensioners die, too bad.” It is supposed to have resulted in that strategy being revised on foot of a report from Imperial College London. This report considers that there are two possible strategies: mitigation and suppression, outlining evidence that the Government strategy was mistaken and that ‘suppression’ of the virus was the only way to avoid a ‘likely result’ of ‘hundreds of thousands of deaths’.
It describes as its main conclusion “that mitigation is unlikely to be feasible without emergency surge capacity limits of the UK and US healthcare systems being exceeded many times over.” The Government strategy therefore appears compromised because the health service can’t cope. This is why the ‘strong and stable’ mantra of the latest Tory Prime Minister includes the dictum ‘protect the NHS’, which actually means protect the political fortunes of the Tory Government that fought the demands of junior doctors, cut nurses pay and inflicted a decade of unprecedented austerity on the NHS.
The difference between the two approaches is to move the R number, the average number of secondary cases which each antecedent case generates, to below 1, thus reducing the number affected over time. It argues that only a strategy of suppression can do this. The study recognises that the main challenge to this is that it has to be maintained indefinitely, until a vaccine becomes available; but it also suggests that there should be periodic relaxations of restrictions when infection numbers reduce and their reimposition when they increase again.
It may be doubted if such fine tuning is possible given lack of data on the extent of infection, the potentially misleading character of the data available as a true indicator of infection rates, and the risk that people will not find it easy or reasonable to open and shut down their lives at instruction from the Government. The study itself notes that:
‘Once interventions are relaxed . . . infections begin to rise, resulting in a predicted peak epidemic later in the year. The more successful a strategy is at temporary suppression, the larger the later epidemic is predicted to be in the absence of vaccination, due to lesser build-up of herd immunity.’
So what the report doesn’t do, as we can see, is condemn in principle the idea of ‘herd immunity’; in fact it notes that such an approach has been taken before,’by the world more generally in the 1957, 1968 and 2009 influenza pandemics’.
The report also doesn’t factor into its ‘suppression’ strategy the ‘enormous social and economic costs which may themselves have significant impact on health and well-being in the short and longer-term.’ It does assume that on recovery from infection individuals are immune to re-infection in the short term.
The significant assumption on which the study rests is an infection fatality rate (IFR) of 0.9%, based on an estimate of the experience in China. (It should be noted that the paper referenced in the Imperial College study states that ‘we obtain an overall IFR estimate for China of 0.66% (0.39%-1.33%), again with an increasing profile with age.’ That is, the application of the estimate of the IFR for the GB population derived from the estimate for China results in a figure over a third higher.)
The study then estimates the impact of the virus in age cohorts based on this figure and taking account of its increasing severity with age (for much more analysis of the full table see Boffy’s blog here):
|Age group (years)||Infection Fatality Ratio %|
|0 to 9||0.002|
|10 to 19||0.006|
|20 to 29.||0.03|
|30 to 39||0.08|
|40 to 49||0.15|
|50 to 59||0.6|
|60 to 69||2.2|
|70 to 79||5.1|
What this shows is that it is only for those aged 60 and above that the virus contains a significant risk. As noted, the figures above rest on estimates for China and there has been criticism that decisions are being taken without reliable data. Others have pointed out that many cases of the virus have not been detected, because carriers have been asymptomatic or their symptoms were too mild to report:
‘Research published last week by Jeffrey Shaman of Columbia University in New York and his colleagues analysed the course of the epidemic in 375 Chinese cities between 10 January, when the epidemic took off, and 23 January, when containment measures such as travel restrictions were imposed. The study concluded that 86 per cent of cases were “undocumented” – that is, asymptomatic or had only very mild symptoms (Science, doi.org/ggn6c2).’
The Imperial College report quotes unidentified cases as 40 to 50 per cent of infections, based on the experience of China and those returning on repatriation flights.
This would mean that the Infection Fatality Rate in the table above would be too high since deaths recorded would be a smaller proportion of those infected, many of whom were ‘undocumented’. This does not nullify the seriousness of the threat to those in older age groups, or to those with a suppressed immune system, or who rely on the immune system for effective treatment, such as targeted cancer drugs. It means that this is where the real problem lies.
It is also recognised that all deaths of patients with the virus have not died because of it, just as it is well known that all men with prostate cancer will not die of it. The Government advisor mentioned above noted that one half to two thirds of those dying might have died anyway.
So it is not just that the health service was, and still is, unprepared for a pandemic, which the Government knew, but that the various arrangements that are required to protect the most vulnerable are still not in place. Lots of initiatives have come from outside Government, which can barely coordinate its own actions, and many of the grand schemes announced by it are like its promises on testing and equipment, they remain promises. The second category of people who may suffer is therefore health service staff themselves if, as seems possible, they become exposed too much to the virus without adequate protection.
It is therefore clear that the strategy of suppression may go the way of the previous strategy of mitigation. The Imperial College report states that its preferred strategy involving social distancing, home quarantine, case isolation at home and closure of schools should be in place for five months, not the 12 weeks spouted by Johnson. It envisages maintenance of such policies for perhaps 18 months until a vaccine is discovered. This raises the question whether the shift of NHS resources to treatment of the virus for such a long time would have implications for the treatment of other patients.
The report also states that ‘suppression policies are best triggered early in the epidemic’, and ‘for suppression, early action is important’, while the British and Irish Governments cannot be accused of acting quickly, and it also admits to ‘very large uncertainties around transmission of the virus.’
In accepting the difficulties of long term suppression policies it states that ‘social distancing of high-risk groups is predicted to be particularly effective at reducing severe outcomes given the strong evidence of an increased risk with age.’
The report ends by noting that ‘we emphasise that is not at all certain that suppression will succeed long term; no public health intervention with such disruptive effects on society has been previously attempted for such a long duration of time. How populations and societies will respond remains unclear.’
What should be clear is that the promises of the Government have a sell by date and a use by date; promises of delivery of tests and equipment and the mobilisation of additional staff and hundreds of thousands of volunteers will require that these are organised effectively. If they are not then this will become a political challenge to the Tory Government that no amount of self-isolation will shield them from.