COVID-19: HAS PM JOHNSON DONE ENOUGH?

Today Wednesday 23 September I was interviewed live on BBC Radio Oxford by David Prever, 3hr 20min in, available until 22 October.  We were discussing PM Johnson's announcements yesterday, so I talked about four things:

• The 6 months of restrictions in prospect, and what that meant for football clubs, live music and the night-time industry.  "I want to see these places open"
• The "limbo" that the UK Government has put us in, which is by doing "too little too late"
• What the UK Government should have done, which is #NearZero, and sadly a month's lockdown.  Though as light as possible, such as leaving outdoor or well-ventilated hospitality open.  That is why it would have been "easier in the summer", alongside schools and universities being on holiday
• The importance of adequate "financial support" from the Government, and that means for a shorter time than the six months now in prospect.  Lower cost to the Government in support payments and lost taxes

There are some other improtant practical aspects to a lockdown that I didn't have chance to cover on air, but cover here.

David had introduced the conversation by saying "Do the measures go far enough?".   During the conversation, he said on Monday that "the Chief Scientists didn't mince their words, they predict 50,000 cases a day by the end of October" yet for Tuesday's measures "there wasn't a great deal that changed".  Too little, too late.

Half an hour later the news bulletin included a clip (4h00) of a member of the SAGE group advising the Government, Professor John Edmunds of London School of Hygiene and Tropical Medicione (LSHTM). He said  “stringent measures... will be too late again... let the epidemic double and double and double... didn’t learn from mistake back in March, and unfortunately about to repeat it”  Precisely.  Too late.  And too little.


WHY #NEARZERO?

There's talk today that the Swedish epidemiologist Anders Tegnell may have visited Downing Street, to share ideas about what Sweden has done.  He had previously said that the Swedish approach wouldn't suit the UK.  Here's an analysis as to why that would be the case.  A key issue is the likelihood of over-running the NHS, even with the Nightingale hospitals in place, though there are also other significant reasons.

Indeed the UK Government had other options, such as New Zealand's "Elimination" approach, known in the UK as "ZeroCOVID".  This has been proposed by the Independent SAGE group and the All-Party Parliamentary Group for Coronavirus in Westminster.  Great ambition, but if New Zealand can't make it work in their geographically seperate situation, how could the UK?  Zero is just not feasible  in practice for the UK.

So what should the UK do?  Here's the analysis of the options, and why #NearZero is best.  Or indeed given no option is ideal, least worst.

COVID-19: WHAT DID THE SCIENTISTS SAY ON 21 SEPTEMBER?

WHAT DID THE SCIENTIFIC ADVISERS AND PM JOHNSON SAY IN COMMON?

It's worth picking up on a few key points that both PM Johnson and the Scientific Advisers said:

• The exponential increase in new infections followed inevitably by hospitalisations and death
• Action is needed now.  But whether enough?
• Dispelling the idea that younger people should get on with their lives whilst older people take greater precautions.

Indeed what was the intersection between what the scientists were saying and what PM Johnson said in his national address?:

ON YOUNGER PEOPLE

On the very important issue of younger people, the idea that they should get on with life as if COVID-19 wasn't happening was dispelled:

Sir Patrick Vallance, CSA

• Sir Patrick Vallance said "In Spain and France we have seen an increase in the numbers of cases. It started with younger people in their twenties and spread gradually to older ages as well...as the disease spreads, as it spreads across age groups, we expect to see increase in hospitalisations and unfortunately those increase in hospitalisations will lead to an increase in deaths."

Professor Chris Whitty, CMA

• Professor Chris Whitty added "If I as an individual increase my risk, I increase the risk to everyone around me and then everyone who’s a contact of theirs, and sooner or later the chain will meet people who are vulnerable or elderly or have a long term problem from COVID. So you cannot in an epidemic just take your own risk. Unfortunately, you’re taking a risk on behalf of everybody else."

• PM Johnson said: "To those who say we don’t need this stuff, and we should leave people to take their own risks, I say these risks are not our own.  The tragic reality of having COVID is that your mild cough can be someone else’s death knell.  And as for the suggestion that we should simply lock up the elderly and the vulnerable – with all the suffering that would entail – I must tell you that this is just not realistic, because if you let the virus rip through the rest of the population it would inevitably find its way through to the elderly as well, and in much greater numbers. That’s why we need to suppress the virus now, and as for that minority who may continue to flout the rules, we will enforce those rules with tougher penalties and fines of up to £10,000.

OTHER POINTS TO HIGHLIGHT

A couple of other specific points from the scientists worth highlighting:

• From Sir Patrick Vallance:
• He added at current growth rates, this would lead to "something like 50,000 cases in the middle of October per day. 50,000 cases per day would be expected to lead a month later, so the middle of November say, to 200 plus deaths per day"

• "...something under eight per cent of the population have been infected as we measure the antibodies, so about eight per cent, so 3 million or so people, may have been infected and have antibodies. It means that the vast majority of us are not protected in any way and are susceptible to this disease." though this does exclude the possibility of cross-immunity

• From Professor Chris Whitty:
• "So seasonal flu normally in the UK would on average a year would kill around 7,000 people a year tragically, and in a bad flu year, as there was for example about three years ago, it might kill upward of 20,000 a year. This virus is more virulent than flu."  As we've seen, excess deaths were around 53,000 up until early September, with a similar number of COVID-related death certificates.

COVID-19: FINDING THE LEAST WORST OPTION

Now PM Johnson has nailed his colours to the mast, with a strategy announced for six months.

Yesterday he said words to the effect "we need to strike a balance between pushing down the R versus letting the economy flourish".  As discussed yesterday, there's problems with both sides of that statement.  But there's no doubt that lives and livelihoods need to be balanced.

So what options did the Government have?


THE EXTREMES

Firstly the two extremes:

OPTION	PROS	CONS
No restrictions	Get on with life	High deaths and LongCovid.  Health service inevitably overrun.
"Elimination" (ZeroCOVID)  as tried by New Zealand	Back to normal.  Hugs again	Measures needed are unrealistic long term

PRACTICAL OPTIONS

Then near the two extremes:

OPTION	PROS	CONS
Some restrictions as done by Sweden	Get on with most of life,  but     no gatherings over 50	High death and LongCovid initially
#NearZero	Back to near normal after 3-4 weeks	Relatively tough measures

THE UK GOVERNMENT'S CHOICE

Then what the UK Government has chosen for England:

OPTION	PROS	CONS
UK Government	Schools and some businesses staying open	Drifting on for 6 months at least

IN SUMMARY

Putting these options into one spectrum:

OPTION	PROS	CONS
No restrictions	Get on with life	High deaths and LongCovid.  Health service inevitably overrun.
Some restrictions as done by Sweden	Get on with most of life, but     no gatherings over 50	High death and LongCovid initially
UK Government (for England)	Schools and some businesses stayed open	Drifting on  for 6 months at least
#NearZero	Back to near normal after 3-4 weeks	Relatively tough measures
"Elimination" (ZeroCOVID)  as tried by New Zealand	Back to normal.  Hugs again	Measures needed unrealistic long term

ASSESSMENT

There's no right answer.  It's a matter of finding the least worst option.  So which is it?

"No restrictions" is a non-starter, as the health service would soon be overrun.  New Zealand is more remote from the rest of the world than the UK, and they can't even make "Elimination" work.  Not practical for the UK.

As discussed here, there are various reasons why the strategy adopted by Sweden wouldn't work in the UK.  Not least because it is highly likely the NHS would be overrun, even with the Nightingale hospitals.

Which leaves us with the choice between:

• #NearZero
• The Government's strategy

PM Johnson has announced that these restrictions are likely to be in place for six months.   Yet we could get to #NearZero in just one month, 3-4 weeks.

So here's why the UK Government has made the wrong choice.  Too little too late.

COVID-19: SO WHERE HAS THE GOVERNMENT GONE WRONG?

Not so busy today, distanced

Note: Written after PM Johnson's speech to Parliament 22/9/20

Have you heard of 'R'?  It's rather like a mystical beast.  It is back-calculated using an estimate of transmission frequency.    Of itself it has no sense of timescale, so the only use of it is whether it is greater than or less than 1. 

And there lies the problem.  The mantra has been that "as long as we keep R below 1".  That means not growth in the infection rate.  That is equivalent to keeping the daily growth rate below zero, a much more useful metric.

In practice that has meant the Government being satisfied with the current level of infection, whatever it was, rather than striving to reduce it.  Reopening the economy provided the growth rate didn't become positive.  A big risk, as we are now finding.

It was clear from PM Johnson's speech that here we go again.  Today he said words to the effect "we need to strike a balance between pushing down the R versus letting the economy flourish"

There are problems with both sides of that balance:

• Pushing down 'R' to 1 (or growth rate to zero) only stops infections rising.  It does nothing to get them down further.  The measures announced today sound like they will do no more than stop growth in infections.  Too little, and weeks too late
• The economy cannot flourish with infection rates at current levels, and not even as they have been over the summer. Certainly not higher levels which is happening every day now.

PM Johnson spoke of these measures being in place for six months, right across the winter, presumably in the hope of a safe and effective vaccine after Christmas. 'Hoping for the best' again, rather than erring on the side of caution. A vaccine is not guaranteed in that timescale, nor indeed at all. 
 
Alternatively we saw in this analysis that by getting new infections down to very low levels, #NearZero, we can re-open most if not all of the economy.  Even the night-time economy of theatres and music venues can reopen in accordance with the  NTIA's "Nightclub & Venue Reopening Strategy", which seems broadly sensible.

#NearZero is potentially achievable in as little as 3-4 weeks, or at least would have been over the summer.  A relatively short, sharp medicine for major improvement.  Rather than half-hearted medicine for the foreseeable future that will not properly address the economic 'symptoms', whilst still being unpleasant in itself. 

We certainly cannot expect the economy to flourish if people cannot plan their business ahead, nor if customers are reluctant to go out into indoor settings.  I'm nowhere near as reluctant as some people I know, but getting my first haircut since before lockdown, and a trim of my new Lockdown Beard, was a risky step for me.


IN CONCLUSION

Today's propopals were too little too late again:

• If we really want to re-open the economy and let it flourish, and 
• If we want to preserve our lives, livelihoods and lifestyles.  

The Government missed the opportunity over the summer to more easily get infection rates down to very low levels, #NearZero.

More difficult to do it now, but that would still be better than drifting on with today's proposals.

COVID-19: COMPARING #NEARZERO TO GOVERNMENT APPROACH

Let's get music venues open

Note: This was written before PM Johnson's speech to House of Commons 22/9/20
Update 24/9/20 after Chancellor Sunak announced financial support measures.  In tital, the fundamental Government policy has not changed significantly enough for this analysis to need adjustment: 

Over the last 6 months the UK Government has arguably done too little too late, and decisive action is now needed.

We've previously looked at the benefits of #NearZero strategy.  To get life back to near-normal before the arrival of a safe and effective vaccine.  That would include ending the "interval" in live entertainment, the most difficult industry to unlock.

We need to find the best balance between lives, livelihoods and life.

Here's the comparison of #NearZero to where we find ourselves after six months of this Government's "Too little too late" policies:

ISSUE	#NEARZERO	TOO LITTLE TOO LATE
Risk of meeting someone infectious	Low risk	Unacceptable, increasing risk
Deaths	Low number	Increasing number
LongCOVID	Low number	Increasing number
Testing capacity constraints	Keep within	Overload testing capacity
Do ‘normal’ activities	Most normal activities	Increasingly stopped
Shielding people	Let them get back to life	Back to shielding (or ought to be)
Indoors – restaurants, pubs, etc	Safe	Increasingly unsafe
Nightlife - theatres, concerts, gigs, nightclubs	Open in accordance with NTIA guidance	Stay closed
Sports events	Attend them	Not attend events, have to stop them
Preparation for winter	Prepared	Unprepared
NHS staff	Protecting them	Overloaded
Universities	Keep open, face to face	Risk of closure
Schools	Keep open	Start-stop pupils being sent home
Parents	Keep at work	Start-stop at home to look after kids, catch disease
Public transport	Be safe, with masks	Unsafe
Workplaces	Keep open	Stop/start, unable to plan
All leading to:
Economy	Grow quickly	Stunted

Here are the benefits of #NearZero in diagrammatic form:

THE SWEDISH APPROACH

Some people are suggesting that we should now follow the Swedish approach.  That was actually similar to how the UK Government started in February/March. but there are some key reasons why that approach would not work in UK, neither then nor now:

• In the UK, there was a bigger threat of the NHS being overrun.  
• Even with the additional capacity of the Nightingale hospitals, that is still the case, with the additional consequence of very high death numbers again
• The Swedish culture is more about looking after one another than in UK.  They had a voluntary lockdown, for example with as little internal travel as  neighbouring countries
• They stopped gatherings of more than 50 people
• They kept most schools open, but closed educational estanlishments for the over 16s
  

The best alternative is to drive down infections to #NearZero


GETTING TO #NEARZERO

Whatever the measures needed to get to #NearZero, the benefits in lives, livelihoods and economy can only be achieved with a financial investment from the UK Government.  The payback to the Treasury of a stronger economic recovery would be massive.

Public information and education needs to step up a gear, explaining and persuading through the whys not just the whats.  The only way to get to #NearZero and importantly stay there.

We can't drift on like this.  Let's get to #NearZero, open the economy and benefit in so many ways!

Here's a more detailed analysis.

Update 22/9/20: PM Johnson has now announced various changes to national restrictions , subject to debate "next week" 

COVID-19: WHAT SHOULD THE GOVERNMENT ANNOUNCE TODAY?

Last night the Government announced restrictions for the hospitality industry. As outdoors is far safer than indoors, let's hope there's some scope for small groups to meet socially.

Otherwise in pursuit of #NearZero, the best approach was set out in this "Too Little Too Late. It's Time To Take Decisive Action"

A key issue is that COVID-19 is far worse than 'flu, especially as there will not be a mass vaccine until at least after Christmas.  Action is needed now.

The Independent SAGE group has also just made some specific recommendations.  Here's some thoughts in response.

The key matter is making sure businesses and individuals are suitably supported, whether that's:

• Self-isolation, otherwise the Isolate part of Test and Trace doesn't work as well as it should
• As a result of more general restrictions, such as being announced today 

In particular, the SEISS Self-Employed Income Scheme needs further instalments.

iSAGE RECOMMENDATIONS	THOUGHTS
IMMEDIATE MEASURES (to be reviewed, as appropriate, when a functional testing system is in place and infections are back under control)
1. Pubs and restaurants limited to outdoor service.	Outdoor and very well ventilated e.g. gazebos.  Keep open in any lockdown
2. Work at home if possible. No return to workplaces until certified COVID safe.	Agreed
Provide financial support to employees in the interim.	So important. Scottish approach "Test, Trace, Isolate, Support" should be adopted
3. Fund schools to allow smaller, socially distanced classes.	Ideally, especially for older teens
Provide digital resources for all students and teachers for study/work at home.	Ideally
4. No in-person teaching at Colleges and Universities	OK if socially distanced
5. Limit indoor social interaction to a bubble of three households	On each occasion
6. Create an emergency fund in each local authority area and provide wrap around support for all those needing to shield or self-isolate (including those unable to get tested)	Support so important
7. Re-establish the 2 metre distance rule.	Mask needed less than 4 metres
A STRATEGY FOR BUILDING A FUNCTIONAL TESTING SYSTEM
8. Rebuild the testing system based on tried and trusted local authority,  NHS and public health structures, including recruiting and deploying contact tracers locally	Local 'COVID wardens' that can act as both contact tracers and 'COVID marshals'
9. Provide clear consistent messaging about testing and other protective measures that is culturally competent and accessible to all sections of the community	Communication generally needs to be improved massively, to include more of the why as well as the what
10. Establish a clear strategy and set of priorities for symptomatic and asymptomatic testing	Agreed.  Two-tier structure of daily 'warning tests' for everyone and confirmatory tests for those warned.

COVID-19: LONGCOVID AND THE COMPARISON TO 'FLU

When we have 'flu, we're in bed for a couple of days, and then are pretty well back to normal.  Some people develop pneumonia, and the more vulnerable are given free vaccines to protect them from the disease.  Though according to Professor Chris Whitty yesterday, 21 September, about 7,000 people die each year.  20,000 in a bad year.

If you don't rest properly, lethargy and 'brain fade' symptoms can last for months, just like for any serious illness. Tell me about it.

The progression of 'flu is like this:

COVID-19 is more complex:

• There can be a second stage illness, after the person has apparently recovered.  This is what happened to PM Johnson. which led to a more serious illness into hospital.
• There can similarly be long-term lethargy
• When the SARS-COV-2 virus gets into a cell, it replicates until such time as the cell bursts, infecting surrounding cells.  This can lead to the virus getting into the blood where it can do three things:
• Form microclots that can cause strokes
• These microclots can go around the body and cause damage to organs they reach
• The virus can also attack organs that have ACE2 receptors, which is the mechanism by which respiratory system cells are infected

If we compare 'flu and COVID-19 we get this summary:

KEY DIFFERENCES

As highlighted in the table above, there are some significant differences, which can affect young and old alike:

• The initial illness is far longer and tougher
• When people think they are over it, there can be a second stage.  Like PM Johnson, who then needed to go to hospital
• If virus gets into blood stream, microclots form:
• Causes strokes
• Causes organ damage, in addition to lungs and the respiratory system:
• Heart
• Liver
• Kidneys
• Digestive system
• Brain

Further details here


IN CONCLUSION

COVID-19 is about far more than 'flu and far more than just death.  It's more about the survivors.   Catch this disease and its misery for you, and then likely misery for family and friends.  Please don't ignore restrictions

The only solution is to get infections down to very low levels.  Here's why, and how.

COVID-19: A FOCUS ON DEATHS

Scepticism.  It is absolutely right to question what we are being told.  Professionally I have to be sceptical all the time, whether that is evaluating business software or, back in the day, auditing stock takes.

Scientifically I will always remember a school textbook saying that in the early days of microscopes, 'scientists' believed they could see a tiny man in sperm, just as Aristotle had suggested.  That became the wisdom of the day, but we now know that is incorrect. 

So it is no surprise that people question what they are being told, and have indeed been challenging me and what I have been saying.  So let's get to some of the facts.

Death is one of 6 distinct risks of COVID-19, so let's look at that now.  Did the lockdown actually increase deaths?   What age groups were affected?

We looked at deaths up to week 36, 4 September, recently.  But let's expand on that analysis, using the same weekly data set from the Office for National Statistics.


TOTAL DEATHS

"Excess deaths" is the number of deaths over (or indeed often under) the average for the last 5 years.  In 2020 this is:

• Deaths due to COVID-19
• Plus deaths indirectly caused by COVID-19, such as due to delayed treatment of other medical issues such as strokes
• Minus deaths saved by COVID-19, such as lower road traffic accidents as might be expected due to lower traffic during the lockdown
• Plus or minus usual annual variations

For 2020, the ONS has also disclosed the number of deaths where COVID-19 has been mentioned on the death certificate:

• Primary cause
• Secondary cause, once doctors became clear on what was expected

Comparing the two on a cumulative basis:

 What this graph shows is:

• Deaths in January and February were below normal levels until COVID-19 came along
• The 23 March lockdown was just after the first deaths were recorded, but these are some weeks after original infection, probably in February.  It was clear in mid-March that infections were rising rapidly.
• The lockdown starting on 23 March would not have had an impact on deaths for some weeks:
• On a rising trend in new infections, confirmed cases didn't return to the 23 March level until more than a week  
• Infections in late March wouldn't have resulted in a significant number of deaths until late April at least.  
• Lockdown had reduced excess deaths to be near zero by around week 20, mid-May
• Excess deaths initially ran ahead of official COVID-19 deaths.  But this was likely due to confusion on how to complete death certificates in co-morbidity situations, where there was also some other cause of death
• Both excess deaths and COVID-19 deaths had levelled off by early September.
• The excess deaths total some 53,000 so far, almost exactly matching the official number of COVID-19 deaths
• If the shortfall in official COVID-19 deaths in April and May compared to excess deaths  represents an 'error' in co-morbidity situations, then:
• COVID-19-related deaths actually exceed the excess deaths
• Causes that reduced deaths exceed the causes increasing them.  So for example, any reduction in situations such as road traffic accidents more than compensated for any increase through health treatment not being available
• If there hadn't been a lockdown:
• Deaths would have continued to rise to far higher levels 
• The impact on the health service to provide non-COVID diagnosis and treatments would have been at least as severe as lockdown

COMPARISON TO 'FLU

Professor Whitty disclosed in the press briefing this morning, 21 September, that influenza kills around 7,000 a year, with some 20,000 in a bad year such as three years ago.

Deaths from COVID-19 of 53,000 in only some of the year represents a far bigger problem.  That is due, at least in part, to the lack of a vaccine as is used for influenza.


EXCESS DEATHS BY AGE

The comparative data for 2015-2019 is only available in a small number of age ranges.  Calculating the excess deaths for 2020 on that basis gives this graph:

We hear that the death problem from COVID-19 is mainly for the over 50s.  But this shows that the problem with excess deaths is for the over 44s, with lower deaths than expected for the under 15s.

That leaves the rather wide 30-year age range 15-44 having excess deaths peaking at 5% of normal.  But what if we were to look at smaller age ranges?  The relevant data is not available publicly, but we can look from a different angle with the data that is available. 


TOTAL DEATHS FOR 15-44 YEAR-OLDS

Whilst we can't look at excess deaths, we can look at the absolute number.  If we assume the number of people in each age band is broadly similar, then the different levels indicate how much COVID-19 affects each age group:

In broad terms this shows that you are more likely to die as you get older.  But is there any evidence for increased deaths from COVID-19?

Let's look more closely at the middle section between weeks 10 and 20.  Week 20 was the peak of excess deaths for older year groups in the graph above.  An increase in the slope would indicate the death rate had increased.  We can only see a very slight increase in the slope for the 35-39 and 40-44 age groups:

IN CONCLUSION


There's been around 53,000 deaths from COVID-19 in the first 8 months of the year, whether it's based on excess deaths or death certificates.  That is so much worse than 'flu, which is at worst 20,000 in a bad year.

This is mainly because of the lack of a vaccine against the virus behind the COVID-19 disease.  There won't be a vaccine proven safe and effective, and available in significant quantities, until 2021.  In the meantime there have been some improvements in treatments, but a resurgence of COVID-19 infections in 2020 will result in many more deaths.

Looking at age ranges:

• Death from COVID-19 is a clear risk for those aged 45+, not just those over 50
• There is some risk of death for those 35-44
• There is little risk of death for the under 35s.

That doesn't let the under 35s off the hook though:

• There are five other significant risks of COVID-19 that affect all ages, which we'll look at in more detail in a separate posting
• The under 35s can be carriers, infecting other younger adults who in turn can infect older and more vulnerable people