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And next time?

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In the next six weeks we will find out if we are at the start of a Covid-19 second wave.  What we know today is that the number of confirmed cases of Covid-19 in the UK has been growing dramatically from the beginning of July; with the seven day average standing at 2,032 on 7 September – the same number of cases as we had on the eve of the lockdown in mid-March.  For this reason, UK officials have begun imposing local lockdowns in counties with the highest case rates, while tightening social distancing rules across the whole of the UK.

The understandable fear is that the rise in cases will soon translate into a rise in deaths similar to that in March.  We should not be complacent, of course.  But there are two things that we also know that suggest something else is happening.  The first is that the rise in cases has not been accompanied by a rise in deaths.  In fact, UK deaths have followed the same curve as the rest of northern Europe (including Sweden, which was initially criticised for not locking down):

The curve is more obvious when deaths per million people are plotted:

There is also a somewhat morbid factor at play here.  According to the Office for National Statistics:

“In the 2018 to 2019 winter period (December to March), there were an estimated 23,200 [Excess Winter Deaths] in England and Wales. This was substantially lower than the 49,410 EWD observed in the 2017 to 2018 winter and lower than all recent years since 2013 to 2014 when there were 17,280 EWD.”

In effect, a large number of older and vulnerable people had dodged a bullet in the year prior to the arrival of SARS-CoV-2; and so there were more potential victims for Covid-19 at the beginning of 2020.  The large number of deaths resulting from decanting infected people into care homes no doubt inflated the figures in March and April.  And the excess deaths then mean that there are fewer vulnerable potential victims left to succumb to the disease today.  Moreover, many of the remaining elderly and vulnerable people will have adjusted their behaviour in a way that minimises the risk of infection.

Some of the fall in deaths may also be due to clinicians better understanding the disease and developing more effective treatments.  However, this seems unlikely to have had a big impact.  This is because the second thing we also know is that the number of hospitalisations has not increased with the number of cases either:

How else, then, might we explain the big increase in confirmed cases?

The most obvious explanation is that we are repeating an error which was made in the aftermath of the 2009 Swine Flu.  Initially, testing was patchy and inaccurate, so that the majority of cases went unrecorded.  Later, as the quantity and – crucially – the sensitivity of the tests improved, so far more cases began to be recorded.  We might be repeating this.  As Rachel Schraer and Nick Triggle at the BBC explain:

“…at the start of the pandemic, the UK was only largely able to test hospital patients. There was limited testing capacity.

“This targeted testing meant infections in the community were completely missed, whereas now we have mass testing in the community. It means that if we compare numbers now to numbers during the peak, we are essentially comparing apples with pears.

“Estimates from the London School of Hygiene and Tropical Medicine suggest there may have been as many as 100,000 cases a day at the end of March. Mass testing in the community only started in the second half of May.

“Clearly not all cases are now being picked up, although the surveillance programme run by the Office for National Statistics suggests a large proportion are, whereas earlier in the pandemic maybe only 5% of cases were being detected.”

The key question – which nobody in the establishment media is asking – is why we have become so obsessed with testing anyway?  In medicine, there is a general rule that you don’t test for conditions for which you have no treatment.  There’s no point.  This is certainly true for Covid-19 in the UK at the present time, because there is no approved outpatient treatment.  Without testing, if you have suspected symptoms of Covid-19 you should isolate for 14 days.  With testing, if you are shown to have Covid-19 you should also isolate for 14 days.

Testing, then, is being done for economic rather than clinical reasons; and its aim is to identify people who test negative.  That is, once you get your negative result you may stop isolating and get back to work.  Of course, the risk of false negatives to older and vulnerable people should be obvious enough.

Rather than spending a fortune on mass testing (which the government has so far botched) it would be easier and cheaper just to raise the rate of sickness benefit so that poorer workers can afford to isolate when they develop symptoms.  This would also have the benefit of not raising false alarms and subjecting people to unnecessary lockdowns and restrictions solely because the way cases are identified has changed.

For the moment the no-man’s land we find ourselves in has given rise to two opposing political narratives based upon exactly the same data.  The first – and most common – is that the UK government – along with several others – made a complete dog’s breakfast of handling the initial stages of the pandemic. Not least, because they prioritised the economy over public health.  Failing to close the borders in time; underestimating the seriousness of the disease; failing to stockpile protective equipment; lacking an adequate track-and-trace system; and transferring infected people into care homes are all believed to have added to the toll of unnecessary deaths.  It follows that government needs to get ahead of the curve as autumn draws in, through mass testing and pre-emptive local lockdowns and tighter social distancing regulations.

The second narrative points to the fact that all countries (and north eastern states in the USA) in the temperate northern hemisphere experienced the same Gompertz curve irrespective of the measures taken by their government.  Although those with better healthcare systems and governments sensible enough not to send infected people into care homes managed to have lower death tolls, the pattern was the same – a big spike in deaths in March and April, followed by an equally rapid decline once 15-20 percent of the population had been infected.  According to this view, the northern hemisphere pandemic ended in June, and that what we are witnessing today is a “casedemic,” resulting from an over-zealous testing regime.  Far from failing to act, government is to be criticised for over-reacting.  People have already died from non-Covid accidents and diseases which went undiagnosed and untreated because clinics were cancelled and because people were scared into not seeking early treatment.  And in the long-term the consequence of undermining an already fragile economy is going to result in far more deaths.  Unemployment and poverty have long been known to increase the risk of dying from cancers, heart disease and suicide.

Which of these narratives is correct?

Only time will tell.  But for once I have a great deal of sympathy with the governments charged with responding to what was, at the time, an entirely unknown virus.  In April I quoted General Practitioner and Science writer Ben Goldacre’s response to the lack of data during the 2009 pandemic:

“We are poorly equipped to think around issues involving risk, and infectious diseases epidemiology is a tricky business: the error margins on the models are wide, and it’s extremely hard to make clear predictions…

“All people have done is raise the possibility of things really kicking off, and they are right to do so, but we don’t have brilliantly accurate information. Someone has said that up to 40% of the world could be infected. Is that scaremongering? Well it’s high, and I’m sure it’s a bit of a guess, but maybe up to 40% could be. Annoying, isn’t it, not to know.”

This was where governments found themselves in February and March; which, by the way, is one reason why I find myself agreeing with Donald Trump about not wanting to cause a panic.  After all, just to remind you, in February and early march some of you had stripped the supermarket shelves bare and were prepared to commit murder just to get your hands on the last roll of toilet paper.  The very last thing we needed was the president of the most powerful country on Earth responding like this.

It is also why I continue to have some sympathy with governments as they try to understand whether they are witnessing a second wave or a casedemic.  Because the path they choose to follow is going to have serious consequences.  Although now would be a good time to stand back, take a breath and study all of the evidence from around the world.

The various state support schemes that have protected companies and jobs since the lockdown, are still in place.  The fear is that hundreds of thousands of job losses will follow the withdrawal of support when the schemes end at the end of October.  We have already seen a dramatic fall in demand for commercial property – much of it owned by our pension funds – as companies discover it is just as easy – and a lot cheaper – to have employees work from home.  This trend is likely to accelerate as state support is withdrawn; and will have serious implications for city centre retail and services whose customer base will no longer exist.  And as general demand across the economy falls, we risk an epidemic of business failures and job losses.  If the second wave fails to put in an appearance, we can be sure government will be castigated for failing to do more to save the economy.

On the other hand, of course, if government opens everything up prematurely and a second wave does appear, there will be far more deaths and long term injury.  In that case, government will be criticised for failing to be draconian enough.

The compromise position would be for government to take a lead from our former European Union partners and extend the various forms of state support to Easter 2021.  In this way, a large part of the economy might be protected without the need to expose older and vulnerable people to the threat of a second wave of Covid-19 this winter.

There is though, an even longer-term problem that any foresighted government might want to consider before messing around with the economy more than they have already done.  At present, we are so focused on this pandemic that we are losing sight of the broader predicament.  As human settlement and industrial agriculture further encroaches into the final wild habitats of planet Earth, we can expect to see many more novel zoonotic viruses emerging.

In an ideal world, states stockpile resources with which to meet emergencies like pandemics.  But with each new economic shock and each year we pass beyond the 2018 energy peak, our ability to overcome disasters of all kinds is weakened.  At the start of the pandemic I cautioned about the risks of presenting a simplistic false choice between “the economy” and public health, precisely because the more prosperous an economy, the better the health of the population.  This is one reason why Germany has far fewer Covid-19 deaths than the UK; and why ex-industrial towns like Ebbw Vale appear in lists of the worst places for cancer, heart disease and mental illness.

Next time we may not be so lucky.  With our economy already facing the biggest depression in centuries, we can but pray that pandemic viruses keep themselves to themselves for the remainder of the decade.  Unfortunately, nowhere is it written that because we had a pandemic in 2020 we cannot have another in 2021, 2022 or 2023.  And for all of the personal tragedy involved in the thousands of excess deaths in March and April, Covid-19 is considerably less deadly even than some strains of seasonal flu.  Imagine for a moment that the next novel virus that embarks on a world tour proves to be as infective as SARS-CoV-2 and as lethal as Ebola!  That alone would be bad enough.  But imagine how much worse it would be if it arrives while our economies are in freefall.

As you made it to the end…

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